Testicular choriocarcinoma in a case of inguinal hernia: a rare subtype of non-seminomatous mixed germ cell tumour with a misleading presentation requiring a unique treatment approach

Abstract

Testicular choriocarcinoma is a rare and aggressive variant of non-seminomatous germ cell tumor (NSGCT) with early metastatic spread and dismal prognosis. Early recognition of the diagnosis by elevated β-human chorionic gonadotropin (β-HCG) levels in a young male improves his chances of survival following a radical orchiectomy, which establishes the diagnosis and staging. We report a case of a 21-year old young male presenting with a right groin swelling for 2 months. The clinical history was that of a right inguinal hernia but examination findings suggested a testicular tumor, which was confirmed with an ultrasonograhy and contrast enhanced computed tomography (CECT) of abdomen and scrotum and an elevated β-HCG of 23,559 IU. The metastatic workup was clear and so the patient was taken up for immediate right high inguinal orchidectomy and Lichtenstein tension-free mesh repair. HPE of the postoperative specimen proved a mixed germ cell tumor with choriocarcinoma predominance. Semen analysis and sperm banking were done and the patient was started on chemotherapy and sequential normalization of β-HCG levels was observed. Choriocarcinoma is an aggressive variant of NSGCT with inherent invasive and metastatic potential rapidly metastasizing to the liver, lung, brain, etc. So a thorough knowledge of the varied clinical manifestations of the choriocarcinoma syndrome ensures early detection even when the presentation is misleading. Treatment is directed towards confirming the diagnosis and staging with histopathology examination and postoperative chemotherapy for persistent normalization of the tumor markers.