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

S. N. Pravindhira, P. Prabhakar, R. Kannan, T. Suganthan


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. 


Testicular tumor, Germ cell tumor, Choriocarcinoma, Inguinal hernia, β-HCG

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Beck, Stephen D W. Management options for stage 1 nonseminomatous germ cell tumors of the testis. Indian journal of urology: IJU : journal of the Urological Society of India. 2010;26(1):72-5.

Adra N, Einhorn LH. Testicular cancer update. Clin Adv Hematol Oncol. 2017;15(5):386-96.

Bethesda MD. SEER Cancer Stat Facts: Testicular Cancer. National Cancer Institute. Accessed on 02 November, 2020.

Oldenburg J, Fosså SD, Nuver J, Heidenreich A, Schmoll HJ, Bokemeyer C, et al. Testicular seminoma and non-seminoma: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2013;24(6):125-32.

Siegel RL, Miller KD, Jemal A. Cancer statistics. CA Cancer J Clin. 2018;68:7-30.

Stang A, Rusner C, Trabert B. Incidence of testicular tumor subtypes according to the updated WHO classification, North Rhine-Westphalia, Germany, 2008- 2013. Andrology. 2018.

Woodward PJ, Heidenreich A, Looijenga LHJ, Oosterhuis JW, McLeod DG, Moller H, et al. Choriocarcinoma. In: Eble JN, Sauter G, Epstein JE, Sesterhenn IA, editors. WHO classification of tumors. Pathology and genetics of tumours of the urinary system and male genital organs. 3rd ed. Lyon: IARC Press. 2004;240-3.

Yokoi K, Tanaka N, Furukawa K, Ishikawa N, Seya T, Horiba K, et al. Male choriocarcinoma with metastasis to the jejunum: a case report and review of the literature. J Nippon Med Sch. 2008;75:116-21.

Sobin LH, Gospodarowicz MK, Wittekind C, editors. TNM classification of malignant tumors. ed. 7. Oxford, UK: Wiley-Blackwell. 2009;249-54.

Mead GM, Stenning SP. The International Germ Cell Consensus Classification: a new prognostic factor-based staging classification for metastatic germ cell tumours. Clin Oncol. 1997;9:207-9

Cheriyan SK, Nicholson M, Aydin AM. Current management and management controversies in early- and intermediate-stage of nonseminoma germ cell tumors. Transl Androl Urol. 2020;9(1):S45-S55.

Saxman SB, Nichols CR, Foster RS. The management of patients with clinical stage I nonseminomatous testicular tumors and persistently elevated serologic markers. J Urol. 1996;155:587-9.

Culine S, Theodore C, Terrier-Lacombe MJ. Primary chemotherapy in patients with nonseminomatous germ cell tumors of the testis and biological disease only after orchiectomy. J Urol. 1996;155:1296-8.

Dash A, Carver BS, Stasi J. The indication for postchemotherapy lymph node dissection in clinical stage IS nonseminomatous germ cell tumor. Cancer. 2008;112:800-5.

Lv ZJ, Wu S, Dong P. Clinical outcomes in patients with stage I non-seminomatous germ cell cancer. Asian J Androl. 2013;15:558-63.

Mezvrishvili Z, Managadze L. Three cycles of etoposide and cisplatin chemotherapy in clinical stage IS nonseminomatous testicular cancer. Int Urol Nephrol. 2006;38:621-4.

National Comprehensive Cancer Network, Clinical Practice Guidelines in Oncology (NCCN Guidelines®), Testicular Cancer, Version 1. 2019. Accessed on 02 November, 2020.

Smith ZL, Werntz RP, Eggener SE. Testicular Cancer: Epidemiology, Diagnosis, and Management. Med Clin N Am. 2018;102:251-264.

van den Belt-Dusebout AW, de Wit R, Gietema JA. Treatmentspecific risks of second malignancies and cardiovascular disease in 5-year survivors of testicular cancer. J Clin Oncol. 2007;25:4370-8.

Horwich A, Fossa SD, Huddart R. Second cancer risk and mortality in men treated with radiotherapy for stage I seminoma. Br J Cancer. 2014;110:256-63.