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Ulcerated neck mass and testicular carcinoma

A 34-year-old man was referred to our hospital with the diagnosis of metastatic squamous cell carcinoma for further management. He had a slowly growing neck mass that recently became ulcerated (Fig. C-1). CT scan of the neck soft tissue showed a necrotic supraclavicular mass, 6 cm in the greatest diameter (Fig. 1). A biopsy in an outside hospital was reported as metastatic squamous cell carcinoma. On the review of the glass slides reactive/ regenerating cells were seen, but no malignancy was identified. Tonsillectomy and multiple biopsies of the nasopharyngeal area in our hospital did not show any malignancy. A biopsy of the mass was performed in our institution, but did not show any malignant cells. We recommended fine needle aspiration (FNA) of the mass as a helpful procedure that may reveal the etiology. In our discussion with the patient at the time of FNA, he mentioned ‘‘a minor change in the left testicle.’’ FNA showed loosely cohesive tumor cells with pleomorphic hyperchromatic nuclei, irregular nuclear membranes and prominent nucleoli. Prominent apoptosis with focal necrosis was present (Fig. C-2). A panel of immunohistochemical stains was performed, and the tumor cells were reactive with placental specific alkaline phosphatase (PLAP) and CD30 and negative for S100 protein, CD10, beta-HCG, and inhibin. Therefore, it was diagnosed as embryonal carcinoma. Later, the ultrasound of the left testis showed inhomogeneous echotexture with few questionable microcalcifications. Five months later, after four cycles of chemotherapy and significant decrease in the tumor mass, the second FNA showed viable tumor cells. Salvage chemotherapy was started. Orchiectomy will be done after he completes his chemotherapy. Testicular tumors are responsible for <2% of malignancies in men. However, testicular neoplasm is the most common neoplasm in the 25–34-year-old men. Embryonal carcinoma has a tendency to early hematogenous spread and >70% of the patients have metastasis at the time of diagnosis. The differential diagnosis on cytology is mainly melanoma and other germ cell tumors. Immunohistochemical panel that can help to reach a diagnosis is PLAP (for seminoma), CD30 (for embryonal carcinoma), beta-HCG (for choriocarcinoma), and S100 (for melanoma). We also performed CD10 (for renal cell carcinoma) and inhibin (for adrenal neoplasm). Presentation of embryonal carcinoma with neck mass is uncommon. In a young man, we should always think about germ cell tumors. Taking history at the time of FNA can be very helpful to reach the diagnosis.