Who Shot the Cannonballs? Extensive Lung Metastases in a 39 Year Old Man.

Case: A 39 year-old man presented to the emergency department complaining of a cough of 2 months in duration. He also complained of weight loss of 20 pounds in two months and night sweats over the same period. An x-ray of the chest was performed and revealed innumerable lung nodules and masses. Computed tomography of the chest and abdomen were subsequently performed which confirmed the masses, but imaging did not reveal an obvious primary source. A testicular exam was performed but no obvious abnormalities were noted. Because of his age as well as the appearance of the lesions, a testicular ultrasound was then performed. The ultrasound found evidence of a 1.5 cm hypoechoic mass on the right testicle with dystrophic calcification in the interpolar region. Urology performed a right radical inguinal orchiectomy. Pathology demonstrated a malignant mixed germ cell tumor with seminoma and yolk sac components being prominent. He underwent four cycles of etoposide, ifosfamide, and cisplatin. His last positron emission tomography scan did not demonstrate active disease.

Discussion: Each year about 8700 men are diagnosed with testicular cancer. 75 percent of these occur between the ages of 20 to 44, and the median age of diagnosis is 33. Testicular cancer should be suspected when a young male presents with metastatic disease such as in this case. In this patient, the genital exam was normal due to the small size of the testicular mass, but he had significant metastatic lesions. When cannonball metastases are seen on imaging, germ cell tumors and renal cell carcinoma should be high in the differential diagnosis.