Clinical Pathology Case

59Urology Journal    Vol 7    No 1    Winter 2010

Biochemical Failure After Treatment of Testis Tumor
Abbas Basiri, Mohammad Hadi Radfar

Urol J. 2010;7:59-60. 
www.uj.unrc.ir

Urology and Nephrology Research 
Center, Shahid Beheshti University 

of Medical Sciences, Tehran, Iran

Corresponding author:
Abbas Basiri, MD

Urology and Nephrology Research 
Center, 9th Boustan St, Pasdaran 

Ave, Tehran, Iran
Tel: +98 21 2256 7222

Fax: +98 21 2256 7282
E-mail: basiri@unrc.ir

CASE PRESENTATION
A 37-year-old man was admitted 
with a hard large mass in the 
right testis in 1992. Serum 
levels of β-human chorionic 
gonadotropin and α-fetoprotein 
(α-FP) were 280 IU/mL and 0.5 
IU/mL, respectively. After right 
inguinal orchidectomy, pathologic 
examination result was reported 
as teratoma with choriocarcinoma 
without involvement of the 
spermatic cord. The patient was 
followed up with laboratory tests 
and computed tomography (CT).

In 1994, CT revealed a lymph node 
in the right iliac fossa. Since tumor 
markers were within reference 
ranges, lymphadenectomy was not 
performed. In 2001, following a rise 
in β-human chorionic gonadotropin 
and α-FP levels, CT results of the 
patient was normal except for the 
right iliac fossa lymphadenopathy 
(Figure 1). The patient underwent 
retroperitoneal lymph 
node dissection. 
Although the lymph 
node was adhered 
to the iliac vessels 
and the bladder, 
it was completely 
removed. Pathology 
examination revealed 
the lymph node 
contained metastatic 
adenocarcinoma 
confirmed by 
immunohistochemistry. 
Para-aortic lymph 

nodes did not contain any tumoral 
tissue. Postoperative chemotherapy 
was administered using 4 courses 
of bleomycin, etoposide, and 
cisplatin regimen. Tumor markers 
dropped into the normal range after 
chemotherapy. Follow-up studies 
including upper gastrointestinal 
tract endoscopy, colonoscopy, total 
body bone scan, and CT did not 
show any abnormality.

In 2002, about 7 months after 
the last course of chemotherapy, 
serum α-FP levels rose again. 
Chemotherapy was performed 
using 4 courses of vinblastin, 
ifosfamide, and cisplatin. 
Again, CT scan and bone scan 
were normal. In 2003, nearly 6 
months after the last course of 
chemotherapy, α-FP level rose 
again. High-dose chemotherapy 
(carboplatin, etoposide, and 
ifosfamide) and autologous bone 
marrow transplantation were 

Figure 1. Computed tomography in 2001 revealed 
lymphadenopathy in the right iliac fossa. L indicates lymph node, 
and B, bladder.



Clinical Pathology Case

60 Urology Journal    Vol 7    No 1    Winter 2010

performed. However, α-FP levels increased to 
550 IU/mL in 2004. Computed tomography, 
bone scan, and positron emission tomography 
revealed no evidence of metastasis. Since all 
other tests were normal, the patient was treated 
with 3 courses of capecitabine. Serum level of 

α-FP did not change; therefore, 3 courses of 
paclitaxel were administered. Serum α-FP level 
increased to 2250 IU/mL, while imaging studies 
were normal. In December 2004, CT showed 
a lymphadenopathy in the right iliac fossa 
(Figure 2). Lymphadenectomy was undertaken 
and pathology assessment revealed germ cell 
tumor in 8 of 12 removed lymph nodes. Two 
months later, serum level of α-FP decreased to 157 
IU/mL. However, in 2005, serum α-FP level again 
rose to 450 IU/mL. Computed tomography and 
other imaging studies were normal.

qUIZ
What could be the possible source of AFP raise? 

What is your suggestion as the next step of 
diagnosis and treatment?

The answers will be discussed in the next issue of 
Urology Journal.

Figure 2. Computed tomography in 2004 showed 
lymphadenopathy in the right iliac fossa.