Introduction

Pure Embryonal Carcinoma (EC) of the testis accounts for roughly 10-15% of testicular Germ Cell Tumors (GCT), which frequently present as a component of mixed GCT in approximately 90% of the cases. The typical age of presentation is between the 2^nd and 3^rd decade of life. Clinically they can present as a painful testicular lump, although in 20 to 60% of cases they present as metastatic lesion at the time of initial diagnosis [3,2]. We report a case of a 25-year-old male that presented with multiple lesions throughout the body detected by Positron Emission Tomography (PET). On left adrenal gland biopsy, a preliminary diagnosis of metastatic embryonal carcinoma was made on imprint cytology [2-4].

Case Report

We present a case of a 25 years old man who was transferred to our institution from an outside hospital for work up of a pancreatic mass. On PET CT, the patient was found to have multiple lesions throughout the body including pancreas, liver, bilateral adrenal glands, right pleural space, pelvic lymph node, mesenteric lymph node, left supraclavicular, meditational lymph nodes and right testis (Figure 1). Our preliminary diagnosis was based on adrenal gland lesion core biopsy imprint cytology (Figure 2-3) and was confirmed on immunohistochemistry (Figure 4a-4e), which led to the surgical excision of the tumor primary, the right testis (Figure 5) with subsequent chemotherapy following confirmation of the EC diagnosis.

Discussion

The technique of imprint cytology allows quick assessment of core and excisional biopsies, providing opportunity to redirect the interventional radiologist to obtain a more representative sample for accurate diagnosis of primary and metastatic lesions. The use of this technique with subsequent evaluation of H&E core sections in the above case, led to a rapid diagnosis of embryonal carcinoma in this patient. This was followed by timely surgery and chemotherapy improving the patient’s prognosis even with his advanced stage disease

Figure 1: Positron Emission Tomography Showing Multiple Hyper Metabolic Meditational, Retroperitoneal, Peripancreatic and Pelvic Lymph Nodes (a & b) and Axial View’s Showing Right Scrotum with a Maximum SUV Focus (b) and Bilateral Adrenal Glands Replaced by Hyper Metabolic Process (c).

Figure 2: Diff-Quikstained Core Imprint of the Metastatic Embryonal Carcinoma to the Left Adrenal Gland. Note the Increased N/C Ratio, Course Chromatin and Occasional Prominent Nucleoli X40.

                             Figure 3: Papanicolaou Stained Core Imprint of the Metastatic Embryonal Carcinoma to the Left Adrenal Glandx40  

Figure 4a-4e: (4a) Left Adrenal Gland Core Biopsy Showing Extensive Necrosis (Black Arrow) and Sheets of Highly Malignant Cells with Increased Nuclear to Cytoplasm Ratio and Prominent Nucleoli H&E Stain;(4b)CD30;(4c) CK AE1/AE3;(4d)PLAP and (4e)CD117 Supporting the Diagnosis X10.

Figure 5: Orchiectomy Specimen with Sheets and Clusters of Malignant Cells Confirming the Preliminary Cytological Diagnosis of Embryonal Carcinoma, H&E Stain X4.

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3. Khan L, Verma S, Singh PK, Agarwal A (2009) Testicular embryonal carcinoma presenting as chest wall subcutaneous mass. J Cytol 26:39-40.
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