CASE REPORTS Endoscopy 9 (1977) 101-103

0 Georg Thieme Verlag, Stuttgart

Endoscopic Retrograde Cholangiopancreaticography (ERCP) in Obstructive Jaundice Caused by Metastatic Testicular Teratoma I. Rentsch, U. Gärtner, P. MiiIler, L. Kerk

two fist's size in the upper abdomen rapidly devel-

Endoskopisch-radiologische Cholangiopankreatikographie (ERCP) bei durch Hodenteratommetastasen hervorgerufenem Verschluflikterus

oped an obstructive jaundice. A pancreatic tu-

Ein 28jähriger Mann mit doppeltfaustgrofkm

mor was suspected and therefore ERCP was carried out. Unusual alterations caused by metastatic

Oberbauchtumor entwickelte einen schnell zunehmenden Verschlufiikterus. Unter dem Verdacht auf einen Pankreastumor wurde die endoskopisch-radiologische Cholangiopankreatikographie (ERCP)

Summary

A 28-years-old patient with a palpable mass of

lesions of a post mortem diagnosed testicular teratoma narrowing and invading the common bile duct and displacing the main pancreatic duct were visualized.

Key-Words: Common bile duct, metastatic stenosis of bile duct, ERCP.

durchgeführt. Dabei zeigte sich das ungewöhnliche Bild der Tumorummauerung und des Tumoreinbruchs in den Ductus hepatocholedochus sowie der Verlagerung des Ductus Wirsungianus durch Metastasen eines klinisch nicht nachweisbaren Hodenteratoms.

In about 20% of cases, testicular malignancies may remain undetectable by means of palpation for a long period. Diagnosis can

be established only after metastases have

formed by our team, nor in previously published observations. Case Report A 28-years-old male was admitted to hospital

been found. At the point of diagnosis, more than 500/o of patients with testicular teratoma suffer from metastases. First metastatic

with a firm tumor in the upper abdomen of more than fist's size. Chief complaints were progressing back ache of about 3 months' duration, then upper

lesions are formed in paraaortic lymph nodes, the primary route of metastasis occur-

weight loss and slight pallor. Laboratory studies showed the following: ESR 53/80, normochromic

abdominal pain. He had noted inappetence,

ing via the lymphatic system. Later on,

anemia, u2-globuline 11, y-globuline 26°/o of total.

malignant cells having entered the thoracic duct, involvement of supraclavicular nodes follows, and lymphogenous spread converts

Within a couple of days, he developed rapidly progressing icterus, liver chemistries now beeing indicative of biliary obstruction (high yGT, alka-

to hematogenous distribution (2).

and SGPT).

Our patient developed a palpable mass in the upper abdomen of more than fists size along with progressively deepening jaundice. ERCP revealed uncommon, but also characteristic findings, which we have

not seen before in 582 examinations per-

line phosphatase, moderate elevation of SGOT cholecystography showed the gallbladder without contrast, cholangiography was unsuccess-

ful. By means of upper g.i. series and i.v. urography a retroperitoneal tumor with displacement of upper abdominal organs was suspected. Lapa-

roscopy revealed a fist-sized firm tumor in the upper abdomen, located near the midline, and caudal of ligamentum teres, below the omentum.

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Med. Dept. and Radiological Dept. of the Sebaldsbrück Hospital, Bremen

102

I. Rentsch, U. Giirtner, P. Miller, L. Kerk

Fig. 2

Filiform stenosis of common bile duct with incomplete obstruction, caliber irregularities of biliary tree caused by metastatic testicular teratoma, gallbladder not remarkable.

Anterior wall of the stomach, liver, gallbladder and spleen were not remarkable on examination.

Sonography demonstrated a space occupying parenchymatous process extending backwards to the great vessels, suspected of beeing a carcinoma of the pancreas. Lymphangiography revealed lymphatic ob-

struction at the level of vena iliaca communis. Abdominal lymph nodes were not visualized, and retroperitoneal lymphadenopathy was suspected, either caused by metastatic tumor or by involvement of a malignant lymphoma. The patient then received combination chemotherapy. 5 weeks after admission, he died. ERCP (Figs. 1,2) had revealed normal papilla of

Vater. Wirsung's duct being completely visual-

ized, it had been displaced ventrad in a convex manner. Moreover, main pancreatic duct had been slightly narrowed in its preparillary part, with diminution of small ducts. The common bile

duct had shown irregular caliber, several parts being extremely stenosed. Intrahepatic ducts had shown no signs of obstruction, g-allbladder not being remarkable.

Post-mortem examinations (Prof. Dr. Wing, Med.-Dir. Dr. Schmidt, Inst. of Pathology, St.Jiirgen-Str., Bremen) revealed the following: cherry-sized teratoma of the right testicle, without enlargement of this organ. There were masses of confluent metastatic lymph nodes in the inguinal region, in paravertebral, paraaortic, mesenteric, and portal parts of lymphatic system. Left pyelon

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Fig. 1

Ventrad and upward displacement of Wirsung's duct with slight stenosis caused by metastatic lymph nodes of a testicular teratoma.

ERCP in Obstructive Jaundice Caused by Metastatic Testicular Teratoma

in its distal part caused stasis gallbladder and severe ascending and abscessed cholang-itis.

Discussion

Testicular teratoma, being a germinal tumor, uses to be malignant. Comprising 1-20/o of all malignant growths in the male,

it represents, together with diseases of the reticuloendothelial system, one of the commonest causes of death due to cancer in the

group of males being 20-35 years of age. Where, as in our case, primary tumor cannot be demonstrated, secondary symptoms and signs are of considerable diagnostic assist-

ance. In each

case

of upper abdominal

tumor and/or obstructive jaundice, approved conventional methods having failed to reveal the cause, ERCP is performed. Up to February 1977, 582 patients underwent this examination in our departments. In about 90°/o of cases, valuable diagnostic information, either by endoscopic or by radiologic findings, was obtained. There are well-known characteristic types

of extrahepatic obstruction visualized by means of ERCP, caused by benign or malignant diseases of the upper abdomen (1, 3, 4,

5, 6). Our radiologic findings, as described in this case report, are different from altera-

tions of the pancreato-biliary tree previously published.

Pondering of all available information, of hematological, sonographic, laparoscopic,

lymphangiographic findings was helpful in making the clinical diagnosis of metastatic lymphadenopathy and metastatic invasion of common bile duct. The primary tumor remained undetectable, its origin in the pancreato-biliary tree being improbable. References classen, M., L. Demling: Endoskopie der Papilla Vateri eine und retrograde Cholangio-Pankreatikographie Zwischenbilanz. In: Die Oberbaucheinheit. Int. Symp. Wien. (Hrsg. v. L. Demling, W. Rösch, K. Moser.) Sdiattauer, Stuttgart 1974 2 Dörr, W., K, Wurster: Geschlechtsorgane. Organpathologie, Bd. II. (Hrsg. v. W. Dörr.) Thieme, Stuttgart 1974

3 Cundid, H., E. v. Fritsch, H. Koch: Die Bedeutung der endoskopisch-radiologischen Cholangiographie bei Cholestase und Postcholezystektomiesyndrom. Dtsch. med. Wschr. 100 (1975) 1877

4 Miederer, S. E., O. Stadelrnann, A. Löffler, E. Wobser, K. Koischwitz: Die endoskopische retrograde CholangioPankreatikographie (ERCP): Indikation, Methode, Wertigkeit und Risiko. Leber, Magen, Darm 4 (1975) 187

5 Seifert, E., H. St, Stender, H. Fromm, H. Huchzermeyer, P. Lesch, F. Misa/si, Ch. W. Rasmussen: Zur klinischen Bedeutung der endoskopischen retrograden CholangioPankreatikographie (ERCP). Inn. Med. 2 (1975) 279 6 Seifert, E., L. Safrany, H. St. Slender, P. Lesch, G. Luska, F. Misa/si: Identification of bile duct tumors by means of endoscopic retrograde pancreato-cholangiography (ERCP). Endoscopy 0 (1974) 156

Priv.-Doz. Dr. I. Rentsch, Med. Klinik im Krankenhaus Sebaldsbriick, Saarburger Str. 56, 2800 Bremen 44

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and ureter were obstructed, obstruction resulting in hydronephrosis. Common bile duct obturation

103

Endoscopic retrograde cholangiopancreaticography (ERCP) in obstructive jaundice caused by metstatic testicular teratoma.

CASE REPORTS Endoscopy 9 (1977) 101-103 0 Georg Thieme Verlag, Stuttgart Endoscopic Retrograde Cholangiopancreaticography (ERCP) in Obstructive Jaun...
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