PMC8256245_01
Case-1: (a) axial abdomen CT scan with contrast (venous phase) on 7th October 2018,
shows a large retro-duodenal mass displacing the second part of the duodenum
anteriorly and compressing the IVC, (b) sagittal CT scan with contrast shows large
retroperitoneal mass invading the duodenum that appears displaced anteriorly, (c) CT
scan with contrast on the 24th June 2019 shows progression in size of the
retroperitoneal mass with more invasion of the duodenum, (d) low power magnification
of the bowel wall with ulceration, with underlying immature cartilage consistent with
the teratomatous component of the germ cell tumor (H&E, x20), (e) squamous
epithelium and glandular component are other components of teratoma (H&E, x20),
and (f) cartilaginous component is seen in other foci (H&E, x20).
10.1177_20363613211029487-fig1.jpg
PMC8256245_01_10.1177_20363613211029487-fig1.jpg
fig1-20363613211029487
Further investigation by CT scan demonstrated a large mass lesion posterior to the second part of the duodenum which is displaced anteriorly (Figure 1(a) and (b)), compressing and stretching the inferior vena cava (IVC). A CT-scan revealed progression in the size of the retro-duodenal mass (Figure 1(c)). The tumor was composed of choriocarcinoma (50%), and mature cystic teratoma (50%), showing ulceration of the overlying mucosal lining (Figure 1(d)), with squamous and glandular epithelium (Figure 1(e)), and cartilage (Figure 1(f)) as the main components of the teratoma.
PMC8256245_02
Case-2: (a) abdomen CT scan with contrast (venous phase) on the 11th December 2015
shows a retroduodenal mass measuring 6 cm that appears inseparable from the posterior
duodenal wall. There is also left para-aortic metastatic lymph node with similar
features, measuring 1.8 cm, (b) a group composed of cells with large clear cytoplasm,
vesicular nuclei, with a single prominent nucleoli (H&E, x40), (c) SALL-4
immunostain is positive in the tumor cells (x20), confirming the diagnosis, (d)
scrotal ultrasound was performed on the 25th February 2016. Both testicles are normal
in size, homogeneous with good color flow mapping in both testes. There were multiple
calcific foci in the stroma bilaterally, more prominent on the right, but with no
definite solid mass lesion seen. (e) Abdomen CT scan with contrast (venous phase) on
the 12th April 2016 after two cycles of chemotherapy showing regression of the
retroduodenal mass from 6 to 2 cm. The left para-aortic lymph node has regressed from
1.8 to 0.6 cm. (f) Abdomen CT scan with contrast (venous phase) on the 28th June 2016
showed further regression of the retroduodenal mass with residual post-treatment
thickening that measured 1 cm. There was no evidence of left para-aortic lymph node
enlargement.
10.1177_20363613211029487-fig2.jpg
PMC8256245_02_10.1177_20363613211029487-fig2.jpg
fig2-20363613211029487
An abdominal CT scan revealed a 6 cm right upper retroperitoneal and abdominal mass (Figure 2(a)). Review of his original pathological slides revealed a germ cell tumor with large areas of necrosis, as well as focal granulomatous reaction (Figure 2(b)). SALL4 (Figure 2(c)), OCT 3/4, and CD30, with focal positivity for pan CK AE1/E3. Scattered groups of tumor cells were positive for Glypican3. Testicular ultrasound showed multiple small calcific foci that could represent microlithiasis (Figure 2(d)). He had excellent response to chemotherapy with regression of the tumor noted in April (Figure 2(e)) and June 2016 (Figure 2(f)).