Metastatic seminoma presenting as neck and axillary lymphadenopathy in an elderly man

Abstract

A man in his 60s presented with a gradual progressive right-sided neck mass. Initial core biopsy was inconclusive and he was treated with a short course of oral prednisone for presumed sarcoidosis. Two months later, the patient developed worsening dysphagia, hoarseness of voice, dyspnea, and weight loss. Physical examination revealed bilateral cervical and right axillary lymphadenopathy. A right axillary lymph node excisional biopsy was performed and immunohistochemistry was diffusely positive for OCT4, SALL4, CD117, PLAP, confirming the diagnosis of metastatic seminoma. He received three cycles of bleomycin, etoposide, and cisplatin; bleomycin was omitted for the fourth cycle due to concern for toxicity. Restaging scans after four cycles of chemotherapy showed a favorable response to therapy. Unfortunately, the patient died from bleomycin pulmonary toxicity. This case illustrates a rare and atypical presentation of metastatic seminoma in an elderly patient.

Keywords: Cervical lymphadenopathy; elderly men; metastatic seminoma.

Figure 1.

Right cervical lymphadenopathy measuring 15.0 × 11 cm with marked activity (max SUV of 18.1) and a few areas of necrosis. The mass extended into the right parapharyngeal, retropharyngeal, and right paraglottic space. The left cervical conglomerate measured 4.1 × 3.0 cm with a max SUV of 17.3. Right axillary 4.9 × 3.0 cm lymphadenopathy is noted with a max SUV of 15.6.

Figure 2.

(a) Hematoxylin and eosin stain shows sheets of large cells with eosinophilic cytoplasm and squared-off nuclei with prominent nucleoli admixed with background inflammatory cells (200× magnification). (b) OCT4 immunohistochemical stain shows a sheet of large cells with diffuse nuclear positivity (100× magnification).