Pitfalls in Diagnosis and Management of Testicular Choriocarcinoma Metastatic to the Brain: Report of 2 Cases and Review of Literature.

INTRODUCTION: Pure choriocarcinoma of the testes is a rare, aggressive germ cell tumor that can metastasize to the brain. Although its prognosis has improved with the development of cisplatin-based chemotherapy regimens, cerebral metastases are prone to hemorrhage and associated with high morbidity. Here, we present 2 cases of testicular choriocarcinoma with cerebral metastasis and discuss potential pitfalls in their diagnosis and management. We also review cases in the literature that feature these rare lesions.

METHODS: Medline was searched for all publications including the terms "testicular choriocarcinoma" and "cerebral metastasis" or "brain metastasis." Articles that included patients with tumors classified as a mix of choriocarcinoma and other germ cell tumor subtypes were excluded.

RESULTS: A total of 15 cases from the literature and our own 2 cases were included in the analysis. The mean age at presentation was 25.5 years. Neurologic symptoms accounted for the initial presentation of 9 patients (60%). Outcomes were predominantly poor, with 10 patients (67%) expiring shortly after their initial diagnosis. Three of these deaths were related to mass effect from metastasis-related hemorrhages. Two patients underwent emergent decompressive craniectomies, and both died from cerebral herniation.

CONCLUSION: The potentially catastrophic nature of choriocarcinoma-related cerebral hemorrhages underscores the need for prompt, accurate diagnosis and aggressive surgical management of these lesions. Their highly vascular nature and lack of findings on cerebral angiography may cause them to be confused with occult vascular malformations.