To the Editor: Testicular cancer is the most common solid malignancy in males aged 15–44 years 1. While it carries an excellent prognosis, testicular cancer treatment can precipitate serious complications. We present a case of disseminated intravascular coagulation (DIC) in a patient with a recently diagnosed non-seminomatous germ cell tumor (NSGCT), highlighting the potential complications in the management of advanced disease. An 18-year-old male presented with weight loss, abdominal pain, and distention at an outside hospital. Cross-sectional imaging showed a large left testicular mass, innumerable liver metastases, extensive retroperitoneal lymph node conglomerates that measured greater than 10 cm in the largest dimension, and multiple bilateral pulmonary nodules and pulmonary emboli (Figure 1). Initial tumor markers were elevated (alpha-fetoprotein AFP 2636 ng/mL, and beta human chorionic gonadotropin β-HCG 31,689 mlU/mL). The patient underwent a left-sided radical orchiectomy and ureteral stent placement. He was diagnosed with Stage IIIC NSGCT, given the elevated tumor markers and visceral metastases. The patient was transferred to a tertiary medical center. Initial complete blood count was notable for anemia (hemoglobin 8.9 g/dL), leukocytosis (19.7 × 103/µL), and normal platelet count (317 × 103/µL). Lactate dehydrogenase was elevated to 7060 units/L. Coagulation studies revealed normal prothrombin time (PT) (14 s) and prolonged activated partial thromboplastin time (aPTT) (55.4 s) secondary to continuous heparin infusion that was started at the outside hospital. Chemotherapy was initiated on Day 3 of admission with bleomycin, etoposide, and cisplatin (BEP). With the initiation of chemotherapy, the patient's anemia continued to worsen with a nadir hemoglobin of 5.7 g/dL on Day 6 of treatment. The patient developed small-volume hemoptysis, raising suspicion for DIC. Repeat coagulation studies demonstrated prolonged PT (25 s), prolonged aPTT (87.7 s), and an undetectable fibrinogen level (<60 mg/dL). The patient required transfusion of 12 units of packed red blood cells, four units of platelets, and 11 units of cryoprecipitate over 17 days (Figure 2A). Interestingly, the patient's serum tumor markers initially increased when assayed on Day 8 of treatment (AFP 5834 ng/mL and β-HCG 154,900 mlU/mL) and then decreased appropriately (Figure 2B). The acute rise and fall of serum tumor markers in this case were likely secondary to brisk tumor lysis. His coagulopathy resolved with normalization of coagulation studies. The patient completed four cycles of BEP along with retroperitoneal lymph node dissection. He had no further complications from coagulopathies, and the pulmonary emboli resolved after chemotherapy and anticoagulation. His liver and pulmonary metastases resolved on follow-up imaging, tumor markers normalized, and he has remained in remission without evidence of disease over 18 months off therapy. Testicular germ cell tumors usually have exquisite sensitivity to systemic chemotherapy, resulting in excellent outcomes even in cases of advanced metastatic disease at diagnosis 2. Despite this generally favorable prognosis, testicular cancer and its treatment carry significant complications. Malignancy is associated with an increased risk of aberrations in coagulability, in some cases manifesting as DIC. DIC involves the widespread activation of coagulation with concurrent consumption of procoagulant factors and subsequent bleeding 3. Approximately one-third of all cases of DIC occur in patients with solid tumor malignancy 4, 5. Chemotherapy can also trigger DIC in patients through injury and ensuing endothelial dysfunction. Unlike in sepsis or trauma, DIC in malignancy may have a more insidious presentation with a protracted coagulopathy that proceeds subclinically until the consumption of coagulation factors presents with bleeding 6. Our patient's extensive tumor burden likely precipitated his coagulopathy, though the concurrent initiation of chemotherapy confounds the etiology of DIC in this patient. Hepatocellular carcinoma, lung cancer, and gastric cancer have been most widely implicated in DIC, but DIC has not been reported in testicular cancer 7. This report describes the complex management of DIC in a young adult patient with recently diagnosed NSGCT. Although the incidence of testicular cancer is rising, most medical centers see a limited number of cases 8. In cases of advanced NSGCT, hospitals with higher oncology volumes were associated with improved survival 9. This case of a potentially catastrophic complication demonstrates the importance of treating patients with testicular cancer at high-volume centers with experience managing complex malignancies and their life-threatening complications. The authors declare no conflicts of interest.
Fleisher et al. (Fri,) studied this question.