A 32-year-old male presented with intense, worsening headaches associated with conjugated gaze palsy to the left and ipsilateral photophobia. Two years prior to presentation he was diagnosed with SCTT that was treated with right orchiectomy followed by retroperitoneal lymph node dissection (RPLND) that revealed cancer-free lymph nodes. Additionally, systemic chemotherapy and pelvic irradiation were performed due to malignant secondary infiltration of the pelvic lymph nodes. One year after the initial diagnosis, the finding of a metastatic infiltration of the right homerus led to seven cycles of radiation therapy followed by surgical resection of the tumor and metal plates osteosynthesis. This surgery, although necessary, resulted in severe movement impairment with preservation of flexion and extension movements of the forearm alone.
At admission, neurological examination disclosed left sixth nerve palsy without any other significant focal deficit, whereas blood tests showed normal levels of the free ß-subunit of the human chorionic gonadotropin (ß-hCG), lactate dehydrogenase (LDH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone, with significant elevation of serum α-fetoprotein levels. A total body computed tomography (CT) revealed the presence of two nodules located in the superior lobe of the right lung with associated confluent lymph node enlargement, and multiple round lesions of the hepatic segment VII. A magnetic resonance (MRI) of the head showed an extra-axial, ovular mass located in the right frontal lobe extending to the parietal hemisphere, exhibiting avid contrast enhancement and leptomeningeal involvement (Figure 1). In the suspect of an intracranial metastasis from SCTT, the patient was treated with a right fronto-parietal craniotomy, followed by complete resection of the extra-axial tumor. Intraoperatively, diffuse infiltration of the epicranial soft tissues, diploe, and dura mater was noticed and the tumor appeared greyish to light brown in color with a jelly-like surface and consistency.
Histological examination of the lesion demonstrated the presence of moderately large, pleomorphic cells, with pale cytoplasm, exhibiting a trabecular architecture and nested growth pattern (Figure 2). Peculiar features included a high mitotic index and multiple necrotic areas. The tumor cells were moderately immunoreactive to inhibin, vimentin, and CEA but negative for EMA. Pathological diagnosis confirmed the metastatic origin of the intracranial lesion.
Postoperatively, the headaches disappeared, and the visual impairment significantly improved, and the patient was referred to the oncology department for the optimal management of the pulmonary nodules. One month after surgery, he underwent six courses of chemotherapy with cisplatin, etoposide, and bleomycin obtaining complete regression of the lesions. Unfortunately, he died 16 months later of pulmonary insufficiency caused by a local recurrence.