S4595 Metastatic Teratoma Resulting in Upper Gastrointesinal Bleeding

Introduction: Hematemesis with hemodynamic instability is a medical emergency requiring immediate intervention. While the differential for source of bleeding is broad, there typically can be an educated prediction of likely sources based on a patient’s history. There are however times where an unanticipated culprit is discovered. We describe a patient with hematemesis who underwent esophagogastroduodenoscopy (EGD) found to have a duodenal mass secondary to an undiagnosed metastatic teratoma. Case Description/Methods: A 44-year-old man with past medical history of alcohol use disorder and prior infection with Helicobacter pylori treated with antibiotics, had experienced 2 days of abdominal pain with hematemesis and melena. Physical exam was notable for tachycardia and laboratory data revealed anemia hemoglobin of 8.7 g/dL. EGD was performed and demonstrated a mass with active bleeding from a visible vessel in the second portion of the duodenum near the major papilla. The vessel was cauterized with cessation of bleeding and biopsies obtained were positive for helicobacter pylori. Given the size and on evaluation there was concern for further depth of invasion cross sectional imaging was obtained. Computed tomography revealed a heterogeneous right testicular mass measuring 8.4 cm, concerning for a primary testicular cancer, as well as a large necrotic conglomerate of retroperitoneal pericaval lymph nodes at the level of the duodenum with likely invasion, suspicious for metastatic disease. Endoscopic ultrasound showed a 32 mm by 39 mm heterogeneous duodenal mass with poorly defined borders sparing the ampulla. Fine need biopsy was performed which showed areas of keratinizing squamous type mucosa on histology. Fluorescence in situ hybridization (FISH) was positive for isochrome 12p, supporting diagnosis of metastatic mature cystic teratoma. Orchiectomy was subsequently performed, and patient was treated with etoposide and cisplatin. Restaging scan after second chemotherapy cycle demonstrated a decrease in retroperitoneal nodal mass. Discussion: Gastrointestinal metastases are seen in a handful of germ cell tumors of the testes. The most common sites of metastases for testicular cancers such as teratomas are brain, liver, and lungs. Metastasis to the duodenum is exceedingly rare. This case highlights a rare and abnormal presentation of gastrointestinal symptoms due to an uncommon metastatic disease source.