Case Report

Pathological Femoral Neck Fracture as the Presenting

Manifestation of a Testicular Mixed
Nonseminomatous Germ Cell Tumor: Report of a Case

Marcelo Chen, Stone Yang, Der-Yang Hwang1,

Allen W. Chiu2

Departments of Urology and 1Orthopedics, Mackay Memorial Hospital,

2
Taipei City United Hospital, Taipei, Taiwan, R.O.C.
Taipei, Taiwan, R.O.C.

Testicular cancer initially presenting as a pathological femoral neck fracture without aware-
ness of a testicular mass after a traffic accident is unusual and misleading. We report on an
18-year-old male who complained of severe left hip pain after involvement in a minor traffic acci-
dent. A physical examination incidentally revealed an enlarged left scrotum. Based on radio-
graphic and pathological findings of a biopsy of the fracture site, metastatic testicular cancer was
confirmed. A radical orchiectomy was later performed. This presentation is rare, but we suggest
that testicular cancer should be included in the differential diagnoses of pathological fractures in
young male patients.(JTUA 16:36-9, 2005)

Key words: pathological fracture, germ cell tumor, metastasis.

INTRODUCTION where physical examination revealed enlargement of the

left scrotum. Scrotal ultrasonography revealed a hetero-
When a patient is incidentally found to have scrotal geneous ovoid 16 x 11-cm mass in the left hemiscrotum.
swelling after a traffic accident, the first impression is
usually traumatic injury to the testes and scrotum, espe-
cially if the traffic accident is severe enough to cause
femoral neck fracture. We report on a patient who pre-
sented with a traffic accident-related femoral neck frac-
ture and scrotal enlargement, which turned out to be
testicular cancer with pathological fracture secondary to
bony metastasis.

CASE REPORT
An 18-year-old male was involved in a traffic ac-
cident when he was grazed by a motorcycle while
crossing the road. He felt pain in his left hip and sought
Fig. 1 Computed tomography of the hip revealing
a traditional Chinese physical therapist for massage
left scrotal enlargement with heterogeneous
therapy. During the massage, he felt a snap in his left
enhancement after contrast injection, which
hip. The pain became so severe that he was unable to
was highly suspicious of testicular cancer.
walk. He therefore visited our emergency department,

Received: Nov. 19, 2003 Revised: Apr. 6, 2004 Accepted: June 26, 2004

Address reprint requests and correspondence to: Stone Yang, MD

Department of Urology, Mackay Memorial Hospital, No. 92 Chungshan N. Rd., Sec. 2, Taipei 104, Taiwan, R.O.C

36 JTUA Vol.16 No.1, March 2005

 M Chen, S Yang, DY Hwang, et al
No hematoma was seen, and normal testicular tissue
could not be identified. Serum tumor markers were
checked, and the β-HCG level was < 5 mIU/ml and the
AFP level was 2942.50 (normal range, < 6.00) ng/ml.
Computed tomography revealed left scrotal enlargement
with heterogeneous enhancement after contrast injection,
which was highly suspicious of testicular cancer (Fig. 1).
Intra-abdominal para-aortic lymphadenopathy was
noted, but no lung metastasis or mediastinal lymphade-
nopathy was found. A left hip X-ray revealed osteolytic
bone destruction and a pathological fracture of the left
femoral neck suggesting a metastatic lesion (Fig. 2).
Open biopsy of the left femur showed features of a
nonseminomatous germ cell tumor. Retracing his past
history, right shoulder soreness had been noted in the
past few months; therefore, a Tc-99m MDP whole-body
bone scan and magnetic resonance imaging of the right
shoulder were arranged and further revealed osseous
metastases in the right proximal humerus. A left radical
orchiectomy was performed. The specimen showed a
grayish tumor with hemorrhaging, necrosis, and myxoid
Fig. 2 Film of the left hip joint showing osteolytic
bony destruction involving the intertro-
chanteric region of the left proximal femur
leading to a pathological fracture.
台灣泌尿醫誌第十六卷第一期（94 年 03 月）
Fig. 3 Histological features of mixed germ cell tumor
components. (a) Embryonal carcinoma with
primitive cells in solid and pseudoglandular
patterns. (H&E 200x) (b) Mature squamous
epithelial element (arrowhead) and keratinous
material (double arrowhead). (H&E 100x) (c)
Immature teratoma with neuroepithelial ele-
ments (arrow). (H&E 100x) (d) Reticular pat-
tern of the yolk sac tumor. (H&E 100x)
degeneration measuring 16 x 11 x 10 cm in diameter
and weighing 837 g. The pathology confirmed a malig-
nant mixed nonseminomatous germ cell tumor. Micro-
scopically, the tumor revealed features of a malignant
mixed germ cell tumor. The major elements were em-
bryonal cell carcinoma, yolk sac tumor, and primitive
tissue. A few teratomatous components were present,
including mature squamous epithelium with keratinous
material, immature cartilage, and neuroepithelial tubules
(Fig. 3). The testis had been completely replaced by the
tumor. A left partial hip replacement was performed 10
days later. The patient underwent 6 courses of chemo-
therapy with bleomycin, etoposide, and cisplatin. The
follow-up AFP level was 3.03 ng/ml 2 months after the
last course of chemotherapy.
DISCUSSION
Almost 20% of testicular cancer patients present
with signs or symptoms of metastatic disease such as
back or abdominal pain, weight loss, a neck mass, gy-
necomastia, or breast tenderness [1]. Bone metastasis
can cause pain, bony tenderness, and increasing disabil-
ity. In some cases, it may even present as a bone frac-
ture. Nonseminomatous germ cell tumors are more ag-
gressive than seminomas. Sixty percent to 70% of non-
seminomatous germ cell tumor patients have nodal or
other metastases at presentation [2,3] compared with
25% of seminoma patients [4]. For all tumor types, the
37
 Pathological Femoral Neck Fracture as a Presentation of a Nonseminomatous Germ Cell Tumor
most common sites of distant metastasis are the lung
(89%), liver (73%), brain (31%), and bone (30%) [5].
There is a relatively high incidence of brain metastases
with choriocarcinomas and of bone metastases with
seminomas. Bone metastasis is common in cancers of
the breast (73%) and prostate (68%), followed by can-
cers of the thyroid (42%), bronchus (36%), kidney
(35%), rectum (11%), esophagus (6%), and gastrointes-
tinal tract (5%) [6]. Venous blood from the pelvis has
been shown to flow directly to the vertebral-venous
system and this may be a significant anatomic pathway
for metastatic spread to the skeleton [7]. This valveless
network carries blood under low pressure and is prone
to constant reversal of the direction of flow. It provides
a pathway for metastatic spread between distant organs
through its connections with and bypasses of the portal,
pulmonary, and caval systems of veins [6].
Germ cell tumors of the testes typically spread in a
stepwise lymphatic fashion, and hematogenous dis-
semination develops later [6]. An exception occurs with
choriocarcinomas, which demonstrate early hematoge-
nous spread [8]. In this patient, both lymphatic and he-
matogenous spread had occurred before diagnosis, and
if we take into account the patient’s statement about the
traffic accident-related injuries, the presentation as a
pathological bone fracture was both unusual and mis-
leading. Delays in seeking medical attention for testicu-
lar masses are frequently seen and are due to ignorance,
denial, or fear on the patient’s part. Patients with tes-
ticular cancer often seek medical attention late in the
disease, and therefore it is imperative that
self-examination of the testes be performed monthly as
suggested by Clore in 1993 [9].
In cases of advanced nonseminomatous germ cell
tumors where there is no doubt about the diagnosis,
immediate initiation of chemotherapy without perform-
ing an orchiectomy has been advocated, because
postoperative complications after an orchiectomy may
result in delays in beginning the chemotherapy. In such
cases, an eventual orchiectomy is still necessary as
viable tumors have been found within the retained testes
38
mors have been found within the retained testes [10].
Testicular cancer with a pathological fracture as its main
presentation is rare, and to the best of our knowledge, it
has not previously been reported in the English litera-
ture. Testicular cancer should therefore be included in
the differential diagnoses of pathological fractures in
males, particularly young patients.
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