Case Report: Life-saving emergency chemotherapy in a critically ill patient with suspected metastatic testicular cancer prior to histological confirmation.

Introduction: Patients with metastatic germ cell tumors undergo therapy including orchiectomy, chemotherapy and residual tumor resection. Even in case of metastatic disease, the treatment is still administered with curative intent. We present a case in which chemotherapy was successfully applied in an emergency setting prior to having histological confirmation of the suspected diagnosis of a germ cell tumor on our intensive care unit (ICU) while the patient was requiring mechanical ventilation, continuous renal replacement therapy (CRRT) and vasopressor support. Case presentation: A 35-year-old man presented with massive testicular swelling, severe dyspnea, bilateral leg edema and acute postrenal kidney failure. A computed tomography (CT) scan revealed extensive pulmonary and retroperitoneal metastases and pneumonia. He was admitted to our intensive care unit with multiorgan dysfunction requiring mechanical ventilation, CRRT and vasopressor support. Laboratory findings revealed moderately elevated beta-human chorionic gonadotropin (570 mIU/ml) and an elevated lactate dehydrogenase over 2000 U/L. Due to his critical condition and high clinical suspicion of a metastatic germ cell tumor, chemotherapy according to the PEI regimen (cisplatin, etoposide, ifosfamide) was initiated only one day after the admission to our ICU before histological confirmation of the diagnosis. The patient showed marked clinical, laboratory and radiological improvement after one cycle. An orchiectomy later revealed necrotic tissue with residual seminoma. Subsequent cycles required dose reductions due to prolonged kidney failure, infectious complications during aplasia and cardiomyopathy leading to heart failure. Application of ifosfamide was discontinued after the patient suffered from severe ifosfamide-related toxicities, including Fanconi-syndrome and neurotoxicity. A Positron Emission Tomography-CT scan after four cycles demonstrated an overall regression of the tumor with residual lesions. Conclusion: Advanced testicular cancer can present as an acute emergency. In selected life-threatening situations, immediate chemotherapy is justified in patients with high clinical suspicion of a germ cell tumor, even in the absence of histological confirmation. The combination of clinical findings, the pattern of metastases, morphological findings in imaging and tumor markers should be used to define the most likely diagnosis beforehand.