Abstract
Testicular choriocarcinoma is a rare cancer that comprises 1-2% of all malignancies in males, yet it remains one of the most common malignancies in young males. Through hematogenous spread, testicular choriocarcinoma can metastasize to multiple organs including the GI tract and lead to hematochezia or melena. The infrequency with which it occurs and the presence of hemoptysis as a confounding factor can lead to delays in diagnosis and treatment. A 21-year-old male, recently diagnosed with metastatic testicular choriocarcinoma status post right orchiectomy, presented to the emergency department with multiple episodes of melenic stools. Vitals showed sinus tachycardia. The physical exam revealed severe skin and conjunctival pallor. Laboratory values showed severe normocytic anemia with a hemoglobin of 6.3 g/dL. A CT of chest, abdomen and pelvis with IV contrast revealed an 8 cm retroperitoneal mass and cannon ball lesions in the lungs consistent with hematogenous metastatic dissemination. The patient was transfused but continued to have a steady decline in hemoglobin with the provisional diagnosis of melena secondary to ingested blood from hemoptysis. An EGD was performed which was grossly normal. This was immediately followed by a small bowel capsule endoscopy and a malignant appearing mass was visualized in the jejunum with no evidence of active bleed. The patient was started on intensive induction chemotherapy regimen consisting of etoposide, ifosfamide and cisplatin. Unfortunately, the patient developed multi-organ failure and eventually died from massive pulmonary hemorrhage. Less than 5% of patients with testicular choriocarcinoma have GI tract involvement. The most common site of GI metastasis is the stomach, though lesions can rarely be found in the colon and small intestine. An important characteristic of choriocarcinoma is its tendency to hemorrhage at both primary and metastatic sites. This phenomenon relates to its biology in which malignant trophoblastic cells infiltrate and invade blood vessels causing bleeding and metastasis. The lungs are commonly involved which can lead to hemoptysis and consequently melena due to ingestion of blood. The main stay of treatment is chemotherapy. GI bleeding, though rare, can be a consequence of metastatic choriocarcinoma. Since ongoing hemoptysis can be a confounding factor, there should be a high index of suspicion for a potential metastatic GI source of blood loss to decrease morbidity and mortality.