The story began in 2021, when the man, previously healthy, presented with testicular pain and swelling. Scrotal ultrasonography revealed a solid intratesticular mass, and he underwent a radical orchiectomy, the surgical removal of the affected testicle. Histopathological examination confirmed a mixed germ cell tumor composed of roughly 70 percent post-pubertal type yolk sac tumor and 30 percent teratoma. Critically, the tumor was still confined to the testis, with no lymphovascular invasion and no involvement of the spermatic cord, placing it in the favorable pT1 category. His preoperative alpha-fetoprotein, a key tumor marker for yolk sac tumor, was elevated at 200 ng/mL, while beta-human chorionic gonadotropin and lactate dehydrogenase were normal.

At that point, the standard of care was clear: adjuvant chemotherapy after orchiectomy substantially reduces the risk of relapse in patients with this tumor profile. The patient declined. He also declined the recommended staging workup and did not return for regular follow-up visits. According to the case report, his repeated refusals stemmed from a combination of financial constraints, limited health literacy and educational background, and fear of chemotherapy-related toxicity. Those decisions, the authors suggest, likely allowed early hematogenous dissemination of tumor cells and may have contributed to the chemoresistance that emerged later in his disease course.

Roughly twelve months after the orchiectomy, the man returned to care with cough, shortness of breath, and episodes of coughing up blood. Contrast-enhanced computed tomography of the chest revealed multiple pulmonary metastases, including a large 80 by 57 millimeter solid mass with central necrosis in the left upper lobe, an adjacent 36 by 28 millimeter lesion, and a 42 by 26 millimeter cavitary lesion in the left lower lobe. A 15 by 12 millimeter mediastinal mass sat adjacent to the main pulmonary artery. Notably, cardiac evaluation at that time was unremarkable, with no pleural or pericardial effusion, a detail that underscores how quietly intracardiac disease can later develop. He received four cycles of bleomycin, etoposide, and cisplatin, the standard first-line BEP regimen, and responded well, with resolution of his hemoptysis and shrinkage of the lung lesions.

The reprieve did not last. During follow-up in 2024, serial monitoring showed a rising alpha-fetoprotein level accompanied by radiologic progression of the pulmonary metastases. Once again, the patient declined systemic therapy. A few months later he developed numbness and tingling in the fingers of his right hand, and brain magnetic resonance imaging revealed a metastatic lesion in the left temporoparietal lobe. For the third time during his illness, he declined recommended treatment. Approximately a year after the initial marker rise, he presented with a decreased level of consciousness, a neurological emergency. Repeat brain MRI showed a large left temporoparietal mass with significant perilesional edema and mass effect causing midline shift, the dangerous displacement of brain structures across the cranial midline that signals impending herniation.

Surgeons performed an emergency decompressive craniectomy, removing part of the skull to relieve intracranial pressure. Histopathology of the resected tissue confirmed metastatic yolk sac tumor, showing the characteristic reticular and microcystic architecture with prominent Schiller-Duval bodies, the pathognomonic finger-like structures of this tumor type, set within a loose mesenchymal-like stroma. About a month after surgery, the patient began four cycles of TIP chemotherapy, a salvage regimen combining paclitaxel, ifosfamide, and cisplatin, completed over approximately two months. TIP is a well-established option for relapsed or cisplatin-resistant non-seminomatous germ cell tumors, and in this case it helped stabilize the central nervous system disease when combined with subsequent whole-brain radiotherapy.

What came next was the most unusual chapter of the case. Approximately one month after completing TIP chemotherapy, follow-up chest CT revealed a persistent dominant pulmonary mass with stable dimensions. The patient underwent thoracotomy for surgical resection of that mass. During the operation, surgeons identified a separate, discrete metastatic deposit measuring 50 by 50 by 25 millimeters in the right atrium of the heart, anatomically discontinuous from the pulmonary lesion. It, too, was surgically excised. The precise route of hematogenous spread to the right atrium, potentially via the systemic venous circulation, could not be definitively established from the available operative and pathological documentation. Histopathology confirmed yolk sac tumor involvement of the atrial tissue, matching the morphology seen in the pulmonary and cerebral resections.

Cardiac metastasis from testicular non-seminomatous germ cell tumors is exceedingly rare, reported in fewer than one percent of cases, with most evidence drawn from autopsy series and scattered case reports. When it does occur, it typically involves the right side of the heart and carries life-threatening risks including intracardiac obstruction and tumor embolism, in which fragments of tumor break loose and block blood vessels in the lungs. The literature suggests that aggressive surgical resection can be beneficial when feasible, but overall survival in such cases remains suboptimal because complete disease control with chemotherapy alone is difficult to achieve. This case demonstrates that, even in heavily pretreated patients with disease in multiple organs, thoracotomy with resection of cardiac lesions can be accomplished safely in selected individuals.

The treatment sequence continued to build. About one month after the thoracotomy, the patient received whole-brain radiotherapy at a total dose of 30 Gy to consolidate control of the CNS disease. Then, approximately one month after completing radiotherapy, his oncologists initiated maintenance therapy with oxaliplatin and bevacizumab, a combination drawn from a published Phase II clinical trial regimen for refractory germ cell tumors. Bevacizumab is a monoclonal antibody that blocks vascular endothelial growth factor, starving tumors of their blood supply, while oxaliplatin is a platinum chemotherapy agent that offers a mechanism of action distinct from the cisplatin used in his earlier regimens. The rationale was to hold the disease in check after maximal cytoreduction through surgery and radiotherapy.

At the time of the report, the patient had been on maintenance therapy for approximately six months and clinically stable for roughly eight months after the thoracotomy. Serum alpha-fetoprotein levels, the most reliable biochemical fingerprint of residual yolk sac tumor, have remained stable without significant elevation. He reports no new neurological or cardiopulmonary symptoms, and his general condition is stable, with no biochemical evidence of overt disease progression. The authors caution that longer-term follow-up will be necessary to determine the durability of this response, and they acknowledge limitations, including the absence of complete serial tumor marker data that would have allowed formal risk stratification under the international consensus classification, a gap that itself reflects the patient’s repeated loss to follow-up, and the lack of detailed intraoperative documentation of the atrial resection technique.

Beyond its rarity, the case carries several lessons that the authors emphasize for practicing clinicians. New neurological or cardiopulmonary symptoms in a patient with a history of non-seminomatous germ cell tumor should prompt a high index of suspicion for metastasis at atypical sites, including the brain and heart. Multimodal therapy, combining chemotherapy, radiotherapy, and surgery, remains critical for disease control in aggressive or unusually metastatic cases. Salvage regimens such as TIP can produce meaningful responses even in chemotherapy-resistant disease, and urgent neurosurgical intervention can be lifesaving when brain metastases cause mass effect. Maintenance therapy with oxaliplatin and bevacizumab may offer benefit in selected patients with chemoresistant tumors. Finally, the case stands as a stark reminder that adherence to recommended treatment and close surveillance are not optional extras in testicular cancer care; in this patient’s trajectory, each interval of refused therapy preceded a stepwise escalation in the difficulty and danger of his disease, and only an extraordinary coordinated effort across neurosurgery, thoracic surgery, oncology, and radiotherapy brought it back under control.

Subject of Research: A case report of intracardiac, brain, and pulmonary metastases from a testicular yolk sac tumor managed with multimodal treatment.

Article Title: Intracardiac Metastasis From a Testicular Yolk Sac Tumor With Brain and Pulmonary Involvement: A Multimodality Management Case Report

Article References: Intracardiac Metastasis From a Testicular Yolk Sac Tumor With Brain and Pulmonary Involvement: A Multimodality Management Case Report. (n.d.). https://doi.org/10.1002/ccr3.73528

Image Credits: AI Generated

DOI: 10.1002/ccr3.73528

Keywords: testicular cancer, yolk sac tumor, non-seminomatous germ cell tumor, cardiac metastasis, brain metastasis, pulmonary metastases, BEP chemotherapy, TIP salvage chemotherapy, decompressive craniectomy, whole-brain radiotherapy, bevacizumab, case report