Metastatic Germ Cell Tumor Presenting with Renovascular Hypertension

İsmail Çelik, MD, Department of Medical Oncology, Hacettepe University School of Medicine, TR-06100 Sihhiye-Ankara (Turkey) Dear Sir, Renovascular hypertension (RVHT) is encountered not infrequently after combination chemotherapy of testicular cancers, as cisplatin-based regimens could induce renovascular lesions leading to systemic hypertension [1]; however, a pretreatment-settled RVHT due to the primary involvement of renal vasculature is very uncommon [2] and not reported secondary to a metastatic germ cell neoplasm. A 21-year-old man had been diagnosed to have primary mixed germ cell tumor of testis after right inguinal orchiecto-my, but he had refused subsequent evaluation and therapy. On readmission after 7 months, physical examination revealed a high blood pressure and a solid nontender mass beneath the left costovertebral angle. Metastatic workup disclosed a tumoral lesion surrounding left renal artery and vein (fig. 1). Urinalysis and laboratory examinations, including serum electrolyte levels and renal functions were normal except for a nor-mochromic normocytic anemia (hemoglobin 5.41 mmol/l, hematocrit 0.31) and high lac-tate dehydrogenase levels (9.65 μkat/1). Beta human chorionic gonadotropin, plasma re-nin activity, and active and total renin levels were also found to be elevated (fig. 2). PEB chemotherapy consisting of cisplatin, etopo-side, and bleomycin was started. Although initially a favorable response was obtained with regard to blood pressure and tumor burden, he developed progressive renal failure after successive cycles of PEB (fig. 2), and he died after a stroke leading to respiratory arrest. No autopsy was allowed. As there was no evidence of vasculitis, coagulopathy, cardiac lesion, or a history of radiotherapy, a vaso-occlusive theory or radiation-induced nephritis does not hold true for RVHT. The acceptable response to PEB therapy on the basis of a decline in blood Fig. 1. Computed tomography scan of the upper abdomen demonstrating a hypodense mass with irregular contours, extending from the renal hilum to the aortic wall. The mass is almost completely occupying the renal hilum and involving renal vascular pedicle and left psoas muscle. Pulsatility and resistivity indices of the involved kidney were lower after Doppler ultrasonography. Hydronephrosis was not present, and there were no additional lesions in contralateral kidney, liver, spleen, adrenal gland, and lymph nodes. Note the absence of a