Compared to testicular seminoma, non-seminoma germ cell tumor (NSGCT) has a poor prognosis. Testicular mixed germ cell tumors (TMGCTs) are rare malignant tumors that are more common in men aged 20–40 years. We reported a case of rapid clinical progression to huge painful inguinal mass and multiple lymphatic metastases after diagnosis of TMGCTs.

A 40-year-old man with medical history of schizophrenia lived in mental health care institution presented with right testicular tumor incidentally. According to his father’s statement, patient underwent radical orchiectomy in other hospital, and pathologic report was mixed GCTs. Abdomen computed tomography (CT) scan revealed suspected retroperitoneal lymph node metastases. He underwent once chemotherapy with bleomycin, etoposide and cisplatin (BEP), however he refused to receive further management due to attack of psychological episode. After 6 months, he presented with right inguinal pain to our clinic and physical exam revealed right huge, hard and painful inguinal mass (Fig. 1), without lymphadenopathy of supraclavicular or contralateral inguinal area. Following abdomen CT scan showed the right inguinal mass measuring about 8.5 cm x 13.5 cm and retroperitoneal lymph node enlargement (para-aortic, aorto-caval and iliac chain lymphadenopathy with the largest lymph node measured 4.8×6.2 cm) (Fig. 2). The tumor markers for metastatic TMGCTs were LDH 549 U/l; AFP 9430 ng/ml; and b-HCG 4.9 mIU/ml. Although the patient had poor medical adherence, we suggested that he should be referred to oncologist for subsequent chemotherapy with BEP regimen.

TMGCTs are composed of two or more types of germ cell tumors and primarily occur in the testis. They account for only approximately 16% of all testicular tumors, and patients usually have a median survival period of 42 month. Radical resection combined with adjuvant chemotherapy is the classic treatment for TMGCT. According to the National Comprehensive Cancer Network (NCCN) guideline, chemotherapy with bleomycin, etoposide and cisplatin (BEP) is suggested as the first-line treatment for advanced NSGCT.

We reported a schizophrenia case of rapid clinical progression of metastatic testicular mixed germ cell tumor without scheduled follow-up and treatment. Well medical adherence and longer follow up is important to prevent rapid clinical progression of aggressive mixed GCTs.