Primary, Nonmidline, Extragonadal, Immature Teratoma of the Palm with Axillary Nodal Metastasis: A Rare Case Report and Review of Literature

Primary, nonmidline, extragonadal germ cell tumors are rare. Numerous hypotheses have been proposed regarding their origin. There is lack of consensus regarding their appropriate management. We report a case of an immature teratoma arising of the left palm. A 36-year-old lady presented with a recurrent left palm swelling. Histopathological features with immunohistochemical evaluation were characteristic of an immature teratoma. Alpha-fetoprotein (AFP) and lactate dehydrogenase (LDH) were elevated. She received preoperative chemotherapy with bleomycin, etoposide, cisplatin (BEP) followed by wide excision of the palm lesion and reconstruction with free latissimus dorsi flap. Postoperatively, two more cycles of BEP were given. Eight months later, she presented with large left axillary mass which showed metastatic deposits of immature teratoma on trucut biopsy. AFP and LDH were mildly elevated. On staging fluorodeoxyglucose-positron emission tomography (FDG-PET), there were no distant metastases. She received two cycles of vinblastine, ifosfamide, and cisplatin (VeIP). Postchemotherapy FDG-PET showed good metabolic response; however, the mass remained morphologically stable. Complete resection of the axillary mass was achieved with resection of a segment of axillary vein and end-to-end reanastomosis. At 12 months of follow-up the patient is disease free. This is the first report of axillary metastases in immature teratoma of the upper extremity. Axilla is a possible site of lymph node metastases in extremity teratoma. Primary extragonadal germ cell tumor should be managed with complete surgical resection and chemotherapy.