Case Presentation: A 34-year-old non-smoking man with no significant medical history presented with a one-month history of a rapidly enlarging, painful right neck mass. He denied voice changes, dysphagia, and constitutional or respiratory symptoms. Initial CT at an outside hospital showed multiple necrotic right level II cervical lymph nodes, the largest 1.2 × 1.9 × 2.8cm, without pharyngeal or mediastinal mass. Biopsy of the largest node revealed poorly differentiated carcinoma possibly consistent with seminoma, though interpretation was limited by necrosis and crush artifact. PET-CT showed FDG-avid right cervical and supraclavicular nodes without an identifiable primary. Testicular ultrasound was negative, and serum AFP, β-hCG, LDH, and lymphoma flow cytometry were normal. He was advised to undergo empiric bilateral orchiectomy. Due to progressive pain, he presented to our hospital two weeks later. Given the atypical presentation and incomplete immunohistochemistry (IHC) and FISH studies, repeat biopsy and direct laryngoscopy were recommended after multidisciplinary discussion with oncology, pathology, and otolaryngology (ENT). Repeat CT showed interval progression, the largest node now 1.6 x 2.2 x 3.0cm. Laryngoscopy was negative. Fine needle aspiration and core biopsy revealed sheets of malignant cells with clear cytoplasm and prominent nucleoli. IHC was positive for SALL4, OCT3/4, and SOX17, and negative for cytokeratin, EMA, and CD30, supporting seminoma. FISH analysis demonstrated a gain of iso(12p), confirming seminoma. The patient was diagnosed with stage IIIB extragonadal seminoma confined to cervical lymph nodes and started on bleomycin, etoposide, and cisplatin (BEP) chemotherapy.
Discussion: Hospitalists are increasingly involved in diagnosing atypical lymphadenopathy and cancer. A structured approach to lymphadenopathy is essential when malignancy is suspected. This case highlights the diagnostic complexity of atypical lymphadenopathy and the role of hospitalists in coordinating multidisciplinary care. Guidelines from the American Academy of Otolaryngology-Head and Neck Surgery recommend that any adult neck mass be considered malignant until proven otherwise.[1] Our patient’s lymphadenopathy was concerning for malignancy given the persistence (>2 weeks), firmness, and size >1.5 cm. Evaluation should include imaging, laboratory testing, and fine-needle aspiration with core biopsy, preferred over open biopsy to reduce seeding risk. Laryngoscopy is also critical, as most cervical lymphadenopathy represents metastases from head and neck primaries.[2] Although seminomas usually arise in the testes, < 5% of germ cell tumors are extragonadal, and usually in the mediastinum or retroperitoneum.[3] Cervical presentations are exceptionally rare, and in >50% of cases, crush artifact and necrosis obscure histology, complicating diagnosis.[4] Molecular confirmation by FISH demonstrating gain of iso(12p) was essential for establishing the diagnosis of seminoma and avoiding unnecessary orchiectomy.
Conclusions: This case illustrates the hospitalist’s pivotal role in diagnosing and managing rare and complex oncologic presentations. Recognition of seminoma in atypical sites and timely molecular testing are critical for accurate diagnosis and treatment. Hospital-based clinicians must maintain a broad differential for cervical lymphadenopathy, as early identification of rare malignancies like extragonadal seminoma directly impacts prognosis.