Germ cell tumours, which are in complete remission two years after treatments have a high probability of cure and reports of late relapse, are rare (1.3%–6.2%) [2
]. Late relapse may occur at any time; of 81 patients treated for late relapse at Indian university, 47 patients (60%) relapsed more than 5 years after the achievement of a complete initial response [7
The possible mechanisms of development of a late relapse in germ cell tumors include the followings: malignant degeneration of mature teratoma to germinal malignancy, growth of an occult testicular tumor not eliminated by chemotherapy, development of a second primary germinal malignancy, persistent microscopic viable tumor with an atypical less aggressive biologic behaviour [8
Patient with bulky retroperitoneal disease and patient found to have teratoma following cisplatin-based chemotherapy appear to be at an increased risk of late relapse. Of 51 patients with mature teratoma in resected retroperitoneal residual tumor masses after chemotherapy, 9 patients (17.6%) relapsed. In five patients (9.8 %) relapse resulted from growing mature teratoma [9
Teratoma is a chemo resistant, nonseminomatous germ cell tumor composed of somatic cell type from two or more germ layers and is derived from a toti potential, malignant precursor cell (embryonal carcinoma or yolk sac tumor). Although teratoma is a benign tumor but its biologic potential is unpredictable and it should be resected completely because it may grow and become unresectable.
Disease free survival following resection of teratoma is related to completeness of resection; therefore, there are significant advantages to surgery with low volume disease. Moreover, there is the risk of malignant transformation of teratoma to carcinoma or sarcoma [10
], so unresected teratoma may result in late relapse. A late relapse often shows a slow growth and usually responds to chemotherapy poorly. Complete surgical resection of late relapse is preferred mode of therapy but cure rate are relatively low in patients with viable cancer. In addition, patients with symptomatic disease and patients presenting with visceral metastases carried a poor prognosis [2
Herein we report a case of late relapse in the left side of neck 17 years after treatment of left testicular teratocarcinoma. The incidence of cervical metastasis in testicular germ cell tumor is about 5% [11
]. In germ cell tumour, metastatic disease first involves the retroperitoneal lymph nodes, then the tumor spreads via thoracic duct to the latter's termination near the junction of the left internal jugular and subclavian veins, the area where we resected the mature teratoma of our patient. The mechanisms of late relapse in the neck and upper thorax may include the altered lymphatic drainage from an incompletely resected spermatic cord, a second primary extragonadal tumor focus, or growing of a mature teratoma. Late relapse may occur at any time. In a recent study from Memorial Sloan Kettering Cancer Center the medium time to relapse for 17 patients among 551 patients who had previously complete response to first line chemotherapy was 7.8 years [5
]. In a recent analysis of 122 cases of late relapse medium time to relapse was 64.5 months in nonseminomatous germ cell tumours[12
]. Lehman et al. reported a case of retroperitoneal mature teratoma 15 years after initial treatment of testicular germ cell tumor [13
]. Late relapse was observed up to 32 years after initial treatment [7
Whereas chemotherapy has only minor curative potential in the treatment of late relapse, patient with localized resectable disease can be cured. Modified neck dissection has a demonstrated valuable role in the treatment of metastatic non-seminomatus germ cell tumours [14
Our patient has been well with no evidence of disease after resection of cervical mature teratoma until the date of last follow-up (October 2006). However, continued close follow-up of this case is necessary because the large tumor burden of teratoma is a significant adverse factor predictive for further relapse [15
]. In our opinion, a reasonable follow up schedule would evaluate the patient monthly in the first year. The frequency of visits should be decreased to 2–3 months in the second and third year, and every 6 months in year 4 and 5, and annually thereafter. Physical examination, tumor markers and radiological examinations are complementary. Annual CT scan can detect late relapse at an asymptomatic phase.