• Fang Guo, Hongbing Wang, Heshun Xia, Hongwei Shi, Peng Xu, and Guoliang Pi.
• Department of Pathology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
• Medicine (Baltimore). 2022 Jul 29; 101 (30): e29281e29281.

RationaleGerm cell tumors in the head and neck are very rare. In cases of germ cell tumors, it is uncommon for lymph node metastasis to be the only and initial symptom, and this can easily lead to a misdiagnosis. Herein, we report about a 28-year-old woman with lymph node metastasis, in whom a primary tumor appeared in the nasal cavity.Patient ConcernsA 28-year-old woman presented with enlarged left submandibular lymph nodes. No other mass was found on whole-body screening using positron emission tomography-computed tomography.DiagnosisAfter partial submandibular lymphadenectomy was performed, histopathological and immunohistochemical examinations revealed a metastatic germ cell tumor. However, it was difficult to further classify and affirm the origin.InterventionsAs the patient was receiving four cycles of bleomycin, etoposide, and cisplatin chemotherapy, a primary tumor emerged in the nasal cavity, which was finally confirmed as an immature teratoma of a high World Health Organization histological grade and Norris grade 3. This tumor was found to contain similar components to lymph nodes with respect to histopathological and immunohistochemical characteristics, especially the immature neural tubes or nervous tissue in the nasal cavity. Fortunately, the patient recovered well with no signs of relapse, and the size of residual lymph nodes remained unchanged after she received another four cycles of bleomycin, etoposide, and cisplatin chemotherapy and two cycles of doxorubicin and ifosfamide (AI) chemotherapy.OutcomesUnfortunately, 11 months later, during the coronavirus disease pandemic, the patient died owing to respiratory failure and pulmonary infection.ConclusionsIn cases of malignant tumor in the submandibular lymph nodes of adults, the metastasis of a germ cell tumor should be considered an important differential diagnosis even if a primary tumor does not emerge. In this case, adequate postoperative chemotherapy is necessary.Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.

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