Helen Forristal Cancer Nurse Co-Ordinator St.Vincent’s University Hospital

Helen ForristalCancer Nurse Co-Ordinator

St.Vincent’s University Hospital

Case Presentation

Presentation • John• 35 male, presented to A&E October 2010 • Smoker – Smoking Advice Service• Alcohol – 20 units C2H5OH per week• History of left loin pain & back pain lasting 2

months • CT KUB – Large lobulated retroperitoneal mass

consistent with lymphadenopathy & mild to moderate hydronephrosis secondary to compression of the right renal pelvis

Presentation (cont)• On further questioning John describes first

noticing a right testicular swelling in August 2009 ( did not seek medical advice)

Investigations• Testicular ultrasound showing a primary right

testicular mass lesion with cystic, solid and calcified components. Appearances consistent with a germ cell tumour.

• CTTAP – bulky retroperitoneal adenopathy extending from the renal hilum to the aortic bifurcation raising the possibility of a metastatic germ cell tumour.

• Two tiny peripheral pulmonary nodules in the lower lobe of the right lung

Medications

• Oxycontin 10 mgs BD, Increased to 75mgs BD• Oxynorm 5 mgs PRN - 4 hourly• Paracetamol PRN• Difene 75 mgs BD• Lyrica 25mgs TDS

Pre- OperativeTumour Markers 4/7/2010

• LDH 1074 (240-480)• AFP 480 (0-5.8)• HCG 91 <0.6

Right Radical Orchidectomy 9/7/2010

• Histology p T1• Malignant Germ Cell Tumour, non

seminomatous type (4cms), comprising teratoma.

• Many cysts contain old haemorrhage.• Atypical cartilage• Tumour does not invade the spermatoic cord,

tuna albuginea, epididymis or rete testis.• No lymphovascular invasion identified

1

2

3

M

IGCN

N

C

HH

H

Post operative Tumour Markers 15/07/2010

• LDH 1024 (240-480)• AFP 605.4 (0-5.8)• HCG <0.6 (<0.6)

MDT 22/07/2010• Intertubular Germ Cell Tumour • Need tissue diagnosis• Booked for CT Guided Biopsy of Lymph Node

MDT 12/8/2010• Orchidectomy Specimen – Cystic tumour,

mature teratoma• Malignant non - seminomatous germ cell

tumour • p T1• Retroperitoneal Biopsy 3/8/2010 – no evidence

of carcinomatous changes, similar in appearances to orchidectomy specimen

• p T 1• Referred to Medical Oncology – 3 cycles BEP• Referral for RPLND

Post Chemotherapy• 3 cycles BEP, tumour markers decreased but

did not normalise• Referred for RPLND surgery Dec 2010• Extensive RPLND Jan 2011• Surgically achieved complete remission,

histopathology teratoma, no adjuvant chemotherapy required.

Recovery • Bilateral Lymphoedema• No respiratory embarrassement.• Retrograde ejaculation

• Follow up CTTAP – post operative changes only with some intermediate very small pulmonary nodules which require follow up.

• Follow up Oncology 14/11/2011 – all tumour markers normal.

Pain• Back Pain • Constant knee pain radiating to Hip • Heavy Legs• “ Pins and Needles” & “Burning”• “hips appear to seize on walking”• Referred to Palliative Care locally for

pain control

Lymphoedema

• Physiotherapy – waiting list 7 months• Self referral to Lymphoedema Specialist- daily

visits initially with bandaging on alternate days, gradually decreasing visits over time to weekly, monthly since 2011

• Spent 6,000 plus euro

Retrograde Ejaculation

PersonalHEALTH PROMOTION

HEALTH EDUCATION

FAST – EASY ACCESS

RAPID DIAGNOSIS

TREATMENT

FOLLOW - UPSYMPTOM CONTROL

SUPPORT