General Data:  OR, 24 year-old male, single, living in Cabatuan, Isabela Chief complaint:  Enlarging abdominal mass with sharp pain

1 month PTA (May 2008)  Enlarging abdomen with painful, sharp sensation described as “hinihiwa sa tiyan” with concomitant dizziness, cold sweats and fever, resolved upon resting  Intake of unprescribed amoxicillin and mefenamic acid  Pain persisted for 4 days

2 weeks PTA  sought consult at a local hospital; UTZ of the lower abdomen revealed an 18cm mass  referred to PGH for further management.

June 2008  admitted to PGH ward 3, with an enlarged abdomen  decreased appetite, irregular bowel movements (normally once a day, but at that time, he defecated every 2 days), but no difficulty of defecation  weight loss of approximately 4kgs (from 52 to 48 kgs), dysuria, urinary incontinence, and a change in urine color from the usual yellow to white.

 born with both testes undescended; left testes descended at age 6.  (+) mumps during elementary  (+) UTI episode (1) when he was 18 or 19 years of age, with concomitant right flank pain. He took unrecalled medications for 7 days with resolution of symptoms.

 (+) TB, mother's side  (-) cryptorchidism  (-) cancer  (-) heart disease  (-) hypertension  (-) stroke  (-) diabetes  (+) asthma

 finished 2 years of vocational school and used to work as an electrician  lives with his father, mother and 3 siblings  pays for his chemotherapy with the help of relatives abroad.

 (+) weight loss, 4 kgs  (-) nausea, vomiting  (-) anorexia  (+) diarrhea for one week, after chemotherapy  (-) constipation  (+) dysuria, incontinence  (+) numbness of R flank  (+) abdominal pain  (+) knee pain in the morning upon arising  (-) chest pain, palpitations  (-) easy fatigability  (-) cough

Colon Cancer Urinary Bladder Cancer Lymphoma Testicular Cancer

Inflammatory Bowel Disease (Crohn’s) Intestinal Obstruction Diverticulitis Abdominal Abscess

At the time of consult (prior to treatment): Abdomen:  Enlarged abdomen, size consistent with 5-month pregnant abdomen  Mass palpable, ~20cm in largest diameter, at left lower hemiabdomen Genitals:  Empty scrotal sac on the right  Normal testicle on the left, (-) masses/nodules, lesions, tenderness  Essentially normal findings for other systems

Colon Cancer Urinary Bladder Cancer Lymphoma Testicular Cancer

Inflammatory Bowel Disease (Crohn’s) Intestinal Obstruction Diverticulitis Abdominal Abscess

Scrotal Ultrasound: for any male with suspicious or questionable testicular mass on palpation Abdominal and Pelvic CT: to ID metastasis to retroperitoneal LN; also to determine presence of cryptochordism Chest CT and Xray: to confirm abnormal chest findings o In the use of bleomycin, life-threatening pulmonary toxic effects can occur so the drug should be discontinued if early signs of pulmonary toxic effects develop.

Plain and contrast axial scan of the whole abdomen shows:  There is a large solid mass measuring 18.0 x 11.0 x 14.0 cm noted in the peritoneal cavity of with close attachment to the mesentery. There are small packets of contrast with areas of fluid.  The liver is normal in size with low attenuation of the parenchyma.  The gall bladder has no intraluminal densities.  The pancreas, and spleen is unremarkable.  Both kidneys are normal in size with good function noted.  The prostate is normal in size.  The abdominal aorta is unremarkable.

Result PGH Normal Values Interpretation BUN12.7 mmol/L mmol/LHigh Creatinine167.7 umol/L umol/LHigh Total Bilirubin12.5 umol/L umol/L Direct Bilirubin0.5 umol/L0-5 umol/L Indirect Bilirubin12 umol/L umol/L Alkaline Phosphatase 224 U/L U/LHigh AST58 U/L15-37 U/LHigh ALT36 U/L35-65 U/L LDH (done twice)2080 U/L U/LHigh Sodium142 mmol/L mmol/L Potassium4.2 mmol/L mmol/L Chlorine103 mmol/L mmol/L

* AFP (Alpha-Feto Protein) * Beta-hCG (Beta Subunit of Human Chorionic Gonadotropin) * LDH (Lactate Dehydrogenase)

A tumor marker which is elevated when yolk sac elements are present (i.e. nonseminomatous GCT). Expected finding (if seminoma): low levels Tumors that appear to have a seminoma histology but that have elevated serum levels of alpha- fetoprotein (AFP) should be treated as nonseminomas Patient’s Data:AFP = 1.12 IU/ml(N: IU/ml) Taken 10/31/2008

In 5-10% of seminoma patients, this may be elevated; levels may be correlated with metastasis but not with overall survival o If levels do not normalize after orchiectomy, treatment approach should be that for NSGCT Patient’s Data:hCG = IU/ml(N: mIU/ml) Taken 10/30/2008

Less specific for GCTs, but levels can correlate with overall tumor burden Increases in the serum level are influenced primarily by tumor burden and growth rate, cell proliferation and death. Patient’s Data:LDH = 2080 U/L(N: U/L) Taken 10/30/2008

 PLAP has been distinguished from the common tissue alkaline phosphatases by its heat resistance, its inhibition by L-phenylalanine, and its immunological properties.  Raised serum concentrations of PLAP are found in seminomas and NSGCT, as well as in ovarian tumors.  Serum values were more frequently elevated in seminoma patients than in nonseminoma patients unless the latter disease was far advanced.

>10,000or>50,000or>10 x NS3 1,000-10,000or5,000-50,000or x NS2 <1,000and<5,000and<1.5 x NS1 NormalandNormaland£ NS0 Not assessed Sx AFP (ng/mL)hCG† (mIU/mL)LDHS

Patient Results  Cell findings were consistent with seminoma; immunohistochemical staining for PLAP was suggested for confirmation.  There were three specimens submitted:  “Abd Mass Core”: cream tan irregular tissue fragments with an aggregate diameter of 0.5 cm. Block all.  “Abd Mass Cell Block”: 20 cc cream white turbid fluid. For cell block.  “Abd Mass FNAB”: 8 unstained slides with smear. For staining and interpretation Taken July 19, 2008 (PGH)

Seminoma

 Cryptorchidism - several-fold higher risk of Germ Cell Tumors (GCT),~10-40x  Abdominal cryptorchid testes > inguinal cryptorchid testes.  Orchiopexy recommended  Testicular feminization - ↑ risk of testicular GCT

 Trauma  Mumps  prenatal exposure to maternal hormones  Familial risk for testicular CA (Hemminki et al, 2004)  4-fold increased risk in a male with a father who had a GCT  9-fold increased risk if a brother was affected

 An isochromosome of the short arm of chromosome 12 [i(12p)] is pathognomonic for GCT of all histologic types.  Excess 12p copy number occurs in nearly all GCTs, but the genes are still unidentified.

 Right testicular tumor  interaortocaval lymph nodes  Left testicular tumor  para-aortic lymph nodes  Lymphatic involvement extends cephalad  retrocrucal, posterior mediastinal, and supraclavicular lymph nodes

LDHhCG (mIU/ml) AFP (ng/ml) S0NNN S1< 1.5 x N< 5000< 1000 S x N5000 – 50, – 10,000 S3> 10 x N> 50,000> 10,000 Patient’s values2, 080 (Normal: ) IU/ml (Normal: 0-5) 1.12 IU/ml (Normal: )

 Initial laboratory results done prior to treatment, as well as the history strongly suggest a diagnosis of testicular carcinoma, seminomatous type.  The stage of the disease, as well as the capacity of the patient will determine the course of treatment.

Usual pattern of metastasis of seminoma:

 Examination of the other testicle  CT of the abdomen  Chest X-ray  CT of the chest  Liver ultrasound

* Harrison’s Principles of Internal Medicine, 17th edition

November 2008  transferred to the Cancer Institute; set to receive chemotherapy, but was delayed due to financial constraints.  difficulty defecating, difficulty urinating and anorexia.

January 18, 2009  started first of six cycles of chemotherapy (Carboplatin, Bleomycin, and Etoposide) every 21 days, each cycle lasting 5 days.

Recently  currently on the second day of the last cycle  reported an increase in appetite since beginning his chemotherapy, return of regular bowel movements and urination  abdominal mass has also visibly reduced in size  In addition to chemotherapy, the patient is on continuous intravenous hydration while undergoing chemotherapy to ensure proper excretion of the drugs  For referral to nephrology for assessment of kidneys after the chemotherapy cycles

 Flat abdomen  (-) visible masses, lesions  Normoactive bowel sounds  (-) tenderness, organomegaly  Generally tympanitic, aside from left lower hemiabdomen  Abdominal mass at left lower hemiabdomen:  10cm x 6cm on percussion; 7cm x 6cm on deep palpation  Liver span: 8cm  Intact Traube’s space  (-) fluid wave, shifting dullness

 Circumcised  (-) penile discharge and lesions along the shaft and scrotal sac  Pubic hair is absent probably due to chemotherapy  (-) scrotal swelling or discoloration  Empty scrotal sac on the right  Left testicle is smooth, non tender and firm; nontender epididymis  (-) inguinal or femoral hernia  Nonpalpable inguinal lymph nodes

Good Prognosis  Any primary site  No pulmonary visceral metastases  Normal AFP; any hCG or LDH Intermediate Prognosis  Testis or retroperitoneal primary site  Normal AFP; any hCG or LDH  Nonpulmonary visceral metastases Campbell’s Urology, 8 th Ed.

 All stages have at least a 90% cure rate  Stage I is 98%-100%  Stage II (B1/B2 nonbulky) is 98%-100%  Stage II (B3 bulky) and stage III have a 90% complete response to chemotherapy and an 86% durable response rate to chemotherapy  Second cancers and cardiac disease among long-term survivors  Patients with testicular cancer are at an increased risk of secondary cancers (malignant mesothelioma and those of the lung, colon, bladder, pancreas, and stomach  Patients with seminoma need counseling and long-term follow-up

Check bHCG, LDH: if levels became lower, tx might be working. If not… Repeat biopsy (if consistent with NSGCT, use tx approach for NSGCT) Repeat CT (to check extent of mass left post- chemotherapy; also, to check for possible metastasis?) If with testicular mass, scrotal UTZ Chest X-ray (if with abn findings, confirm with chest CT to check for mets)