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

1. Helen ForristalCancer Nurse Co-Ordinator St.Vincent’s University Hospital Case Presentation

3. 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

4. Presentation (cont) • On further questioning John describes first noticing a right testicular swelling in August 2009 ( did not seek medical advice)

5. 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

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

8. Pre- OperativeTumour Markers 4/7/2010 • LDH 1074 (240-480) • AFP 480 (0-5.8) • HCG 91 <0.6

9. 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

11. 1 3 2

12. M

13. IGCN N

14. H H C H

16. Post operative Tumour Markers 15/07/2010 • LDH 1024 (240-480) • AFP 605.4 (0-5.8) • HCG <0.6 (<0.6)

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

18. 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

19. 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.

22. 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.

23. 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

24. 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

25. Retrograde Ejaculation

26. Personal FAST – EASY ACCESS HEALTH PROMOTION RAPID DIAGNOSIS HEALTH EDUCATION TREATMENT SYMPTOM CONTROL FOLLOW - UP SUPPORT