1. Helen Forristal Cancer 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 2 3

12. M

13. IGCN N

14. C H H 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 HEALTH PROMOTION HEALTH EDUCATION FAST – EASY ACCESS RAPID DIAGNOSIS TREATMENT FOLLOW - UP SYMPTOM CONTROL SUPPORT