Case RepoRt
Delayed diagnosis in an adolescent with a malignant testicular tumour Amani Roushdi MD1, Mylène Bassal MD FRCPC2, Donna L Johnston MD FRCPC2 A roushdi, M Bassal, DL Johnston. Delayed diagnosis in an adolescent with a malignant testicular tumour. paediatr Child Health 2009;14(6):393-394. Feelings of embarrassment and fear in adolescents may contribute substantially to a delay in the diagnosis of malignant tumours arising from the genital region, with subsequent increase in morbidity and mortality. A case of a 15-year-old boy who had multiple visits to physicians with complaints of recurrent lower abdominal and back pain is presented in the current case report. He refused examination of his genital area during all visits, stating that there were no problems. The patient was admitted to the hospital with a working diagnosis of lymphoma after finding an abdominal mass and a neck mass. During bone marrow aspiration, while the patient was sedated, a large testicular mass was discovered. Each time the patient had been examined, he refused a genital examination and denied any change in the genital region.
Un diagnostic retardé chez un adolescent atteint d’une tumeur maligne du testicule Des sentiments de gêne et de peur de la part des adolescents peuvent beaucoup contribuer à retarder un diagnostic de tumeurs malignes trouvant leur origine dans la région génitale et entraîner une augmentation de la morbidité et de la mortalité. Le cas d’un garçon de 15 ans qui a consulté des médecins à maintes reprises en raison de douleurs récurrentes du dos et du bas-ventre est exposé dans le présent rapport. Le patient a refusé l’examen de la région génitale à toutes les consultations, affirmant qu’il n’avait pas de problème. Après la découverte de deux masses, l’une à l’abdomen et l’autre au cou, on a posé un diagnostic provisoire de lymphome et hospitalisé le patient. Pendant l’aspiration de la moelle osseuse, alors que le patient était sous sédation, on a découvert une grosse masse testiculaire. Le patient avait toujours refusé l’examen de la région génitale et nié toute modification à cette région.
Key Words: Adolescents; Delayed diagnosis; Health education; Malignant tumours; Physical examination
CASE prESEntAtion A 15-year-old boy was admitted to hospital with a history of excessive gagging, increased fatigue, shortness of breath with effort, lower abdominal pain, back pain and loss of weight for one month, with increased vomiting, abdominal pain and development of neck swelling during the three days before admission. A physical examination revealed a generally stable 15-year-old boy, with neck swelling measuring 10 cm × 12 cm, and a right-sided hard abdominal mass in the iliac region. There were no other palpable lymph nodes, no hepatosplenomegaly and no significant findings in examination of the other systems. The patient refused genital examination, and he denied any abnormalities in the genital area. A working diagnosis of lymphoma was made, and a computed tomography scan of the neck, chest and abdomen was performed to screen for areas of involvement, and showed left neck, mediastinal and abdominal lymphadenopathy. A pulmonary nodule and hepatic lesions were also seen. The patient was admitted, and biopsy of the neck mass was performed. As part of the workup of lymphoma, a lumbar puncture and bone marrow aspirate were performed. During this procedure, a large right testicular mass was found measuring 10 cm × 15 cm. The patient was reassessed, with a new working diagnosis of testicular germ cell tumour stage IIIC with metastatic disease.
On further questioning, he admitted to a history of testicular swelling for two years. The patient was embarrassed to mention this swelling to anyone because he thought that it was a sexually transmitted disease. He had six health visits to different walk-in clinics in the previous six months for recurrent abdominal and back pain, and had never mentioned the testicular swelling; in fact, he denied any testicular abnormalities on questioning. Histological examination of the resected left testicle confirmed the diagnosis of mixed testicular germ cell tumour. The tumour marker levels were very high – beta-subunit of human chorionic gonadotropin of 232,850 IU/L (normal less than 5 IU/L) and alpha fetoprotein of 3167 µg/L (normal 0 µg/L to 9 µg/L). Treatment was started with bleomycin, etoposide and cisplatin chemotherapy, with adequate response and a marked decrease in tumour marker levels – beta-subunit of human chorionic gonadotropin of 4463 IU/L and alpha fetoprotein of 267 µg/L, after two cycles of chemotherapy. After four courses of chemotherapy, the tumour marker levels increased, and new lung and liver lesions were found on scanning. The patient’s therapy was changed to high-dose chemotherapy with autologous stem cell transplantation. He progressed following this therapy and died of his disease. DiSCUSSion Testicular cancer, the most common solid malignancy among males 15 to 35 years of age, has become one of the most curable
1Division
of Pediatrics; 2Division of Pediatric Hematology/Oncology, Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario Correspondence: Dr Donna L Johnston, Division of Pediatric Hematology/Oncology, Department of Pediatrics, Children’s Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Ontario K1H 8L1. Telephone 613-737-7600 ext 2370, fax 613-738-4828, e-mail
[email protected] Accepted for publication November 26, 2008
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solid neoplasms. Remarkable treatment advances have been shown since the late 1970s, with improvement in the fiveyear survival from 64% to 95% (1). Early diagnosis and prompt treatment are required for the successful management of most tumour patients. Patients with cancer limited to the testicles have an excellent prognosis and are subjected to a surveillance program after orchidectomy. Patients with metastases, however, have a lower cure rate and may need additional surgery, as well as chemotherapy and radiation treatment. Thus, knowledge of the early symptoms of testicular cancer is crucial. Yet, several studies (2-6) have shown that a delay in presentation is common and may result in metastases and increased mortality and morbidity, especially among adolescent patients. Early diagnosis of testicular cancer depends mainly on thorough history and physical examinations, including an examination of the genital area. Changes in the genital region and the psychosexual development are the source of unique feelings during adolescence. Feelings of embarrassment and fear are common emotions among individuals in this age group. These feelings may contribute substantially in the delay of the adolescent patient with a genital tumour in seeking health service, and subsequent delay in diagnosis and treatment. Adolescence is a transition period between childhood and adulthood. It is a stressful developmental period filled with major changes in physical maturity and sexuality, cognitive processes, emotional feelings and relationships with others. Preventive health care and providing health education regarding specific health care needs to adolescents requires special consideration and effort to ensure understanding and encourage compliance. Interesting to note in our patient is that the diagnostic delay of the malignant tumour was mainly attributed to the patient’s embarrassment and fear, as well as his lack of health education. This emphasizes the importance of extra and continuous education of this age group on all expected normal and abnormal physical and emotional changes during adolescence, and discussing with them during all possible occasions, the early warning signs and the importance of self-reporting of any symptoms. One more important reason for the delay in diagnosis found in our patient was the incomplete physical examination rEFErEnCES
1, Ries LA, Eisner MP, Kosary CL, et al. SEER Cancer Statistics Review 1975-2001, National Cancer Institute, Bethesda, 2004. 2. Schnurr C, Pippan M, Stuetzer H, Delank KS, Michael JW, Eysel P. Treatment delay of bone tumours, compilation of a sociodemographic risk profile: A retrospective study. BMC Cancer 2008;8:22. 3. Mavinkurve-Groothuis AM, Hoogerbrugge PM, Meijer-Vandenbergh EM, Brouwer HG, van Enk JG. Patient delay due to embarrassment and fear in two adolescents with a malignant tumor. Pediatr Blood Cancer 2008;50:1083. 4. Arias de la Vega F, Illarramendi JJ, Martinez E, Vila E, Martinez-Peñuela JM, Domínguez MA. Spontaneous pneumothorax as the first manifestation of Ewing’s sarcoma. Pediatr Pulmonol 1995;19:182-4.
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performed by different health professionals. Adolescents are in a unique age group, and they need a special approach while performing the physical examination. Therefore, during all consultations, health care professionals should try to pursue different approaches with adolescents to overcome any barriers to perform a complete physical examination. Other suggestions that may be helpful in such cases include a school-based educational and assessment program run by community nurses. Nurses are in a unique position to help identify the sexual health-related symptoms in adolescents, educate school personnel about these symptoms, educate adolescents about the risks they face when they do not report any health symptoms and assist parents to access the resources they need to help adolescents who may be having health problems (7). Another study (8) has shown that the senior-junior peer education program is effective in leadership role preparation in improving youth leaders’ abilities to share sexual and reproductive health knowledge. Success also rested on the fact that adults played a critical role in providing the opportunity, assistance and guidance so that young people could develop their leadership capacity in an atmosphere of trust and respect. Such programs should be encouraged among the adolescent age group to improve the adolescents’ attitude toward the importance of examination and early reporting of genital symptoms. Overall, the present case highlights the need for complete questioning and examination of adolescents who present to clinicians. KEY pointS • Early diagnosis and prompt treatment are required for successful management of most tumour patients. Patients with testicular cancer limited to the testicles have an excellent prognosis and a very high cure rate. • The feelings of embarrassment and fear in adolescents may contribute substantially to the delay in the diagnosis of genital tumours, and subsequently results in an increase in morbidity and mortality. • This age group needs ongoing education on the importance of self-reporting symptoms. • Health professionals should have no barriers to perform complete physical examinations on adolescents during any consultation. 5. Dang-Tan T, Trottier H, Mery LS, et al. Delays in diagnosis and treatment among children and adolescents with cancer in Canada. Pediatr Blood Cancer 2008;51:468-74. 6. Klein-Geltink J, Pogany L, Mery LS, Barr RD, Greenberg ML. Impact of age and diagnosis on waiting times between important healthcare events among children 0 to 19 years cared for in pediatric units: The Canadian Childhood Cancer Surveillance and Control Program. J Pediatr Hematol Oncol 2006;28:433-9. 7. Bartlett R, Holditch-Davis D, Belyea M. Problem behaviors in adolescents. Pediatr Nurs 2007;33:13-8. 8. Fongkaew W, Fongkaew K, Suchaxaya P. Early adolescent peer leader development in HIV prevention using youth-adult partnership with schools approach. J Assoc Nurses AIDS Care 2007;18:60-71.
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