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CASE CHALLENGES
The patient was a 36-year-old man with a limited past medical history who presented
with complaints of abdominal pain. The pain had an achy sensation — ranked two out
of 10 in intensity — radiating down toward his groin. The patient reported taking some
magnesium citrate two nights prior to his initial presentation without much relief in his
pain. He had no nausea or emesis. He had no fevers or chills. He said he had lost
approximately 25 lb in the previous three months, but he had been dieting and trying
to lose weight. He denied any chest pain or cough. He had no rashes on his skin. He
had no changes in urinary symptoms, urgency or micturition, and also did not have
any changes in his bowel habits. The remainder of his review of systems was
negative.
Medications: None.
Family history: Mother, maternal grandmother and paternal grandfather all had type 2
diabetes. Maternal grandfather and maternal grandmother had a history of
cerebrovascular accident. No history of malignancy.
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5/16/2019 36-year-old man with abdominal pain and retroperitoneal lymphadenopathy
Social history: He had been in a monogamous homosexual relationship for the past
decade. He had no tobacco use or illicit drug use. He rarely consumed alcohol.
Physical examination: vital signs: Temperature is 97.8 °, pulse 78, respirations 18,
blood pressure 122 mm Hg/74 mm Hg, O2 saturations are 98% on room air. HEENT:
Head examination is normocephalic, atraumatic, extraocular movement are intact.
PERRLA: no pharyngeal erythema or exudate. Neck: Supple, no carotid bruits. No
lymphadenopathy noted. Respiratory: Chest is clear to auscultation bilaterally, no
wheezing, rales or rhonchi. Cardiac: S1, S2, regular rate and rhythm. No S3, S4
appreciated. No murmurs, gallops or rubs noted. GI: The patient has a mild
tenderness to deep palpation of the right lower quadrant. Bowel sounds are positive
and active in all four quadrants, no rebound tenderness. No rigidity and no severe
tenderness. GU: He did not have any testicular enlargement. The patient did not have
any scrotal edema. There were no palpable masses appreciated.
Laboratory: WBC 7.2, hemoglobin 14.3, platelets are 275,000. Kidney function was
normal. Alpha-fetoprotein was < 1.5,="" beta="" human="" chorionic=""
gonadotropin="">< 3,="" and="" ldh="" was="" 630,="" which="" is="" within=""
normal="" institutional="" limits.="">
Case Discussion
This patient is a 36-year-old man with stage II seminoma involving the right testicle
and the retroperitoneal lymph nodes. Although the definition of bulky disease can vary,
it appears this patient has stage II bulky seminoma. Testicular cancer is the most
common malignancy affecting men aged 15 to 35 years. It is a highly treatable
https://www.healio.com/hematology-oncology/news/print/hemonc-today/%7B312cd970-c9c3-4469-b213-9dad3fe99723%7D/36-year-old-man-with-abd… 2/4
5/16/2019 36-year-old man with abdominal pain and retroperitoneal lymphadenopathy
disease, even in the presence of metastatic disease. Eighty percent of patients with
seminomatous testicular cancer are diagnosed with stage I disease, while 15%
present with metastatic disease involving the infradiaphragmatic lymph nodes (stage
II); the remaining 5% present with disseminated disease involving either the brain,
liver, lungs or bones.
However, for patients with bulky lymph node involvement such as our patient, it is
more optimal to consider systemic chemotherapy. Single-agent chemotherapy has
been tried in this setting with poor outcomes. The German Testicular Cancer Group
treated 108 patients with three to four cycles of carboplatin as an alternative to
radiation therapy. In this case, patients initially responded, but 19% relapsed. As a
result, single-agent carboplatin is not recommended. For patients with bulky lymph
nodes measuring at least 5 cm to 7 cm in diameter at presentation, treatment with
radiation therapy alone results in five-year disease free survival rates of 65%. Relapse
rates are as high as 50%. Although the subsequent salvage rates are considered high,
leading to overall survival rates of up to 91% at five years, adjuvant radiation therapy
alone in patients with bulky disease is not considered optimal.
https://www.healio.com/hematology-oncology/news/print/hemonc-today/%7B312cd970-c9c3-4469-b213-9dad3fe99723%7D/36-year-old-man-with-abd… 3/4
5/16/2019 36-year-old man with abdominal pain and retroperitoneal lymphadenopathy
High-dose chemotherapy with stem cell rescue is typically reserved for metastatic
testicular cancer tumors that have relapsed or have not responded to initial platinum-
based chemotherapy with disease free survival rates of approximately 70%.
Retroperitoneal lymph node dissection is typically reserved for patients with
nonseminomatous germ cell tumors.
In our particular case, the patient was treated with four cycles of etoposide and
cisplatin. He tolerated the treatment without significant toxicities. He had a PET scan
following therapy that revealed a residual 2 cm mass with no SUV uptake. Based on
the results of the SEMPET study that resulted in a positive predictive value of 100%
and a negative predictive value of 96%, the patient was observed. Postchemotherapy
residual masses usually represent fibrosis, and given the negative PET scan, the
patient was monitored without any additional therapy.
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