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The Six-Month Tune-Up: A Case Study.

History

A 33-year-old white male presented for a "six-month tune-up". He complained of mild stiffness in the left "hip", pointing to the left Sacroiliac region. It was not painful, but made it hard to get out of bed the past few mornings. He had no other complaints and denied any changes in his health status over the past six months.

Objective Findings

Height: 68 inches. Weight: 160 pounds. BP: 117/78. Pulse 70 bpm. Temperature: 98.5.

Appearance healthy. Patient in good spirits. Lungs are clear, depth of inspiration appeared normal and heart sounds were patent. Mild restriction at the left S-I was noted. Decreased ROM lumbar spine in flexion and left rotation was noted. Kemps and SLR tests were negative bilateral. DTR and dermatomes were 2+ bilateral in the lower extremities. Heel/toe raises were performed. Joint lock was noted at levels T10-11, L2-3, and the left sacroiliac joint. No muscle imbalance detected.

Assessment

Segmental biomechanical dysfunction of the thoracolumbar spine and left sacroiliac joint.

Plan

CMT-Diversified Technique, side posture.

The office visit took an odd turn just as soon as the patient was positioned on his right side. With this new position, he complained that his "endowment" was getting bound. He was allowed to re-adjust his genitalia. He was wearing sweat-pants and did so easily. He then stated that over the past few months he had become rather large.

Now, it is not uncommon for a male chiropractic patient to become compressed in the genitalia while in a side-posture position, but his comment about becoming larger prompted further questioning. The patient stated he had noticed over the past 2-3 months that his left testicle had become heavier and had begun to hang lower than his right. It had also gotten somewhat larger, but it "didn't hurt" and made him feel "more well-endowed". This prompted further examination.

Testicular examination revealed a grossly enlarged left testis. It was hard, non-painful to palpation, pressure, or fingertip percussion as compared to the right. The left testicle had an apparent circumference of 6 cm larger than that of the right testis. The left testis did not transilluminate and the right testis did.

The patient was questioned further and he denied any history of undescended testicle in childhood, trauma, sexual dysfunction, or genitourinary dysfunction.

Further evaluation revealed no palpable adenopathy in the inguinal, axillary, cervical, abdominal or supraclavicular regions. No abdominal masses were detected. Distal pulses were intact and no edema was noted in the lower extremities. There was no evidence of inguinal hernia. Dermal temperature of the left testicle measured two degrees warmer than the right.

The patient was informed that further testing needed to be performed to ascertain why his testicle was enlarged. He begrudgingly agreed.

AP and lateral lumbar-pelvic x-rays and chest films were taken. Blood testing including CBC with differential, UA, comprehensive metabolic panel, LDH, lipid panel, ESR, CRP, TSH, AFP (Alpha-fetoprotein), [beta]-HCG (beta human chorionic gonadotropin), and PSA tests were ordered, and specimens were acquired at this initial visit. A prostate/rectal exam was then performed and was unremarkable for palpable masses, or prostate enlargement.

X-ray evaluations of pelvis, lumbar and chest regions were unremarkable for visualized fracture, dislocation or gross pathology.

Working Diagnosis: Undetermined testicular enlargement with DDX of testicular cancer. Segmental biomechanical dysfunction of the spine.

Manipulation of the segmental joint dysfunction was performed with improved mobility attained post-treatment. A follow-up visit was scheduled upon return of laboratory data.

Within five days all laboratory test results were received. [beta]-HCG was elevated to 2,000 mIU/ml. AFP was high at 900 [micro]g/ml. All other tests demonstrated clinically normal levels.

Working Diagnosis: Testicular Cancer

The patient had been referred to a nearby urologist/ internist and since his appointment was scheduled for 10 days after the initial evaluation, all data was received by my office prior to his appointment. The patient had a C-T scan of the pelvis and chest, and both were reported as unremarkable for metastatic involvement. He underwent orchiectomy of the left testicle and histological evaluation confirmed testicular cancer without evidence of tumor dissemination.

Monitoring of the [beta]-HCG and AFP have demonstrated a return to normal, and the patient is six years post orchiectomy and doing well. He opted to not undergo chemotherapy or radiation treatments. He continues yearly physical exams and laboratory testing, as well as self-exams.

Discussion:

There are multiple reasons that a testicle can swell or enlarge. They include:

* Hydrocele: nontender but translucent

* Hematocele: nontender, translucent, but usually with history of trauma

* Chylocele: nontender and translucent

* Tuberculosis: nontender and non-translucent, biopsy must be performed for diagnosis

* Gumma: nontender, indurated, with positive syphilis serologic tests

* Neoplasm: nontender, hard, frequently heavier than hydrocele, does not transilluminate, possible evidence of metastases, gynecomastia may be present

Malignant tumors of the testis are rare. Approximately 2-3 new cases per 100,000 males are reported each year in the United States, and the lifetime probability of developing testicular cancer is 0.2% for an American white male. However, it is the commonest neoplasm in men aged 20-35. It typically presents as a patient identified painless nodule. While the cause of testicular cancer is unknown, both congenital and acquired factors have been associated with tumor development. Approximately 5% of testicular tumors develop in a patient with a history of cryptorchism, with seminoma being the most common. All testicular cancers except pure seminomas have serologic markers. Orchiectomy is necessary for diagnosis and is the treatment of choice for all testicular cancers.

The most common symptom of testicular cancer is painless enlargement of the testis. Sensations of heaviness sometimes occur. Just as with this case, delay in seeking medical evaluation may be delayed for 3-6 month since patients do not recognize this as abnormal--the "If it doesn't hurt, it isn't a problem" attitude. Ten percent of patients are asymptomatic at presentation, and 10% have symptoms relating to metastatic disease, such as back pain (retroperitoneal metastases), cough (pulmonary metastases), or lower extremity edema (vena cava obstruction). [1] This is why one must also evaluate a patient's general health status to assess metastatic involvement of the lymphatic chain, liver, lungs and pelvis, etc., as involvement may be present, though asymptomatic.

An important aspect of the diagnosis and follow-up of testicular cancer is the use of serum markers. Serum markers include AFP, [beta]-HCG, and LDH. They may detect a tumor which is too small to be detected on physical examination or x-rays. Below the age of 15, about 90% of testicular germ cell cancers are yolk sac tumors. In virtually all of these patients, the AFP is elevated at diagnosis and is an excellent indicator of response to therapy and disease status. [3] Serum markers and chest x-rays are important parts of the monthly checkups for patients after definitive therapy of testicular cancer as well as periodic abdominal computer tomographic (CT) scans for 2-3 years to evaluate the retroperitoneal lymph nodes. [4]

The absence of markers does not mean the absence of tumor. Patients typically receive follow-up monthly for the first year and every other month for the second year after diagnosis and treatment. While the majority of tumor recurrences appear within two years, late relapse has been reported and lifelong marker, radiologic, and physical examination are recommended. [5]

Testicular cancer is a highly treatable, often curable cancer that usually develops in young and middle-aged men. Testicular cancer is broadly divided into seminoma and nonseminoma types for treatment planning because seminomas are more sensitive to radiation therapy. For patients with seminoma (all stages combined), the cure rate exceeds 90%. For patients with low-stage disease, as with this patient, the cure rate approaches 100%. [6]

The American Cancer Society recommends a cancer checkup that includes testicular examination every three years for men over 20 and annually for those over 40. [7] Though the ACS gives no recommendation for testicular self-examination, the American Academy of Pediatrics recommends testes self-examination beginning at age 18. [8] The American Academy of Family Physicians recommends an annual clinical testicular examination for men aged 13-39 years who have a history of cryptorchidism, orchiopexy, or testicular atrophy. [9]

As physicians we must be aware of those rarities that can occur, such as testicular cancer. We must be proficient in detecting those suspicious entities and seeing that proper diagnosis and treatment is initiated. We each have patients that we evaluate at certain time intervals for preventative purposes. We need to LISTEN TO THEM... because we just don't know when that "six-month tune-up" may turn into a life saving event.

Harold M. Chalker, DC DABC1, is a Magna Cum Laude graduate of Cleveland Chiropractic College, Kansas City. He earned his diplomate from the American Board of Chiropractic Internists in 1996. He has published multiple article on chiropractic. He is in private practice in Meade, Kansas and is currently on the Allied Helath Staff of Meade District Hospital. Dr. Chalker was a winner of the 1998 Regional Comunity Health Service Award from "Prevention Magazine" and the Alliance for Chiropractic Progress.

REFERENCES

(1.) CMDT. 34th edition. Tierney, McPhee and Papadakis. 824-826.

(2.) Huddart SN, Mann JR, Fornall P, et al.: "The UK Children's Cancer Study Group: Testicular malignant germ cell tumours 1979-1988." Journal of Pediatric Surgery, 1997; 25(4):406 410.

(3.) National Institutes of Health. "National Institutes of Health Consensus Development Conference: Magnetic resonance imaging." JAMA, 1988; 259(14):2132-8.

(4.) Gerl A, Clemm C, Schmeller N, et al.: "Late relapse of germ cell tumors after cisplatin-based chemotherapy." Annals of Oncology, 1997; 8(1):41-7.

(5.) Bosl GJ, Bajorin DF, Sheinfeld J, et al. "Cancer of the testis." In: DeVita VT Jr, Hellman S, Rosenberg SA, eds.: Cancer: Principles and Practice of Oncology. Philadelphia, Pa: Lippincott-Raven Publishers, 5th ed., 1997; 1397-1425.

(6.) American Cancer Society. "Guidelines for the cancer-related checkup: an update." Atlanta: American Cancer Society, 1993.

(7.) American Academy of Pediatrics. "Guidelines for health supervision II." Elk Grove Village, IL: American Academy of Pediatrics, 1988.

(8.) American Academy of Family Physicians. "Age charts for the periodic health examination." Kansas City, MO: American-Academy of Family Physicians, 1994. (Reprint no. 510)
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Author:Chalker, H. M.
Publication:Original Internist
Geographic Code:1USA
Date:Mar 1, 2001
Words:1680
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