Article

Diagnosis of testicular cancer with a urine pregnancy test in an austere military medical environment

Correspondence / American Journal of Emergency Medicine 31 (2013) 16121620 1615

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    Diagnosis of testicular cancer with a urine pregnancy test in an austere military medical environment B

    To the Editor,

    Testicular cancer is an uncommon cancer in the United States, responsible for approximately 8000 new cases per year [1]. Although diagnosis of testicular cancer in the United States is fairly straightforward in a hospital environment, obtaining the correct diagnosis can be more challenging in an austere medical environ- ment, such as that encountered in a forward-deployed combat zone. Here is presented the case of a patient whose testicular cancer was diagnosed using a bedside pregnancy test–one of the few diagnostic tests available at our medical facility to assist with the diagnosis.

    A 19-year-old male Marine presented to a clinic at a military base in western Iraq with a 3-week history of a painless mass in the right testicle that had been gradually increasing in size. He denied fever, chills, weight loss, hematuria, dysuria, or other associated symptoms. During that 3-week period, he had been confined to a small forward operating base without any physician consultation available; and he presented to the medical clinic at his first opportunity upon his return from the forward operating base to the main base.

    ? Disclaimer: The views represented herein are those of the author and do not represent the official position of the U.S. Navy, U.S. Department of defense, or U.S. Government.

    Vital signs were normal. Physical examination was remarkable for a very firm 3-cm mass on the upper pole of the left testicle that was nontender and not fluctuant. No epididymal tenderness was present, and there was no urethral discharge expressible. There was no palpable lymphadenopathy, and the result of the remainder of the physical examination was normal. Bedside ultrasonography of the testis revealed an irregular, hypoechoic mass in the area of concern; Doppler flow testing was not per- formed. A qualitative urine pregnancy test was obtained that had a positive result, indicative of human chorionic gonadotropin (hCG) in the urine. This finding was highly concerning for testicular malignancy, and the patient underwent helicopter medical evacu- ation (MEDEVAC) to a US Military hospital in western Iraq with surgical capabilities, where he underwent left orchiectomy. Pathologic analysis confirmed a diagnosis of choriocarcinoma. The patient was evacuated to the United States but was lost to follow- up after this time.

    Practicing medicine in an austere medical environment, such as that found while forward deployed in a combat zone, can be challenging; many diagnostic adjuncts that are readily available in a hospital environment, such as laboratory and radiographic testing, are not available. Testicular cancer is typically diagnosed with a combination of physical examination; testicular ultraso- nography; computerized tomography of the chest, abdomen, and pelvis; and measurement of tumor markers (including ?- fetoprotein, lactate dehydrogenase, and hCG) [2]. In our for- ward-deployed facility, we did not have access to advanced Imaging techniques (save for a portable ultrasonographic ma- chine); and our laboratory capabilities were limited to point-of- care testing of urine and blood.

    Serum testing for hCG is not sensitive for the diagnosis of testicular cancer because only a fraction of testicular malignancies secrete hCG; in one study, 21% of seminomas and 53% of nonseminomatous germ cell tumors were hCG secreting [3]. However, an elevated hCG level in a male patient is very specific for malignancy. This patient’s positive urine hCG test result significantly increased the likelihood that his testicular mass was malignant and solidified the decision to MEDEVAC him for treatment. However, a negative result would have made the decision more difficult, given the risks associated with helicopter MEDEVAC in a combat environment (including potential exposure to hostile fire).

    Despite the challenges posed by a lack of more advanced diagnostic testing in a combat environment, sometimes, the simple ones–like a urine pregnancy test–can provide valuable clues to a patient’s diagnosis.

    Shaun D. Carstairs MD

    Department of Emergency Medicine

    Naval Medical Center San Diego, CA 92134-5000, USA

    E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2013.08.010

    References

    Anonymous. What are the key statistics about testicular cancer? http://www. cancer.org/cancer/testicularcancer/detailedguide/testicular-cancer-key-statistics (Web site). Accessed 15 July 2013.

  13. Stenman UH, Lamerz R, Looijenga LH, Bosl GJ. National Academy of Clinical Biochemistry guidelines for the use of tumor markers in testicular cancer (Web site). http://www.aacc.org/SiteCollectionDocuments/NACB/LMPG/tumor/ chp3a_testicular.pdf . Accessed 15 July 2013.
  14. Germa-Lluch JR, Garcia del Muro X, Maroto P, Paz-Ares L, Arranz JA, Guma J, et al. Clinical pattern and therapeutic results achieved in 1490 patients with germ-cell tumours of the testis: the experience of the Spanish Germ-Cell Cancer Group (GC). Eur Urol 2002;42:553-62 [discussion 562-3].

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