Testicular cancer with metastasis to the bones

Recently I took care of a patient with testicular cancer and multiple metastasis to bones, lungs and the brain. This was a mid adulthood male who was admitted to the ICU with shortness of breath and pain all over the body related to pathological fractures.

The patient in his history talked about a lump he had on his testicles years ago and he described it as “itchy” lunp under the skin but didn’t hurt enough to seek medical attention. It went on for years and later he forgot about it as he got used to the mild itchy feeling in his scrotum.

On arrival to ER, the patient had been having shortness of breath with blood tinged sputum and sudden weight loss. He also complained on bones pain all over the body and on x-ray, he was found to have pathological fractures of long bones of the upper and lower legs bilaterally. He also got a chest x-ray that showed multiple masses in his lungs consistent with lung cancer.

Further, the patient was sent for CT-Scan of the whole body and was found to have brain masses sitting on the 4^th ventricle and brain stem areas. The outcome is almost certain that it was just a matter of time before bidding goodbye to this world.

Any physician at such a time when a patient has stage 4 cancer would explain things to the family and facilitate end life tough decisions. This was done and with Hispanic community, letting go of a loved one no matter how sick they are is never an option. Hispanics are known to keep their patients even when there is no possibility of survival.

Chaplain was contacted and after the family insisted that everything possible should be done to save the life of their loved one, the doctors in ER sent the patient to ICU and I was the one to take care of this patient.

Immediately on arrival, serial labs were ordered and drawn. The physicians in ICU without wasting time inserted a central line anticipating the need of good intravenous access for fluid resuscitation.

The patient shortness of breath was getting worse by the minute and the doctors decided to draw an arterial blood gas to check oxygenation status of the patient. In 15 minutes the results were called from the lab as panic with CO2 level of 78. The normal CO2 level in arterial blood gas is 35-45. The oxygen level was only 42 (normal is 78-95). This warranted immediate intubation to secure the airway and optimize oxygenation.

Anesthesia team was paged and within a matter of minutes, they arrived in the ICU and intubated the patient. Everything was explained to the family that he might never be able to breathe on his own for the rest of his life. The family insisted that they wanted everything done.

The following day, the oncology experts evaluated the patient and was started with chemotherapy. Radiation therapy was not an immediate option as cancer had spread to many parts of the body.

The first round of chemotherapy was done with every expectation explained clearly to the family. The patient was first given 4 units of blood as he had very low hemoglobin count. He also received several units of platelets that he needed the most.

24 hours after the initial chemotherapy dose, the patient was literally fighting for his life on the ventilator. His heart rate was in 160’s and poor perfusion was evident. Doctors were concerned because of the fact that the bone marrow was destroyed so bad by cancer that the patient was barely making any new blood cells. This meant that the patient had to be transfused many times with multiple blood products.

The struggle fighting for life went on and on and eventually, he coded after being in ICU for about 2 weeks. His bones were so fragile and brittle that CPR the sternum and most ribs, making it a bloody experience.

He died days later after his initial arrest, leaving behind a wife and three beautiful girls. The youngest was 6 years old and the oldest was 10 years old.

Everyone in the unit was feeling the pain just imagining the family and the loss they have incurred. No words could have been good enough for the young girls who came to bedside to view the body of their beloved dad. No tears were painful enough than those shed by the wife, a homemaker who never had a job and could barely speak a word in English. It is a life ahead full of broken dreams for the family. It was an experience painful enough even for doctors and nurses who took care of the patient until their final breath.

Moral of this story

1. Testicular exams are very necessary and every man should do it every month.
2. Never ignore anything that feels or appear abnormal to you. See a doctor immediately for evaluation.
3. Testicular cancer is curable if identified early. Lance Armstrong survived it because it was caught early before metastasis.
4. Testicular cancer can metastasize fast especially to the spine, lungs and the brain. The earlier it is diagnosed, the better the outcome.
5. Multiple organ metastasis called stage 4 cancer and has poor prognosis. Chances of surviving stage 4 cancer are very low, sometimes none.
6. When cancer is a true end stage, hospice care could be a better option that aggressive treatment which the already cancer weakened body cannot tolerate.
7. There is no age too young for cancer. Testicular cancer is commonest between 14 and 40 years. This is such a young age that a lot of people may not think they are in danger.
8. Testicular cancer is one of the most curable cancers known but it has to be identified early enough to increase chances of survival.
9. Any pain, swelling, lump, lack of sexual interest, blood in the semen, lower abdominal dull ache should be reported immediately to your physician.
10. Annual physical exams are vital in detection of testicular cancer.