CASE STUDY Karen Fitzmaurice

Urology Cancer Coordinator Tallaght Hospital

Presentation• 25 yr old single

man• No PMX of note• Sept 2012

generally unwell• Weight loss• Fever• Night sweats

• Seen by GP

• CT – large retroperitoneal mass

15 x 12 x 11cms

• Referred to Oncology

Presentation

• Tumour Markers

• AFP – 1.0 (0 - 5.0)• HCG – 6.2 (<5 )• LDH – 2475 (100 - 350)

• Testicular exam - NAD

• Bx. of mass – extra gonadal germ cell tumour – embryonal carcinoma.

• Sperm banking attempted - no sperm seen

Treatment

• 4 cycles EP (Etoposide & Cysplatin)

• Complicated by intrahepatic thrombosis of the IVC

• Commenced Clexane

• CT - mass reduced in size to

5.2 x 4.2 x 3.7 cms

• Referred to Mr Thornhill

Surgery

• Extensive RPLND on 24/05/2013 - mass was densely adherent and required an arterial graft from aorta to the right iliac artery.

• Operating time 8 ½ hours

• EBL= 3,600mls

• Developed right leg ischemia in the recovery room & returned to theatre

Exploration of graft with popliteal &

pedal embolectomy

• Significant amount of thrombus recovered

• Transferred to ICU

1ST Day Post Op

• Developed right leg pain & reduced ankle movement.

• Possible compartment syndrome (increased pressure within a muscle compartment)

• Patients are at higher risk of compartment syndrome when a blood vessel is damaged & subsequently repaired through surgery.

Right Calf Fasciotomy

Closure of medial fasciotomy &VAC dressing to lateral

fasciotomy 27/05/13

Post Operative care

• MDT – nursing & medical staff, dietician, physiotherapy, Pain team, occupational health, discharge planning.

• PCEA • TPN• NPO, N/G, central line• U/C • Clips & tension sutures• Heparin x 7 days then

clexane

• 6/7 ICU• Weight bear 3/7 post op• Exercises - prevent foot

drop• Resting calf splint • Mobilising frame 2/52 post

op. • Vac dressing x 15 days• Occupational health home

visit• Discharged on 12/06/13

Discharge

• Convalescence x 1/52• Community physiotherapy• 24/07/13 seen in clinic for histology

results – no evidence of residual viable tumour.

• D/C from urology to oncology.• October 2013 – resumed normal

activity i.e. swimming & cycling.• Continues to attend physiotherapy

sessions.