Over 10 years ago, I saw a very unusual case that involved a new consultant surgeon – who I will call Mr Head-Holes. The patient was a pale, unwell, young man presenting with weight loss and a noticeable lump. The lump was in his left supraclavicular fossa, a site associated with nasty tumors arising below the neck. After an ultrasound, the radiologist thought it was lymphoma.
I agreed it was malignant, but the clustered epithelioid tumor cells were definitely not lymphoma, and the varied features – including syncytial giant cells – made me think of a germ cell tumor. One great advantage I had in the clinic was the ability to solidify a diagnosis “in the moment” by getting more clinical information before reporting. So, after telling the patient I had collected a diagnostic sample I snuck out of the room to talk to the surprised-yet-skeptical surgeon, Mr Head-Holes.
“Can you examine his testicles?” I asked.
“I don't examine testicles!” he said, dumbfounded. “I’m an ear, nose and throat surgeon! I only examine lumps above the clavicles and these five head holes,” pointing to his ears, nose and mouth.
The nurse turned to him shyly and said, “Sorry, Tim is usually right. I think you'll have to do it!” Her mouth dropped when I added, “And would you mind running a pregnancy test as well?”
Of course, a testicular lump would confirm a germ cell tumor. And if it contained a significant proportion of choriocarcinoma, he may also produce a positive pregnancy test. Mr Head-Holes reappeared triumphantly telling me, “The balls were normal!” But further tests confirmed my suspicions.
“And the pregnancy test?” I hear you cry. It was negative. Amazingly, despite chemotherapy and neck and retroperitoneal lymph node dissections, a positive pregnancy test did eventually occur (for his partner), and he is now a father.
Mr Head-Holes was impressed with my diagnostic skills, but said it was the last time a pathologist would coerce him into examining anyone’s testicles…