Reining in a cowboy's uncontrollable vomiting
“At first, I thought the problem was more ‘hyper' than ‘emesis.' I only got concerned when I learned that he had associated left subcostal epigastric discomfort radiating to his back. These episodes were initially infrequent, but they seem to have progressed over the past three weeks. In fact, he was seen at another emergency room, where they got some normal labs, including amylase, and sent him home on Percocet (oxycodone and acetaminophen).
“He drinks only three or four beers a week, so I discounted an alcohol-related gastritis. His only GI complaints are the vomiting and a definite decrease in appetite. It's hard to be sure about real weight loss; he's tall and lean anyway. Occasionally, he has a low-grade fever. There really aren't any pulmonary symptoms. He smokes three to four cigarettes a day. There's some recent urinary hesitancy that I attribute to liberal use of Percocet; urinalysis was normal. He had an angioma of the leg resected in childhood. Oh yes, his maternal grandfather died of Hodgkin's disease.”
This information came from Dr. K in response to the negative groin lymph node I had just read. “I guess you could tell the surgeon to go after one of the enlarged axillary lymph nodes,” I offered. “I don't like to compromise the nodal specimen of a possible lymphoma, but I could do a touch prep and frozen section on part of it just to see if we have diagnostic tissue.”
I should have contained my optimism. We both knew the chances were good that the axillary node would also be nondiagnostic. Unfortunately, it was.
I suggested CT-guided biopsy/aspiration. “Given the generalized adenopathy, particularly the para-aortic glands, and that 5-cm left adrenal area mass, we should be able to fix on something diagnostic. I'll be in the radiology suite reading the smears after each pass. If it's lymphoma, I can send a sample on for flow cytometry at the same time.”
“We need some success here real fast,” Dr. K said. “I've got to get him on nasogastric suction.” Apparently, the patient had already dislodged the Dobbhoff feeding tube that the gastroenterologist had put in during esophagogastroduodenoscopy (EGD). “The EGD found only some diffuse mild gastritis. Esophagus and duodenal sweep were okay. The situation is this: The Tigan (trimethobenzamide) is not holding him, and I'm using IV morphine to control his retroperitoneal pain.”
“Here are the first-pass slides,” said Dr. W, the invasive radiologist. “As you can see by the CTs, my stick is right in the central part of the paraspinal mass just above the adrenal. There was no resistance to the needle cores.”
After scanning the four smears, I said, “All I can see is necrotic, fibrotic debris. Maybe you should try another pass, more at the edge?”
The next pass was very bloody, and Dr. W decided he'd make no additional attempts. I stayed to screen the second-pass smears. He was relieved when I said that I saw rare large cells and groups, which, with the cell block and Cytospin preparation on permanent study, might prove to be tumor. While Dr. W was satisfied with his diagnostic effort, I realized that the material was probably too scanty to be of help.
“What we have are a few large cells, occasionally clustered, with large nuclei and indistinct nucleoli. The cytoplasm is somewhat bubbly, but there is no pigment.”
Next came Dr. S, the oncologist. I could have toured him around a few more slides on the double-headed microscope to delay the inevitable, but I decided to quit. Glumly, I anticipated his question and said, “So we don't have enough on the cell block to do immunohistochemistry. Since we still have a histologic differential diagnosis of melanoma, adrenal carcinoma, hepatoma, and maybe one or two possibilities I can't think of at the moment, why don't you run some serum tumor markers like carcinoembryonic antigen (CEA), a-fetoprotein (AFP), and ß-human chorionic gonadotropin (ß-hCG). Maybe we can put a name to this tumor if we use laboratory medicine.”
“Those markers really did the job,” Dr. S gloated. “The CEA and AFP were within normal range. But the ß-hCG was 192,500 mIU/mL! And the lactate dehydrogenase was six times normal, reflecting a significant tumor burden.”
I asked if anybody had done a testicular exam.
“You bet! In fact, I even got a testicular ultrasound just to make sure we don't have a small primary gonadal tumor.” Dr. S was ready to reveal his entire analysis of the case to me. “This is a retroperitoneal nonseminomatous germ-cell tumor. Almost half of cases have necrotic-fibrotic histology, which was largely seen on the CT-guided biopsy, but there are enough viable cells to make the diagnosis. This is high-burden disease. So, after cisplatin, etoposide, and bleomycin chemotherapy, our patient will need bilateral retroperitoneal lymph node dissection. Even if the glands are normal in size by CT and the ß-hCG normalizes, there's a 20 percent chance of residual metastatic nodal disease. Complete tumor resection is the best chance of cure, since late recurrence is often chemotherapy-resistant, with poor survival. Nerve sparing is generally not an option in bulky disease such as this if there's residual disease postchemotherapy. I know that the prospects of ejaculatory dysfunction and sterility are a tough sell, but we're talking about only a 30-50 percent chance of survival.”
“So our cowboy had pseudocyesis,” I mused. “I hope this isn't his last roundup.”