A Pathologist Helps Avoid A Balls Up

Dr Tim Bracey and his dog Paddy (22.12.09 to 11-12-23) more than a few years ago!

By Tim Bracey | 18 December 2023

Every year, The Pathologist Magazine publishes ‘The Power List’ of who they see as the most influential international laboratory medicine professionals. I have always feigned a lack of interest in this list, while secretly reading it every year and wishing I might one year make the grade! This year, a friend and, in my opinion, a much more worthy potential recipient of this kind of accolade, Professor Ali Khurram, recommended I apply. 2023 was titled ‘The Storybook Edition,’ where the magazine asked applicants to come up with a heart-warming, educational, or amusing narrative to portray laboratory medicine from a different perspective. After initially writing a conventional article about my career, I had a last-minute change of tack when I remembered the following story from my early consultant experience.

If you don’t work in laboratory medicine, I’m sure you are thinking to yourself, ‘There must be no end of hilarious stories when you work in a Histopathology Department,’ but no, amazingly, I had to dredge my memory archives for this story from more than 10 years ago!

It relates to a very unusual case I encountered in the days when I did fine-needle aspiration (FNA) of neck lumps in the one-stop clinic, and my first meeting with a new consultant ear, nose, and throat (ENT) surgeon, who to protect his identity from now I will refer to as ‘Mr. Head-Holes.’

The first patient we saw that day was a pale, gaunt young man in his early 20s. He had lost weight and noticed a neck lump. The lump was in his left supraclavicular fossa, an anatomical site notorious for its association with nasty tumours arising below the neck. It is the site of the so-called Virchow node, which is eponymously related to gastric cancer, albeit usually in older patients. The ultrasound in this young man confirmed very large abnormal round and hypoechoic lymph nodes and the radiologist was confident the features represented malignant lymphoma.

I agreed the sample was malignant, but the clustered epithelioid tumour cells were not of lymphoma. The heterogeneous epithelioid features and syncytial giant cells, particularly in this clinical context, made me think about a germ cell tumour. A great advantage in practising one-stop clinic cytopathology, rather than reporting in an office remote from the patient, is the ability to solidify a diagnosis ‘in the moment’ by getting more clinical information before issuing a report. So, after telling the patient I had collected a diagnostic sample, I snuck out of the room to talk to the surgeon. Mr. Head-Holes was surprised, and unsurprisingly sceptical of my proposed diagnosis. ‘Can you examine the patient’s testicles?’ I asked! He turned towards the specialist nurse dumbfounded, saying, ‘I don’t examine testicles! I am 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. She turned to him with a grave expression on her face and said, ‘Sorry, Tim is usually right, I think you’ll have to do it!’ Her mouth dropped open next, when I next turned to her and said, ‘Oh yes, and Steph, would you mind doing a pregnancy test as well?

My thoughts, of course, were that if this were a mixed germ cell tumour, the patient should have a testicular lump, and if it contained a significant proportion of malignant trophoblast (choriocarcinoma), he might also have a positive pregnancy test, since the test detects the hormone beta hCG (produced by benign pregnancy-related placenta, or malignant tumour-related trophoblast). I was disappointed when Mr. Head-Holes reappeared triumphantly telling me that ‘the balls were normal’! The ultrasound scan performed later, however, did confirm a testicular tumour, and a subsequent biopsy confirmed the lump was indeed metastatic mixed germ cell tumour. ‘What about the pregnancy test though?’ I hear you cry; well, it was negative, but amazingly, despite going through chemotherapy and neck and retroperitoneal lymph node dissections, his partner later did get a positive test, and they conceived a child together. Mr. Head-Holes finally admitted he was impressed with my diagnostic skills, and conceded he had made the right career choice, but that it would be the last time a pathologist would coerce him into examining anyone’s testicles again!

Share This Post

Leave a Reply