Neglected right testicular tumor presenting as metastatic pleural empyema

Leema Rebekal Rosy1*, Gobi2, Esthar Rani3

1Assistant Nursing Superintendent, Kauvery Hospital, Tennur, Tamil Nadu

2Nursing Incharge, Kauvery Hospital, Tennur, Tamil Nadu

3Nursing Superintendent, Kauvery Hospital, Tennur, Tamil Nadu

*Correspondence

Abstract

A 23-year-old male presented with chronic cough and intermittent fever for one month and was found to have right-sided empyema thoracis. Detailed evaluation revealed a history of right orchiectomy performed two years ago for a testicular mass, which the patient failed to disclose during the current admission. Histopathology from pleural biopsy confirmed metastatic germ cell tumor, predominantly yolk sac type, indicating relapse and dissemination of the primary malignancy. This case highlights the consequences of poor follow-up compliance and the importance of detailed clinical history-taking. The report also emphasizes the nursing perspective in diagnosis, management, and patient education for continuity of care.

Introduction

Testicular germ cell tumors (GCTs) are the most common malignancy in young adult males, with high cure rates if detected early and followed up appropriately. However, patient negligence in follow-up or lack of disclosure can lead to disease recurrence or metastasis. Metastasis commonly occurs in the lungs, lymph nodes, and liver, but pleural involvement presenting as empyema is extremely rare. This case demonstrates how incomplete medical history and non-adherence to follow-up led to late presentation with thoracic metastasis, complicating the clinical course.

Past History

Two years ago, the patient developed scrotal swelling and pain. He was treated at a local government hospital and subsequently underwent right inguinal orchiectomy at outside hospital. Histopathology revealed right testicular tumor embryonal carcinoma and yolk sac tumor components (mixed germ cell tumor) with elevated alpha-fetoprotein (AFP) and lactate dehydrogenase (LDH) levels. The patient was advised periodic review and oncology follow-up every three months but failed to comply due to being asymptomatic post-surgery.

Present Illness

A 23-year-old male, two months prior to current admission, the patient developed on and off fever and mild right-sided chest pain with productive cough. He sought treatment at a government hospital and was later referred to the tertiary centre (Kauvery Hospital, Trichy) for further management. On admission, he did not disclose his previous orchiectomy history.

Clinical Findings

Vitals

HR110–120 bpm
BP130/70 mmHg
RR20 bpm
SpO₂96% on room air
Temp99–100°F
Respiratory SystemDecreased breath sounds on right side with dullness on percussion.

Investigations

CXRRight-sided empyema thoracis; bilateral lung field changes.
CT Chest (19/9/25)Large multiloculated pleural collection with enhancing wall, thick septations, diffuse pleural thickening, and right ICD in situ.
USG ChestChronic loculated empyema with passive atelectasis of right lung.

Tumor Markers

AFP520 ng/ml (elevated)
LDH671 U/L (elevated) β-hCG :<2.39 mIU/ml
Histopathology (Pleural Biopsy)Metastatic germ cell tumor, predominantly yolk sac type.

Treatment

Procedure

  • VATS (Video-Assisted Thoracoscopic Surgery) and Decortication performed on 15/9/25 under GA and epidural.
  • Post-operative Findings: Thickened pleura with chronic empyema cavity drained.

Antibiotics

  • Pre-op: Inj. Dalacin, Cefactam, Pan IV, Magnesol.
  • Post-op: Cefactam, Monopen, Tigecycline, and supportive medications (Paracetamol, Tramadol, Emeset).
  • Chest physiotherapy and spirometer exercises initiated post-surgery.
  • Pleural drain removed on 25/9/25 after confirming lung expansion and stable vitals.

Discharge

26/9/25 with advice to follow up with Medical Oncology for systemic chemotherapy.

Final Diagnosis

Metastatic Germ Cell Tumor (Predominantly Yolk Sac Type) – Status Post Right Orchiectomy (2 years back) – Chronic Right-Sided Loculated Empyema Thoracis.

Discussion

Metastatic pleural involvement secondary to testicular germ cell tumors is an uncommon presentation and often poses diagnostic and therapeutic challenges. In the present case, the patient’s delayed disclosure of his prior right orchiectomy and lack of oncology follow-up led to an initial misinterpretation of the thoracic symptoms as an infectious empyema rather than a neoplastic process. This highlights two significant concerns—poor patient compliance and the need for comprehensive history-taking in all cases of atypical thoracic disease.

From an oncological perspective, germ cell tumors (GCTs) of the testis have an excellent prognosis when managed appropriately with surgery and adjuvant chemotherapy. However, neglecting periodic follow-up and tumor marker monitoring increases the risk of recurrence and distant metastasis. Pleural metastasis typically occurs through hematogenous spread or lymphatic dissemination, leading to pleural thickening, effusion, or loculated empyema-like collections. In this case, imaging and pleural histopathology confirmed the metastatic nature of the lesion.

From a nursing standpoint, this case offers important learning insights into the multifaceted role of nursing professionals in critical care and oncology settings. Nurses are in a unique position to detect incomplete patient histories through detailed assessment and effective communication. Early identification of inconsistencies or missing clinical information can guide timely diagnostic interventions, as seen here.

The nursing role extends beyond routine postoperative care. It encompasses clinical vigilance, patient education, and psychosocial support. In this case, nurses played a pivotal role in monitoring respiratory parameters, maintaining pleural drain function, and ensuring aseptic techniques to prevent secondary infections. Pain management, respiratory physiotherapy, and gradual mobilization were integral components of recovery.

Additionally, patient education formed a cornerstone of nursing intervention. The nurse’s responsibility included educating the patient about the nature of metastatic disease, the necessity of oncology referral, and the importance of lifelong follow-up and tumor marker evaluation. This case reinforces the essential contribution of nurses in bridging the gap between medical treatment and patient adherence. Psychologically, patients who learn of metastatic cancer often experience denial, anxiety, and fear. The nursing team’s empathetic communication and reassurance were essential in helping the patient and his family cope with the diagnosis and prepare for continued treatment. Providing accurate information, emotional support, and involving the family in care planning enhanced compliance and trust. This case also underscores systemic challenges in healthcare, such as lack of follow-up tracking mechanisms and inadequate patient awareness about cancer recurrence risks. It highlights the importance of integrated multidisciplinary care where nursing, surgical, and oncology teams coordinate seamlessly.

In conclusion, this case underlines that successful management of oncological complications is not limited to surgical or medical interventions. Nursing involvement through vigilant monitoring, infection prevention, pain management, education, and psychosocial support is equally crucial for positive outcomes. Continuous education, communication, and follow-up strategies should be strengthened within hospital systems to prevent similar delays in diagnosis and treatment.

Nursing Diagnosis

  • Impaired gas exchange related to pleural collection and decreased lung expansion.
  • Acute pain related to surgical incision and chest tube placement.
  • Risk for infection related to invasive procedures and immunocompromised state.
  • Deficient knowledge related to disease process, follow-up, and long-term management.
  • Anxiety related to diagnosis of metastatic cancer and hospitalization.

Nursing Management

Respiratory Care

  • Monitored respiratory rate, SpO₂, and ABG.
  • Encouraged deep breathing, incentive spirometry, and chest physiotherapy.
  • Maintained oxygen therapy as prescribed and gradually wean off.
  • Ensured ICD drainage system patency and monitor output color, quantity, and consistency.

Pain Management

  • Assessed the pain level using a pain scale.
  • Administered prescribed analgesics (Tramadol, Paracetamol).
  • Provided positioning during coughing to reduce discomfort.

Infection Control

  • Maintained aseptic technique during dressing changes and drain handling.
  • Monitored temperature, WBC count, and surgical site for signs of infection.
  • Administered antibiotics as prescribed and monitor for adverse effects.

Psychological and Educational Support

  • Provided emotional support and counselling to reduce anxiety.
  • Educated the patient and family on the importance of follow-up with the oncologist.
  • Explained medication regimen, dietary advice, and warning signs requiring medical attention.
  • Reinforced adherence to periodic tumor marker evaluation and imaging studies.

Post-Discharge Care

  • Advised on breathing exercises and gradual physical activity.
  • Educated on maintaining personal hygiene and nutrition.
  • Emphasized regular oncology review for chemotherapy and surveillance imaging.

Outcome

The patient recovered from the empyema and was discharged in stable condition with a follow-up plan for oncology evaluation. His condition underscored the need for better patient education and active follow-up tracking after oncologic surgery.

Conclusion

Neglecting post-surgical follow-up in testicular cancer can lead to severe and atypical metastatic presentations such as pleural empyema. Early detection, adherence to medical advice, and proper nursing education are vital in improving prognosis. This case also highlights the indispensable role of nursing professionals in continuity of care, patient education, and long-term surveillance for cancer survivors.

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