Delivered by Ingenta to: University of Bath IP: 141.101.132.222 On: Fri, 22 Jul 2016 17:56:28 Copyright: Aerospace Medical Association CASE REPORT 1136 Aviation, Space, and Environmental Medicine x Vol. 85, No. 11 x November 2014 B ERMUDEZ DJ, G ROH J. Metastatic testicular cancer presenting as lower back pain in a pilot. Aviat Space Environ Med 2014; 85:1136–8. Background: Lower back pain is ubiquitous in the helicopter commu- nity and testicular cancer is the most common solid organ tumor that affects approximately 1% of men ages 15 to 35. However, rarely is lower back pain caused by testicular cancer and, in an otherwise healthy male, it is generally low on the differential diagnosis. Literature review discov- ered the most recent case report where lower back pain was the present- ing symptom for testicular cancer was in 1987. Case Report: A 26-yr-old male helicopter pilot presented to clinic complaining of lower back pain for greater than 1 yr for which conservative treatment had failed. The pain was so severe he was unable to sleep and had to remove himself from the flight schedule. The patient was seen by physical therapy and a chiropractor and treated with NSAIDs and other pain medications, in- cluding narcotics. After further investigation, it was discovered that the patient’ s lower back pain was a result of a retroperitoneal metastatic tu- mor originating from his right testicle. Discussion: It is important to con- sider that, although most aviators in their twenties have been screened for chronic illness, they are still at risk for developing cancer. In this case, the patient never complained of testicular mass or pain and even denied symptoms during review of systems questioning. Proper education re- garding the importance of self-examination and reporting of abnormali- ties is key to early detection and intervention. The 5-yr survival for metastatic testicular cancer is greater than 95%. Keywords: helicopter, retroperitoneal, tumor. T ESTICULAR CANCER is the most common solid organ tumor for men between the ages of 18-44. Its origins are either seminoma or nonseminoma in its histology. In either case the primary presentation is re- lated to some testicular abnormality with respect to change in size, texture, swelling, or altered function. This is a case of a helicopter pilot whose chief complaint was progressive and unremitting back pain to the point of inability to sleep. Aircrew members in the helicopter community have a very high prevalence of back pain, documented to be as high as 50–92% (3). That a pilot should have back pain is not surprising, but its degree and clinical course is rarely so bad that the member cannot sleep. He was seen by multiple providers in the course of 2 wk, including an emergent neurosurgical evaluation, and all save one ar- rived at the cause of this pilot’s back pain. Testicular cancer is an extremely rare cause of back pain, presump- tively caused by para-aortic lymph node involvement, which may not be obvious on physical exam. A literature review revealed that the most recent case report of lower back pain as the presenting symptom for testicular cancer was in 1987. Data presented by Cantwell et al. (2) illustrated the need to consider tes- ticular cancer as etiology of lower back pain in young men. The article reported two cases involving men with lower back pain, ultimately caused by testicular cancer metastases, presenting without unilateral testicular en- largement. Both patients were found to have para-aortic lymph node metastases. This initiated a review of 42 pa- tients’ medical records with proven germ cell testicular malignancy. Nine (21%) patients with a presenting symptom of lower back pain had lymph node metastases. The au- thors found that in patients who presented with low back pain, time from onset of symptoms to doctor’s visit was 20 wk versus 8 wk for patients with testicular signs and symptoms without lower back pain. Also in pa- tients with lower back pain, the delay from first doctor’s visit to diagnosis was 12 wk versus 1 wk in the testicular symptom group. Clearly, patients with testicular symp- toms without lower back pain were diagnosed more quickly. The patients who presented with lower back pain re- gardless of testicular enlargement suffered long delays in diagnosis. It remains prudent, 27 yr later, to question men with prolonged, nontraumatic back pain about tes- ticular abnormalities. Unmistakably, back pain may be a sign or symptom of testicular malignancy and in our case, due to lack of testicular symptoms, our differential diagnosis was confounded. It is prudent to raise aware- ness that prolonged lower back pain which fails to im- prove with conservative treatment should be further assessed, including ruling out testicular malignancy in young males. CASE REPORT A 26-yr-old active-duty Caucasian male helicopter pi- lot presented to an aviation medicine clinic to reassess chronic lower back pain (LBP). His intermittent lower back pain began 2 to 3 mo after a minor motor vehicle incident 1 yr prior, for which he was seen previously by several providers. His chief complaint at this visit was From the U.S. Navy, Jacksonville, FL. This manuscript was received for review in October 2013. It was accepted for publication in August 2014. Address correspondence and reprint requests to: Daniela J. Bermudez, D.O., U.S. Navy, 2080 Child St., Naval Air Station Jacksonville, Jacksonville, FL 32214; drdjbermudez@gmail.com. Reprint & Copyright © by the Aerospace Medical Association, Alexandria, VA. DOI: 10.3357/ASEM.3886.2014 Metastatic Testicular Cancer Presenting as Lower Back Pain in a Pilot Daniela J. Bermudez and Jonathan Groh