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Lump not looked into

01 May 2004

Mr Y, a railway engineer and father in his 20s, visited his GP, Dr O, as he’d noticed a small lump in his right testicle. He initially raised the issue whilst his wife was seeing Dr O and he was accompanying her. Dr O reportedly examined Mr Y’s testicles and said the lump was probably a cyst.

He told Mr Y that he should keep an eye on it and come back to see him if the lump grew any bigger. Dr O has no recollection of the consultation and has no record of it.

Mr Y came back to the surgery seven months later, and saw Dr J. According to Mr Y’s account, he told Dr J that the lump in his right testicle had grown larger and that his right testis had become hard, lumpy and heavier compared to the left side.

He also told Dr J that he had noticed lumps beneath his nipples. The consultation note reads,‘ C/O testicular swelling. O/E NAD. Reassured. C/O lumps under nipples, O/E palpable breast lesion. Both nipples grape sized. No axillary LN.No discharge.Imp. physiological, reassured.’

About a year later, Mr Y saw Dr O again. By now, he was experiencing pain in his right testicle. Dr O examined Mr Y and, finding an abnormal enlarged testicle, made an immediate referral to hospital, where Mr Y was seen the next day.

Shortly after this, testicular cancer was diagnosed. Mr Y had a 4.5 cm tumour in the right testis, retroperitoneal/intrathoracic lymph node invasion and metastases in the lungs and brain. Initially, his prognosis appeared poor.

Fortunately, Mr Y responded well to surgery and chemotherapy, surviving without evidence of tumour recurrence three years later. He started legal proceedings against Dr O and Dr J, alleging that their initial failure to refer him to hospital was negligent.

He claimed compensation because he could no longer do the physical work his job demanded and had been rendered infertile (a semen sample had, however, been extracted and preserved prior to chemotherapy).

Expert opinion

GP experts felt that Dr O’s response to Mr Y’s initial report of a testicular lump represented poor care. In their opinion, he should at least have made firm arrangements for a follow-up examination, instead of leaving it to the patient to judge whether he needed to be seen again.

Regarding Dr J’s inaction when he saw Mr Y with a history of a prolonged and enlarged testicular lump along with new gynaecomastia, the experts felt that this would not be supported by a responsible body of GPs.

According to an expert in oncology, Mr Y would probably not have suffered metastasis and could have been treated with surgery and monitoring alone, had the cancer been diagnosed after his first visit to the GP. If he had been referred at his second visit, Mr Y’s prognosis would have been significantly better and it was unlikely that he would have developed cerebral metastasis. In light of the opinions on liability and causation, we settled the claim out of court.

Learning points

  • Negligence claims for failed or delayed diagnosis of testicular disease are a regular occurrence. An article in Casebook [1], published in 2002, discusses pitfalls in diagnosing acute and chronic testicular complaints. Take a cautious approach to swellings within the substance of the testis and/or testicular pain; examine the testes carefully and, if the diagnosis is equivocal, refer the patient as a matter of urgency.
  • Testicular cancer is not a common cause of gynaecomastia, but is known to be associated with it. In a recent survey of 127 men presenting with gynaecomastia, 4 were found to have testicular cancer. Of these, 2 had palpable testicular masses, and 2 required ultrasound evaluation to make the diagnosis. Testicular examination and consideration of ultrasound of the scrotum, as part of the assessment of gynaecomastia, is recommended.
  • If someone asks you for a consultation while you’re seeing another member of their family, be sure to make a note of your findings and add them to the patient’s records. Alternatively, ask them to make a separate appointment, when you will have their medical record available. Dr O failed to record the substance of his impromptu consultation with Mr Y, and this hampered his defence when the claim was made.

Further reading

Anthony S, ‘Scrotal Confusion’, UK Casebook 19; International Casebook 17 (2002)

See Daniels IR and Layer GT. ‘Testicular Tumours Presenting as Gynaecomastia’.Eur J Surg Oncol, 29(5):437–9 (2003).