Keep looking until you find

The patient is 24-years old male with no previous medical history. He has worked for the last 3 years in the packaging line of Divigel, the estradiol gel of the pharmaceutical company Orion. He sought medical attention 11/2014 due to soreness of both breasts, that had continued for a few weeks. In laboratory tests taken in primary health care, E2 was elevated at 0.49 nmol/l (reference range <0.15 nmol/l), LH immeasurably low (1,7–8,6 U/l), testosterone 33 nmol/l (10–38 nmol/l). Liver and thyroid values were normal. An ultrasound examination of the breasts revealed gynecomastia: mammary gland tissue was seen under the nipple on both sides, 2 cm on the left, 1.5 cm on the right. The ultrasound examination of the testicles did not reveal any abnormality. The patient was referred to the endocrinology outpatient clinic. E2 was then 0,236 nmol/l, testosterone 42, free testosterone 547 pmol/l (190–560 pmol/l), SHGB 51 (18–54 nmol/l), LH <0,10 U/l, FSH 0,12 U/l (1,5–12,4 U/l), PRL 426 (86–324 mU/l), hCG elevated 37 U/l (<2 U/l) and free β-hCG 5,8 pmol/l (<2 pmol/l). In 12/2014, the patient underwent a CT scan of the body and ultrasound examination of the testicles was repeated: no abnormality was found in either examination. 18F-FDG PET/CT of the body was performed in the same month, also with normal findings. At the beginning of 2015, MRI examinations of the mediastinum, lower and upper abdomen, and head were performed; no explanation was found. Cerebrospinal fluid hCG, which was low <1,0 IU/l, and S-AFP, which was 2 kU/l (<10 kU/l), were also checked. At follow-up, hCG continued to rise to 135 U/l and E2 to 0.424 nmol/l. Imaging studies were repeated: CT of the body was performed in 11/2015 and 8/2015, ultrasound examination of the testicles in 4/2015, 8/2015 and 12/2015. In 3/2016, a 11C-metionine PET/MRI of the body was performed. No abnormal findings were found. In the sixth ultrasound examination of the testicles in 6/2016, a 5×6 mm low-echo, solid tumor was finally found on the surface of the left testicle at the very front edge. No abnormalities were found in the right testicle. Testicular operation was performed 6/2016. Findings suitable for seminoma were found in the ice section, after which the left testicle was removed. Histopathological findigs were consistent with seminoma. In immunostaining, the tumor cells were PLAP- and CD117-positive, and a widely positive reaction was seen around the tumor in the seminiferous tubules, consistent with carcinoma in situ findings. CD30-, CKPan-, hCG-, inhibin- and AFP-stainings were negative. The findings were consistent with seminoma, and no other germ cell tumor components were found. After surgery, E2 and hCG values normalized. Abdominal CT examination did not reveal any metastases. Follow-up by an oncologist continued for five years, and no signs of recurrence were found. Sometimes we know what we are looking for, but reaching a diagnosis may require persistence and repeated examinations.