CLINICAL RISK REDUCTION
Testicular cancer O
Professor Krishna Sethia explores some of the pitfalls in the diagnosis and management of testicular cancer
VER 2,000 new cases of testicular cancer are diagnosed in the UK every year. Te majority of these occur in men aged between 15 and 45, making it the commonest tumour in
this age group. However, 25 per cent of cases occur in men over the age of 45 and 6 per cent in men over the age of 60. Germ cell tumours, seminomas and teratomas are common in the younger age group; in older patients the diagnosis of a lymphoma should be considered. Whereas 50 years ago most of the germ cell tumours proved
fatal, advances in chemotherapy since 1970 have resulted in overall cure rates of 95 per cent, rising to 99 per cent for patients with stage 1 disease. Given the potential for some tumours to grow quickly, early diagnosis and referral is therefore important in maintaining this success.
Presentation Men with testicular cancer commonly present having noticed either a painless swelling or enlargement of the whole testicle. A history of trauma is present in about 10 per cent of cases – where this has happened it is important to realise that it is usually the injury that has brought the swelling to the patient’s attention rather than the swelling being the result of the trauma. Occasionally, with hormone-producing tumours, patients present with gynaecomastia. Testicular cancer is not usually painful but is associated with
some discomfort in about 20 per cent of cases – oſten this is a dragging sensation due to its increased weight. If the testis is obviously painful and/or tender it may be due to epididymo- orchitis, but the possibility of a testicular torsion must also be considered. Where there is any doubt the patient should be referred to hospital as an emergency. A few men present with symptoms due to metastatic disease.
General malaise or back pain may occur, as well as a mass in the neck due to enlargement of supraclavicular lymph nodes. Te risk of developing testis cancer is increased if there is a
history of an undescended testis, infertility (especially with a small testis) or a first-degree relative with the disease.
Clinical examination It is important to note that over 95 per cent of men presenting with testicular swellings have benign disease. Te common differential diagnoses include hydrocele, epididymal cyst and varicocoele. Most of these can be distinguished from a tumour by accurate clinical examination, noting particularly the anatomical
16
relationship of the swelling to the body of the testis and whether the swelling transilluminates. Tumours are always within the body of the testis so if a swelling can be separated from the body it is almost certainly benign. Comparison with the normal side is useful, noting particularly
differences in the size, shape and consistency of the testes, any of which may indicate malignancy. In particular, the presence of a small testis should not automatically be assumed to be due to atrophy as it may simply reflect abnormal enlargement of the contralateral testis or, if the small testis itself is abnormally firm, a tumour in a previously atrophic organ. A swelling that transilluminates is likely to be a hydrocoele but
in some men this may be associated with the presence of a tumour – it is therefore important for the clinician to confirm that the body of the testis itself feels normal. Where there is any doubt, an urgent ultrasound scan should be arranged. As described above, metastatic testicular cancer forms part of
the differential diagnosis of neck, especially supraclavicular, swellings and gynaecomastia. In either of these scenarios examination of the genitalia is essential.
Investigation In experienced hands, the diagnosis of a tumour can usually be made by clinical examination alone but in the primary care setting the clinician needs to be confident that a tumour has been excluded. If there is any doubt, an urgent scrotal ultrasound
SUMMONS
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24