Main: coloured transmission electron micrograph of a section through teratoma cancer cells in a testis. Above: coloured ultrasound of testicle with teratoma.
enlargement of the lesion requires that the testis be explored. Tere are a small number of patients who present acutely ill
with advanced, possibly life-threatening, metastatic disease. Tese patients should be referred immediately to an oncologist as they may require immediate chemotherapy before any treatment for the primary tumour. For the majority, however, radical inguinal orchiectomy is the treatment of choice. Apart from the complications of infection and bleeding,
scan should be arranged or the patient should be referred under the two-week rule for suspected cancers. Ultrasound is usually diagnostic but there are a small number of lesions which remain equivocal even when Doppler studies are included. In addition, ultrasound has a small false-positive rate with some benign conditions (e.g. epidermoid tumours, infarction) capable of mimicking cancers. If the scan shows a tumour or if it is inconclusive, an urgent referral to the local urology department is mandatory, again under the two-week pathway. Serum α-fetoprotein (αFP) and β- Human chorionic
gonadotrophin (βHCG) levels are valuable markers for germ cell tumours, being elevated in 50-70 per cent of patients. Tese markers can provide useful prognostic information and must be measured wherever there is a suspicion of a tumour. In the case of uncertainty, raised marker levels may also aid diagnosis.
Management Where the ultrasound scan leaves doubt about the nature of a testicular abnormality and the tumour markers are normal, it is reasonable for a urologist to monitor a lesion by arranging a further ultrasound in 6-8 weeks’ time. However, before adopting this strategy the scans must be discussed and agreed in a multidisciplinary team (MDT) meeting. Te outcome of this meeting should be clearly recorded in the patient’s notes, and both the patient and his GP should be informed. If the lesion remains stable, continued observation may be justified but any
SUMMER 2015
patients should be warned of the small possibility that the testicular lesion may be benign – a scenario which frequently gives rise to litigation. At operation the spermatic cord is clamped at the internal ring and the testis delivered through the groin incision. Where there is a history of increased risk (e.g. small testis, maldescent) biopsy of the contralateral testis should be considered. Te risk of postoperative pain can be reduced by taking care not to damage the ilioinguinal nerve during surgery. Postoperatively, αFP and βHCG levels should be re-measured – persistence of raised levels suggests the presence of distal disease. In patients with only one testicle, if the lesion is small and
tumour markers are normal it may be possible to perform a partial orchiectomy thus maintaining some hormone production and avoiding the need for testosterone replacement therapy. All patients undergoing orchiectomy should be offered
insertion of a testicular prosthesis as part of the same procedure. Tey should be informed that the prosthesis will provide only an approximate match to the remaining normal testis and that it may tend to ride high in the scrotum – this can be improved by gently manipulating the testis downwards daily in the postoperative period. Tey should also be warned of the risk of infection which could result in the prosthesis having to be removed. As both the surgery and any subsequent treatments can impair
fertility, patients should be offered sperm cryopreservation before orchiectomy, and they should also be informed that fertility rates using thawed sperm fall with increasing age of the female. Following surgery all patients require CT scanning and then
should be referred to the regional testicular cancer MDT meeting for consideration of adjuvant treatment.
n Professor Krishna Sethia is a consultant urologist and medical director at Norfolk and Norwich University Hospitals and an honorary professor at the University of East Anglia
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PHOTOGRAPHS: STEVE GSCHMEISSNER/SCIENCE PHOTO LIBRARY; DU CANE MEDICAL IMAGING/SCIENCE PHOTO LIBRARY
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