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Testicular Cancer Diagnosis and Management

April 05, 2014

Introduction

Around forty years ago testicular cancer was one of the worst cancer a man could have. In the last 25 years however we discovered that anti metabolite drug like Methotrexate can successfully cure testicular cancer and if resistant, radiotherapy works well as well. Testicular cancer has become probably success story of our times. In addition, blood markers like B hCG and AFP produced by the tumor can help early diagnosis. All that we now need is for young man be aware that the condition will need seek early help.

It happens in young men and the cancer is notorious for it’s propensity for rapid spread. Also, since the early presentation is always innocuous and as the patient understandably embarrassed to seek early help, it was most commonly diagnosed late.

The cases described in the Mail-online are sad in that as a result of a combination of problems ranging from late referrals to surgical goof-ups, a lot of these men lost at least one testis. It however should not overshadow the fact that early referral and appropriate treatments still has saved hundred times more cases than the ones in the news on this occasion. This small write-up explain how the diagnosis and treatment of testicular cancer work.  There is a small number of cases which can present quite ambiguously in terms of investigation reports. This can cause a wrong removal of testes. That is of course way different with the various mistakes mentioned in the report.

Presentation

a. Testicular cancer rarely presents with pain. So men have to look out for painless growth in one of their testis that makes it  heavy.

b. Typically the lump in the testis is firm to hard but can also be pliant. The testis may feel irregular.

c. It is for this reason we recommend men examine their testes every few weeks just like we address women’s examine their breasts once every month.

d. The couple could not just remind each other about this crucial examination but do it to each other which brings some sort of playfulness in what is an essential screening test and can be life saving.

Investigations for testicular cancer.

a.Most important test is blood test for the following hormones Beta hCG and alpha feto protein. These two are chemicals which are produced by various embryonic tissues. As testicular cancer is described as a “germ cell” cancer, it almost always produces either or both of these chemicals which are medically called “tumor markers”.

b. A testicular examination by the surgeon to document any physical abnormality.

c. An ultrasound scans check for any presence of lump and compare the two testes.

Confirming the diagnosis.

The presence of lumps as well as tumor markers is suggestive almost diagnostic of testicular tumor. The confirmation of this has to be by a testicular biopsy.

Unlike breast cancer and many other cancers, the biopsy cannot be using a needle  (for the risk of encouraging the spread of the tumour) it has to be by removal of the testes. This is called excision biopsy by which we excise the testis and move it completely along with the chord attaches with the abdomen cavity. Technically the operation is called high ligation and excision biopsy of the testis.

Treatment of the cancer.

Germ cell tumors such as testicular tumor are highly sensitive to both radiations as well as oral course of oral methotrexate . The choice is methotrexate because it not just destroys the tumors but also spares the un-affected testicular tissue and thus preserves fertility. Radiation will most likely destroy all testicular tissue in both testes.

What if the diagnosis by tumour markers and USG is wrong ?

In the above diagnostic process we mentioned that the confirmation of the diagnosis will be by “excision” biopsy i.e. removal of the entire testis. The tumour markers being elevated and an ultrasound scan showing tumour is the classic finding and in the presence of these two findings, it is extremely unusual that the biopsy report will show that the testis was normal. However sometimes surgeons get it wrong. These are limitations of the diagnostic system not fault of treating physician. It is a small risk (probably one in 1000) which is explained to the patient on by and large most patients are happy to accept this.

The clear-cut picture of testicular mass by ultrasound scan the tumor markers being elevated may not be present in all presenting cases. Here comes the question of interpretation and clinical judgement. In such cases the risk that a normal testis was removed is obviously higher but nevertheless it is a legitimate risk and it explained to the patient will be seen as an unavoidable complication of the procedure. It is a question of balancing the risk of malignancy spread against the risk of unnecessarily removing normal testes.

Prognosis

The prognosis of removing one testis (with or without cancer) is excellent in all that is expected that of testis. The remaining testis can not only reduce adequate hormone to sustain the man’s metabolism but also give him a necessary libido and rest of life. The remaining testis produces the same number of sperm as the two testes did before, and by and large there is nothing that is changed apart from the cosmetics. In today’s world plastic surgery and prosthetic replacement can effectively solve that problem as well.

Conclusion

All men especially young men need to be made aware about the risk of getting testicular cancer and importance regular testicular examination.

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