notes by dr Claudio Italiano
Do you have weight and pain in the testicle? Never underestimate this condition and contact your doctor immediately: it could be a simple >> varicocele but it could also be a tumoral lesion of the testis. Let's see, in the most serious case, what it is and what a testis cancer is. In other cases it may be an >>orcitis, ie infection of the testis itself or of a >>prostatitis.
Be that as it may, do not hesitate to visit us immediately: you should not waste precious time with your testicles!
You must regularly check your testicle:
- stand in front of a mirror and see if a scrotum is thicker than the other
- palpate each of the two testicles, to appreciate volume, if there are masses,
if pain is evoked
- check if there are swellings, even if small, as excresciences when a grain of
rice and observes if the scrotum or the upper part of the testicle, epididymis,
is inflamed or painful.
In young men between the ages of 20 and 35, testicular cancer is the most common malignant neoplasm. In the United States, testicular carcinoma is characterized by an annual incidence of 4 cases per 100,000. If the diagnosis is made at an early stage, the cure rate is almost 99%.
-cryptorchidism, if after the age of 12 increases the risk by 5 times, if it has
not been corrected before.
- a family history, for example if a brother is affected, then the risk is 6 to
10 times higher.
- infertility,
- smoking of the mother during pregnancy and of the patient
- the white race.
- estrogen in pregnancy: synthesis of diethylstilbestrol synthesis during
intrauterine life and exposure to a higher risk of developing a carcinoma of the
testes;
genetic factors, possible connection between the carcinoma of the testes and a
gene located on the Xq27 chromosome. '
- diet and trauma as a contributory cause for increased risk.
Routine checks such as routine routinely self-examination and screening exams do
not seem to improve outcomes. The US Preventive Service Task Force and the
American Cancer Society do not recommend this type of intervention in
asymptomatic patients. Patients who present themselves to the doctor complaining
of a painless testicular mass, a sensation of "scrotal heaviness", a dull pain
or an acute pain localized to the testicles must be subjected to an accurate
evaluation.
The testicles masses should be evaluated by scrotal ultrasound. If the ultrasound indicates the presence of an intratesticular mass, the patient must be referred to a urologist, to receive a definitive diagnosis and to undergo, if necessary, an orchiectomy and further examinations, such as a computerized tomography of the abdomen and an x-ray. of the chest. After a diagnosis of testicular carcinoma has been made, the family doctor must advise the patient regarding the use of sperm banks (due to the risk of infertility), and must keep the patient under observation for recurrence and complications, especially cardiovascular diseases.
Testicular cancer is responsible for 1-2% of all male malignancies. '
Testicular cancer is the most common malignant neoplasm among otherwise healthy
men between the ages of 20 and 35, and has an annual incidence in the United
States of approximately 4 cases per 100,000. 1 In the course of the last 40
years the incidence of testicular cancer has doubled, and continues today to
increase, especially among white people. ' The family doctor must be aware of
the risk factors for the carcinoma of the testicles, must be able to diagnose
the neoplasm and must be aware of their role in the treatment of patients.
Screening
Some authors recommend the routine execution of screening tests and testicular
self-examination, on a monthly basis, in young males; according to some studies,
on the other hand, these interventions would not improve patient outcomes.`
Testicular carcinoma is indeed a rare disease, and treatment is highly effective
even when the diagnosis is placed accidentally during an objective examination,
or following the appearance of symptoms.
| stadium
I |
seminoma |
Not
seminoma Dissection of retroperitoneal lymph nodes or observation with menisyl visits IB: Consider 2 cycles of chemotherapy S: Full-dose chemotherapy if serological neoplasm markers do not decrease rapidly after surgery |
| II | IIA: radiotherapy of regional lymph nodes IIB and IIC: Three
cycles of chemotherapy
|
IIA: Dissection of retroperitoneal lymph nodes, followed by observation with
monthly follow-up visits and frequent laboratory tests, or 2 cycles of
chemotherapy with two drugs IIB or IIC: Three or 4 cycles of chemotherapy with 3 drugs, followed by dissection of retroperitoneal lymph nodes if the computed tomography continues to highlight the lymph nodes High levels of serological neoplasm markers: chemotherapy followed by lymph node dissection |
| III | Chemotherapy with 3 drugs; in the absence of an answer, consider clinical studies with other chemotherapy combinations Presence of brain metastases: cerebral radiotherapy or surgical removal |
Chemotherapy with 3 drugs; surgical removal of persistent tumors. Elevated serological neoplasm markers: these patients often do not respond to standard chemotherapy; therefore more aggressive clinical studies can be considered |
Ache
Acute pain at the level of the testis or scrotum
Dull pain in the scrotum or abdomen
Scrotal "heavyness"
Mass effect
Reduced testis mobility
Infertility
Intratesticular mass
Swelling and redness without pain
Metastasis *
Gastrointestinal symptoms
Gynecomastia
Lumbar pain
Mass at the level of the neck
Respiratory symptoms (eg cough, hemoptysis, dyspnoea)
Anamnesis and objective examination
Testicular carcinoma typically occurs in the form of a small non-painful mass
located at the testicular level; some patients also present widespread
testicular pain, swelling, and hardening of the scrotum. The testicular changes
are usually highlighted during a self-examination, following testicular trauma,
or from the patient's sexual partner.
The patients with carcinoma of the testicles
are often mistakenly treated for an alleged epididymitis;
these patients do not respond to antibiotic treatment. In cases where an
epididymitis is suspected, and the patient is treated with a course of
antibiotics, the doctor should arrange a follow-up visit so that the efficacy of
antibiotic treatment and resolution of symptoms can be assessed. If the local
physical examination is too painful, the patient may undergo an ultrasound
examination during antibiotic treatment. When the patient is even in metastasis
(about 5% of patients with testicular carcinoma) may have masses in the neck or
abdomen, low back pain, cough, hemoptysis, dyspnoea or gastrointestinal symptoms.
Approximately 10% of patients with carcinoma of the testes have gynecomastia,
attributable to the production by the neoplasm of the beta subunit of human
chorionic gonadotropin (B-HCG, beta-human corionic gonadotropin). Normally the
testes are homogeneous, movable in the scrotum, and separated by the epididymis.
In patients there may be increased alpha-fetoprotein, and occasionally cause an
increase in B-HCG.
Lactate dehydrogenase levels are often elevated in patients
with widespread and metastatic testicular carcinomas. Once a testicular
carcinoma has been diagnosed, the patient must undergo a computed tomography
(CT) of the abdomen and pelvis, in order to identify possible metastases to
level of retroperitoneal lymph nodes, as well as a radiograph of the thorax. A
CT scan or chest X-ray should be performed in patients suspected of mediastinal
neoplasia, hilar or pulmonary parenchyma. Patients with neurologic symptoms
should be screened or screened for nuclear magnetic resonance imaging in the
brain.
The primary treatment of testicular tumors consists of the inguinal rootectomy, which includes the removal of the testis and the spermatic cord. Once the orchiectomy is conducted, the subsequent treatment is defined based on the results of the microscopic examination (seminorna or non-seminoma) and staging. This article discusses only the treatment of germ cell tumors (seminars). Therapetitic options, after orchiectomy, include patient observation, retroperitoneal lymph node dissection, radiotherapy and chemotherapy. "Observation is a therapeutic option in patients with stage 1 seminomas, and should be frequent ( probably monthly) clinical and laboratory follow-up evaluations. Observation requires a significant collaboration of the patient during the course of treatment.
Chemotherapy with 2 drugs usually includes cisplatin and etoposide, while
chemotherapy with 3 drugs usually includes cisplatin etoposide and bleomycin.
Following the treatment of a testicular carcinoma survival rates are very good;
between 1980 and 2000, mortality rates decreased by 50%. In cases of early
carcinomas without metastasis, the cure rate is approximately 99%. 'In patients
with metastases to retroperitoneal lymph nodes, the 5-year non-recurrent
survival rate is 91-96%. In patients with advanced metastatic carcinoma, 10-year
survival is equal, according to the spread of the disease, to 66-94%.
Following treatment, the task of the family doctor is to ensure adequate
follow-up for the patient; in this context the doctor must discuss with the
patient the possible problems concerning fertility, the risk of relapse, the
complications deriving from the treatment
Up to 60% of patients with testicular carcinoma are sub-fertile at the time of
diagnosis;
Possible complications of treatment of testicular carcinoma
Related to chemotherapy: Azoospermia and pulmonary disorders (from bleomicina)
Neuropathy (from etoposide)
Kidney damage or ear (from cisplatin)
Infertility Recurrence Mortality from cardiac causes after radiotherapy
Second malignant neoplasms (eg leukemia) after radiotherapy or chemotherapy
Medical treatment of testicular cancer can also affect fertility. Chemotherapy
exerts a toxic effect on germ cells; this may result in increased levels of
follicle-stimulating hormone and luteinizing hormone, as well as decreased
testosterone levels.
Azoospermia is a common side effect of chemotherapy; however, many patients have
recovered to normal over time. 21 Dissection of retroperitoneal lymph nodes can
cause nerve damage that can lead to ejaculatory changes. Has a study in Norway
described, in patients treated for testicular cancer, fertility rates of 30%
lower? Because of the risk of infertility, patients should be encouraged to turn
to a sperm bank before treatment.
Patients with a history of testicular carcinoma have a higher risk of developing
a contralateral testis neoplasm. In a study involving almost 30,000 patients
with a previous testicular carcinoma, the overall risk of a new testicular
carcinoma was 12 times higher than that described in the general population.
A possible complication of the carcinoma of the testicles is constituted by the
development, in other sites, of a second malignant neoplasm. The most common
forms are leukemias, which can be a complication of radiotherapy or chemotherapy.
Acute exposure of bone marrow to radiation can cause acute myelocytic or
lymphocytic leukemia.
Numerous studies have shown an increase in cardiovascular risk in patients
treated for a testicular carcinoma. In most cases, cardiac events involved
angina or myocardial infarction, with no increase in mortality rates.
see also other topics tumor index