Managing testicular cancer
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7302.1583 (Published 30 June 2001) Cite this as: BMJ 2001;322:1583All rapid responses
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EDITOR
We read with interest the excellent, comprehensive review article on
Managing Testicular Cancer (1).
However, we were surprised that the combination of bleomycin,
etoposide and cisplatin was recommended as standard treatment for
metastatic seminoma more advanced than stage IIB. This contradicts a
recent paper by the same authors (2). Trials in metastatic seminoma are
difficult because of its rarity. This study closed early and showed no
difference between single agent carboplatin and cisplatin with etoposide.
The authors concluded that the two drug combination would be a reasonable
recommendation for standard practice in good prognosis cases (2). A
retrospective analysis of 142 cases compared four multi-drug regimens and
concluded that cisplatin and etoposide was highly effective; it was the
authors standard therapy (3). This view is endorsed by the COIN
guidelines (4).
The risk of fatal bleomycin pulmonary toxicity increases with age to
as much as 10% in the over 40 age group (5), and is, therefore, higher in
the seminoma population which has a peak incidence between the ages of 30
to 40 years, with a significant number of cases over that age. Using
bleomycin, in addition to etoposide and cisplatin, increases this
potential fatal risk without offering proven benefit; such an approach
would only be appropriate for the few patients presenting with adverse
risk factors (2).
Jane Robson
Oncology Nurse Practitioner Testicular Tumours
Oncology Centre Box 193, Addenbrookes NHS Trust, Cambridge CB2 2QQ
Michael V Williams
Consultant Clinical Oncologist
Oncology Centre Box 193, Addenbrookes NHS Trust, Cambridge CB2 2QQ
1 Dearnaley D P, Huddart R A & Horwich A. Managing Testicular
Cancer, BMJ 30 June 2001; 322: 1583 - 1588
2 Horwich A, Oliver RTD, Wilkinson PM, Mead GM, Harland SJ, Cullen MH
et al. A Medical Research Council Randomised trial of single agent
carboplatin versus etoposide and cisplatin for advanced metastatic
seminoma. British Journal of Cancer 2000;83(12): 1623-1629
3 Mencel PJ, Motzer RJ, Mazumdar M, Vlamis V, Bajorin F and Bosl GJ.
Advanced seminoma: treatment results, survival and prognostic factors in
142 patients. Journal of Clinical Oncology 1994 Jan;12(1): 120-126
4 Clinical Oncology Information Network (COIN). Guidelines on the
management of adult testicular cancer. Clinical Oncology
2000;12(Suppl):S173-210
5 Simpson AB, Paul J, Graham J, Kaye SB. Fatal blemycin pulmonary
toxicity in the west of Scotland 1991-95: a review of patients with germ
cell tumours. British Journal of Cancer 1998;78(8):1061-1066
Competing interests: No competing interests
Regular review: Managing testicular cancer
EDITOR- Dearnaley et al1 have given a lucid textbook account of
management of testicular cancer in their review article. This paper is
useful for practising urologists and oncologists. However it fails to
bring some important messages for general practitioners and other
clinicians who see a number of patients with various testicular symptoms
including malignancy. Apart from a high index of clinical suspicion,
ultrasound examination remains the single most important and initial
investigation available to all clinicians in the initial diagnosis of
testicular malignancy. Any patient with testicular symptom/s in this day
and age should unquestionably have the benefit of ultrasonography. This is
particularly important in common conditions like testicular pain and
hydroceles as the testicular cancer could be easily missed. Even patients
presenting with equivocal symptoms of epididymo-orchitis should have pre
and post anti-microbial therapy ultrasonography. The statement 'ultrasound
examination only should be done within 2 weeks if there is clinical
uncertainty' is misleading. Authors should have highlighted the importance
of ultrasound in summary points.
The authors have not addressed some important and practical clinical
issues in the management of testicular cancer. They have probably
overlooked the fact that there are 2 testes. In the incidence and
aetiology section, the details of incidence of cancer in contralateral
testis and the possibility of developing future testicular cancer should
have been mentioned. Currently anyone presenting with rapidly developing
testicular swelling is screened for testicular cancer. There are, however,
other unusual presentations, which can easily mislead an unwary clinician.
Not infrequently we see patients with large para-aortic masses with silent
or small primary focus in the testis. There is no mention of testicular
microlithiasis in the aetiology section as there is an increased
association of testicular cancer with it2. We routinely follow these
patients with serial ultrasound examinations. Male infertility is another
rare but not uncommon presentation.
Finally, the most difficult issue as far as the patient is concerned
is future fertility in presence of bilateral testicular tumours. Due to
advances in assisted conception techniques, patients with bilateral
testicular cancer can store normal testicular tissue after bilateral
orchdectomy.
Vinod H. Nargund
Consultant Uro-Oncological Surgeon and Honorary Senior Lecturer in Surgery
St Bartholomew's Hospital, West Smithfield, London EC1A 7BE
REFERENCES:
Dearnaley D P, Huddart R A, Horwich A. Regular review: Managing
testicular cancer. B M J 2001;7302:1583-1588.
Miller R L, Wissman R, White S, Ragosin R. Testicular microlithiasis:
a benign condition with a malignant association. J Clin Ultrsonography
1996; 24: 197-202
Competing interests: No competing interests
The Regular Review - "Managing testicular cancer" was very
comprehensive but I would like to draw attention to a possible omission in
aetiological factors. "Scrotal temperature is increased in disposable
plastic lined nappies" (1). The authors of this article suggest that
raised scrotal temperature may be a cause of increased testicular cancer.
(1) C-J Partsch, M.Aukkamp, WG.Sippell. Scrotal temperature is increased
in disposable plastic lined nappies.Arch Dis Child 2000;83:364-368. (16th
May).
I have a competitive interest. I am Medical Adviser to a company
developing a cotton based re-usable nappy.
Competing interests: No competing interests
Editor
In this otherwise excellent review of the management of testicular
cancer there is a glaring omission regarding the need for assessment and
management of sexual difficulties in men after treatment for such
malignancy. Whilst accepting that Moynihan et al did not find additional
routine formal counselling or psychosocial therapy helpful (1)any
involvement with patient decision making must include adequate information
about potential difficulties in this area. Health professionals need to
know how best to elicit patient's needs and readiness for information as
well as their desire for involvement in decision making (2). A review and
meta-analysis of thirty-six empirical studies published between 1975 and
2000 (3)suggests that patients can be accurately informed about the
physiological-sexual risks to be expected after specific treatments as
well as about psychological-sexual vulnerability that may evolve. The
authors found that all treatment modalities reported a decrease of sexual
desire, orgasmic intensity, sexual activity, and sexual satisfaction and
that adequate information and support may prevent or reduce unnecessary
sexual or relational anxiety and suffering. Additionally recent work (4)
suggests that the impact or significance of a diagnosis of testicular
cancer might be influenced by the presence of a current partner that may
be protective against future problems and this should form part of the
overall assessment of risk.
Yours sincerely
Dr Kevan R Wylie
Consultant in Sexual Medicine & Consultant Psychiatrist
Caren Sheppard
Nurse Psychotherapist & Specialist Nurse Counsellor (Oncology)
1. Moynihan C, Bliss JM, Davidson J, Burchell L, Horwich A.
Evaluation of adjuvant psychological therapy in patients with testicular
cancer: randomised controlled trial. BMJ 1998;316:429-35.
2. Centre for reviews and Dissemination at University of York.
Informing, communicating and sharing decisions with people who have
cancer. Effective Health Care 2000;6:1-8.
3. Jonker-Pool G, Van de Wiel HBM, Hoekstra HJ, Sleijfer DT, Van
Driel MF, Van Basten JP, et al. Sexual functioning after treatment for
testicular cancer- review and meta-analysis of 36 empirical studies
between 1975-2000. Archives of Sexual Behavior 2001;30:55-74.
4. Sheppard C, Wylie KR. An assessment of sexual difficulties in men
after treatment for testicular cancer. Sexual and Relationship Therapy
2001;16:47-58.
Competing interests: No competing interests
I thank Dr Rushden for his interest. The overall cure is 95% or more
because 85% of seminomas and 65-70% of non seminomas are stage I and have
cure rates in the order of 99%. With the majority of the patients with
good prognosis doing at least as well as the quoted overview figures 92%
survival and most major centers reporting cure rates of 95% it is only the
smaller proportion of poorer prognosis patients who have survival rate
significantly worse than 95%.
The survival figure quoted is therefore a good 'guestimate' of the results
though clearly selected groups are doing worse
Competing interests: No competing interests
Dear Sir
For many years the BMJ has been criticising newspapers and other media for
misrepresentation and for producing headlines which bear little
resemblance to the story contained in the article. Unfortunately with your
publication of the article by Dearnley et al. you have managed to give
misleading information in the summary box which states that cure rates of
>95% can be achieved. Excuse me if I have misinterpreted the data given
in the prognosis box toward the end of the article, but in this box, the
five year survival for the 56% of patients with good prognosis teratoma is
92% whereas that for the 90% of seminoma patients with good prognosis, the
five year survival is 86%. I was even more confused on reading the text to
discover that "overall survival is nearly 100%" and "about 98-99% of men
with high risk will remain free of recurrence after two courses of
adjuvant chemotherapy containing cisplatin" for stage I teratoma and that
"the cure rate after salvage treatment approaches 100%" for the 2-3% of
stage I seminoma patients who relapse after adjuvant radiotherapy.
I realise that all these rates are exceptionally good when compared with
virtually any other type of malignant disease, especially when even poor
prognosis teratoma patients have a 48% 5 year suvival. But I would have
liked the article to be a bit more consistent with its figures.
Competing interests: No competing interests
TNM Classification in Testicular Cancer: Response to manuscript on managing testicular cancer
We read the review on “Managing testicular cancer” by Dearnaley,
Huddard and Horwich with great interest. The authors of the review of
management of testicular cancer are to be congratulated for their review
of the subject and the presentation of the management concept in a clear
and unambiguous manner. The review is very thorough in most respects and
will be interesting to patients, primary care physicians as well as to
specialists.
However, considering the worldwide appeal of the British Medical
Journal and its international reputation, it is regrettable that the
authors ignored the existence of the internationally accepted UICC TNM
staging classification for testicular cancer. Its TNM Classification is
available for almost all cancers and is used worldwide. The most recent
revision was published in 1997 (2). The classification of testicular
tumours was revised to meet the special needs of clinicians dealing with
this disease. The TNM testis tumour classification used the stage
groupings initially proposed by the Royal Marsden Hospital. However, it
also incorporated the knowledge provided by the International Prognostic
Index for germ cell tumours of the testis developed by a large group of
experts in testicular cancer. It is one of the few TNM classifications
that combines the anatomic extent of disease with tumour markers that are
surrogates for anatomic disease extent. We regret that this important
review missed the opportunity to draw attention to the classification and
to recommend its use worldwide. We append a copy of the TNM classification
for testicular cancer. The UICC version is identical to the AJCC TNM
classification (3) and has been developed with the participation of
experts throughout the world. We believe that the publication of this
classification alongside the review of the management of testicular cancer
would have enhanced the value of this review.
Mary Gospodarowicz, MD, FRCPC
Leslie H. Sobin, MD
1. Dearnaley DP, Huddard RA, Horwich A. Managing testicular cancer.
BMJ 322:1583-8, 2001
2. Sobin LH, Wittekind Ch (Eds). TNM classification of malignant tumors,
Fifth edition. UICC. Wiley, New York, 1997:174-179.
3. Fleming ID, Cooper JS, Henson DE, Hutter RVP, Kennedy BJ, Murphy GP,
O'Sullivan B, Sobin LH, Yarbro JW (Eds). AJCC Cancer Staging Manual, Fifth
edition. Lippincott, Philadelphia 1997:225-228.
TNM Classification Testis
pT – Primary Tumor
pTX Primary tumor cannot be assessed (if no radical orchiectomy has been
performed TX is used)
pT0 No evidence of primary tumor (e.g. histologic scar in testis)
pTis Intratubular germ cell neoplasia (carcinoma in situ)
pT1 Tumor limited to testis and epididymis without vascular/lymphatic
invasion; tumor may invade tunica albuginea but not tunica vaginalis.
pT2 Tumor limited to testis and epididymis with vascular/lymphatic
invasion, or tumor extending through tunica albuginea with involvement of
tunica vaginalis.
pT3 Tumor invades spermatic cord with or without vascular/lymphatic
invasion.
pT4 Tumor invades scrotum with or without vascular/lymphatic invasion.
N – Regional Lymph Nodes
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis with a lymph node mass 2 cm or less in greatest dimension or
multiple lymph nodes, none more than 2 cm in greatest dimension
N2 Metastasis with a lymph node mass more than 2 cm but not more than 5 cm
in greatest dimension, or multiple lymph nodes, any one mass more than 2
cm but not more than 5 cm in greatest dimension
N3 Metastasis with a lymph node mass more than 5 cm in greatest dimension
M – Distant Metastasis
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
M1a Non-regional lymph node or pulmonary metastasis
M1b Distant metastasis other than to non-regional lymph nodes and
lungs
S – Serum Tumor Markers
SX Serum marker studies not available or not performed
S0 Serum marker study levels within normal limits
Sobin LH, Wittekind Ch: TNM Classification of Malignant Tumors, fifth
edition (1997). Union Internationale Contre le Cancer Wiley-Liss, New
York, 1997.
Competing interests: LDH hCG (mIU/ml) AFP (ng/ml)S1