Tag Archive for: testicular cancer

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#RudeFood: Foodporn for a purpose

The Internet is full of weird and wonderful things. Of course, we all know what is most frequently viewed and shared online. That’s right – food! Nonetheless, when celebrity chef Manu Fieldel posted a photo of his latest creation, it certainly made people look long and hard!


Soon it became clear that this naughty creation had a noble purpose – supporting a campaign to raise awareness of the so-called #BelowTheBelt cancers. While most people may have heard of prostate and bladder cancers, being relatively common, other #BelowTheBelt cancers such as penile and testicular cancers are rarer and relatively unknown. To make matters worse, these cancers affect men either exclusively or predominantly – and we all know how reluctant men can be to go to the doctors.

Hence, the #RudeFood campaign was developed by the Australian and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group. ANZUP is the peak co-operative trials group for #BelowTheBelt cancers in Australia and New Zealand. ANZUP has and continues to develop and run many significant clinical trials, including the Enzamet and Enzarad trials for prostate cancer, the Phase III accelerated BEP trial for germ-cell tumours, the sequential BCG-mitomycin trial for bladder cancer and the Eversun and Unison trials in kidney cancer.

The week started with things heating up at ANZUP as they brought #RudeFood to the unsuspecting world!

Manu’s phallic creation was also matched by Ainsley Harriot, Sonia Meffadi and Monty Kulodrovic.

To counterpoint the raunch, there were also poignant personal connections from Simon Leong and Scott Gooding who both described family members who had suffered from prostate cancer.


Over the week, #RudeFood has certainly drawn some attention, including from media outlets such as Mamamia, news.com.au and GOAT. 

A poetic contribution on #RudeFood caught the eye of @UroPoet across the seas. Let us hope this campaign will also lead to greater awareness of #BelowTheBelt cancers and improved outcomes for those affected by them.


Shomik Sengupta is Professor of Surgery at the EHCS of Monash University and visiting urologist & Uro-Oncology lead at Eastern Health. Shomik has particular interests in prostate cancer, including open and robotic prostatectomy, as well as bladder cancer, including cystectomy with neobladder diversion. Shomik is the current leader of the UroOncology SAG within USANZ, and the past chair of Victorian urology training.  Shomik is a Board member and scientific advisory member of the ANZUP Cancer trials group and is heavily involved in numerous clinical trials in GU oncology.

Twitter: @shomik_s 


Article of the Week: Occupational variation in the incidence of testicular cancer in the Nordic countries

Every Week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Time trends and occupational variation in the incidence of testicular cancer in the Nordic countries

Outi Ylönen*, Sirkku Jyrkkiö, Eero Pukkala§, Kari Syvanen and Peter J. Bostrom

*South-Karelian Central Hospital, University Hospital of Turku, Lappeenranta, Finland, Department of Oncology, ¶Department of Urology, University Hospital of Turku, Turku, Finland, School of Health Sciences, University of Tampere, Tampere, Finland and §Finnish Cancer Registry, Helsinki, Finland

 

Abstract

Objective

To describe the trends and occupational variation in the incidence of testicular cancer in the Nordic countries utilising national cancer registries, NORDCAN (NORDCAN project/database presents the incidence, mortality, prevalence and survival from >50 cancers in the Nordic countries) and NOCCA (Nordic Occupational Cancer) databases.

Patients and Methods

We obtained the incidence data of testicular cancer for 5‐year periods from 1960–1964 to 2000–2014 and for 5‐year age‐groups from the NORDCAN database. Morphological data on incident cases of seminoma and non‐seminoma were obtained from national cancer registries. Age‐standardised incidence rates (ASR) were calculated per 100 000 person‐years (World Standard). Regression analysis was used to evaluate the annual change in the incidence of testicular cancer in each of the Nordic countries. The risk of testicular cancer in different professions was described based on NOCCA information and expressed as standardised incidence ratios (SIRs)

Fig. 2. Testicular cancer incidence time trends by age in the Nordic countries 1960-2014 (5-year floating averages).

Results

During 2010–2014 the ASR for testicular cancer varied from 11.3 in Norway to 5.8 in Finland. Until 1998, the incidence was highest in Denmark. There has not been an increase in Denmark and Iceland since the 1990s, whilst the incidence is still strongly increasing in Norway, Sweden, and Finland. There were no remarkable changes in the ratio of seminoma and non‐seminoma incidences during the past 50 years. There was no increase in the incidences in children and those of pension age. The highest significant excess risks of testicular seminoma were found in physicians (SIR 1.48, 95% confidence interval [CI] 1.07–1.99), artistic workers (SIR 1.47, 95% CI 1.06–1.99) and religious workers etc. (SIR 1.33, 95% CI 1.14–1.56). The lowest SIRs of testicular seminoma were seen amongst cooks and stewards (SIR 0.56, 95% CI 0.29–0.98), and forestry workers (SIR 0.64, 95% CI 0.47–0.86). The occupational category of administrators was the only one with a significantly elevated SIR for testicular non‐seminoma (SIR 1.21, 95% CI 1.04–1.42). The only SIRs significantly <1.0 were seen amongst engine operators (SIR 0.60, 95% CI 0.41–0.84) and public safety workers (SIR 0.67, 95% CI 0.43–0.99).

Conclusions

There have always been differences in the incidence of testicular cancer between the Nordic countries. There is also some divergence in the incidences in different age groups and in the trends of the incidence. The effect of occupation‐related factors on incidence of testicular cancer is only moderate. Our study describes the differences, but provides no explanation for this variation.

Article of the Week: RA-RPLND – Technique and Initial Case Series of 18 Patients

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Mr. Tim Dudderidge discussing his paper. 

If you only have time to read one article this week, it should be this one.

Robot-assisted retroperitoneal lymph node dissection: technique and initial case series of 18 patients

Scott M. Cheney, Paul E. Andrews, Bradley C. Leibovich* and Erik P. Castle

Mayo Clinic Arizona Department of Urology, Phoenix, AZ, and *Mayo Clinic Rochester Department of Urology, Rochester, MN, USA

OBJECTIVE

To evaluate outcomes of the first 18 patients treated with robot-assisted retroperitoneal lymph node dissection (RA-RPLND) for non-seminomatous germ cell tumours (NSGCT) and paratesticular rhabdomyosarcoma (RMS) at our institution.

PATIENTS AND METHODS

Between March 2008 and May 2013, 17 patients underwent RA-RPLND for NSGCT and one for paratesticular RMS. Data were collected retrospectively on patient demographics, preoperative tumour characteristics, and perioperative outcomes including open conversion rate, lymph node (LN) yield, rate of positive LNs, operative time, estimated blood loss (EBL), and length of stay (LOS). Perioperative outcomes were compared between patients receiving primary RA-RPLND vs post-chemotherapy RA-RPLND. Medium-term outcomes of tumour recurrence rate and maintenance of antegrade ejaculation were recorded.

RESULTS

RA-RPLND was completed robotically in 15 of 18 (83%) patients. LNs were positive in eight of 18 patients (44%). The mean LN yield was 22 LNs. For cases completed robotically, the mean operative time was 329 min, EBL was 103 mL, and LOS was 2.4 days. At a mean (range) follow-up of 22 (1–58) months, there were no retroperitoneal recurrences and two of 17 (12%) patients with NSGCT had pulmonary recurrences. Antegrade ejaculation was maintained in 91% of patients with a nerve-sparing approach. Patients receiving primary RA-RPLND had shorter operative times compared with those post-chemotherapy (311 vs 369 min, P = 0.03). There was no significant difference in LN yield (22 vs 18 LNs, P = 0.34), EBL (100 vs 313 mL, P = 0.13), or LOS (2.75 vs 2.2 days, P = 0.36).

CONCLUSION

This initial selected case series of RA-RPLND shows that the procedure is safe, reproducible, and feasible for stage I–IIB NSGCT and RMS in the hands of experienced robotic surgeons. Larger studies are needed to confirm the diagnostic and therapeutic utility of this technique.

Editorial: RPLND – Open Surgery’s Next Challenger Is Ready To Enter The Ring

By Tim Dudderidge

The da Vinci surgical system delivers the benefits of laparoscopic surgery with an easier and more precise human–tissue interface than conventional laparoscopic instruments. Nearly all major uro-oncological procedures are being performed robotically. In this issue of BJUI, Cheney et al. [1] present their technique and initial experience of robot-assisted retroperitoneal lymph node dissection (RA-RPLND) for patients with primary and post-chemotherapy non-seminoma germ cell tumours. Quality indicators for RA-RPLND include adequate clearance of the desired surgical field, satisfactory lymph node yield, acceptable perioperative morbidity and length of stay, as well as longer-term functional and oncological outcomes. So how well does RA-RPLND stand up to scrutiny?

The technique employed by Cheney et al., placing the robot at the head of the patient, is unfamiliar to most urologists I suspect. It appears to offer excellent access to the retroperitoneum, but still requires a re-docking when performing full bilateral dissections. Whether this technique is superior to the lateral approach that I and others have used for modified dissections requires further study [2,3]. The lymph node yield was lower than that previously reported for open RPLND and while Cheney et al. [1] observe this may be due to the use of a modified template where appropriate, the absence of any in-field recurrences at a median of 22 months is perhaps the more reliable sign that there is oncological equivalence. Concerns that a true template dissection cannot be completed with a robot-assisted laparoscopic approach are probably unjustified in my opinion. The description of surgical technique by Cheney et al., including suture ligation and division of lumbar vessels, confirms that if a surgeon is minded to do so, a complete bilateral or modified template clearance can be completed.

The absence of significant complications in this series is impressive; however, there were three out of 18 conversions to open surgery. The mean length of stay of 2.4 days is close to the 3–4 days stay I would expect after an uncomplicated open RPLND in a young fit man. However, 1–2 night stays were seen in their later cases as they gained experience. Perhaps more importantly in a group of working age men, return to full physical activity within 3 weeks is possible [2].

As highlighted by Cheney et al. [1], minimally invasive primary RPLND has been previously reported both by laparoscopic and robotic approaches. Their larger series provides an important demonstration that the robotic approach facilitates the more complex undertaking of post-chemotherapy RPLND. Furthermore they show that except for operative time, all other outcomes were similar in primary and post-chemotherapy cases.

As an enthusiast for minimally invasive therapies, I of course welcome these results and think that along with other published and presented series, they provide sufficient evidence to consider a more formal evaluation of this approach. However, how feasible is the wider introduction of RA-RPLND? Despite having experience of robotics and working in a team performing around 30 RPLNDs a year, I was only able to identify five cases during a 1-year period suitable for a robotic approach. With experience this could have been a higher proportion, but it is fair to conclude that suitable cases in typical cancer centres would be limited in number. This is particularly so for the UK and other European countries, where primary RPLND is not used. Cheney et al. [1] had similarly low numbers each year and recruited their cohort of 18 cases over 5 years.

An international multicentre registry is arguably the best way to gather more information on the safety and completeness of template dissection RPLND. Existing registries, e.g. the BAUS complex operations database, have already provided valuable insights into the results of RPLND in the UK [4] and could be combined with other international RA-RPLND databases already being compiled (Erik Castle MD personal communication). Partnership of testicular cancer surgeons without robotic experience with experienced robotic surgeons may also facilitate the development of additional centres for development of this procedure. They will also aid optimal patient selection and help avoid incomplete template dissections, which may compromise the excellent cancer control we are now used to.

There are clear potential advantages with a minimally invasive approach to RPLND, not least of which are the avoidance of a laparotomy scar, the reduction of complications and an earlier return to normal activity. Cheney et al. [1] have shown that their technique is feasible, safe and effective in the medium term and their results justify wider consideration of the procedure for further study and improvement.

Tim Dudderidge

University Hospital Southampton, Southampton, UK

References

1 Cheney SM, Andrews PE, Leibovich BC, Castle EP. Robot-assisted retroperitoneal lymph node dissection: technique and initial case series of 18 patients. BJU Int 2015; 115: 114–20

2 Dudderidge T, Pandian S, Nott D. Technique and outcomes for robotic assisted post-chemotherapy retroperitoneal lymph node dissection (RPLND) in Stage 2 non-seminomatous germ cell tumour (NSGCT). BJU Int 2012; 110: 97

3 Dogra PN, Singh P, Saini AK, Regmi KS, Singh BG, Nayak B. Robot assisted laparoscopic retroperitoneal lymph node dissection in testicular tumor. Urol Ann 2013; 5: 223–6

4 Hayes M, O’Brien T, Fowler S, BAUS RPLND Group. Contemporary retroperitoneal lymph node dissection (RPLND) for testis cancer in the UK – a national study. J Urol 2014; 191 (Suppl.): e89–90

 

Video: Robot Assisted Retroperitoneal Lymph Node Dissection

Robot-assisted retroperitoneal lymph node dissection: technique and initial case series of 18 patients

Scott M. Cheney, Paul E. Andrews, Bradley C. Leibovich* and Erik P. Castle

Mayo Clinic Arizona Department of Urology, Phoenix, AZ, and *Mayo Clinic Rochester Department of Urology, Rochester, MN, USA

Abstract

OBJECTIVE

To evaluate outcomes of the first 18 patients treated with robot-assisted retroperitoneal lymph node dissection (RA-RPLND) for non-seminomatous germ cell tumours (NSGCT) and paratesticular rhabdomyosarcoma (RMS) at our institution.

PATIENTS AND METHODS

Between March 2008 and May 2013, 17 patients underwent RA-RPLND for NSGCT and one for paratesticular RMS. Data were collected retrospectively on patient demographics, preoperative tumour characteristics, and perioperative outcomes including open conversion rate, lymph node (LN) yield, rate of positive LNs, operative time, estimated blood loss (EBL), and length of stay (LOS). Perioperative outcomes were compared between patients receiving primary RA-RPLND vs post-chemotherapy RA-RPLND. Medium-term outcomes of tumour recurrence rate and maintenance of antegrade ejaculation were recorded.

RESULTS

RA-RPLND was completed robotically in 15 of 18 (83%) patients. LNs were positive in eight of 18 patients (44%). The mean LN yield was 22 LNs. For cases completed robotically, the mean operative time was 329 min, EBL was 103 mL, and LOS was 2.4 days. At a mean (range) follow-up of 22 (1–58) months, there were no retroperitoneal recurrences and two of 17 (12%) patients with NSGCT had pulmonary recurrences. Antegrade ejaculation was maintained in 91% of patients with a nerve-sparing approach. Patients receiving primary RA-RPLND had shorter operative times compared with those post-chemotherapy (311 vs 369 min, P = 0.03). There was no significant difference in LN yield (22 vs 18 LNs, P = 0.34), EBL (100 vs 313 mL, P = 0.13), or LOS (2.75 vs 2.2 days, P = 0.36).

CONCLUSION

This initial selected case series of RA-RPLND shows that the procedure is safe, reproducible, and feasible for stage I–IIB NSGCT and RMS in the hands of experienced robotic surgeons. Larger studies are needed to confirm the diagnostic and therapeutic utility of this technique.

In Defence of Lance…

As this year’s Tour de France starts and we wonder if Chris Froome can take over from Sir Bradley this blog thinks about previous Tours with some sadness. As an oncologist treating testicular cancer the Tour used to be a reminder of one of the great successes of modern oncology. Seeing Lance Armstrong on the podium showed how chemotherapy can overcome even poor prognosis testicular cancer. Lance was an inspiration to our patients. I doubt there has been a happier sight on the chemotherapy day unit at Guy’s Hospital than seeing the young men cheer Lance as he surged past Jan Ullrich, whilst they were receiving their chemotherapy.

So rather than become too melancholy I thought I would use this blog to provide a little balance to all the stick Lance has been taking. Whilst Lance as a cyclist is tarnished forever, the other aspect of his story seems to have been forgotten. The incredible part is that he overcame such aggressive disease and was able to ride competitively. He should therefore remain an inspiring figure for those of us treating testicular cancer, and more importantly for young men battling this disease. Whilst as oncologists we quote impressive survival figures, for patients an example of someone who has survived is far more tangible.

So I have been re-reading ‘It’s not about the bike’ (how ironic that title seems now!). The chapters dealing with diagnosis, treatment and recovery are informative and remain inspiring. It’s easy to see why it became and could still be a touchstone for young men battling testicular cancer.

Whilst many will argue that Armstrong’s well publicised battle against cancer was just part of his ego let’s not forget that it takes guts in the macho world of professional sport to admit illness and potential weakness. Many famous men have been affected by cancer but all too often don’t feel able to talk about it or use their position in a positive way. Armstrong was the polar opposite, happy to provide inspiration and also to raise millions for his cancer charity. He also raised the profile of testicular cancer and the need for ongoing research and there remain many important unanswered questions in this disease:

  • Who need’s adjuvant treatment?
  • What adjuvant treatment should we give?
  • How to minimise toxicity of treatment?
  • Long term toxicity and survivorship issues
  • Why are some patients’ cisplatin insensitive?
  • The role of RPLND and metastatectomy
  • The best second line chemotherapy
  • And many others…..

TUF Cycling Across the Andes: More intrepid cyclists supporting research into urological cancers. For more information visit www.theurologyfoundation.org or www.actionforcharity.co.uk.

So as this year’s Tour de France winds its’ way towards those punishing Alpine stages perhaps we should draw a line and move back to Armstrong as the inspiration for the next generation of men with testicular cancer. I for one will always enjoy that ascent on Alpe D’Huez and how it shows we can over come even the worst disease. So Lance your boys still need you! It’s time to eat a very large slice of humble pie and rewrite the book, warts and all, so that you can be an inspiration to the next generation of men with testicular cancer.

Simon Chowdhury is a Consultant Medical Oncologist at Guy’s, King’s and St Thomas’ Hospitals, London. He is actively involved in clinical trial research into urological cancers.

 

Comments on this blog are now closed.

 

 

An unusual presentation of teenage testicular cancer

We present an unusual case of testicular cancer in a 13-year-old boy, referred by his GP with an acute onset of right testicular pain and a provisional diagnosis of testicular torsion. 

Authors: Harwood R, Short M, Hosie G

Royal Victoria Infirmary, Newcastle Upon Tyne, UK

Corresponding Author: Harwood Rachel, Royal Victoria Infirmary, Newcastle Upon Tyne, UK. E-mail: [email protected]

Abstract
A 13-year-old Afro-Caribbean boy presented with acute testicular pain. His examination was not typical of testicular torsion and an ultrasound scan suggested malignancy. In view of his resulting pathology, his case is unusual both in presentation and epidemiology. This case highlights the need to remain vigilant for alternative differential diagnoses when assessing a child with testicular pain. It has been proven that obesity can increase cancer risk, learn how to prevent it by reading this article from DiscoverMagazine.
Case history
We present what, in our experience, is an unusual case of testicular cancer.  The patient is an Afro-Caribbean 13-year-old boy, referred by his General Practitioner with an acute onset of right testicular pain and a provisional diagnosis of testicular torsion. On further questioning he was found to have had right testicular pain for four hours but an increase in the size of his right testicle over the previous 2 months. Prior to this, he had no history of cryptorchidism, testicular trauma or previous surgery. He was otherwise fit and well and not on any regular medication. There was no significant history of cancer in first degree relatives, but three uncles had died between 60 and 70 years of age from lung, liver and prostate cancer. On examination he was found to have a mildly tender, firm, smooth right testicle with normal position and lie. There was no associated erythema, skin discoloration or swelling. The left testicle was normal and abdominal examination was unremarkable.  He was graded as Tanner Stage 4.
Investigations
In view of his history, an ultrasound scan was requested and showed a 2.5 x 1.5cm avascular mass within the right testicle.
Figure 1. 

Tumour markers at presentation were within normal ranges for his sex and age (beta-HCG (bHCG) <1, alpha-feto-protein (AFP) 3).
Treatment and Follow-Up
At surgery, the patient was found to have a macroscopically normal testicle and a radical orchidectomy was performed via a groin incision. Histology revealed a mixed seminoma and germ-cell tumour.
Figure 2. 
Figure 3. 
Postoperatively, he underwent a staging CT scan.  No evidence of metastases was found and he is being followed up with biochemical marker monitoring.
Discussion
Although testicular tumours are the most common malignancy in men aged 15-35 yrs [1], they are rare in children under 15yrs of age, accounting for <2% of solid tumours [2].  The most common type of gonadal tumour in children are germ cell tumours, which are divided into subgroups based on cellular components and degree of differentiation [3] [4].
There are many causes for testicular pain in children.  The incidence of testicular torsion is 26% with a peak in adolescence, torted Hydatid of Morgagni 45%, epididymitis 10%, incarcerated inguinal hernia 8% and other conditions including malignancy 11% [5].  Testicular tumours most commonly present as a testicular mass, a symptom which RW had had for two months.  A much less common presentation is testicular pain or a dragging sensation. This boy’s acute symptoms were consistent with testicular torsion.  Had attention not been paid to his extended history and scrotal exploration been performed through a scrotal excision, an inappropriate surgical approach would have been undertaken, risking seeding of the tumour to the inguinal lymph nodes.
It is well documented within observational studies of adults that there is a significantly smaller incidence of testicular cancer within the Afro-Caribbean population (0.3-1.4 per 100,000) than in the Caucasian population (3.2-6.2 per 100,000) [6] [4].  There is little information about the incidence in boys of RW’s age with regards to ethnicity, however in the UK in 2008 there were only three new cases of testicular neoplasm in boys aged 10-14 (rate 0.2 per 100,000) [7].
In our patient, tumour markers were all within normal range and in combination with the factors mentioned above made us wary of performing an orchidectomy without a histological diagnosis. However, in view of his history and radiological findings, this was decided as being the most appropriate surgical management.  We were undeterred by his tumour markers as AFP is increased in 50-70% of non-seminomatous germ cell tumours (NSGCTs) and bHCG is elevated in 40-60% of patients with NSGCTs [8].
Conclusion
This case highlights the importance of remaining vigilent to uncommon causes of unilateral testicular pain in children. A careful history and examination is important as is imaging when there is doubt over the diagnosis. This case is of particular interest in the UK given the rarity of testicular cancer both in this age-range and in this ethnic group.
With thanks to Dr A. Husain (Dept. Cellular Pathology)
References
 
1. Fernandes ET, Etcubanas E, Rao BN, Kumar AP, Thompson EI, Jenkins JJ. Two decades of experience with testicular tumors in children at St Jude Children’s Research Hospital. J Pediatr Surg. 1989 Jul;24(7):677-81; discussion 682
2. Ross JH, Kay R. Prepubertal Testis Tumours; J Pediatr Surg. 1989 Jul;24(7):677-81
3. Stringer M, Oldham K, Mouriquand P. Pediatric Surgery and Urology – long term outcomes;  2nd Edition 2006
4. Alanee S, Shukla A. Paediatric testicular cancer: an updated review of incidence and conditional survival from the Surveillance, Epidemiology and End Results database; BJU International. 2009 Nov;104(9):1280-3
5. Makela E, Lahedes-Vasama T et al.  A 19-year review of paediatric patients with acute scrotum;  Scand J Surg. 2007;96(1):62-6.
6. Holmes L Jr, Escalante C, Garrison O, Foldi BX, Ogungbade GO, Essien EJ, Ward D. Testicular cancer incidence trends in the USA (1975-2004): plateau or shifting racial paradigm? Public Health. 2008 Sep;122(9):862-72
7. National Office for Statistics, 2010
8. European Society of Urology, Guidelines on testicular cancer, 2010

Date added to bjui.org: 21/10/2011


DOI: 10.1002/BJUIw-2011-063-web

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