Study by NCCS oncologists link testicular ultrasound finding to cancer risk

Friday, 19 Jul 2010

Singapore, 19 Jul 2010 – A study by two medical oncologists at the National Cancer Centre Singapore (NCCS) have clarified the link between testicular microlithiasis, a common finding on testicular ultrasound affecting 4% of males and the risk of testicular cancer. This prompts the possibility of a change in clinical guidelines to manage patients diagnosed with the condition.

Their findings have recently been published in CANCER, a peer-reviewed oncology journal of the American Cancer Society that serves as a platform for the exchange and integration of high impact scientific findings amongst various oncologic disciplines worldwide.

Testicular microlithiasis , or TM, is a condition where microscopic calcium stones can be seen on ultrasound with a “starry sky” appearance in the testicles and has been associated with the development of a type of testicular cancer known as testicular germ cell tumour (TGCT) as well as intratubular germ cell neoplasia of unclassified type (ITGCNU), a non-invasive precursor of TGCT. TM can be discovered in about 4% of asymptomatic young men when they are being referred for scrotal ultrasound for other conditions.

However, the actual risk, management and follow-up of this condition have been controversial. Doctors around the world recommend a variety of approaches, from testicular biopsy to self-examination to repeated ultrasound imaging over the long term.

There is no clear consensus on diagnosis and follow-up, though according to proposed European guidelines, self-examination is recommended for most individuals and testicular biopsy is recommended for young men with TM and those who have at least one risk factor for TGCT such as sub-fertility.

Following a review of literature with an accompanying analysis, Dr Tan Min-Han and Dr Iain Tan, oncologists in the Department of Medical Oncology at NCCS suggest that there is opportunity for improvement.

“Using a technique called meta-analysis, we have found that majority of otherwise healthy people with TM need not be concerned and are unlikely to benefit from aggressive investigations such as testicular biopsy which carries a 3% risk of complications, such as pain, swelling, bruising or infection,” said Dr Iain Tan.

“But testicular biopsy can be considered for patients with a considerable risk of pre-malignant ITGCNU if they have TM and sub-fertility or had a previous TGCT as 50% of ITGCNU will progress to malignancy within five years.”

The NCCS authors pointed out that a major influence on the outcomes of TM and TGCT would be the use of adjuvant chemotherapy, which reduces recurrent cancers and ITGCNU.

Hence, patients with TM, and who have received chemotherapy for testicular cancer, will not reap much benefit from a testicular biopsy for the other testicle, as chemotherapy will have treated any pre-existing TGCT or ITGCNU, if any. In this instance, a testicular self-examination and follow-up will suffice.

“Providing nuance to this issue is important, as incidental detection of TM is common with the increasing use of testicular ultrasound, and that there was no medical consensus as to appropriate management. The proposed guidelines have taken the clinical context of the patient into account, including risk factors, reserving aggressive management primarily for patients at high risk, and provide immediate practical guidance for medical professionals and their patients,” said Dr Tan Min-Han.

He added that even though testicular cancer is becoming more common in Singapore over the last few decades, its actual incidence of testicular cancer is still relatively low compared to the West. Its diagnosis is important, as it is one of the highly curable cancers that usually affects younger men.

About NCCS