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PAGE C4 Spotlight SALUBRIS July / August 2009 RATIONAL APPROACH TO TESTICULAR SWELLING Continued from page C3. Some 90% of testicular torsions occur in men younger than 30 years old. A teenager with sudden onset scrotal pain and a normal urinalysis most likely has testicular torsion. Unrelieved torsion (longer than six hours) leads to testicular ischemia and atrophy. A delay in diagnosis longer than 12 hours will result in irreversible damage. Testicular torsion can be confirmed by Doppler ultrasound (greater than 90% sensitivity, 70% specificity). However, if in doubt, scrotal exploration and detorsion should always be performed. The common anatomical defect is high “investment” of the tunica vaginalis – the so called bell-clapper deformity. This inherent defect is usually bilateral, and detorsion should always be followed by testicular fixation (orchiopexy) of both gonads. If epididymitis or epididymo-orchitis is diagnosed especially with the finding of pus cells and bacteria on urine microscopy, the patient can be treated with a course of bactrim and doxycycline for two weeks. The etiology is commonly bacterial infection of the urinary tract. In sexually active young adults especially when associated with urethritis, chlamydial and neisseria gonorrhoeae infection must be considered. It is prudent to review the patients after treatment for resolution of symptoms and signs. If in doubt, an ultrasound scrotum should be ordered. An underlying testicular malignancy must still be a consideration. Testicular cancer is the most frequent cancer in young men (15 to 35 years of age). Cryptorchidism is a well-known risk factor even after orchiopexy. Testicular tumours usually present as painless lumps, but some men (20-25%) develop scrotal pain as a result of bleeding caused by rapid tumour growth and necrosis. Most tumours are discovered as hard testicular lumps detected on self examination. Reactive hydrocele may make appreciation of a testicular lesion difficult. Scrotal ultrasound is an excellent modality for the assessment of testicular mass. Testicular cancers are typically non-homogenous with hypoechoic areas. Testicular microcalcifications are associated with a high propensity for developing seminomas and warrants regular ultrasound surveillance. More than 95% of testicular tumours originate from germ cells. Germ cell tumours can be seminomas or nonseminomatous germ cell tumours. Seminomas are more likely to be confined to the testis (stage I) and are exquisitely radiosensitive. Nonseminomatous germ cell tumours consist of embryonal cell carcinomas, yolk sac tumours, or teratomas, alone or mixed with other elements. Sertoli cell tumours, Leydig cell tumours, and lymphomas are the most-common non-germ cell tumours. In men older than 60 years, most tumours are non- Hodgkin’s lymphoma, with a predilection for bilateral involvement. Tumour markers are helpful in the diagnosis, staging and management of malignant testicular tumours. α-fetoprotein (AFP) is often associated with embryonal carcinoma, whereas β-subunit of human chorionic gonadotropin (β-hCG) elevations occur with choriocarcinomas. However, many testicular cancers are mixed germ cell in origin and tumour marker elevation is variable. Persistent elevation of tumour markers post orchiectomy suggests the presence of metastatic disease. However, there is a 25% false-negative marker elevation rate. Avoidance of scrotal skin violation is mandatory when obtaining histological diagnosis. The lymphatics of the testes drain primarily into the retroperitoneal para-aortic and inter-aortocaval lymph nodes while the scrotal skin lymphatics drain into the inguinal nodes. Trans-scrotal needle biopsy or orchiectomy is therefore contraindicated. Suspected testicular tumours should be explored via an inguinal incision with early control of the spermatic cord to prevent vascular or lymphatic dissemination. Further treatment is based on histological assessment of the tumour and staging consisting of computed tomography (CT) scanning and chest x-ray. A false-negative rate on 20 to 25% occurs in the presence of non-enlarged (smaller than 1.5cm) but microscopically involved retroperitoneal lymph nodes. Treatment modalities include retroperitoneal lymphadenectomy, external beam radiation to the retroperitoneum and chemotherapy, alone or in combination.
40th SMA National Medical Convention BREAKING THE MYTHS ABOUT CANCER PAGE A5 Community SALUBRIS July / August 2009 In recent years, the number of cancer patients and high-risk groups have been on the rise. Consequently, more cancer prevention methods are finding their way to the media, having evolved from a wide variety of sources ranging from official cancer research centres to the good neighbour next door. While it is good to have choices, the same cannot be said for making flawed choices, which are a waste of time and money better spent on prevention methods that are actually effective. To dispel mistaken notions about cancer prevention, the 40th SMA National Medical Convention based its theme on “Cancer Prevention – Breaking the Myths”. The National Cancer Centre Singapore (NCCS) was one of the few institutions to collaborate with the Singapore Medical Association to organise this event. Madam Halimah Yacob, MP for Jurong GRC, was the Guest-Of-Honour to the event held at Suntec City Convention Centre on 11 July 2009. As cancer is the principal cause of death in Singapore, the convention sought to provide objective insights on cancer prevention, with the consequential goal of reducing the number of cancer patients and cancer-related deaths in the long run. To expand its outreach to the general public, the morning public seminar was held in three concurrent sessions in English, Malay and Mandarin. Dr Wong Zee Wan, Senior Consultant from the Department of Medical Oncology, was one of the speakers representing NCCS. The afternoon session began with a lunchtime seminar, followed by the medical symposium for healthcare professionals. Dr T. Agasthian, Senior Consultant from the Department of Surgical Oncology, spoke on behalf of NCCS. A wide variety of topics was covered during the convention: PUBLIC SEMINAR • Does altering your eating habits change the risk of cancer? • Getting a friend to stop smoking • New cancer screening techniques LUNCH SYMPOSIUM • HPV Vaccination for Cervical Cancer Prevention in Singapore – Are we a leader or a lagger? • Cancer vaccines of the Past, Present and Future MEDICAL SYMPOSIUM • Cervival Cancer: to vaccinate or not to vaccinate? • Screening Lung Cancer: useful or harmful? • Decision making in cancer screening in the elderly • The era of individualising cancer management
Page 1 and 2: Issue No. 05 • MICA (P) 207/10/20
Page 3 and 4: PAGE A3 In Other Words SALUBRIS Jul
Page 5 and 6: ADVANCES IN RADIOTHERAPY IN THE MAN
Page 7: RATIONAL APPROACH TO TESTICULAR SWE
Page 11 and 12: WHERE DID YOUR FINGERPRINTS GO? PAG

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