Episode 43 - Testicular Cancer - a podcast by Rio Bravo Family Medicine Residency Program

Episode 43: Testicular Cancer. 

Testicular cancer screening and diagnosis (basics), chlorthalidone vs hydrochlorothiazide, and jokes.

Today is March 8, 2021. 

For many years, we have heard about the superiority of chlorthalidone over hydrochlorothiazide to control hypertension, but in clinical practice, hydrochlorothiazide is prescribed more often as the initial therapy for most patients with hypertension as compared to chlorthalidone. 

As a matter of fact, the Microsoft Word automatic corrector detects hydrochlorothiazide as a correct word, but flags chlorthalidone as misspelled. Also, we know how to abbreviate hydrochlorothiazide (HCTZ), but did you know that chlorthalidone has an abbreviation as CTD?

We have been neglecting chlorthalidone regardless its apparent effectivity.  

In January 2006, the American Heart Association published on its journal Hypertension, a comparison between chlorthalidone and hydrochlorothiazide to control hyperension[1]. 

A randomized, single-blinded, 8-week active treatment, crossover study compared 12.5mg/day chlorthalidone (force-titrated to 25 mg/day at week 4) and HCTZ 25mg/day (force-titrated to 50mg/day at week 4) in untreated hypertensive patients. 24-hour BP monitoring was assessed at baseline and week 8 plus standard office BP readings every 2 weeks. 

30 patients completed the active treatment period.  At week 8 there was a greater reduction in baseline systolic blood pressure with chlorthalidone 25mg vs HCTZ 50mg. The effectiveness of chlorthalidone was evidenced by ambulatory blood pressure measurement (ABPM) although this difference was not apparent with office BP measurements. It was a short duration study with a small sample size.

More recently, in January 2021, the Journal of Hypertension, which is the official journal of the International Society of Hypertension and the European Society of Hypertension[2], published on PDF a more comprehensive review of these long-time rivals. According to the short version of this article, there is no difference in the short-term net clinical benefit between CTD and HCTZ, BUT long-term available data suggests that CTD is better at reducing major adverse cardiovascular events (MACE) over HCTZ. Stay tuned for the final version of this study.

Way to go chlorthalidone!

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This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

 

Page Break

Question of the Month: Polyarthralgia
by Claudia Carranza  

A 49-year-old female comes to clinic reporting bilateral wrist and ankle pain for 1 month. The pain is worse with movement and responds well to ibuprofen. She denies joint swelling, warmth, or morning stiffness. She reports feeling more fatigued than usual this past month. You note on her chart that she was diagnosed with COVID-19 approximately 6 weeks ago for which she did not need to be hospitalized.  She denies history of diabetes, thyroid disease, lupus, rheumatoid arthritis, trauma, or anemia. She denies fecal, urinary, or vaginal bleeding, no headaches, chest pain, SOB or dizziness. Exam is remarkable for a “tired look” and tenderness to palpation at bilateral wrist and ankles. No signs of inflammation on joints is noted. What do you think is the etiology of this patient’s symptoms and what workup would you order (if any)? 

Let’s repeat the question: What do you think is the etiology of the symptoms in a 49-year-old female who complains of symmetrical POLYARTHRALGIA and fatigue for 1 month, and what workup would you order (if any)? Clue: Listen carefully to the history of the patient. Send us your answer to rbresidency@clinicasierravista.org before March 22, 2021. The winner will receive a prize.

“I am not my body. My body is nothing without me.” Tom Stoppard

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Testicular Cancer

 

Testicular cancer is the most common solid tumor among males 15 to 34 years of age, with an estimated 8,850 new cases and 410 deaths in the past years. The good news is that with effective treatment, the overall five-year survival rate is 97%[3]. 

Risk factors. 

Cryptorchidism: The relative risk of developing testicular cancer ranges from 2.9 to 6.3; the risk is increased in both testes, although the risk is much higher in the ipsilateral testis (6.3 vs. 1.7). Among these patients, the risk of cancer increases when orchiopexy is delayed until after puberty or never performed compared with early orchiopexy. Even after early orchiopexy, the risk of testicular cancer remains elevated compared with the general population.  

Personal or family history of testicular cancer: Patients with a personal history of testicular cancer have a 12-times greater risk of developing a contralateral testicular cancer than the general population. However, the greatest risk is in the first five years after diagnosis. Patients with a father or brother with testicular cancer have a 3.8- and 8.6-times greater risk, respectively. 

Infertility: Men with infertility have an increased risk of testicular cancer, with a standardized incidence ratio of 1.6 to 2.8, although the underlying mechanism is unclear. 

HIV: Human immunodeficiency virus infection/AIDS increases the risk of seminoma, but this is negated with highly active antiretroviral treatment.  

Inconclusive risk: Associations between testicular cancer and marijuana use, inguinal hernia, diet, maternal smoking, and body size are inconclusive.  

Not a risk factor: Testicular microlithiasis, vasectomy, and scrotal trauma are not risk factors for testicular cancer. 

Screening for testicular cancer. 

The U.S. Preventive Services Task Force, National Cancer Institute, and American Academy of Family Physicians recommend against screening for testicular cancer (by a clinician or through self-examination) in asymptomatic adolescents and adults because of its low incidence and high survival rate. 

The American Cancer Society states that a testicular examination should be part of a routine cancer-related checkup but does not include a recommendation on regular testicular self-examinations for all men.

Assessment of suspected testicular cancer patient.

History and physical exam are the foundation for the diagnosis. Men with symptoms should receive a complete history and physical examination. Scrotal ultrasonography is the preferred initial imaging study. Testicular cancer may present as a painless scrotal mass, an incidental radiologic finding, posttraumatic symptom, or scrotal pain. Less commonly, presenting symptoms may indicate metastatic disease.  

Symptoms of testicular cancer include scrotal symptoms such as acute pain in the testis or scrotum, scrotum or abdomen discomfort or aches, painless mass of the testis, scrotal heaviness and swelling. Symptoms related to metastasis are non-specific and depend on the location of metastasis, including dyspepsia, abdominal pain or discomfort, gynecomastia, headaches, low back pain, neck mass, chest pain, cough, dyspnea, and hemoptysis.

Testicular changes may be detected by the patient or by a sex partner. Epididymitis is an important part of the differential diagnosis of a scrotal mass.

The normal testis is 3.5 to 5 cm in length, smooth, homogenous, movable, and detached from the epididymis. Hard, firm, or fixed areas within or adjacent to the testes are abnormal and warrant further evaluation. 

Physical examination should also include evaluation of the inguinal and supra-clavicular lymph nodes, the abdomen, and the chest for gynecomastia (related to tumor secretion of beta human chorionic gonadotropin). If a solid intratesticular mass is discovered, orchiectomy is both diagnostic and therapeutic. 

Imaging.

Scrotal ultrasonography is the preferred initial imaging study for evaluating a testicular mass.

Ultrasonography has a sensitivity of 92% to 98% and specificity of 95% to 99.8%. A solid intratesticular mass on ultrasonography warrants rapid referral for radical inguinal orchiectomy because this procedure provides pathologic diagnosis and is the cornerstone of treatment.

Staging. 

Staging through chest radiography, chemistry panel, liver function tests, and tumor markers guides treatment. Active surveillance, chemotherapy, retroperitoneal lymph node dissection, and radiation therapy are treatment options following orchiectomy. 

For patients desiring future fertility, sperm banking should be discussed early in the course of treatment. 

Treatment. 

Radical inguinal orchiectomy, including removal of the spermatic cord to the internal inguinal ring, is the primary treatment for any malignant tumor found on surgical exploration of a testicular mass. Testis-sparing surgery is generally not recommended but may be performed for a small tumor in one testis or for small bilateral tumors. Orchiectomy may be delayed if life-threatening metastases require more urgent attention. The risk of testicular cancer recurrence is greatest within two to three years of primary treatment, and surveillance is continued for up to five years.

Classification of Testicular Tumors: 

Germ cell tumors (95% of all testicular cancers)

Derived from germ cell neoplasia in situ

Seminoma

Nonseminoma (nonseminomatous germ cell tumors)

Embryonal carcinoma

Yolk sac tumor (postpubertal)

Trophoblastic tumors (e.g., choriocarcinoma, placental site trophoblastic tumor)

Teratoma (postpubertal) with or without malignant transformation

Mixed and unclassified germ cell tumors

Not derived from germ cell neoplasia in situ

Spermatocytic tumor

Teratoma (prepubertal)

Yolk sac tumor (prepubertal)

Sex cord–stromal tumors (< 5% of all testicular cancers)

Leydig cell tumor

Sertoli cell tumor

Granulosa cell tumor

Mixed and unclassified sex cord–stromal tumors

Mixed germ cell and stromal tumors (proportion of all testicular cancers not well defined) 

Gonadoblastoma

Miscellaneous tumors (proportion of all testicular cancers not well defined) 

Ovarian epithelial-type tumors 

Hemangioma 

Hematolymphoid tumors 

Tumors of the collecting duct and rete testis (adenocarcinoma)

Differential diagnosis of testicular cancer.

Tip 1: Testicular torsion is one of the most important differential diagnosis of testicular cancer. Testicular torsion is an emergency, and the presentation is quite different than cancer as it presents with acute, sudden, severe, unilateral testicular pain. Patients are very apprehensive to the exam. The scrotum may appear discolored and swollen; and the affected testicle is typically horizontal and at a higher position than expected in the scrotum. The treatment is surgical. In isolated areas, where surgery cannot be performed in a 2-hour period, a manual testicular detorsion can be attempted with appropriate analgesia and/or sedation. Try to rotate the affected testicle twice, 360 degrees, from medial to lateral. A “drop” of the testicle in the scrotum is felt with relief of pain. One-third of patients need detorsion to the opposite direction, from lateral to medial instead.

 

Tip 2: Epididymitis presents as a pain for about 1-2 weeks. Tenderness is located behind the testicle and patient may complain of dysuria as well. Perform a urine test or urethral swab for gonorrhea and chlamydia. In patients younger than 35, consider empiric treatment while you wait for the results with ceftriaxone PLUS doxycycline or azithromycin. In patients older than 35, consider gram negative coverage with levofloxacin or trimethoprim-sulfamethoxazole.

 

Tip 3: Consider other causes of infection in testis or scrotum, including viruses such as mumps (in unvaccinated populations) and even tuberculosis. If you are curious, read my article about it in PubMed titled “A Case of Testicular Granulomatous Inflammation Mistaken for Malignancy: Tuberculosis Identified Post Orchiectomy”[4]. 

 

Tip 4: Epidydimal cyst, spermatocele, and hydrocele are asymptomatic or minimally symptomatic, they are not located in the testis, but you can palpate a distinctive mass posterior or higher than the testis. You can try transillumination of these masses, and they should be translucent. Confirm with testicular ultrasound if in doubt.

 

Tip 5: A testicular hematoma can happen after blunt trauma, but don’t be fooled by the history of traumas as up to 10% of testicular cancers may be discovered after trauma. Perform ultrasound and tumor markers to establish a diagnosis.

 

Tip 6: A scrotal hernia may cause concerns in a patient. Clinically, the inguinal canal appears full and the mass in the scrotum is reported to improve with rest. If the mass is exquisitely tender and not reducible, emergent evaluation by surgery is warranted to rule out hernia strangulation, especially if scrotal pain is accompanied by abdominal distension, abdominal pain, nausea, and vomiting.        

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For your Sanity: Jokes
by Anonymous Medical Assistants

How does a deaf gynecologist communicate? They read lips!

How do you get a squirrel to like you? Act like a nut.

Why did the math book look so sad? It had a lot of problems.

Why can’t a nose be 12 inches long? Because then it’d be a foot.

What’s brown and sticky? A stick.

Why did the rope go to the doctor? Because it had a knot on the stomach.

Why did the mattress go to the doctor? Because it had Spring fever.

 

Now we conclude our episode number 43 “Testicular cancer”, marking our podcasts one year anniversary!. Dr. RAVA covered the recommendations given by USPSTF and the American Cancer Society regarding screening for testicular cancer. Screening in asymptomatic adults is mostly not recommended but it can be a part of a cancer-related checkup. As part of our introduction today, we mentioned effective chlorthalidone is in preventing major adverse cardiovascular events. Our question of the month is still on, and we look forward to reading your answers. The question is: What is the etiology of polyarthralgia in a 49-year-old woman with pain on wrists and ankles for 1 month, and what work up would you order (if any)? The listener who sends the best answer will win a prize! Remember, even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Valerie Civelli, Sapna Patel, Manjinder Samra, Dr. RAVA, and voluntarily-unidentified medical assistants. Audio edition: Suraj Amrutia. See you next week! 

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References:

Roush, George C.a; Messerli, Franz H. Chlorthalidone versus hydrochlorothiazide, Journal of Hypertension: January 19, 2021 - Volume Publish Ahead of Print - Issue - doi: 10.1097/HJH.0000000000002771. https://journals.lww.com/jhypertension/Abstract/9000/Chlorthalidone_versus_hydrochlorothiazide__major.96738.aspx

 

Ernst, Michael E., Barry L. Carter, Chris J. Goerdt et al., American Heart Association, Hypertension, Volume 47, Issue 3, 1 March 2006, Pages 352-358, https://doi.org/10.1161/01.HYP.0000203309.07140.d3

 

Baird DC, Meyers GJ, Hu JS. Testicular Cancer: Diagnosis and Treatment. Am Fam Physician. 2018 Feb 15;97(4):261-268. PMID: 29671528. https://www.aafp.org/afp/2018/0215/p261.html

 

Civelli VF, Heidari A, Valdez MC, Narang VK, Johnson RH. A Case of Testicular Granulomatous Inflammation Mistaken for Malignancy: Tuberculosis Identified Post Orchiectomy. J Investig Med High Impact Case Rep. 2020 Jan-Dec;8:2324709620938947. doi: 10.1177/2324709620938947. PMID: 32618206; PMCID: PMC7493239. https://pubmed.ncbi.nlm.nih.gov/32618206/

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