BERKELEY, CA (UroToday.com) - This study has designed to assess the risk of testicular malignancy is patients with known microlithiasis. It is a follow-up study to the 2001 prospective screening study previously published by the authors which established the prevalence of testicular microlithiasis to be 5.6% in a healthy asymptomatic population of Army volunteers (18 to 35 years old). The initial study identified 84 patients with testicular microlithiasis (5.6%). These men were entered into the follow-up phase of the study and instructed regarding testicular self-examination and the need for follow-up. They were told to report any changes in their examination or a finding of testicular mass or cancer. Five years after the initial screening study, the authors attempted to contact all remaining 84 men by e-mail, standard mail and telephone.

Of the original 84 men with testicular microlithiasis, identified in the original screening study, 63 have been contacted via e-mail and by telephone (75%). Only one of the 63 subjects developed a mixed germ cell tumor 64 months after the initial screening study.

Compared to the incidence of testicular cancer in the general population, the odds ratio of developing testicular cancer in our study population is 317 (95% CI 36-2,756). Testicular cancer will not develop in the majority of men with testicular microlithiasis (98.4%) during a 5-year follow-up interval.

We believe that an intensive screening program for men with testicular microlithiasis is not cost-effective and would do little to improve outcomes associated with testicular cancer. We continue to recommend testicular self-examination in men at risk.

Editorial Comment

This is an important study for assessing the importance of microlithiasis in an asymptomatic screened population. The authors state "Given our odds ratio of TC developing in a man with TM and the prevalence of TM, we would expect between 14,000 to 28,000 cases of testis cancer per year. Based on Surveillance, Epidemiology, and End Results data we know that the actual incidence of TC is estimated to be 7,920 in 2007. Therefore, our calculated odds ratio severely overestimates the incidence of TC. Furthermore, our own data indicate that TC will not develop in the majority of men (98.4%) with TM during a 5-year period. "

The authors carefully assess the risk and perform a cost analysis. Clearly in the population that they describe, the costs seem to outstrip benefit. Interestingly, the authors recommend self-examination for early diagnosis. The case they describe sought consultation after discovering a mass (spermatocele). The malignancy was only detected after imaging. However, it is important to emphasize that this study describes asymptomatic men who do not generally undergo screening USG examination of the testes.

What the current study does not answer is the significance of testicular microlithiasis in the patients who undergo scrotal ultrasonography for currently invoked clinical indications such as orchalgia, a history of cryptorchidism or even more commonly infertility. Does the finding of microcalcification in these clinical settings carry an additional risk? Do these patients require more careful follow-up then the authors recommend. Only 29 of 45 men (65%) stated that they were conducting monthly self-examinations. Self examination does not cost anything but has the potential to improve early detection of testes tumors. The clinical urologist should be certain to teach self-examination to all young men and emphasize its importance. The application of routine USG and tumor markers has been seriously questioned by the current study and its analysis. However, the recommendations of the authors may need to be tempered by the clinical setting.

DeCastro BJ, Peterson AC, Costabile RA

J Urol. 2008 Apr;179(4):1420-1433
doi: 10.1016/j.juro.2007.11.080

PubMed Abstract
PMID: 18289592

UroToday.com Testicular Cancer Section

Written by Harris M. Nagler, MD, a Contributing Editor with UroToday.

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