© 2 0 0 4 B J U I N T E R N A T I O N A L | 9 3 , 11 8 3 – 11 8 7 | doi:10.1111/j.1464-410X.2004.04837.x 1183 Review Article PRACTICAL MANAGEMENT FOR BILATERAL TESTICULAR CANCER B.J.R. BARRASS et al. Practical management issues in bilateral testicular cancer B.J.R. BARRASS, R. JONES*, J.D. GRAHAM and R.A. PERSAD Bristol Royal Infirmary, Bristol, and *University Hospital of North Staffordshire, Staffs, UK Accepted for publication 27 October 2003 be unnecessary [4]. Testicular biopsy can lead to problems with subsequent tumour diagnosis, pain, infection, infertility, testicular dysfunction and emotional distress, so this could generate significant excess morbidity [8]. Patients with risk factors (e.g. testicular atrophy, cryptorchidism and elevated LH or FSH) are more likely to have TIN [3]. However, in a series of 1188 patients undergoing contralateral biopsy at radical orchidectomy, 38% of those in whom TIN was found had no risk factors [4]. Therefore, restricting testicular biopsy to those patients with risk factors may not be a safe way to reduce the number of unnecessary biopsies. Finally, secondary testicular tumours usually have a favourable prognosis [8], so the question of whether diagnosing and treating TIN improves survival is debatable. Nevertheless, we consider that high-risk patients should be offered a contralateral testicular biopsy at radical orchidectomy. However, they should decide for themselves whether to proceed, after a full discussion of the potential risks and benefits. Patients with a solitary testis have achieved successful paternity despite the presence TIN, so patients may wish to defer radiotherapy to achieve natural conception [3]. However, they need to be aware that TIN severely impairs fertility and can progress to invasive cancer at any time [3]. Chemotherapy can also reduce the extent of TIN and the incidence of bilateral testicular cancer [3], but this is unreliable and the relative risk of subsequent tumour diagnosis has been reported to be 21% and 42% at 5 and 10 years, respectively [3]. THE ROLE OF SELF-EXAMINATION Self-examination and early referral result in secondary testicular tumours being diagnosed at an early stage, as reported in a series of 30 bilateral testicular cancers, of which 25 were detected by self-examination, 83% were stage I and 17% were stage IIa [8]. Patients should therefore examine themselves regularly after radical orchidectomy and, as secondary testicular tumours have occurred after an interval of 25 years and follow-up often ceases after 10 disease-free years, this practice should be lifelong. The NICE manual suggests that there is no evidence to support teaching self- examination in young men [1]. Whereas this may be applicable to the general population, patients with a history of cancer are likely to be more motivated. Indeed, the value of self-examination has been shown in this population and should therefore be encouraged [8]. However, it is known that patients are not always aware of the risk of relapse after radical orchidectomy, so education is essential [9]. TREATMENT OF BILATERAL TESTICULAR CANCER CONVENTIONAL TREATMENT Albers et al. [8] evaluated the pathology of 30 secondary testicular tumours and found most to be stage I. In addition, both proliferation rates and vascular invasion were less than that in the primary tumour [8]. Albers et al. also reviewed nine published series of bilateral tumours and found that, of 93 patients with follow-up data, only one died from recurrent disease. Coogan et al. [10] reported similar findings in a series of 21 bilateral tumours and found that, providing patients were properly staged, the outcome with conventional treatment was comparable to that for unilateral disease. Bilateral testicular cancer can therefore be treated in the same way as unilateral disease and patients should expect a similarly good outcome. However, radiation doses may have to be limited and retroperitoneal lymph node dissection might not be possible if it has been performed previously. ORGAN-PRESERVING SURGERY Testis-preserving surgery has been developed as an alternative to radical orchidectomy, with the advantage that physiological androgen production, body image and fertility can all be INTRODUCTION Testicular cancer is the commonest solid tumour among young men and 5% of them develop bilateral disease [1,2]. However, urologists encounter patients with bilateral testicular tumours relatively infrequently and such tumours present some unique problems which require careful management. This review aims to cover these issues in the light of the recent National Institute of Clinical Excellence (NICE) manual on the management of urological cancers [1]. RISK MODIFICATION AND SCREENING FOR BILATERAL TESTICULAR CANCER Should testicular intra-epithelial neoplasia (TIN) be treated to prevent a second testicular tumour? TIN is generally accepted to be the universal precursor for all testicular germ cell tumours [3] and is found in the contralateral testis of ª 5% of patients undergoing radical orchidectomy [4]. This percentage is similar to the proportion of patients who develop a second testicular cancer [1,2], so patients destined to develop a second tumour can be identified by searching for TIN. Indeed, TIN can be detected on biopsy with a false-negative rate of 0.3% [5] and effectively eradicated with low-dose radiotherapy (18–20 Gy) [3,6]. Consequently, it is routine practice in several European countries to biopsy the contralateral testis at radical orchidectomy and treat TIN with radiotherapy. By adopting this policy a second orchidectomy can be avoided and only 25% will develop clinically relevant androgen insufficiency [3]. However this approach is controversial for several reasons. First, the early studies showing low-dose radiotherapy (20 Gy) to be an effective treatment for TIN referred to the eradication of TIN at 2 years [6]. However, it has since been reported that both TIN and testicular cancer can recur within 5 years of completing radiotherapy for TIN, despite a negative biopsy at 18 months [7]. Second, only 5% of patients with testicular cancer have TIN so almost all the biopsies will