Urology cancer update for primary care Jacob Cherian June 2019

Testicular Lump - Case study Day 1 A 40-year-old man – Mr G – attends accident and emergency with a painfully swollen testis. He is seen by a specialist registrar – Dr A – who makes a diagnosis of epididymo-orchitis. Mr G is given a seven-day course of the antibiotic co-amoxiclav and advised to see his GP for follow-up.

Testicular Lump - Case study Day 7 Mr G attends for an appointment at his local general practice surgery. He is seen by Dr B who notes the A&E attendance and antibiotic prescription. The patient reports improvement in his condition but there is still some slight swelling. Dr B prescribes a further seven-day course of antibiotics but this time with ofloxacin.

Mr G phones requesting an urgent appointment. Testicular Lump - Case study Day 16 Mr G phones requesting an urgent appointment. He is concerned that the swelling has not cleared with the second course of antibiotics. Dr B examines the patient again and identifies a small non-tender cyst in the left epididymis but the testis is “normal”. Dr B reassures the patient and instructs him to return in two weeks if the symptoms have not settled.

Day 37 Mr G attends the practice again complaining of a persistent and painful swelling. He sees Dr B and expresses his worry that he might have testicular cancer. Dr B notes “Left testicular pain persists, lump adherent to upper pole” and he refers the patient for an ultrasound investigation of the testicle and issues a further prescription of the antibiotic ciprofloxacin.

Mr G is referred to a urologist the next day. The urologist finds several focal lesions consistent with tumour on the scan. On examination he detects a hard tender mass at the upper pole of the left testis. Two days later Mr G undergoes an Orchidectomy Histological analysis confirms a diagnosis of seminoma. A CT scan shows enlargement of the peri-aortic lymph nodes on the left side Mr G undergoes both chemotherapy and radiotherapy.

Suspected cancer: recognition and referral NICE guideline [NG12] Published date: June 2015 Last updated: July 2017 Testicular cancer Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for testicular cancer in men if they have a non‑painful enlargement or change in shape or texture of the testis. [new 2015] 1 Consider a direct access ultrasound scan for testicular cancer in men with unexplained or persistent testicular symptoms. [new 2015]

Scrotal lump Painless Painful Transluminate Hydrocele Epididymal cyst Spermatocele Epididymo-orchitis Torsion Rarely Testicular tumour Extra-testicular Bag of worms varicocele Reducible Hernia Painless / hard Tumour