Trip Answers

Question answered:24/05/07 Warning! this question is over two years old.

The Cancer Research UK website answered a question on the risk of developing [testicular] cancer in men with undescended testes:

 

“You do have a higher than average risk of testicular cancer. With a history of one undescended testicle, your risk is about four times higher than that of a man with both testicles descended normally. But to try to put this in perspective, this means that out of every 120 men in your situation, one will get testicular cancer at some point in their lives. This compares to one man in 480 with normal testicular development.

 

If both your testicles were undescended, your lifetime risk would be higher, at one in 44.

 

There is no increased risk of getting any other type of cancer, including prostate cancer.” [1]

 

Further information from the Cancer Research UK website on testicular cancer adds:

 

“The most important risk factor is undescended testicle (cryptorchidism). In male babies inside the womb, the testicles develop inside the abdomen. They usually move down into the scrotum at birth, or within the first year of life. If they move down later, or need surgery to bring them down, this is called undescended testicle.  A large Swedish study found that if surgery is done to bring the testicle down before the age of 13, the risk of testicular cancer is about twice that of the rest of the population.  But if the operation is not done until 13 or older, the risk is increased about 5 times” [2]

 

We believe the Swedish study referred to on the Cancer Research website was one originally reported in the New England Journal of Medicine. The Medline abstract of this article reads:

 

“BACKGROUND: Undescended testis, which is a risk factor for testicular cancer, is usually treated surgically, but whether the age at treatment has any effect on the risk is unclear. We studied the relation between the age at treatment for undescended testis and the risk of testicular cancer. METHODS: We identified men who underwent orchiopexy for undescended testis in Sweden between 1964 and 1999. Cohort subjects were identified in the Swedish Hospital Discharge Register and followed for the occurrence of testicular cancer through the Swedish Cancer Registry… RESULTS: The cohort consisted of 16,983 men who were surgically treated for undescended testis and followed for a total of 209,984 person-years. We identified 56 cases of testicular cancer during follow-up. The relative risk of testicular cancer among those who underwent orchiopexy before reaching 13 years of age was 2.23 (95% confidence interval [CI], 1.58 to 3.06), as compared with the Swedish general population; for those treated at 13 years of age or older, the relative risk was 5.40 (95% CI, 3.20 to 8.53). The effect of age at orchiopexy on the risk of testicular cancer was similar in comparisons within the cohort. CONCLUSIONS: Treatment for undescended testis before puberty decreases the risk of testicular cancer.” [3]

 

An e-Medicine article on cryptorchidism notes:

 

“Orchiopexy is the treatment of choice and usually is performed in patients aged 2-10 years. A cryptorchid testis is 20-48 times more likely to undergo malignant degeneration than a normal testis. Orchiopexy does not alter the risk of malignant transformation. The incidence of malignant transformation also is increased in the unaffected testis. Consider hormone treatment with either human chorionic gonadotropin or gonadotropin-releasing hormone analogues for palpable high-scrotal position of the testis; however, efficacy is less than 20%. Surgical treatment is most effective and reliable.”
“The lifetime risk of death from testicular malignancy in men of any age with undescended testis is approximately 9.7 times the risk in men with normally descended testis.” [4]

 

Davis writing in e-Medicine on testicular seminoma gives the following prevalence figures:

 

• “In the US: Testicular GCTs are rare, occurring in only 1-2% of all male malignancies and occurring in 1 of 250 men by age 65 years; however, GCT is the most common malignancy in men aged 15-35 years. Incidence rates are 3.7 and 0.9 cases per 100,000 persons per year for whites and blacks, respectively.
• Internationally: Incidence of testis cancer has increased from the early 1960s to the mid 1980s. Nonwhite populations have a lower incidence than white populations. The highest rates are in Denmark (8.4 cases per 100,000 persons per y) and Switzerland (6.2-8.8 cases per 100,000 persons per y), and rates vary across Europe.” [5]

 

The issue of age is addressed in a patient information leaflet produced by the American Academy of Family Physicians:

 

“How is an undescended testicle treated?
If you are an adult with an undescended testicle, moving the testicle to the scrotum probably won't improve your ability to make sperm. So in adult men, an undescended testicle is usually just taken out. Doctors often don't do anything about an undescended testicle in men over 40. If you are an older man with an undescended testicle, your doctor can help you decide what to do.” [6]

 

Kolon provides current recommendations for the management of cryptorchidism in postpubertal men:

 

• “Younger than 32 years with a unilateral undescended testis - Orchiectomy
• Older than 32 years with a unilateral undescended testis - Close observation and physical examination (orchidopexy vs orchiectomy if difficult to examine)
• Any man with bilateral undescended testes - Bilateral testicular biopsy and orchidopexy.”

 

Concerning the use of ultrasonography, Kolon states:

 

• “Radiologic studies to localize the testis are currently of very little value. CT scan and ultrasonography are associated with high false-negative rates in the evaluation of a nonpalpable testis and are not recommended. Magnetic resonance angiography (MRA) has been reported to have a nearly 100% sensitivity but requires sedation or anesthesia and is expensive and may not be cost-effective. To date, examination by a pediatric urologist has proven to be more valuable than ultrasound, CT scan, or MRA findings.” [7]

 

A search in the NLH Guidelines, TRIP and Medline databases found no guidelines on the management of adult patients with undescended testes or the usefulness of ultrasonography. However, a study by Pekkafali comparing ultrasonographic and lapascopic finding in adult nonpalpable testes reported:

 

“…In this prospective study, we compared the sonographic and laparoscopic findings in adult cases with nonpalpable testes to assess the necessity and the profits of ultrasound. MATERIALS AND METHODS: 50 cases, 38 unilateral and 12 bilateral, with nonpalpable testes were investigated. Patients' ages ranged from 20 to 25 years with a mean of 22. Sonographic examinations were performed with a high-resolution ultrasonography device. RESULTS: Laparoscopic evaluation of the patients with unilateral nonpalpable testis yielded 27 testes out of a total 38. In one case, the testis was detected in the inguinal canal with inguinal exploration. The remaining 10 cases were regarded as vanishing testes. All 24 testes of 12 patients with bilateral nonpalpable testes were found. The pre-laparoscopic ultrasonographic examination detected 20 of 24 testes in bilateral cases (83% sensitivity), and 17 of 26 testes in unilateral cases (65% sensitivity). CONCLUSION: Our results suggest that ultrasonography does not exclude the necessity for laparoscopy, and it is not superior to physical examination in detection of the inguinal atrophic testes or testicular nubbin.” [8]

 

References
1.Cancer Research UK. Does an undescended testicle mean increased risk of cancer? Last updated October 2006. (http://www.cancerhelp.org.uk/help/default.asp?page=2542)
2. Cancer Research UK. Testicular cancer. Last updated April 2007.
3. Pettersson A, Richiardi L, Nordenskjold A et al. Age at surgery for undescended testis and risk of testicular cancer. N Engl J Med. 2007 May 3;356(18):1835-41. (http://www.hubmed.org/display.cgi?uids=17476009).
(http://www.cancerhelp.org.uk/help/default.asp?page=2677#undes)
4. Dogra V. Crytporchidism. E-Medicine. April 2007. (http://www.emedicine.com/radio/topic201.htm)
5. Davis J. Testicular seminoma. E-Medcine. April 2006. (http://www.emedicine.com/med/topic2250.htm)
6. The undescended testical. American Family Physician. November 2000. (http://www.aafp.org/afp/20001101/2047ph.html)
7. Kolon T. Cryptorchidism. E-Medicine. March 2000. (http://www.emedicine.com/med/topic2707.htm)
8. Pekkafali MZ, Sahin C, Ilbey YO et al. Comparison of ultrasonographic and laparoscopic findings in adult nonpalpable testes cases. Eur Urol. 2003 Jul;44(1):124-7. (http://www.hubmed.org/display.cgi?uids=12814687).

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