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Practice Lesson of the week

Testicular tumour presenting as gynaecomastia

BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7545.837 (Published 06 April 2006) Cite this as: BMJ 2006;332:837

Rapid Response:

Urinary Pregnancy test for testicular cancer

Dear Editor,

While agreeing with Harris et al [1] that testis cancer is a rare
cause of gynaecomastia in men, not all men with hCG producing germ cell
tumours of the testis have testis lesions detectable on ultrasound due to
“spontaneous regression” of the primary tumour [2]. These cases can be
rapidly lethal if unsuspected [3] and can present to general surgeons with
abdominal pain, physicians with haemoptysis or symptoms of cerebral
metastasis, or orthopaedic surgeons with back pain or signs of spinal cord
compression. We would recommend a urinary pregnancy test, available in all
casualty departments, to provide instant results, although a negative test
does not rule out the diagnosis [4].

We would also advise one other test to exclude testis cancer in a
patient with gynaecomastia, serum gonadotrophins, as it is not certain
that in either of their cases was the hCG high enough to be the cause.
Testicular atrophy can induce elevation of leutenising hormone acting on
the adrenal gland to increase oestrogen synthesis. Atrophy is present in
more than two thirds of patients at diagnosis and thought to be
aetiologically significant [5]. Such patients often require testosterone
replacement for symptoms of premature andropause.

1. Harris M, Rizvi S, Hindmarsh J, Bryan R. Testicular tumour
presenting as gynaecomastia. BMJ 2006;332:837.

2. Azzopardi JG, Hoffbrand AV. Retrogression in testicular seminoma
with viable metastases. J Clin Pathol 1965;18:135.

3. Raja MA, Oliver RTD, Blomley M. Hurricane growth of malignant
trophoblastic teratoma. Postgraduate Medical Journal 1993;69:472-3.

4. Caulfield MJ, Dilkes MG, Iles RK, Handel BT, Oliver RTD. Rapid
diagnosis of testicular choriocarcinoma by urinary pregnancy tests. In:
Lancet; 1990:1230.

5. Oliver RT, Oliver JC. Endocrine hypothesis for declining sperm
count and rising incidence of cancer [letter] Lancet, 1996; 347:339-40.

Competing interests:
None declared

Competing interests: No competing interests

17 April 2006
J. Cleo Oliver
SpR General Surgery
R. Tim Oliver
Ysbyty Gwynedd, Bangor, LL57 2PW