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Re: Increased Incidence of Testicular Cancer in Men Presenting With Infertility and Abnormal Semen Analysis
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LETTERS TO THE EDITOR
15. Kaaks, R., Lukanova, A., Rinaldi, S., Biessy, C., Soderberg, S., Olsson, T. et al: Interrelationships between plasma testosterone, sex hormone binding globulin, insulinlike growth factor-1, insulin and leptin in prostate cancer cases and controls. Eur J Cancer Prev, 12: 309, 2003 16. Liverman, C. T. and Blazer, D. G.: Testosterone and Aging: Clinical Research Directions. Washington, D. C.: National Academies Press, p. 115, 2004 17. Rhoden, E. L. and Morgentaler, A.: Results of prostate biopsy in men with low serum testosterone. J Urol, suppl., 169: 119, abstract 461, 2003
Re: Increased Incidence of Testicular Cancer in Men Presenting With Infertility and Abnormal Semen Analysis J. D. Raman, C. F. Nobert and M. Goldstein J Urol, 174: 1819 –1822, 2005 To the Editor. I read with great interest the article by Raman et al and the accompanying editorial by Costabile. We have here an important study involving 3,847 infertile patients, of whom 10 (0.26% of the total population considered) presented with a testicular tumor (all seminomatous). Although not all patients had undergone scrotal ultrasound, in no less than 6 (60% of the infertile patients with neoplasia and 0.16% of the infertile population evaluated) diagnosis was made with the help of ultrasound. The authors concluded that infertile patients have a risk of testicular tumor development that is 20 times higher than in the normal population. Although most testicular lesions (to be interpreted as malignant until proved otherwise) are diagnosed by ultrasound, the authors of the article and the subsequent editorial conclude that there is no indication for the use of ultrasound, basing the task of secondary prevention solely on self-palpation. In comment to the results achieved the authors indicate that the possibility of discovering a lesion in the infertile population at high risk for testicular cancer is 1 in 500. Screening with mammogram for breast cancer is justified by the incidence of 1 patient with disease among 1,438 who undergo screening. Recognizing that infertile patients are at high risk, I believe that ultrasound screening in this instance answers all of the criteria established in 1968 by Wilson and Junger,1 and currently accepted by the WHO—the condition is an important health problem, treatment exists that is considered acceptable for patients who have been diagnosed with the disease, adequate facilities exist for diagnosis and treatment, latency or early symptomatology can be identified, a suitable test exists, an acceptable test exists, the natural history of the disease, including its passage from latent disease to symptomatic disease, must be adequately understood, there must be guidelines regarding which patients should be treated, the cost of identifying the disease with screening (including diagnosis and treatment) must be balanced against the possible health cost in its entirety, and
identifying patients with disease must be an ongoing process and not a onetime occurrence.2,3 Respectfully, Luca Carmignani and Giorgio Bozzini Urology Unit Department of Medicine, Surgery and Dental Sciences University of Milan Milan, Italy 1. Wilson, J. M. G. and Junger, G.: Principles and practice of screening for disease. Geneva: World Health Organization, Public Health papers 34, 1968 2. Ferlay, J., Bray, F., Sankila, R. and Parkin, D. M.: EUCAN: Cancer Incidence. Mortality and prevalence in the European Union 1998. Lyon: IARCPress, CancerBase No. 4, version 5.0, 1999. Limited version available at http://www-dep.iarc.fr/ eucan/eucan.htm. Accessed on March 17, 2003 3. IARC handbooks of cancer prevention, vol. 7: Breast Cancer Screening. Lyon: IARCPress, pp. 100 –101, 2002
Reply by Authors. We wholeheartedly agree with Carmignani and Bozzini. We believe that screening scrotal ultrasonography is indicated for nonobstructive male factor infertility.
Re: Melanoma of the Penis, Scrotum and Male Urethra: A 40-Year Single Institution Experience R. Sánchez-Ortiz, S. F. Huang, P. Tamboli, V. C. Prieto, G. Hester and C. A. Pettaway J Urol, 173: 1958 –1965, 2005 To the Editor. We read the article by Sánchez-Ortiz et al with interest. While we agree with many of the points discussed by the authors, we would like to comment on several issues. First, the authors state that fewer than 100 cases of melanoma of the penis have been reported to date. However, Manivel and Fraley, in their investigation of melanoma of the penis and urethra published in 1988, reviewed a total of 57 reported cases of penile melanoma and 26 reported cases of urethral melanoma.1 Since that time, more than 78 additional cases of penile melanoma and 26 cases of urethral melanoma have been reported, bringing the current total to more than 135 and 52 cases, respectively. In addition, urethral melanoma has a high propensity for multifocal involvement and may recur even in the case of distal primary lesions.2– 4 An isolated case of melanoma of the urethra is inadequate to conclude that partial penectomy is adequate treatment for this disease. More importantly, in the absence of clinically demonstrable disease we strongly disagree with the recommendation of routine prophylactic lymph node dissection for penile melanomas 1 mm or greater. Sim et al addressed the question of the usefulness of prophylactic lymph node dissection in the treatment of malignant melanoma.5 Of the 173 patients with stage I or II disease (American Joint Committee on Cancer staging system) included in the study 63 were randomized to no lymphadenectomy, 56 to delayed lymphade-
LETTERS TO THE EDITOR
15. Kaaks, R., Lukanova, A., Rinaldi, S., Biessy, C., Soderberg, S., Olsson, T. et al: Interrelationships between plasma testosterone, sex hormone binding globulin, insulinlike growth factor-1, insulin and leptin in prostate cancer cases and controls. Eur J Cancer Prev, 12: 309, 2003 16. Liverman, C. T. and Blazer, D. G.: Testosterone and Aging: Clinical Research Directions. Washington, D. C.: National Academies Press, p. 115, 2004 17. Rhoden, E. L. and Morgentaler, A.: Results of prostate biopsy in men with low serum testosterone. J Urol, suppl., 169: 119, abstract 461, 2003
Re: Increased Incidence of Testicular Cancer in Men Presenting With Infertility and Abnormal Semen Analysis J. D. Raman, C. F. Nobert and M. Goldstein J Urol, 174: 1819 –1822, 2005 To the Editor. I read with great interest the article by Raman et al and the accompanying editorial by Costabile. We have here an important study involving 3,847 infertile patients, of whom 10 (0.26% of the total population considered) presented with a testicular tumor (all seminomatous). Although not all patients had undergone scrotal ultrasound, in no less than 6 (60% of the infertile patients with neoplasia and 0.16% of the infertile population evaluated) diagnosis was made with the help of ultrasound. The authors concluded that infertile patients have a risk of testicular tumor development that is 20 times higher than in the normal population. Although most testicular lesions (to be interpreted as malignant until proved otherwise) are diagnosed by ultrasound, the authors of the article and the subsequent editorial conclude that there is no indication for the use of ultrasound, basing the task of secondary prevention solely on self-palpation. In comment to the results achieved the authors indicate that the possibility of discovering a lesion in the infertile population at high risk for testicular cancer is 1 in 500. Screening with mammogram for breast cancer is justified by the incidence of 1 patient with disease among 1,438 who undergo screening. Recognizing that infertile patients are at high risk, I believe that ultrasound screening in this instance answers all of the criteria established in 1968 by Wilson and Junger,1 and currently accepted by the WHO—the condition is an important health problem, treatment exists that is considered acceptable for patients who have been diagnosed with the disease, adequate facilities exist for diagnosis and treatment, latency or early symptomatology can be identified, a suitable test exists, an acceptable test exists, the natural history of the disease, including its passage from latent disease to symptomatic disease, must be adequately understood, there must be guidelines regarding which patients should be treated, the cost of identifying the disease with screening (including diagnosis and treatment) must be balanced against the possible health cost in its entirety, and
identifying patients with disease must be an ongoing process and not a onetime occurrence.2,3 Respectfully, Luca Carmignani and Giorgio Bozzini Urology Unit Department of Medicine, Surgery and Dental Sciences University of Milan Milan, Italy 1. Wilson, J. M. G. and Junger, G.: Principles and practice of screening for disease. Geneva: World Health Organization, Public Health papers 34, 1968 2. Ferlay, J., Bray, F., Sankila, R. and Parkin, D. M.: EUCAN: Cancer Incidence. Mortality and prevalence in the European Union 1998. Lyon: IARCPress, CancerBase No. 4, version 5.0, 1999. Limited version available at http://www-dep.iarc.fr/ eucan/eucan.htm. Accessed on March 17, 2003 3. IARC handbooks of cancer prevention, vol. 7: Breast Cancer Screening. Lyon: IARCPress, pp. 100 –101, 2002
Reply by Authors. We wholeheartedly agree with Carmignani and Bozzini. We believe that screening scrotal ultrasonography is indicated for nonobstructive male factor infertility.
Re: Melanoma of the Penis, Scrotum and Male Urethra: A 40-Year Single Institution Experience R. Sánchez-Ortiz, S. F. Huang, P. Tamboli, V. C. Prieto, G. Hester and C. A. Pettaway J Urol, 173: 1958 –1965, 2005 To the Editor. We read the article by Sánchez-Ortiz et al with interest. While we agree with many of the points discussed by the authors, we would like to comment on several issues. First, the authors state that fewer than 100 cases of melanoma of the penis have been reported to date. However, Manivel and Fraley, in their investigation of melanoma of the penis and urethra published in 1988, reviewed a total of 57 reported cases of penile melanoma and 26 reported cases of urethral melanoma.1 Since that time, more than 78 additional cases of penile melanoma and 26 cases of urethral melanoma have been reported, bringing the current total to more than 135 and 52 cases, respectively. In addition, urethral melanoma has a high propensity for multifocal involvement and may recur even in the case of distal primary lesions.2– 4 An isolated case of melanoma of the urethra is inadequate to conclude that partial penectomy is adequate treatment for this disease. More importantly, in the absence of clinically demonstrable disease we strongly disagree with the recommendation of routine prophylactic lymph node dissection for penile melanomas 1 mm or greater. Sim et al addressed the question of the usefulness of prophylactic lymph node dissection in the treatment of malignant melanoma.5 Of the 173 patients with stage I or II disease (American Joint Committee on Cancer staging system) included in the study 63 were randomized to no lymphadenectomy, 56 to delayed lymphade-