In early stage testicular seminoma the cure rate with orchidectomy alone is up to 99% in some series. The most common area for recurrence is in the retroperitoneal and para – aortic nodes and this, coupled with their radiosensitivity, has led to the practice of adjuvant nodal irradiation in stage I seminoma for over 50 years [3
]. The standard portal in this institution is from the lower border of the T10 vertebral body to the lower body of the L5 vertebra, encompassing the spinous processes and the ipsilateral renal hilum. The Medical Research Council (MRC) randomised trial, TE10, compared para – aortic strip irradiation (PAS) only with dog – leg field irradiation (DL), i.e., inclusion of the ipsilateral iliac nodes to a dose of 30 Gy in 478 patients [4
]. The relapse rates in both groups were low with only nine patients relapsing in each group at 4.5 years median follow – up. During radiation treatment, nausea and vomiting, diarrhoea and, in particular, leukopenia occurred less often in the PAS arm than in the DL arm. The later MRC trial, TE 18 [5
], assigned 625 patients to either 20 Gy in 10 fractions versus 30 Gy in 15 fractions. It concluded that there were no additional relapses in those receiving 20 Gy in 10 fractions versus 30 Gy in 15 fractions. Furthermore, it concluded that there was more lethargy, leucopenia and dyspepsia in the 30 Gy group.
Human chorionic gonadotrophin (hCG) is a highly specific and sensitive germ cell tumour marker. It is detectable in the serum of up to 49% of thise with seminomas at the time of diagnosis [6
]. It is secreted by both seminomas and non – seminomas and while the alpha subunit is also found in other human hormones such as luteinising hormone (LH), the beta subunit is specific. A rising hCG can often precede the development of overt clinical or radiological disease and is generally taken to reflect recurrence. While most hospital assays measure the beta subunit, this would not necessarily identify exogenous administration, as seminomas can secrete the beta subunit, the intact molecule or both. A number of other malignancies can also secrete hCG (Table ) and a false positive result can also be caused by smoking marijuana [7
]. Only one previous case of a false positive result due to hCG injection has been previously described in the literature [2
Malignancies known to secrete hCG
The illicit use of supraphysiological doses of anabolic steroids (AS) by male athletes has been common practice since the 1950 's and they are often taken in combination regimens – a process known as ' stacking '. The use of drugs such as Nandrolone in clinical practice is at doses of 50 milligrams every 3 weeks, but can be at doses of up to 800 milligrams weekly in bodybuilding and other sports where they are abused. There are many side effects associated with their use, including hepatic dysfunction, increase in total cholesterol and resultant cardiovascular morbidity, left ventricular hypertrophy, behavioural changes, thyroid dysfunction and even an increase in the risk of developing Wilms tumour, prostate adenocarcinoma and hepatocellular carcinoma. In males, even low doses of anabolic steroids cause hypogonadotrophic hypogonadism via inhibition of the production of Luteinising hormone (LH) and Follicle stimulating hormone (FSH). This can lead to diminished sperm production, testicular atrophy and gynaecomastia. The extent of the suppression of endogenous testosterone production is dependent on the strength of steroid used and the duration of the usage. Therefore, abusers seek to increase the body's own endogenous testosterone production as quickly as possible. This is done with hCG, at doses of up to 15,000 iu every three days. As hCG increases both testosterone and oestrogen, an antioestrogen such as Tamoxifen or Clomid may be taken to avoid oestrogen excess.