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\author{Molly}
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  /Title (2-7-male-reproductive-system-testicular-cancer.pdf)
  /Creator (Cheatography)
  /Author (Molly)
  /Subject (2.7 Male Reproductive System: Testicular Cancer Cheat Sheet)
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    \vspace{-2pt}\large{\bf{\textcolor{DarkBackground}{\textrm{2.7 Male Reproductive System: Testicular Cancer Cheat Sheet}}}} \\
    \normalsize{by \textcolor{DarkBackground}{Molly} via \textcolor{DarkBackground}{\uline{cheatography.com/30516/cs/9588/}}}
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  \mymulticolumn{2}{p{5.377cm}}{\bf\textcolor{white}{Cheatographer}}  \\
  \vspace{-2pt}Molly \\
  \uline{cheatography.com/molly} \\
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  \mymulticolumn{1}{p{5.377cm}}{\bf\textcolor{white}{Cheat Sheet}}  \\
   \vspace{-2pt}Not Yet Published.\\
   Updated 24th October, 2016.\\
   Page {\thepage} of \pageref{LastPage}.
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  Measure your website readability!\\
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\begin{tabularx}{5.377cm}{p{0.4977 cm} p{0.4977 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Anatomy}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{Testicular cancer presentation will often be via a painless swelling, or mass in the scrotum. Sometimes there is localised discomfort or pain, with an associated heaviness.} \tn 
% Row Count 4 (+ 4)
% Row 1
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{If there is pain in the abdomen this can be suggestive of pelvic or abdominal metastases, and should be investigated accordingly. Elevated serum markers should be assessed. These can help the physician distinguish between different types of testicular cancers.} \tn 
% Row Count 10 (+ 6)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{{\bf{The testicles (testes)}} are two small, oval-shaped organs located behind the penis in a skin sack called the scrotum.} \tn 
% Row Count 13 (+ 3)
% Row 3
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{Each testis lies within a fibrous capsule known as the {\bf{tunica albuginea}}, within the scrotum.} \tn 
% Row Count 15 (+ 2)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{The testicles are located outside the body because sperm develop best at a temperature several degrees cooler than normal internal body temperature.} \tn 
% Row Count 18 (+ 3)
% Row 5
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{The germ cells inside the seminiferous tubules (sertoli cells) create sperm. The sperm move into the epididymis where they mature. They are stored there for a few weeks until they eventually move up the vas deferens to combine with fluids from the prostate and seminal vesicles to form what you normally think of as semen. The whole process takes about 7 weeks.} \tn 
% Row Count 26 (+ 8)
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{The leydig cells distributed throughout the testicle are the body's main source of testosterone. Testosterone, the male sex hormone, is essential to the development of the reproductive organs and other male characteristics such as body and facial hair, low voice, and wide shoulders. Without enough testosterone, a man will probably lose his sex drive and suffer from fatigue, depression, hot flashes and osteoporosis.} \tn 
% Row Count 35 (+ 9)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
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\begin{tabularx}{5.377cm}{p{0.4977 cm} p{0.4977 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Anatomy (cont)}}  \tn
% Row 7
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{Lymphatics play an important part in the management of testicular cancer patients.} \tn 
% Row Count 2 (+ 2)
% Row 8
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{The lymphatics directly from the testes follow the spermatic cord, through the inguinal ring, along the iliac nodes and to the para-aortic nodal chain. These lymphatic chains ultimately determine the radiation fields.} \tn 
% Row Count 7 (+ 5)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
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\begin{tabularx}{5.377cm}{p{0.4977 cm} p{0.4977 cm} }
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\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Epidemiology and Aetiology}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{Testicular tumours are {\bf{relatively rare}}, representing approximately 1\% of all cancers.} \tn 
% Row Count 2 (+ 2)
% Row 1
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{In men aged between {\bf{20 and 34}} it is the most common cancerand most common cancer killer} \tn 
% Row Count 4 (+ 2)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{It is associated with {\bf{cryptorchidism}}, which is maldescent of the testes from the abdomen. There is an increased risk 10 to 40 times higher.} \tn 
% Row Count 7 (+ 3)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
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\begin{tabularx}{5.377cm}{p{0.4977 cm} p{0.4977 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Pathology}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{The breakdown of the tumour types expected for testicular tumours are {\bf{95 \% Germinal}}, and the remainder non-germinal.} \tn 
% Row Count 3 (+ 3)
% Row 1
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{The germinal tumours are formed from the germ cells, which form sperm within the testicles.} \tn 
% Row Count 5 (+ 2)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{70 \% of germinal tumours are seminoma, and the rest are teratomas.} \tn 
% Row Count 7 (+ 2)
% Row 3
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{Over the age of 50 tumours tend to be of non-germ cell origin.} \tn 
% Row Count 9 (+ 2)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{Seminoma are sensitive to radiation and often present early at stage 1 where an Orchidectomy is performed and then prophylactic para-aortic node irradiation is delivered.} \tn 
% Row Count 13 (+ 4)
% Row 5
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{Teratoma would be treated with cytotoxic chemotherapy as this is a chemosensitive structure and because there is greater chance of distant spread at presentation.} \tn 
% Row Count 17 (+ 4)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
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\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Spread}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{Seminoma is very {\bf{predictable}} in its spread, and at presentation regional lymph nodes will be present in 25 \% of cases for seminoma, 40 \% for teratomas, and 50 \% for embryonal carcinomas.} \tn 
% Row Count 4 (+ 4)
% Row 1
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{{\bf{Spread is most commonly in the para-aortic lymph node group}}, Local spread may be present to the epididymis and spermatic cord.} \tn 
% Row Count 7 (+ 3)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
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\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Diagnostic work-up}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{General - history and physical examination} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{Bloods - FBE, serum assays} \tn 
% Row Count 2 (+ 1)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{Medical Imaging - {\bf{Testicular ultrasound}} is the first procedure for scrotal abnormality, followed by chest imaging and CT of the abdomen/pelvis to assess nodal involvement.} \tn 
% Row Count 6 (+ 4)
% Row 3
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{{\bf{Surgery consists of an inguinal orchidectomy}}, where the affected testicle is removed through the groin. This is both a {\bf{diagnostic and therapeutic procedure.}}} \tn 
% Row Count 10 (+ 4)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{The complete removal means an accurate diagnosis can be made through histopathology and the primary disease has been removed from the patient.} \tn 
% Row Count 13 (+ 3)
% Row 5
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{If the surgeon removed all or part of the testes through an incision in the scrotum, then there would be a {\bf{high risk of seeding}} within the scar. This technique would also disrupt normal lymphatic flow, altering the natural history of the disease. If partial removal were done, there would be a {\bf{high risk of local recurrence}} or continued growth of the primary disease.} \tn 
% Row Count 21 (+ 8)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
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\begin{tabularx}{5.377cm}{p{0.4977 cm} p{0.4977 cm} }
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\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Staging}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{There are a number of staging systems used for testicular cancers.} \tn 
% Row Count 2 (+ 2)
% Row 1
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{*he {\bf{Royal Marsden system}} is the most widely used one.} \tn 
% Row Count 4 (+ 2)
% Row 2
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\mymulticolumn{2}{x{5.377cm}}{The Marsden system, it is broken up into 4 stages.} \tn 
% Row Count 5 (+ 1)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
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\begin{tabularx}{5.377cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{5.377cm}}{\bf\textcolor{white}{The Royal Marsden staging system}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{5.377cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/molly_1477298510_Capture.PNG}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
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\begin{tabularx}{5.377cm}{p{0.4977 cm} p{0.4977 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Management}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{For non-seminomas and patients with advanced disease, a radical orchidectomy and chemotherapy will be administered.} \tn 
% Row Count 3 (+ 3)
% Row 1
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{Chemotherapy regimes have improved considerably for non-seminoma tumours in the last couple of decades. Therefore after surgery, Platinum-based multi-agent chemotherapy will be delivered to the patient.} \tn 
% Row Count 8 (+ 5)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{{\bf{Radiotherapy}} will not play a role in the management unless there is a large residual mass postchemotherapy.} \tn 
% Row Count 11 (+ 3)
% Row 3
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{For {\bf{pure seminoma}}, surgery via orchidectomy will be undertaken. This is followed by {\bf{radical radiotherapy}}. Seminoma is highly sensitive to radiation; therefore high doses are not required to be tumourcidal. This presents as an interesting scenario for the radiation oncologist, as these men are young and easily curable (greater than 90 \% cure rate). Yet there are a number of critical structures that we will need to discuss.} \tn 
% Row Count 20 (+ 9)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
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\begin{tabularx}{5.377cm}{p{0.4977 cm} p{0.4977 cm} }
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\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Simulation}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{The radiation fields that are used to treat testicular cancer will be dependent upon the disease stage, the administration of chemotherapy and the radiation oncologist's preference.} \tn 
% Row Count 4 (+ 4)
% Row 1
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{There are usually three options:} \tn 
% Row Count 5 (+ 1)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{For {\bf{early stage disease}} only the para-aortic nodal group is irradiated.} \tn 
% Row Count 7 (+ 2)
% Row 3
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{For {\bf{further advanced disease}}, a dog-leg technique will be used to include the iliac nodal group on the ipsilateral (affected) side.} \tn 
% Row Count 10 (+ 3)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{With {\bf{bulky disease in the para-aortic}} it is possible that the contralateral pelvis will be irradiated - an "inverted Y" technique. There will be a central pelvic shield to minimise toxicity to the bladder and bowel.} \tn 
% Row Count 15 (+ 5)
% Row 5
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{The treatment technique for both the {\bf{'dog-leg'}} and {\bf{abdomen techniques}} is using AP/PA photons.} \tn 
% Row Count 18 (+ 3)
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{The energy can be dependent on the patients' AP separation, ranging from 6 to 18 MV.} \tn 
% Row Count 20 (+ 2)
% Row 7
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{The patient will be positioned supine on carbon fibre, with a neck support, bolster under knees and ankle support to ensure reproducible leg position.} \tn 
% Row Count 23 (+ 3)
% Row 8
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{The radiation fields are designed based on the patient's lymphatic chains. Everyone's lymphatics are slightly different, so we need to know where they are.} \tn 
% Row Count 27 (+ 4)
% Row 9
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{The classic {\bf{dog leg technique}} has UL field size is set at T10. The field width is approximately 9 to 12 cm in the para-aortic region, and 2 cm coverage either side of the ipsilateral pelvic nodes. This is achieved by angling at the level of the fourth and fifth lumbar vertebrae towards the affected side.} \tn 
% Row Count 34 (+ 7)
\end{tabularx}
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\vfill
\columnbreak
\begin{tabularx}{5.377cm}{p{0.4977 cm} p{0.4977 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Simulation (cont)}}  \tn
% Row 10
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{The Lower level is at the top of the {\bf{obturator foramen}}, but there is no need to include the surgical scar within the field unless the is a testis capsule was compromised and there {\bf{risk of seeding}}. The radiation oncologist may like to see a {\bf{radio-opaque marker}} along the {\bf{scar}} so that it is {\bf{visualised on CT}}. Most often that not, the LL will run about half way through the scar} \tn 
% Row Count 8 (+ 8)
% Row 11
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{{\bf{Para-aortic strip}}} \tn 
% Row Count 9 (+ 1)
% Row 12
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{If the radiation oncologist has prescribed radiation to the {\bf{abdomen only}}, similar information to the dog-leg technique will need to be acquired.} \tn 
% Row Count 12 (+ 3)
% Row 13
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{The field width is normally 8 – 10 cm wide that may not require any shielding. The upper level of the field will again be the junction of T10 and T11, with the lower level the junction of L5 and S1. There will be little to no shielding required for this technique, so an {\bf{isocentric technique}} is suitable.} \tn 
% Row Count 19 (+ 7)
% Row 14
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{The information to be acquired at simulation/planning for both the dog-leg and para-aortic techniques are essentially the same, as follows:} \tn 
% Row Count 22 (+ 3)
% Row 15
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{-Tattoo positions (centre dependant) eg isocentre, $\frac{1}{2}$ AP laterally, TOX/ML, UBP/ML} \tn 
% Row Count 24 (+ 2)
% Row 16
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{-Stretch TOX (Tip of xiphi-sternum)  to UBP (upper border of pubis)} \tn 
% Row Count 26 (+ 2)
% Row 17
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{-UBP – BOP (Base of penis)} \tn 
% Row Count 27 (+ 1)
% Row 18
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{-A planning CT throughout the treatment volume will be acquired. This will be used to delineate the kidney volume and the field definition for the patient.} \tn 
% Row Count 31 (+ 4)
\end{tabularx}
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\vfill
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\begin{tabularx}{5.377cm}{p{0.4977 cm} p{0.4977 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Simulation (cont)}}  \tn
% Row 19
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\mymulticolumn{2}{x{5.377cm}}{{\bf{Supra-diaphragmatic disease}}} \tn 
% Row Count 1 (+ 1)
% Row 20
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{It is unlikely that we will treat above the diaphragm for testicular cancer. If we were to treat a residual mass, the field dimensions are:} \tn 
% Row Count 4 (+ 3)
% Row 21
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{-Lateral edges to cover the rib cage \{\{nl\}\}-superiorly is 2 cm above palpable disease \{\{nl\}\}-inferiorly is the 10th rib\{\{nl\}\}-similar doses as the abdomen 25/20/5, with boosts to any bulky disease in the neck or mediastinum up to a dose of 30 - 40 Gy.} \tn 
% Row Count 10 (+ 6)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
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\begin{tabularx}{5.377cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{5.377cm}}{\bf\textcolor{white}{Typical field borders for dog-leg technique}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{5.377cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/molly_1477301934_Capture.PNG}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
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\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Planning}}  \tn
% Row 0
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\mymulticolumn{2}{x{5.377cm}}{The planning for these patients is not usually complex, as {\bf{the technique is just opposed photon fields. }}} \tn 
% Row Count 3 (+ 3)
% Row 1
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{From the CT, the kidneys will be marked.} \tn 
% Row Count 4 (+ 1)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{{\bf{Figure A}} (lower image) is a DRR of a patient that was planned for a dog-leg technique for Seminoma. Notice the long field length, the heavy shielding (represented by the horizontal lines), and the partial irradiation of the kidneys can be seen in the upper planning images. There is a higher risk of disease on the ipsilateral side within the para-aortic region, so there is greater coverage on that side. Notice how there is slightly more kidney within the field on the right side compared to the left.} \tn 
% Row Count 15 (+ 11)
% Row 3
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{A senior member of the planning staff will check the data:} \tn 
% Row Count 17 (+ 2)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{The isocentre is in the correct position; \{\{nl\}\}The dose is even across the treatment volume; \{\{nl\}\}Dose to critical structures - Left and right kidneys; \{\{nl\}\}Correct field size, monitor units, patient position, TD used in the calculations \{\{nl\}\}Once the plan has been checked, and everything is satisfactory, the patient is ready to commence treatment.} \tn 
% Row Count 25 (+ 8)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
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\begin{tabularx}{5.377cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{5.377cm}}{\bf\textcolor{white}{Planning data}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{5.377cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/molly_1477302242_Capture.PNG}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{5.377cm}{p{0.4977 cm} p{0.4977 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Treatment}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{Since the tumour type is particularly sensitive to radiation, large doses do not need to be prescribed.} \tn 
% Row Count 3 (+ 3)
% Row 1
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{{\bf{Dose between 24 and 30 Gy in 1.5 -1.6 Gy per fraction.}}} \tn 
% Row Count 5 (+ 2)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{If there is a persistent mass, then a boost will be delivered to an extra 5 - 10 Gy.} \tn 
% Row Count 7 (+ 2)
% Row 3
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{It is just as well that we can deliver {\bf{low daily doses since it is such a large area to be treated}}, with the {\bf{potential for significant treatment toxicity}}. As with most radiation therapy techniques there are some critical structures present:} \tn 
% Row Count 12 (+ 5)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{-The {\bf{contralateral testes}} - probably the most sensitive. \{\{nl\}\}-{\bf{Kidneys}} - will be shielded as much as possible while covering the nodal groups. \{\{nl\}\}-{\bf{Bowel}} - can't do much about this - medication as required.} \tn 
% Row Count 17 (+ 5)
% Row 5
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{If the tumour is sensitive to radiation, it follows that {\bf{the testis is sensitive to radiation also.}}} \tn 
% Row Count 20 (+ 3)
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{{\bf{1 - 2 Gy before sterility is induced}}} \tn 
% Row Count 21 (+ 1)
% Row 7
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{Most patients are informed that it may take a while before they can conceive. Apart from shielding to the lowest dose possible, for young men who wish to have children, {\bf{sperm banking is advised. }}} \tn 
% Row Count 25 (+ 4)
% Row 8
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{Usually a {\bf{FBE (Full blood examination)}} will be performed at simulation to establish a baseline on blood counts. Bloods will then be taken weekly through out the treatment from there.} \tn 
% Row Count 29 (+ 4)
% Row 9
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{When para-aortic nodes are being treated alone, then there is little bone marrow within the radiation fields, but {\bf{a dog-leg will irradiate a fair amount of the pelvis}}, which will affect the bone marrow and {\bf{may alter the blood work up.}}} \tn 
% Row Count 34 (+ 5)
\end{tabularx}
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\vfill
\columnbreak
\begin{tabularx}{5.377cm}{p{0.4977 cm} p{0.4977 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Treatment (cont)}}  \tn
% Row 10
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{{\bf{Acute side effects}}: Significant erythema is not expected, due to the low doses, {\bf{nausea and diarrhoea}} are extreamly likely due to the sheer size of the fields, some {\bf{tiredness}} may be experienced after about two weeks of treatment.} \tn 
% Row Count 5 (+ 5)
% Row 11
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{{\bf{VERIFICATION}}} \tn 
% Row Count 6 (+ 1)
% Row 12
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{{\bf{Weekly imaging}} will be a minimum for these patients; many clinical centres may acquire images each fraction} \tn 
% Row Count 9 (+ 3)
% Row 13
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{Due to the close proximity of the fields to the kidneys, and their relative sensitivity to radiation, {\bf{any lateral movement of the fields will be watched closely.}}} \tn 
% Row Count 13 (+ 4)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{5.377cm}{p{0.4977 cm} p{0.4977 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Complications}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{{\bf{Late toxicities}}:} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{Dyspepsia (a common condition and usually describes a group of symptoms rather than one predominant symptom.) i.e Belly pain or discomfort. Bloating.Nausea. Loss of appetite. Heartburn. Burping. Regurgitation.} \tn 
% Row Count 6 (+ 5)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{Peptic ulcers} \tn 
% Row Count 7 (+ 1)
% Row 3
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{Intestinal obstruction} \tn 
% Row Count 8 (+ 1)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{Gastritis (a group of conditions with one thing in common: inflammation of the lining of the stomach.)} \tn 
% Row Count 11 (+ 3)
% Row 5
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{Impaired hormonal function} \tn 
% Row Count 12 (+ 1)
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{Spermatogenesis impariment.} \tn 
% Row Count 13 (+ 1)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{5.377cm}{p{0.4977 cm} p{0.4977 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{5.377cm}}{\bf\textcolor{white}{Follow up}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{5.377cm}}{The radiation oncologist will follow up the patient around six weeks post completion of the radiation therapy.} \tn 
% Row Count 3 (+ 3)
% Row 1
\SetRowColor{white}
\mymulticolumn{2}{x{5.377cm}}{After six weeks any radiation-induced side effects should have subsided, and there should be some indication of tumour response.} \tn 
% Row Count 6 (+ 3)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}


% That's all folks
\end{multicols*}

\end{document}