Testicular Cancer

What Is Testicular Cancer? What Causes Testicular Cancer?

Testicular cancer, or cancer of the testes, occurs in the testicles (testes), inside the scrotum. The scrotum is a loose bag of skin under the penis. Male sex hormones, testosterone, and sperm for reproduction are produced in the testicles. The testicles are a pair of male sex glands, also known as gonads. Testosterone controls the development of the reproductive organs, and other male physical characteristics.

Although testicular cancer is uncommon compared to other cancers (0.7% of all cancers), it is the most common cancer in males aged between 15 and 35 in North America and Europe. Just under 2,000 men are diagnosed with this type of cancer annually in the United Kingdom. About 70 British males die each year from testicular cancer. 8,000 American males are diagnosed and 390 die each year in the USA of this disease.

Testicular cancer occurs when the cells become malignant (cancerous) in either one or both testicles. White (Caucasian) males, especially those of Scandinavian descent are more susceptible to developing the disease compared to other men.

The incidence of testicular cancer in the USA has more than doubled over the last four decades among Caucasian males, and has recently started to rise among afro-American males. Experts are not sure why people of different ancestries have varying incidence rates.

What are the risk factors for testicular cancer?

Although scientists are not sure what the specific causes of testicular cancer are, there are some factors which may raise a man's risk of developing the disease. These risk factors include:

• Cryptorchidism (undescended testicle) - testicles usually descend from the inside of the abdomen into the scrotum before a baby boy is born. If a testicle has not moved down when a male is born there is a greater risk that he will develop testicular cancer later on. The increased risk applies to both testicles, and is not lowered if surgery is performed to move it down.
• Congenital abnormalities - males born with abnormalities of the penis, kidneys or testicles have a higher risk.
• Inguinal hernia - males born with a hernia in the groin area have a higher risk than others.
• Having had testicular cancer - if a male has had testicular cancer he is more likely to develop it in the other testicle, compared to a man who has never had testicular cancer.
• Family history - a male who has a close relative - sibling or father - with testicular cancer is more likely to develop it himself compared to other men.
• Abnormal testicular development - conditions, such as Klinefelter's syndrome, where the testicles do not develop normally, may increase a person's risk of testicular cancer.
• Mumps orchitis - this is an uncommon complication of mumps in which one or both testicles become inflamed. This painful complication can also raise a male's risk of developing testicular cancer later on.
• Race - testicular cancer is more common among Caucasian males, compared to men of African or Asian descent. Highest rates are found in Scandinavia, Germany and New Zealand.

Having a vasectomy does not increase a man's risk of developing testicular cancer.

What are the signs and symptoms of testicular cancer?

A symptom is something the patient feels or reports, while a sign is something other people, including a doctor, may detect. For example, pain may be a symptom while a rash could be a sign.
In most cases the patient finds the cancer himself. Sometimes they are discovered by doctors during a routine physical exam. If you notice anything unusual about your testicles you should see your doctor, especially if you detect any of the following:

• A lump or swelling in a testicle (painless)
• Pain in a testicle or scrotum
• Discomfort in a testicle or scrotum
• A sensation of heaviness in the scrotum
• A dull ache in the lower back
• A dull ache in the groin
• A dull ache in the abdomen
• A sudden accumulation of fluid in the scrotum
• Unexplained tiredness or malaise

These symptoms may not necessarily be caused by cancer. In fact, less than 4% of lumps in the testicles are found to be cancerous. You should not ignore a lump or swelling in the testicle, though. It is important to see your doctor, who can find out what the cause is.

In rare cases the man may notice that his breast area is enlarged and tender. His nipples may feel sore and tender as well. This is caused by hormonal changes occurring in his body.

Even though testicular cancer can spread to the lymph nodes, it hardly ever travels to other organs. If the cancer does spread, the patient may experience:

• Coughing
• Breathing difficulties
• Swallowing difficulties
• Swelling in the chest

How is testicular cancer diagnosed?

The doctor will interview the patient; perform a physical examination, and possibly order laboratory and diagnostic tests. These may include:

• Blood tests - the aim here is to measure levels of tumor markers. Tumor markers are substances which exist in higher-than-normal levels when cancer is present. If levels of alpha-fetoprotein (AFP), human chorionic gonadotrophin (HCG), and lactate dehydrogenase (LDH) are higher than normal it may suggest there is a testicular tumor, even if a physical exam or imaging tests did not detect it.
  
  Not all forms of testicular cancer produce these markers. It is possible that blood tests come back normal, even though cancer is present.
• Ultrasound - this is a test that uses high-frequency sound waves that bounce off internal organs and tissues. Their echoes are processed and a picture is viewed on a monitor. An ultrasound of the scrotum can reveal the presence and also the size of a tumor. The doctor may also be able to determine the nature of any lump, whether they are solid or filled with fluid, inside or outside the testicle. This information helps the health care provider decide whether or not the lump is cancerous.
• Biopsy - a small sample of tissue is taken from the targeted area in the testicle and examined under a microscope by a pathologist to determine whether the lump is malignant (cancerous) or benign (non-cancerous).
  
  In most cases the only way to perform a biopsy safely is to remove the whole testicle - to perform an orchidectomy. This is because the risk of the cancer spreading if a conventional biopsy is taken is high. The specialist will only remove the testicle for a biopsy if it seems very likely the lump is cancerous. If a patient has two testicles and has one removed he can still produce sperm from the other one and procreate.

Determining what type of testicular cancer it is

When the doctor has determined the type of testicular cancer the patient has, he/she can then devise a treatment plan and make a prognosis. There are two main types of testicular cancer:

• Seminoma testicular cancer - these contain only seminoma cells. All age groups can get this type of cancer. However, most older men who do develop testicular cancer will probably have this type. It is less aggressive than non-seminomas and responds well to radiation therapy.
• Non-seminoma testicular cancer - these may contain many different cancer cells. Non-seminoma tumors tend to affect younger patients and will spread more rapidly than seminoma ones. Many types of non-seminoma tumors exist, including:
  
  
  • Choriocarcinoma
  • Embryonal carcinoma
  • Teratoma
  • Yolk sac tumor
  
  This type of cancer is also sensitive to radiation therapy, but less so compared to seminomas. Chemotherapy is usually effective for non-seminomas.
Most testicular cancers start in the germ cells - the cells in the testicles that produce immature sperm. We don't know what causes those cells to become abnormal and cancerous. Sometimes both types of cancers may be present. If this is the case the doctor will use non-seminoma treatment.

Staging the cancer

If the doctor diagnoses testicular cancer, it is important to determine how advanced it is. In order to find out whether the cancer has left its site of origin (whether it has spread), the doctor may order an MRI (medical resonance imaging) scan, CT (computerized tomography) scan, and X-rays.

Blood tests will help determine whether cancer is still in the patient's body after the testicle was surgically removed.

After carrying out all the relevant tests, the doctor will then be able to stage the cancer. This helps determine what treatment to use.

• Stage I - the cancer is only in the testis (testicle). It has not spread outside.
• Stage II - the cancer has reached the lymph nodes in the abdomen.
• Stage III - the cancer has spread further, to other parts of the body. This could include the lungs, liver, brain and bones.

What are the treatment options for testicular cancer?

Testicular cancer treatment has a success rate of about 95% - in other words, 95% of all testicular cancer patients who receive treatment make a full recover. The sooner a patient is diagnosed and treated the better his prognosis is.

Treatment for testicular cancer may involve surgery, radiotherapy, chemotherapy, or a combination.

Surgery

• Orchidectomy - usually the first line of treatment. The testicle is surgically removed to prevent the tumor from spreading. If the patient is diagnosed and treated in Stage I, surgery may be the only treatment needed.
  
  An orchidectomy is a straightforward operation. The patient receives a general anesthetic. A small incision is made in the groin and the whole testicle is removed through the incision. Patients have the option of having a prosthetic testicle, made of silicon, inserted into the scrotum - this will be for esthetic reasons only (not health reasons).
  
  The patient remains in hospital for a few days.
  
  If the man still has one testicle after the operation, his sex life and chances of reproducing should not be affected.
  
  
  • Ending up with no testicles
    
    If the male either had both testicles removed, or only had one testicle before the operation; in other words, if after the operation the patient has no testicles, he will be infertile. He will not be able to produce sperm. Males who wish to have children one day should consider banking their sperm before the operation - some sperm is kept in a sperm-bank before the testicle or testicles are removed.
  • Hormone replacement therapy
    
    The body will stop producing testosterone if the man has no testicles. Testosterone is a male hormone, which among other things, is involved in driving his libido (sex drive) and maintaining an erection. Testosterone replacement therapy involves providing the patient with testosterone. The patient either receives injections or applies patches to his skin. Injections are given every two to three weeks. Testosterone replacement therapy helps maintain a male's libido and erectile function.
• Lymph node surgery - if the cancer has reached the lymph nodes they will need to be surgically removed. This usually involves the lymph nodes in the abdomen and chest. Sometimes lymph node surgery can result in infertility. Patients who wish to have children one day should consider banking their sperm.
  
  Nerve sparing lymph node dissection is a surgical technique which significantly lowers the risk of subsequent infertility. The procedure is carried out by very specialist surgeons who may not be available in many parts of the world. The risk of cancer recurrence is higher with this procedure because not all of the lymph node is taken out.

Radiation therapy (radiotherapy)

Radiotherapy, also known as radiation therapy, radiation oncology and XRT, is used for treating cancer, thyroid disorders and some blood disorders. Approximately 40% of patients of all types of cancer undergo some kind of radiotherapy. It involves the use of beams of high-energy X-rays or particles (radiation) to destroy cancer cells. Radiotherapy works by damaging the DNA inside the tumor cells, destroying their ability to reproduce.

Patients with seminoma testicular cancer will typically require radiotherapy as well as surgery. The radiotherapy is used to prevent cancer recurrence.

Patients whose cancer has spread to their lymph nodes will need radiation therapy.

Radiation therapy may cause the following temporary side effects:

• Tiredness
• Rashes
• Muscle stiffness
• Joint stiffness
• Loss of appetite
• Nausea

Chemotherapy

Chemotherapy is the use of chemicals (medication) to treat disease - more specifically, it usually refers to the destruction of cancer cells. Cytotoxic medication prevents cancer cells from dividing and growing. When health care professionals talk about chemotherapy today, they generally tend to refer more to cytotoxic medication than others. Cytotoxic simply means it is toxic to cells, it kills cells, which in the case of chemotherapy refers to cancer cells.

Chemotherapy (chemo) drugs either interfere with a cancer cell's ability to divide and reproduce, or kills them.

Chemotherapy is usually given to patients with advanced testicular cancer - cancer that has spread to other parts of the body.

Chemotherapy is also used to prevent recurrence of cancer - to stop the cancer from coming back.

Most commonly, chemotherapy is used for the treatment of non-seminoma tumors.

Treatment is administered either orally (tablets by mouth) or injection.

As chemotherapy attacks healthy (good) cells as well as cancerous ones, the patient may experience the following temporary side effects:

• Nausea
• Vomiting
• Hair loss
• Mouth sores
• Tiredness
• Malaise

Most people immediately link chemotherapy with uncomfortable side effects. However, side-effect management has improved considerably over the last twenty years. Many side effects that were once inevitable can be either prevented or well controlled today. There is no reliable way to predict how patients may react to chemotherapy. Some experience very mild side-effect, others will have none at all, while some people will report various symptoms.

Prevention of testicular cancer

Preventing testicular cancer may not be possible, but making sure it does not advance before diagnosis and treatment is. In other words, if you check yourself regularly for signs and symptoms of testicular cancer you are more likely to be one of those 95% of patients who make a full recovery if you do develop testicular cancer.

How to check yourself

The best time to check yourself is when the scrotal skin is relaxed; usually after a warm shower or bath.

• Gently hold your scrotum in the palms of both your hands. Stand in front of the mirror and look for any swelling on the skin of the scrotum.
• Feel the size and weight of your testicles first.
• With your fingers and thumbs press around and be receptive for any lumps or unusual swellings. Become familiar with your own testicles. Some men have one testicle that hangs lower than the other. Some people have one testicle which is bigger than the other. This is normal.
• Each time you check yourself try to detect any significant increase in the size or weight of your testicles.
• Feel each testicle individually. Place the index and middle fingers under the testicle while your thumbs are on the top. Gently roll the testicle between the thumbs and the fingers - it should be smooth, oval shaped, and somewhat firm; there should be no lumps or swellings. The top and back of each testicle should have a tube-like section which may be slightly tender - this is where sperm is stored (epididymis). It is normal for it to feel tender.

If you are not sure what a testicle should feel like, remember this:

• They should both have a similar feel.
• As cancer in both testicles is extremely rare, you are unlikely to feel two identical testicles that have cancer.
• If one feels different from the other, tell your doctor.
• Also, tell your doctor if a testicle does not have the same feel compared to your last self-check.