Testicular Cancer (283)

The Facts

Testicular cancer is the most common cancer found in men between the ages of 15 and 29 years old, and the incidence of this condition has been increasing over the last several decades. Testicular cancer also seems to be more common in Caucasian men than in those of African descent.

Most cases of this cancer are found by testicular self-examination, often following a trauma or blow to the genital region.

The cancer is divided into two types: seminoma (30%) and nonseminoma (70%).

Causes

There's no known cause for testicular cancer. Risk factors for developing testicular cancer include:

• family history of testicular cancer
• previous cancer in one testicle
• undescended testis

Some studies suggest infertility as a risk factor for developing testicular cancer, but this is not yet proven. There is no association between testicular cancer and vasectomy, diet, or trauma.

Symptoms and Complications

The symptoms of testicular cancer include:

• a painless lump in the testicle (common)
• dull ache or pain in the groin or abdomen (uncommon)
• enlargement of a testicle (common)
• pain, discomfort, or a feeling of "heaviness" in the scrotum (uncommon)
• pain or discomfort in the testicle (uncommon)

Occasionally, symptoms arise from disease that has already spread to other organs, such as lumps in the neck, cough due to cancer in the lungs, back pain due to cancer in the bones, and, rarely, neurological problems because of nerve or brain problems.

The treatment of testicular cancer can cause a variety of complications. Radiotherapy may cause problems gaining or retaining erections, while chemotherapy may cause sterility.

Men who have had testicular cancer also seem to be at a higher risk for developing leukemia and other types of cancers.

Making the Diagnosis

There is currently no strong evidence to support or discourage monthly testicular self-examination. However, self-examination may help alert you and your doctor to abnormal changes in the testicle sooner. If you choose to do the exam, the best time to perform the examination is after a bath or shower, and the best place is in front of a mirror.

To do the monthly exam, gently hold the testicle and feel it with the fingertips of the index finger and thumb, checking for any abnormalities or swelling. Repeat the process with the other testicle. The testicles should feel oval in shape, and smooth and firm. Check for any swelling around the epididymis, a cord-like structure at the top and back of the testicle.

When someone has a suspected testicular tumour, the doctor usually reviews the family medical history and does a full physical exam, including checking the testicles and scrotum and taking blood tests. The blood tests will check for chemical markers which can indicate cancer. This is usually followed by an ultrasound of the scrotum. The ultrasound can show any masses or abnormalities on the testicles.

For diagnostic purposes, a biopsy can be done by removing the entire affected testicle (excisional biopsy) and studying the tissue for signs of cancer. Although the entire testicle is taken, it's removed not through the scrotum but through a small incision made in the groin. The entire testicle is taken because this reduces the risk of the cancer spreading.

Chemical markers of the tumour found in the blood can be very helpful in diagnosing testicular cancer as well as for treatment and later follow-up. A pattern of how these markers appear (alpha-fetoprotein [AFP], beta-human chorionic gonadotropin [beta-HCG], and lactate dehydrogenase [LDH]) can help determine the type of testicular cancer and the type of treatment required.

Once the diagnosis has been made, it's important to determine the cancer's stage, called staging. Staging is done using a chest X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) scans of the abdomen and pelvic area, and bone scans. The chest X-ray will show if the cancer has spread to the lungs, while the CT scans will show if it has spread to the abdominal lymph nodes. Some doctors recommend X-rays be taken with special dyes. An intravenous pyelography shows the urinary system, while a lymphangiography shows the lymph system.

The stages of testicular cancer are:

• stage 0: abnormal cells are found in the testicle, and all tumor marker levels are normal
• stage 1: the cancer is only in the testicle, or the level of at least one of the tumour markers is very high
• stage 2: the cancer has spread into the lymph nodes in the abdomen
• stage 3: the cancer has spread to other parts of the body such as the lungs or liver, or the cancer has spread to the lymph nodes in the abdomen and tumour marker levels are high

Treatment and Prevention

The first line of treatment for testicular cancer is surgery to remove the affected testicle. A testicular implant may be put in place to restore the look of the removed testicle. With the healthy testicle left, you will still be able to have children and normal erection.

Surgery may be followed by radiotherapy, chemotherapy, or a combination of both. For some people, no treatment after surgery is recommended. However, your health care team will monitor you regularly. The oncologist (a doctor who specializes in treating cancer) will often recommend after surgery what follow-up treatment is best based on the type of cancer and the stage of the disease.

Seminomas in the early stage are often treated with surgery and radiotherapy or chemotherapy. Non-seminoma germ cell tumours (NSGCT) are often treated with more extensive surgery such as radical retroperitoneal lymph node dissection (the removal of some lymph nodes behind the abdomen) followed by watchful waiting or chemotherapy. Often, the use of chemotherapy or surgery depends on an estimate of the risk (low, intermediate, or high) of the cancer worsening or spreading. Various factors, such as the type and stage of the cancer and your overall health, may indicate that one treatment is more suitable than another.

For more advanced disease, such as bulky tumours or metastatic disease, treatment with chemotherapy can still be highly effective. There is still a significant rate of cure even for testicular cancer that has moved to other parts of the body. Sometimes for high-risk disease, though most often for a recurring cancer, high-dose chemotherapy with autologous stem cell support (a bone marrow transplant from the patient's own stem cells after high-dose chemotherapy) can successfully bring about long-term remission or even a cure.

Side effects for radiation therapy can include:

• decreased appetite
• diarrhea
• fatigue
• nausea
• red, dry skin at the radiation site

Radiation can affect fertility, but any reduction in sperm production is usually temporary.

Because chemotherapy circulates throughout the body, more of the body systems are affected by the treatment. Side effects from chemotherapy include:

• chills
• diarrhea
• fatigue
• hair loss
• mouth sores
• nausea and vomiting
• shortness of breath

Some chemotherapy can cause sterility, so this should be discussed before treatment starts. Those who want to be able to father children in the future should speak to their doctors regarding storing sperm.

Following cancer treatment, doctors usually recommend blood tests and chest X-rays on a regular basis to make sure the treatment is successful and that the cancer hasn't returned.

Men with testicular cancer may feel particularly vulnerable psychologically, especially since this cancer often hits in the years when they may be starting families. Good psychological support is an important part of the overall healing process.

The outlook for testicular cancer is good – the earlier the cancer is detected, the better the expected outcome. Recurrences of the cancer are possible, however, so those who have had it treated must be watchful for any signs of the cancer returning. Statistics show that most recurrences happen within the first year following treatment.

[references]

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