Testicular Cancer
by A. Pavlakis, MD, PhD, Urologist

Introduction

Testicular cancer is a disease of young men: It usually occurs in males below the age of 35, but rarely before puberty (age range: 15-44 years with a peak incidence in the 25-35 year age range).

Over a lifetime, a man’s risk of testicular cancer is approximately 1 in 250 (0,4%). Almost all cases (95%) of testicular cancer originate from the cells that produce sperm (germ cells).

There are two main types of testicular cancer according to the type of cells:

  1. Seminomas and
  2. Nonseminomas.

Both these types have the same incidence rate (50%) whereas most of the remaining are "sex-cord gonadal stromal tumors", derived from "Leydig cells" or "Sertoli cells".

 

Epidemiology

Epidemiological studies have identified several factors that could predispose to the development of testicular cancer:

  • Race. Caucasian males of Northern Europe present the highest rate of testicular cancer whereas the disease is rare among African and Asian men. The highest prevalence is observed in the Scandinavian countries, Germany and New Zealand. It is reasonable to speculate that both genetic and environmental factors are probably involved.
  • Family history. Brothers and sons of patients with testicular cancer present a higher risk for developing the disease. 
  • Cryptorchidism (undescended testicles). Testes develop in the abdominal region and normally move down to the scrotum before birth. Some babies are born with either one or both testicles not having descended to the normal position. Males with undescended testes are 40 times as likely to develop testicular cancer as males with normally descended testes, particularly when there is delay in surgical treatment. Ten percent of testicular cancers involve males with undescended testes According to studies prepubertal orchidopexy (surgical fixation of the testis in the normal position) reduces the risk. 
  • Infertility. Some studies have demonstrated that infertile males have a slightly higher risk for developing testicular cancer, finding that implies that dysgenetic factors may be responsible for both conditions.
  • HIV infection (AIDS) and Cannabis. Males suffering from AIDS also present a higher risk for cancer of the testicles and the same is true for chronic cannabis users. 

 

Signs and Symptoms of Testicular Cancer

In most cases, the first indication is a palpable painless hard mass (lump) on the testicle. In rare cases, this lump may be painful. It should be known that there are also various other diseases presenting with similar signs and symptoms, most of which are benign in nature.

The widespread use of ultrasound has resulted in recent years in the identification of non-palpable, intratesticular lesions, some of which will eventually prove to be cancerous.

The presence of testicular microcalcifications in the ultrasound In examination warrants closer observation of these men, as they present a higher risk of developing cancer.

In rare cases when cancer has spread, symptoms from other parts of the body may occur, such as pain in the back or the abdomen, loss of body weight or even dyspnea, in case the disease has spread to the lungs

 

Diagnosis

A thorough clinical examination is the cornerstone of diagnosis and for this reason the urological community encourages the male population the perform self-examination of the testicles on a regular basis in order to detect early palpable indurations. Ideally this should be carried out after a warm bath, when the scrotum is relaxed and the testicle easily palpable.

If the finding is further identified by an expert Urologist then additional screening investigation is warranted in order to confirm or exclude the diagnosis of malignancy.

Such tests are:

  • Testicular Ultrasound. Ultrasonography of the testes can clarify whether the palpable induration is due to something solid, such as cancer, or to a benign, fluid-containing cyst. 
  • Blood testing. Certain types of testicular cancer often produce substances that can be detected in the blood, the so-called 'tumor markers'. Blood testing measures the following tumor markers: AFP (Alpha-Fetoprotein), β-hCG (Human Chorionic Gonadotropin) and LDH (Lactase Dehydrogenase). Increase of one or more markers confirms the diagnosis of testicular cancer. However a negative result does not necessarily exclude cancer as there are types of cancer, which do not produce these substances, and hence their level in the peripheral blood remains normal.

 

Staging of Testicular Cancer

Once the diagnosis of testicular cancer has been confirmed, the next step is to identify whether the disease is confined in the testis or if it has spread to other sites. This methodology is called staging and aims in identifying the exact extent of the disease by using certain tests.

These screening tests include imaging studies, such as plain chest X-rays, CT scan and sometimes Magnetic Resonance Imaging (MRI) scans.  The rationale for staging is to identify if the disease has already spread in the retroperitoneal lymph nodes, which represent the primary lymphatic drainage of the testes or other organs such as the lung.

Testicular cancer is categorized as being in one of three stages. The size of the tumor in the testis is irrelevant to staging. In broad terms, testicular cancer is staged as follows:

  1. Stage 1: the cancer remains localized to the testis.
  2. Stage 2: the cancer involves the testis and metastasis to retroperitoneal and/or paraaortic lymph nodes (lymph nodes below the diaphragm).
  3. Stage 3: the cancer involves the testis and metastasis beyond the retroperitoneal and paraaortic lymph nodes, as for example the lungs.

 

Treatment

The three basic types of treatment are surgery, radiation therapy, and chemotherapy.

Surgery is performed by urologists; radiation therapy is administered by radiation oncologists; and chemotherapy is the work of medical oncologists. In most patients with testicular cancer, the disease is cured readily with minimal long-term morbidity.

 

Surgery

Surgical treatment is recommended in all cases and aims at removing the testis afflicted with cancer. It is imperative to perform an incision in the inguinal area of the affected side and proceed with early ligation of the spermatic cord before mobilizing the testis in order to avoid the violation of the scrotal lymphatics and prevent the spread of cancer cells.

If cancer is at an early stage and has not spread, surgery alone can be curative. However, if cancer has metastasized, there may be need for adjunctive radiotherapy or chemotherapy and even secondary surgery for removing any potential residual tumor masses in the abdomen. 

Fertility and erectile function are not affected after orchiectomy, if the remaining testis is normal. Fertility may be affected in case the patient has to undergo adjunctive chemotherapy or radiotherapy. It is the duty of the physician to explain the situation and possibly suggest making a sperm deposit to the sperm bank. Yet, in many patients fertility comes back to normal one year after the completion of chemotherapy/radiotherapy. 

 

Chemotherapy

Nowadays, if the cancer is at an early stage and in view of the excellent prognosis many patients are only placed on surveillance protocols and simply followed on a regular basis.

However, if it is indicated, chemotherapy may have to be given. Chemotherapy is the systemic administration of anti-cancer agents with the goal of elimination of the cancer cells or prevention of their proliferation. The duration and type of the therapeutic program depends on the type and stage of cancer at the time of diagnosis. 

 

Radiotherapy

Radiotherapy is a treatment using radiation to destroy cancer cells. Radiation may be used to treat stage 2 seminoma cancers, or as adjuvant (preventative) therapy in the case of stage 1 seminomas, to minimize the likelihood that tiny, non-detectable tumors exist and will spread (in the inguinal and para-aortic lymph nodes).

Radiation is ineffective against and is therefore never used as a primary therapy for nonseminoma.

 

Follow-up after therapy

For many patients with stage 1 cancer, adjuvant (preventative) therapy following surgery may not be appropriate and patients will undergo surveillance instead.

The form this surveillance takes, the type and frequency of investigations and the length of time it should continue, will depend on the type of cancer (non-seminoma or seminoma), but the aim is to avoid unnecessary treatments in the many patients who are cured by their surgery, and ensure that any relapses with metastases (secondary cancers) are detected early and cured.

This approach ensures that chemotherapy and/or radiotherapy is only given to the patients who need it.

The number of patients ultimately cured is the same using surveillance as post-operative “adjuvant” treatments, but the patients have to be prepared to follow a prolonged series of visits and tests.

 

What is the prognosis of Testicular Cancer?

While treatment success depends on the stage, the average survival rate after five years is around 95%, and stage 1 cancer cases (if monitored properly) have essentially a 100% survival rate (which is why prompt action, when testicular cancer is a possibility, is extremely important).

In conclusion, the prognosis of this disease is generally very good. Thanks to the advancement of chemotherapy, testicular cancer is today curable in more than 95% of cases. If it is diagnosed and treated early, its cure is taken for granted. But even when it has spread to other parts of the body, there are many chance that it can be cured, more than in other types of cancer.

 

Content on this site is not a substitute for professional medical advice. You should always consult your doctor.