The testes are part of the male reproductive system. They are two egg-shaped glands located in the scrotum, the sac of loose skin located directly beneath the penis. The testes are responsible for the production of male hormones, primarily testosterone, and for sperm. There are different types of cells in the testes, which give rise to different types of testicular cancers. These cells can become cancerous when the body’s control mechanisms stop working properly, allowing an accumulation of damaged genetic material. This results in uncontrolled cell growth and the formation of a mass of tissue, which is known as a tumor. If this tumor starts invading other tissues and organs, it is called cancer. Testicular cancer is one of the few cancers that can usually be cured, even at advanced stages.
A brief, general introduction about the key topic discussed throughout the text: Testicular cancer is a rare disease that most commonly affects males in the age group of 15-35 years. It accounts for approximately 1% of all cancers and 5% of cancers in males. Despite its rarity, it is one of the most common cancers in young men. There are about 8,000 new cases of testicular cancer in the United States every year and over 70,000 worldwide. The incidence of this disease is on the increase. Testicular cancer usually is a highly treatable cancer with survival rates close to 95%. In order to comprehend the many facets of testicular cancer and how to best cope with it, as a patient or as a relative of a patient, one must first have an understanding of what testicular cancer is.
Definition and Types
Treatment and management of testicular cancer are based on the type of cancer cells, which tumor cells have spread, and the extent of the disease. The outlook for men with testicular cancer has improved over the last few decades, and approximately 95% of affected men are cured, even if the cancer has already spread.
Testicular cancer is broadly classified into two types – seminoma and nonseminoma. Seminomas are a type of testicular cancer that develop from the cells which produce sperm. Nonseminomas, on the other hand, are made up of a group of unrelated types of testicular cancers that usually affect younger men. These tumors consist of cells that are still in the process of becoming mature sperm cells, as well as those that are derived from other types of cells present in the testicles.
Testicular cancer occurs when malignant tumors develop in one or both of the testicles. These tumors can be made up of several types of cancer cells, most of which are derived from the sperm-producing cells of the testicles. Some testicular tumors, however, are made up of other types of non-germ cells, including those that develop into the different parts of the sperm.
Testicular cancer is a rare but serious disease that affects the male reproductive organs. The testicles, also known as testes, are a part of the male reproductive system. They are located behind the penis in a sac of skin called the scrotum. Testicles are responsible for producing and storing sperm, as well as for producing the male hormone testosterone.
Epidemiology and Risk Factors
Testicular cancer displays a unique age-specific disease distribution. It occurs most frequently in young and middle-aged men, with the median age at diagnosis being 33 years. Approximately 7% of cases occur in adolescents and young adults and about 15% occur in men over the age of 55. There are two important characteristics of the age-specific distribution of testicular cancer. Firstly, its incidence is among the highest of all cancers in young men. Secondly, it is one of the few cancers for which the age-specific incidence is increasing. Indeed, it is estimated that the annual number of new cases of testicular cancer has increased by 60% in the past 30 years.
Testicular cancer is a rare disease, accounting for less than 1% of all new male cancer cases in the USA. The age-adjusted annual incidence of testicular cancer is 7.2 cases per 100,000 men. By comparison, age-adjusted incidence rates of other urologic cancers such as prostate, bladder, and renal pelvis cancers are considerably higher. The advent of platinum-based chemotherapy has ushered in a true cure era for patients with disseminated disease and as a result, long-term survival following a diagnosis of testicular cancer is the rule. With rare exceptions, the only known consistent risk factors for testicular cancer are cryptorchidism (undescended testis) and a prior personal history of testicular cancer in the contralateral testis.
Signs and Symptoms
The most common symptoms of testicular cancer are: a painless lump or swelling in either testicle; a feeling of heaviness in the scrotum; a dull ache in the lower abdomen, back, or groin; and sudden collection of fluid in the scrotum. Since testicular cancer is more common in young and middle-aged men, it’s unlikely that these symptoms are caused by cancer for men past the age of highest risk. However, it is still a good idea to have a medical professional examine you if you have any symptoms to determine the cause and receive proper care.
A common way testicular cancer is found is by noticing signs and symptoms. Testicular cancer can have several symptoms, but in about 20% of patients, the cancer is discovered before they have reported any recognizable symptoms. The earlier cancer is detected in general, the more likely it can be cured. Some symptoms don’t necessarily denote the presence of cancer but could mean that something is wrong with the testicles. Other conditions such as infections, inflammations, or testicular injuries can cause similar symptoms. Therefore, it is important for men to promptly report symptoms to a doctor and undergo an exam to determine the cause.
Common Symptoms
Testicular cancer can also produce symptoms by secreting hormones. One example of this is the condition called gynecomastia, which is the abnormally enlarged breasts in men or boys. In rare cases, testicular cancer can develop in the testicle next to the other one and produce two lumps. It may also break away and spread to other parts of the body before a lump is large enough to be detected within the testicle. In these cases, other symptoms may arise depending on which part of the body gets affected by the cancer cells.
The most common symptom of testicular cancer is a painless lump or swelling in the testicle. It is important to recognize that there are definitely other conditions which can cause a lump in the testicle and are not cancer. In addition, those lumps or swelling are very often painful in the other conditions. However, for a man, any testicular symptoms should be taken seriously, checked by a healthcare provider, in order to determine if the cause is cancer or another condition. Further symptoms, aside from lumps or swelling, may include some testicular pain or discomfort which are not associated with physical exertion, and a dull ache in the lower abdomen, back or groin, apart from the lump or testicle swelling.
Testicular cancer is an uncommon type of cancer that occurs in the male reproductive organs, the testicles. It usually affects young men between the ages of 15 and 49 and is very rare in boys and in men over the age of 50. Testicular cancer is one of the most curable forms of cancer, especially when it is found early. This chapter revises the common symptoms of testicular cancer, which luckily are not only easy to recognize, but also tend to appear early in the course of the disease.
Less Common Symptoms
It is important to remember that having one or more of these symptoms does not mean you have testicular cancer. These symptoms are typical of many other conditions and are rarely caused by testicular cancer. The most common cause of these less common testicular cancer symptoms is an infection, such as epididymitis or orchitis. These are painful inflammations of various parts of the testicle and are usually caused by a viral or bacterial infection. However, because these symptoms can sometimes be caused by testicular cancer, it is important to have them checked out by a doctor. In the vast majority of cases, testicular cancer is found in men with the more classic symptoms of painless testicular swelling or a new lump in the testicle.
In addition to the symptoms listed above, testicular tumors may sometimes be associated with other more unusual symptoms. These symptoms are the result of the extra hormones produced by some tumor types, which can affect the germ cells that are found in testicles and eventually develop into other structures. These less common symptoms include breast growth, pain, and unusual discharge or bleeding from the nipple. Enlargement of the lymph nodes may also occur as a result of disease progression.
Diagnosis and Staging
Once a diagnosis of testicular cancer has been made, other tests will be done to determine the stage of the cancer, or the extent of its spread. The stages of testicular cancer are as follows: Stage 0 is when abnormal cells are present in the lining of the tubules where sperm are formed and do not extend into any nearby blood vessels and lymph nodes; Stages I, II, and III is where cancer is found in the testicle and may have spread to other parts of the body, lymph nodes in the abdomen, or other lymph nodes as well as the lungs and other organs; and Recurrent Testicular Cancer is when the cancer has recurred (come back) after it has been treated.
Diagnosis In order to determine if a patient has testicular cancer, a doctor will perform several tests and procedures to make a diagnosis which include blood tests, physical examination, ultrasound, and biopsy. Blood tests will help determine the levels of specific tumor markers associated with testicular cancer while a physical examination will consider the overall health and past illnesses of a patient as well as examine the testicles and other parts of the body for signs and symptoms of testicular cancer. An ultrasound will use high-energy sound waves to create detailed images of the body and can be used to examine the scrotum and determine if a mass is solid or filled with fluid. A biopsy may also be necessary to diagnose testicular cancer and involve removing a small piece of tissue and examining it for cancer cells.
Physical Examination and Medical History
Some of these symptoms can be caused by other conditions, such as infections, not cancer. Still, if you have any of these symptoms, it is important to see your doctor. Another key part of diagnosis is the medical history. The physician will ask the patient for his history of overall health, past diseases and treatments, and symptoms experienced. A history of the patient’s symptoms and a physical examination usually provide enough information for the physician to diagnose testicular cancer and suggest appropriate tests. The physician may consider the following things during the examination: the patient’s general health and past medical problems, the patient’s family medical history, any injury to the groin area, any other symptoms related to hormone production, such as breast growth or pain in the nipple area. Be sure to tell the physician if the patient has had fever, urinary issues, abdominal pain, shortness of breath, chest pain, headache, or any other symptoms that suggest testicular cancer has spread to other areas of the body.
A physical exam and history taking are usually the first steps in seeking medical care, regardless of the presence of signs or symptoms. In a physical examination, the healthcare provider inspects and feels the body for abnormalities. A history taking uncovers clues about symptoms, family and personal medical history, and risk factors. The healthcare provider asks questions about the patient’s general health, past medical conditions, medications being taken, and changes in appetite, weight, or general health status. Testicular cancer may be detected during routine physical examinations, often by the patient himself. In fact, most testicular cancers are first found by men themselves. Finding testicular cancer early is important to achieve the best chance of cure. In addition to a general physical exam, the physician will perform a special exam to determine what the lump or other symptoms may be.
Imaging Tests
Other imaging tests may be performed to complete the staging process after it has been determined that the patient has cancer. These may include CT (computed tomography) scan, MRI (magnetic resonance imaging), and PET (positron emission tomography) scan.
Imaging Tests: Testicular ultrasound: A painless procedure which uses sound waves to take images of the scrotum. Ultrasound helps determine whether a lump is solid or filled with fluid. It can also detect activity in the testicular area. Chest X-ray: This type of X-ray displays the organs and bones of the chest area in order to identify whether the cancer has spread to the lungs.
Once symptoms have been identified and a physical examination has taken place, the following tests may be conducted in order to confirm, locate, and determine the stage of the tumor: imaging tests, blood tests, and biopsy.
Biopsy and Pathology
Testicular cancers are some of the most curable and require the combined efforts of urology, oncology, and pathology for optimum patient management. Several controversies also exist in the management of testicular cancer. Some of these include the necessity of performing routine contralateral testicular biopsies in patients with testicular cancer, if a testicular-sparing approach can be performed in solitary testis cancer, and finally, if post-chemotherapy surgery can be avoided in patients with residual mass and negative markers.
The biopsy of a suspected testicular neoplasm is not recommended due to the risk of dissemination of the tumor along the needle tract. The entire testicle should be removed by inguinal orchidectomy and examined to establish a diagnosis. Testicular tumors are most commonly discovered at imaging to evaluate scrotal symptoms, such as swelling or pain. In the pre-teen and teenage male, testicular cancer may present with breast development. This occurs because the tumor produces beta human chorionic gonadotropin, which stimulates the testis and has a direct effect on the Leydig cells to produce estrogen. It is important to determine the presence of metastatic disease at the time of diagnosis, as the staging greatly affects the treatment plan and prognosis.
Treatment Options
Before finalizing the treatment plan, it is often recommended that an individual considers discussing the different options available and the potential risks and side effects of each with the healthcare team, family members, and other individuals who have undergone similar treatment. This will help ensure that the treatment plan that is implemented is the most appropriate and best suited for addressing the patient’s needs.
The main treatment options are surgery, radiation, and chemotherapy. The treatment plan is based on several factors, including the type and stage of the cancer, as well as the patient’s age and overall health. The three most common treatment approaches are: 1) radical inguinal orchiectomy which is the removal of the affected testicle through an incision in the groin, 2) retroperitoneal lymph node dissection where the lymph nodes located behind the abdomen are removed through an abdominal incision, and 3) the administration of chemotherapy. Radiation therapy may also be utilized in some cases.
Approximately, one in every 250 men will be diagnosed with testicular cancer at some time during their life. Fortunately, with early diagnosis and the variety of treatment options available, testicular cancer can be cured in the majority of individuals. However, the treatments may affect a man’s future fertility and sexual function.
Surgery
The incision for an inguinal orchiectomy is usually planned in such a way that it can be extended easily, in case a retroperitoneal lymph node dissection is needed later. This usually means that the incision will be longer than the standard subcostal orchiectomy incision, but will not have to be changed if a retroperitoneal lymph node dissection is performed through a modified flank incision. The incision is carried through the subcutaneous tissue and external oblique aponeurosis. The spermatic cord is identified and divided between clamps and suture ligated with absorbable suture (Figure 13). The testis is delivered with the associated tunica vaginalis, which is opened to inspect the testis and epididymis. The scrotal exploration incision can then be sutured closed, in order to prevent a scrotal hematoma from forming, if additional frozen section analysis will be performed on the testicular specimen later at the same surgery.
Surgery Diagnostic Staging In addition to establishing the diagnosis and removing the involved testis, the inguinal orchiectomy provides a specimen for accurate staging of the disease. This staging is based upon the inspection of the testis and its adnexa, and is distinct from the clinical staging, which is based upon the pre-operative evaluation.
Introduction Nearly all patients with newly diagnosed testicular cancer will undergo an inguinal orchiectomy for definitive diagnosis and initial treatment. This chapter will review the initial surgical management of testicular cancer, as well as some potential modifications of that management in specific situations.
Chemotherapy
The blood counts within the peripheral circulation, particularly of the neutrophils and thrombocytes, will signify the readiness of the patient to withstand the next cycle of chemotherapy, which has to be given in a timely fashion to be effective. The various drugs have different modes of action and different toxic effects on the bone marrow. The platinum compounds damage the marrow late, and the blood counts drop 1 to 2 weeks after their administration, while the vinca alkaloids and etoposide affect the marrow early. Consequently, blood counts have to be monitored at regular intervals. Drug regimens have to be modified when serious hematologic and other toxic effects occur. The majority of patients with metastatic testicular cancer are cured by chemotherapy, and the surgeon’s skill will determine the success of the postchemotherapy retroperitoneal lymph node dissection in patients who still harbor residual masses.
Nitrogen mustard was the first chemotherapy found to have some efficacy in patients with disseminated disease. Drugs that followed and that are still used today are the platinum compounds cisplatinum and carboplatinum, the vinca alkaloids vincristine and vinblastine, the natural and synthetic progestational agents, and the high-dose methotrexate. Drugs presently in use that have the greatest activity against testicular germ cell cancer are the combination cisplatinum, vinblastine, and bleomycin (PVB), the combination of cisplatinum, etoposide, and bleomycin (PEB), and cisplatinum in combination with ifosfamide and etoposide. Cycles of PVB are usually given at 3-week intervals. The drugs have dose-related toxicity, and the attending physician will modify dosages according to the patient’s blood counts and ability to tolerate the various drugs. The use of erythropoietin has facilitated chemotherapy by controlling anemia and avoiding transfusions.
Radiation Therapy
External beam radiation is the type most often used to treat testicular cancer. For this treatment, a machine directs the high-energy rays to the body. The rays can be directed to the lymph nodes in the pelvis or other parts of the body that contain cancer.
How is radiation therapy given?
Radiation therapy may be used to treat certain stage I and II seminomas after the affected testicle has been removed. It is sometimes offered as an alternative to chemotherapy in order to help prevent a relapse. If the cancer recurs, radiation therapy is usually used to treat the lymph nodes in the area of the pelvis.
When is radiation therapy used for testicular cancer?
Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells and shrink tumors. Radiation for testicular cancer is usually given after the affected testicle has been removed. It is often combined with chemotherapy.
Living with and Beyond Testicular Cancer
Testicular cancer is mostly a disease of young men. The emotional reality of facing cancer at such a young age cannot be underestimated. In the late 1960s, men with metastatic testicular cancer had only a 10-20% chance of long-term survival. Due to the progress in the field of testicular cancer, today there is a 95% cure rate. No other adult common cancer has a higher cure rate. In fact, most men diagnosed with localized testicular cancer can be cured and are alive today. This is the goal of awareness for all men: to catch this disease early so that 100% of men with localized testicular cancer can be cured.
Supportive information on life after testicular cancer is given to survivors. This includes close monitoring of testicular self-examination, the late effects of treatment (long-term and short-term), and fertility information. There is also an upcoming events section. This highlights patients’ and healthcare professionals’ meetings or seminars to better understand and learn how to deal with testicular cancer. Sponsoring fundraising events to help fight back and support testicular cancer. This guide offers all-encompassing information on testicular cancer from the young patients’ perspective to disease staging, understanding pathology reports, access to the latest treatment guidelines, and clinical trials, to post-treatment survivorship issues. The entire publication can be downloaded in PDF format as well.
Follow-up Care and Monitoring
It is also important to perform regular testicular self-exams and to seek medical attention if you experience any new symptoms, as testicular cancer can sometimes recur. Typically, the risk of recurrence decreases over time, and if you remain cancer-free for five years, you are generally considered to be cured. However, always follow the specific recommendations of your healthcare team. If you have received treatment for testicular cancer and are experiencing difficulty coping with your feelings, emotions, or the stress surrounding your cancer diagnosis, reach out to your healthcare team, family, and friends for support. There are also support groups and counselors who can help you through this difficult time.
After completion of treatment for testicular cancer, it is important to have regular medical check-ups and monitoring to ensure that you remain cancer-free, and to address any concerns or lingering side effects from the treatment. Your oncologist will discuss a follow-up schedule with you, which may include blood tests, imaging scans, and physical examinations to monitor your recovery and overall health, and to detect any signs of cancer recurrence.
Side Effects and Coping Strategies
It’s important to remember that these coping strategies are meant to help patients and their loved ones navigate through the tough emotional effects that testicular cancer and its treatments can have. There is no one-size-fits-all approach, and it is best to use a combination of the below tips and anything else that works best for you in order to feel better.
Surgery and chemotherapy can sometimes impair fertility. Men who may wish to have children in the future should consider sperm banking prior to treatment to preserve their sperm. Sometimes, side effects cannot be alleviated solely by adapting a healthy lifestyle or making specific changes, and more severe coping symptoms for the patient and their family may require counseling with a mental health professional experienced in dealing with cancer patients.
Just as treatments for testicular cancer can have varying side effects, these symptoms can have a profound effect on patients and their loved ones. Both physical and emotional symptoms can make coping very challenging, and although patients will likely continue to lead relatively normal lives, some allowances and coping strategies may need to be considered.