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Testicular Cancer
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Testicular cancer occurs when cells in one or both testicles become cancerous and begin to grow uncontrollably. If not treated these cancerous cells will eventually form a tumour that can spread to other parts of the body. Testicular cancer is a relatively rare cancer and is nearly always curable if it is detected early enough.
The testicles are part of the male reproductive system. They are two egg-shaped glands located under the penis in a pouch called the scrotum. Testicles produce sperm and the hormone testosterone, which plays a role in the development of the reproductive organs and other male characteristics.
Types of testicular cancer
95% of testicular cancers develop in the sperm-producing cells known as germ cells. Two types of tumours occur in the germ cells; seminomas and nonseminomas. They grow and spread differently and need to be treated differently.
Seminomas
Seminomas are slow growing and are more sensitive to radiation.
Nonseminomas
Nonseminomas tend to grow and spread more quickly than seminomas. A testicular tumour that contains both seminoma and nonseminoma cells is treated as a nonseminoma.
Other types of tumours that occur in testicular cancer are leydig cell tumours and sertoli cell tumours. They are both relatively rare and can usually be cured by surgically removing the affected tissue, but if they spread or metastasize, they are difficult to treat.
The cause of testicular cancer is not known. However certain risk factors increase the chances of developing the disease.
Age
Most cases of testicular cancer occur in men between the ages of 15 and 40, but it can occur in men of any age.
Family history
Men who have a relative who has had testicular cancer are at higher risk of developing testicular cancer. Scientists are currently analysing DNA from testicular tumour samples to find out more about the genes associated with testicular cancer.
HIV infection
Men infected with this virus may have a slightly higher risk of developing testicular cancer.
Personal history
Men who have had cancer in one testicle are at increased risk of developing cancer in the other testicle.
Race
Although men of any race can develop testicular cancer, white men are more likely than men of other races to be diagnosed with testicular cancer.
Undescended testicle (cryptorchidism)
The risk of developing testicular cancer appears to increase if the testicles do not descend into the scrotum before birth as they normally should, even if surgery was performed to correct the condition.
Klinefelter's syndrome
Men with this syndrome have an extra X chromosome, which results in low levels of male hormones, sterility, breast enlargement, and small testes. Klinefelter's syndrome can increase the risk of developing germ cell tumours that start in the chest, but this is rare.
Sedentary life style
A recent study has shown that a sedentary life style increases the risk of developing testicular cancer.
Sexually Transmitted diseases
A history of STD's and testicular trauma at least two years before diagnosis have been associated with a mild increased risk of testicular cancer.
Smoking
A study in Denmark of smoking during pregnancy suggests there may be a link between maternal smoking, low birth weight and testicular cancer. However no association has been found between patient smoking and an increased risk.
Vasectomy
There has been no evidence to show that a vasectomy increases the risk of testicular cancer.
Exercise
A recent study has found a decrease in the risk of testicular cancer with an increased amount of exercise.
There is no European screening programme for testicular cancer. Regular testicular self-examination and examinations by doctors can detect the cancer in its early stages when it can usually be cured.
It is recommended that men ages 15 to 40 perform a monthly self-examination. Men are encouraged to examine their testicles to become used to how they look and feel. If any changes are noticed a professional opinion should be sort.
The first sign of testicular cancer may be a small lump on the testicle that often does not cause any pain. Or there may be swelling or discomfort in the scrotum. Some testicular cancers may not cause symptoms and may go undetected until they reach an advanced stage.
The following can be signs of testicular cancer:
- Painless lump or swelling on either testicle. If detected early a testicular cancer tumour may be about the size of a pea but it can rapidly become the size of a marble or larger
- Pain or discomfort in a testicle or scrotum
- Enlargement of a testicle or change in the way it feels
- Feeling of heaviness in the scrotum
- Dull ache in the lower abdomen or groin
- Sudden build-up of fluid in the scrotum
- Breast tenderness or growth. This rarely happens and is due to the fact that some tumours produce hormones that affect breast development
- Lower back pain, shortness of breath, chest pain and bloody mucus can be symptoms of advanced testicular cancer
If testicular cancer is suspected a full family and patient history will be taken. The following tests may be carried out to see if testicular cancer can be diagnosed.
Testicle examination
The testicles will be examined to check for lumps, swelling, or pain. The doctor will also feel the abdomen for evidence of enlarged lymph nodes, which indicate that the cancer has spread.
Ultrasound test
This test is used to detect growths in the testicles. A picture of the testicular tissues are formed using high-energy sound waves or ultrasounds. The echoes of the sound waves produce an image called a sonogram that can help the doctor detect the presence and size of a tumour.
Serum tumour marker test
A sample of blood is taken to test for certain substances. Patients with cancer of the testicles release certain substances or 'tumour markers' that may be found at higher levels if cancer is present. Tumour markers that may indicate testicular cancer include;
Alpha-fetoprotein (AFP)
Beta-human chorionic gonadotropin (β-hCG)
placental alkaline phosphatase (PLAP)
Lactate dehydrogenase (LDH)
Radical inguinal orchiectomy and biopsy
This operation removes the entire testicle through an incision in the groin. A tissue sample from the testicle is then examined to check for cancer cells. If cancer is found, the cell type can then be diagnosed to help plan further treatment.
Once testicular cancer has been confirmed further tests are needed to find out the type and stage of the disease and if it has spread to other areas of the body.
Chest x-ray
An x-ray may be taken to see if the cancer has spread to other organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
CT scan (CAT scan)
A CT scan can help to show up tumours in the testicles and in other organs of the body. A series of detailed pictures are taken of areas inside the body from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be used to help make the organs or tissues show up more clearly.
Lymphangiography
This method is used to x-ray the lymph system and helps to find out if cancer has spread to the lymph nodes. A dye is injected into the lymph vessels in the feet. The dye travels upward through the lymph nodes and lymph vessels and x-rays are taken to see if there are any blockages.
Abdominal lymph node dissection
This method examines the lymph nodes in the abdomen to see if the cancer has spread. Lymph nodes are surgically removed and checked for cancer cells. For patients with nonseminoma, removing the lymph nodes may help stop the spread of disease. Cancer cells in the lymph nodes of seminoma patients can be treated with radiation therapy.
Serum tumour marker test
Tumour marker levels are measured again after radical inguinal orchiectomy and biopsy in order to determine the stage of the cancer. This can show if all of the cancer has been removed or if more treatment is needed. Tumour marker levels can also be measured to check if the cancer has come back.
Treatment depends on the type and size of the cancer, if the cancer has spread, and the number and size of affected lymph nodes. Stages are used to describe the type of cancer and how far the cancer has spread.
Testicular cancer is often curable. However certain treatments can cause infertility that may be permanent. Patients who may want to have children should consider freezing sperm before having treatment.
Three types of standard treatment are used:
Surgery
Initial surgery may have already been carried out at the diagnosis stage and the testicle and some of the lymph nodes may have already been removed.
Surgery to remove the testicle (radical inguinal orchiectomy) is done through an incision in the groin. It is used to treat both early and late stage testicular cancer, regardless of the type of tumour. During the surgery some of the lymph nodes in the abdomen may be removed in case they contain cancer.
Some patients may be given chemotherapy or radiation therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery is called adjuvant therapy.
Side effects of surgery
The removal of one testicle will not affect a man's ability to achieve a normal erection. It will not make him sterile or unable to produce children as the remaining testicle will still produce sperm. Men can opt to have an artificial testicle implanted in the scrotum that has the weight and feel of a normal testicle.
If both testicles are removed, the man will no longer produce sperm and will not be able to father children. A patient may want to store sperm in a sperm bank before surgery.
Radiation therapy
Radiation therapy uses high-energy x-rays or other types of radiation to kill cancer cells. For testicular cancer, the radiation is delivered by a machine in a procedure known as 'external beam radiation'. The radiation is generally directed at lymph nodes in the abdomen and it is more effective on seminoma tumours than nonseminomas.
Side effects of radiation therapy
Common problems experienced by patients because of radiation therapy include fatigue, changes in the skin at the site where the treatment is given, loss of appetite, nausea, and diarrhoea. Radiation therapy can also cause problems with sperm production, but this usually goes away in a few months.
Chemotherapy
Chemotherapy uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing.
Chemotherapy is more often used for non-seminoma testicular cancers but can also be used for seminoma that has spread. A combination of drugs are usually given by an injection into the vein or through a drip. The most common combination of drugs is known as BEP and contains Bleomycin, Etoposide and Cisplatin.
Side effects of chemotherapy
Chemotherapy affects normal cells as well as cancerous cells, and may cause side effects. Side effects vary with the dose and particular drug a patient receives, but common side effects include nausea, loss of hair, fatigue, diarrhoea, vomiting, fever, chills, coughing/shortness of breath, mouth sores, and skin rash. Long-term side effects may include dizziness, numbness, loss of reflexes, and difficulty hearing. Some chemotherapy drugs also interfere with sperm production. This may be permanent in some patients however many eventually recover their ability to produce sperm.
A rare side effect of some chemotherapy drugs is the development of another form of cancer, usually leukaemia.
High-dose chemotherapy with bone marrow transplantation
This is the latest form of treatment for testicular cancer and is currently at the clinical trial stage. This method gives high doses of chemotherapy and replaces blood-forming cells destroyed by the cancer treatment. Before chemotherapy stem cells are removed from the bone marrow of the patient (or donor) they are frozen and saved. After chemotherapy, the stem cells are given back to the patient to replace the ones that were destroyed during treatment. These stem cells grow into and restore the body's blood cells.
World
- The highest rates of testicular cancer occur in white Caucasian populations, particularly in Northern Europe
- Lower rates are reported for black American men compared to white Americans
- Rates for Asian and Hispanic men are in the middle of those for the white and black populations
Europe
Within Europe there is a clear north/south gradient, with rates in Denmark five times higher than those in Spain (Finland being the exception to this rule)
- Denmark has the highest incidence of testicular cancer in Europe
- Austria has the second highest incidence of testicular cancer in Europe
- Spain has the lowest incidence of testicular cancer in Europe
- Finland has the second lowest incidence of testicular cancer in Europe
- Denmark and Germany have the worst mortality rates for testicular cancer
UK
- There are 1,900 new cases in the UK every year
- Testicular cancer makes up 1-2% of all male cancers
- Over 90% of cases are curable
- Half of all cases appear in men under 35 years
- It is the most common cancer in men aged 15-44
Trends
The incidences of testicular cancer are rising throughout the world, particularly in white Caucasian populations. It is unclear why this is happening.
Socio-economic
There appears to be no clear association between incidence and socio economic status.
Survival
Testicular cancers are curable in the great majority of cases. Survival rates continue to improve across Europe.
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