Understanding Testicular Cancer
APRIL is TESTICULAR CANCER AWARENESS MONTH.
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Testicular cancer or cancer of the testis occurs when cancer cells form in one or both testicles. These cells begin to change and grow uncontrollably, forming a mass or tumor. The cells can also invade the blood stream and lymph system and spread, leading to tumors in other areas of the body called metastases.
Most often testicular cancer is detected as a painless lump in one of the testicles. Testicular cancer is highly treatable and one of the most curable forms of cancer. It is especially important to detect testicular cancer in the earliest stages where the cure rate is almost 100%. That is why self-exams, starting in the adolescent years, are key in early detection of testicular cancer.
Testicular cancer is the most common form of cancer in men 15-35 years old.
Each year, approximately 8500 men will be diagnosed with testicular cancer and approximately 350 men will die from the disease. That averages out to every hour of every day some man hears, “You have testicular cancer.”
Testicular cancer strikes approximately six in 100,000 men per year and one in 300,000 men per year will die from the disease. To better understand these numbers, 1 in 250 men will be diagnosed with testicular cancer at some point in their lifetime and 1 in 5000 will die from testicular cancer.
For all cases of testicular cancer the overall 5-year survival rate is 95% but the key is early detection. When testicular cancer is diagnosed in early stages, meaning the cancer is confined to the testis, the 5-year survival rate is 99%. When the cancer has spread to regional lymph nodes the 5-year survival rate drops to 96%. If the cancer has metastasized (spread) to distant areas the 5-year survival rate is 71%.
There are currently more than 195,000 men in the U.S. that are testicular cancer survivors.
Testicular cancer accounts for approximately 1% of all cancers in men.
SIGNS AND SYMPTOMS OF TESTICULAR CANCER
Not much can be done to prevent testicular cancer so the best prevention/protection is to be aware of the risks, the signs, the symptoms and early detection by doing self-testicular exams. Prompt treatment will lead to the best outcomes.
Most testicular cancers are found by men themselves or their partner, not by their doctor. If you notice anything unusual with your testicles you should notify your doctor immediately. The main symptom of testicular cancer is usually a lump, hardness or painless swelling of the testicle. Thirty to 40% of patients may experience a dull ache or heavy sensation in the lower abdomen, anal area or scrotum. Only 10% of patients go to the doctor complaining of new sensations of pain. Unfortunately, 10% of patients go to the doctor with advanced symptoms due to advanced spread of the cancer. Advanced symptoms include: neck mass; coughing or trouble breathing; stomach problems such as nausea, vomiting, bleeding or anorexia; lower back pain; bone pain; nerve pain or leg swelling.
Common signs and symptoms of testicular cancer include:
Painless lump or swelling of the testicle
A change in how the testicle feels
A dull ache in the groin or lower abdomen
A build-up of fluid in the scrotum
Pain or discomfort in the testicle or scrotum
A scrotum that feels heavy or swollen
Bigger or more tender breasts
Testicular cancer is generally found in young men. The exact cause of testicular cancer is unknown and many men without risk factors develop testicular cancer. Strong connections between certain lifestyles, habits or activities, such as bike riding, have not been made with testicular cancer. Injuries and strains will not increase the risk of developing testicular cancer.
Age: Young men between the ages of 15-35 are at the highest risk for testicular cancer. However, it can occur in men of any age.
Race: Testicular cancer is 4.5 times more common in white men verses black men. The risk for Hispanics, American Indians and Asians falls between that of white and black men.
Non-Descending Testicle (Cryptochidism): Normally, after birth, the testicles descend from inside the abdomen down into the scrotum. In some men one or both testicles fail to descend into the scrotum. Men with a history of a non-descending testicle are 3 to 17 times more likely to develop testicular cancer than men whose testicles descended normally. Surgery to correct the non-descended testicle (orchiopexy) may not reduce the risk of testicular cancer but may allow for better observation of the testicle for abnormalities.
Gonadal Dysgenesis: Abnormal development of a gonad (testicle) which is usually part of a genetic syndrome increases the risk of testicular cancer.
Klinefeter Syndrome: A genetic syndrome where males are born with an extra X chromosome increases the risk of testicular cancer.
Personal or family history of testicular cancer: Having a father, brother or uncle with testicular cancer may slightly increase one’s risk of developing testicular cancer.
Weaker evidence suggests that infertility, testicular atrophy, twinship or abnormal semen parameters may increase one’s risk for testicular cancer.
Carcinoma in situ (CIS) also called intratubular germ cell neoplasia: The presence of carcinoma in situ in the testicle increases the risk for testicular cancer.
The removal of one testicle does not affect the sperm producing capabilities of the remaining testicle. However, radiation therapy and chemotherapy can lower sperm counts temporarily or permanently.
All men who are going to receive radiation therapy or chemotherapy should discuss fertility issues with their doctor. Sperm banking, where sperm samples are frozen for long-term storage is possible and samples should be submitted before the start of radiation or chemotherapy treatments. At a later stage the sperm can be thawed and used in fertility treatments.
DIAGNOSIS AND TESTING
In order to diagnose testicular cancer a physician will need a full medical history and a physical examination. If a lump or abnormality is detected the doctor will order an ultrasound of the scrotum. If the ultrasound indicates that there is a solid tumor within the testicle then surgery will be required to remove the testicle and test the tumor to see if it is cancerous. Unfortunately, biopsies are not recommended for testicular cancer as the biopsy itself can increase the chances of the cancer spreading to other areas of the body. If the tumor is determined to be cancerous then other tests will be ordered such as a chest x-ray, CT scan and blood work in order to determine how advanced the cancer is and if it has spread.
Physical Exam: Your physician will examine your testicles by gently rolling them between two fingers and thumb to identify any abnormal lumps. Your physician may also check your groin area, abdomen, armpits and neck to look for swollen lymph nodes. The doctor may also exam you for breast tenderness or enlargement and listen to your lungs.
Scrotal Ultrasound: The scrotal ultrasound is a painless non-invasive procedure in which high frequency sound waves are used to produce images of inside the scrotum and testicles. It is the same technology that is used in pregnant women when they get a sonogram. The images will show if there are any solid masses, swelling or fluid collections within the scrotum.
Transscrotal Biopsy: The procedure of taking a biopsy from outside the scrotum and into the testicle.
Transscrotal Biopsy is to be condemned and should not be performed. The lymph system of the testicles drain into the abdomen while the lymph system of the scrotum drains into the lower legs. By doing a biopsy through the scrotum, cancerous cells can be left in the scrotum and the lymph drainage can be altered. This means that any cancer can spread in a way that is not as predictable as normal testicular cancer spread.
Radical Orchiectomy: Orchiectomy means removal of one or both of the testicles. Radical means that the removal is done by making an incision high up in the groin area. The incision is not made on the scrotum itself. The reason the testicle is removed from higher up is so that there are no changes made to the lymph drainage system. The reason is similar to why the transscrotal biopsy is condemned. Contrary to rumors the removal of a testicle does not affect the ability to achieve an erection and seldom interferes with the ability to father children. Once the testicle is removed a biopsy or a small sample of the tumor is sent to the laboratory to determine if the cells are cancerous (malignant) or non-cancerous (benign).
Appearance After Surgery: There are options for inserting a prosthetic implant or fake testicle after surgery. For cosmetic or psychological reasons some men may opt to have a testicular implant to give the appearance of a normal scrotum. The implants serve no physiological function. The decision is up to the individual and can be discussed with your surgeon. Many men wait until after treatments to take this option into full consideration and some men do not like the prosthesis after it is implanted and end up having it removed.
A front and side chest x-ray are done to see if the cancer has spread to the lungs or chest cavity.
CT Scan: CT-scan is short for Computed Tomography.
CT-Scans create three-dimensional pictures of the inside of the body with an x-ray machine. They usually require you to drink a dye and also have a contrast dye injected into you veins in order to see the internal structures better. CT-scans are the most common imaging tests used for testicular cancer.
A CT-scan of the abdomen/pelvis is done to see if any lymph nodes in the retroperitoneal area (stomach area) or pelvis have been affected by the cancer. The CT-scan is the most effective imaging test to determine if the cancer has spread and scans may also be done of the chest and/or brain.
MRI, Bone Scan, PET Scans
CT-scans are the preferred imaging test for testicular cancer patients. However, other tests such as a MRI, Bone Scan or PET scan may be needed in certain situations. If your doctor orders one of the tests you should discuss with him why the test is needed.
Blood Tests or Tumor Markers: Testicular cancer or germ cell tumors can secrete proteins or hormones into the bloodstream. The levels of these proteins/hormones in the blood can be measured in the laboratory and are often called tumor markers. The levels of the tumor markers can help verify that a diagnosis is correct and/or that a patient is responding to certain treatments. These tumor markers include: AFP (alpha-Fetoprotein), beta-hCG (beta-Human Chorionic Gonadotropin) and LDH (Lactic Acid Dehydrogenase). Not all forms of testicular cancer produce tumor markers or elevate their levels and you can have testicular cancer even if your tumor markers are normal.
AFP (alpha-Fetoprotein): AFP may be produced by pure embryonal carcinoma, yolk sac tumor or combined tumors. It is not secreted by pure seminoma or choriocarcinoma. If a diagnosis of seminoma is made but the APF is elevated then the pathology specimen should be reviewed again.
Beta-hCG (beta-Human Chorionic Gonadotropin: Beta-hCG is the same substance that helps identify if women are pregnant. However, some testicular cancers can also secrete the substance. These tumors include embryonal carcinoma and choriocarcinoma. Only 5-10% of seminomas secrete beta-hCG and if secreted it is usually done so at lower levels.
LDH (Lactic Acid Dehydrogenase): LDH is the least specific tumor marker for testicular cancer. The levels may be elevated for reasons other than testicular cancer. However, monitoring the LDH levels can give your physician more information about your cancer and treatment.
TYPES OF TESTICULAR CANCER
The cells that produce sperm are called germ cells. Almost all testicular cancers (95%) start in these germ cells and are considered germ cell tumors or GCTs.
The germ cell tumors are further classified as either seminomas or nonseminomas. There are other types of cancer that can develop in the testicles but they are very rare and will only be discussed briefly.
Sixty percent of germ cell tumors are seminomas and the others are nonseminomas. Each of these two types of germ cell tumors behave differently. Seminomas tend to spread slower while non-seminomas tend to spread and metastasize more quickly. To be considered a seminoma the tumor must only contain seminoma. If the tumor contains both seminoma and nonseminoma cell types then the tumor should be considered as a nonseminoma. There is also a precancerous condition called carcinoma in situ.
Carcinoma in situ
Carcinoma in situ or intratubular germ cell neoplasia is like a precancerous cell form and may not always progress into cancer. Carcinoma in situ is usually noninvasive and detected only after a biopsy as it doesn’t develop into lumps or cause symptoms. There is still much debate about the treatment for carcinoma in situ.
Seminomas are classified as either: classic, anaplastic or spermatocytic.
Classic Seminoma accounts for 80-85% of all seminoma cases and occurs mainly in men ages 30-50. Classic seminoma rarely, if ever, occurs in adolescents or infants.
Anaplastic Seminoma accounts for 5-10% of all seminoma cases and occurs at ages similar to classic seminoma. Anaplastic seminomas are more aggressive than the other seminoma types.
Spermatocytic Seminomas accounts for 2-12% of all seminoma cases. Spermatocytic seminomas appear to be less aggressive and almost half of the cases occur in men over the age of 50.
There are four types of nonseminomas: embryonal carcinoma, yolk sac carcinoma, choriocarcinoma and teratoma. Most nonseminomas contain at least two or more of these different cell types and are considered mixed. However, pure nonseminomas or tumors containing only one of the nonseminoma cell types are possible.
Embryonal Carcinoma: Approximately 40% of nonseminomas contain embryonal carcinoma. Pure embryonal cell tumors only occur in 3-4% of nonseminoma cases. Embryonal carcinoma occurs mainly in men ages 25-35. This cell type also appears to grow rapidly and spread outside of the testicle.
Yolk Sac Carcinoma: Also called endodermal sinus tumors, infantile embryonal carcinoma, or orchidoblastoma. These cells look like the yolk sac of an early embryo and are the most common form of testicular cancer in children. However, when yolk sac carcinoma develops in adults it is a more serious situation than when it develops in children. This type of tumor releases a substance called alpha-fetoprotein (AFP) into the bloodstream. Measuring the levels of AFP in the blood can help confirm the diagnosis and monitor response to treatments.
Choriocarcinomas: Choriocarcinomas are very rare and very aggressive type of testicular cancer. They rapidly spread to distant areas of the body. This type of cell produces a substance into the bloodstream called human chorionic gonadotropin (HCG). Measuring the levels of HCG in the blood can help confirm the diagnosis and monitor response to treatment.
Teratomas: Teratomas come in three types: mature teratoma, immature teratoma and teratoma with malignant transformation. Teratomas account for 3% of adult and 38% of childhood testicular cancer cases.
Mature Teratoma: These cells are similar to cells of adult tissues and they rarely spread to other areas.
Immature Teratoma: These cells look more like those of early embryos and tend to spread to more distant areas and recur years after treatment.
Teratoma with Malignant Transformation: These tumors are very rare. Some cells appear to be mature teratoma while others look like other forms of cancer.
Other More Rare Testicular Cancers
Stromal Tumors: The stroma is the supportive and hormone producing tissues of the testicles and tumors can develop in these structures. Stromal tumors account for less than 4% of adult testicular cancers but up to 20% of the childhood cases. There are two types of stromal tumors: Leydig cell tumors and sertoli cell tumors.
Leydig Cell Tumors: Leydig cell tumors develop from Leydig cells. In the testicles, Leydig cells normally produce male hormones such as testosterone. Seventy-five percent of Leydig cell tumors occur in adults and 25% occur in children. Surgery usually cures these tumors because they usually do not spread outside of the testicle. However, if they do spread outside the testicle then the prognosis is poor because Leydig cell tumors do not respond very well to chemotherapy or radiation.
Sertoli Cell Tumors: Sertoli cell usually support and nourish the sperm producing germ cells. However, Sertoli cell tumors can develop, although they are usually benign. If they do spread they are usually not very responsive to chemotherapy or radiation.
Secondary Testicular Tumors: Tumors can start in other areas of the body and then spread to the testicles. These are considered secondary testicular tumors. The most common of these is lymphoma. Leukemia cells can also form tumors in the testicle. Other cancers that may form secondary testicular tumors include: prostate cancer, lung cancer, melanoma (skin cancer), kidney cancer and other organ cancers.
Testicular cancer spreads in a predictable and stepwise fashion. An exception to this is the presence of choriocarcinoma. This spread also indicates the stage of your testicular cancer. Staging is a way of describing the testicular cancer as to how big the tumor is, how much it has grown and whether it has spread to other areas of the body such as the lymph nodes or other organs.
Staging: The staging of testicular cancer follows guidelines set up by the American Joint Committee on Cancer (AJC) and the International Union Against Cancer. Staging follows a TNMS protocol and considers:
T (Tumor) – the area of the testicle that the tumor invades
N (Nodes) – the regional lymph nodes, if any, the cancer has spread. The lymph nodes may be assessed by clinical data such as data from CT scans or pathology data from biopsy specimens.
M (Metastses) – Is there any evidence that the cancer spread (metastasized) to an area far from the testicle.
S (Serum Tumor Markers) – Can substances secreted by the tumors be measured in the blood and at what levels can they be measured.
The TMNS data is then all put together to decide the stage of the testicular cancer. The stages are called Stage I, II or III (1, 2 or 3) and then letters indicate where in the stage the cancer falls, for example stage IIa is somewhat less severe that stage IIb.
Testicular cancer is highly treatable especially if caught early. With early detection treatments are more effective and often less aggressive than when the cancer is detected in the later stages. Treatments include surgery, radiation therapy and/or chemotherapy. The treatments depend on the type and stage of the testicular cancer as well individual preferences. Seminomas are usually more responsive to radiation therapy than nonseminomas.
If a patient has early stage testicular cancer and their tumor markers are normal or return to normal after surgery then an active surveillance program may be a treatment option. This option involves regular doctor visits with CT-scans, x-rays and blood work to closely monitor for the cancer returning. This option requires great dedication by the patient and the doctor to follow the surveillance schedule so that any recurrence can be detected early. Many men (70-80%) may be able to avoid additional chemotherapy/radiation after the orchiectomy and active surveillance allows for this option but the follow up schedule does require a lot of dedication and needs to be discussed with your doctor. Some schedules may require check-ups every 1-2 months.
Radiation therapy uses high-energy beams of radiation to help destroy any cancer cells that were left behind after the orchiectomy. These left over cancerous cells can spread through the lymph system to other areas of the body. The external radiation is aimed at the lymph nodes in the abdominal and/or groin area to kill any cancer cells. Radiation therapy is usually done daily for five days a week for 3-4 weeks. Normal cells are also killed by the radiation and can lead to side effects.
Side effects of radiation therapy include: Fatigue, skin changes/burns, loss of appetite, nausea, diarrhea, stiff joints/muscles. These side effects are usually only temporary and should improve once treatments are over. Radiation therapy can also interfere with sperm production despite the use of shields to reduce the amount of radiation that the remaining testicle receives.
Chemotherapy are drugs that are given intravenously to kill any remaining cancer cells and to keep the cancer from returning. Chemotherapy is usually used more for non-seminomas that seminomas. Chemotherapy is usually given in cycles meaning that it is given daily for 5 days and then none is given for the next two weeks and then the cycle is repeated.
Chemotherapy also kills healthy cells and can lead to side effects. Side effects of chemotherapy include: nausea, vomiting, hair loss, loss of appetite, fatigue, mouth sores, fever, chills, numbness. Chemotherapy can also interfere with sperm production which can be permanent.
Retroperitoneal Lymph Node Dissection (RPLND)
This is a surgery to remove the retroperitoneal lymph nodes that are located at the back of the abdomen. The surgery involves an incision down the middle of the abdomen to remove the lymph nodes. A RPLND is a complex operation that requires substantial experience and technical skill in order to remove the lymph nodes and reduce the likelihood of side effects. A RPLND should only be done by a surgeon who is highly experienced with this operation.