Testicular Cancer

Overview

Testicular cancer is the most common cancer in young men between the ages of 15 and 35, but the disease also occurs in other age groups, so all men should be aware of its symptoms. The testicles are a part of the male reproductive system and are contained within a sac of skin called the scrotum, which hangs beneath the base of the penis. Each testicle is somewhat smaller than the size of a golf ball in adult males. The testicles produce and store sperm, and they also serve as the body’s main source of male hormones. These hormones control the development of the reproductive organs and other male characteristics, such as body and facial hair and low voice. In the year 2005, an estimated 8500 cases of testicular cancer were diagnosed in the United States, and about 350 of them died of their testicular cancer. Caucasians are more likely to be diagnosed with testicular cancer than Hispanics, Blacks, or Asians. Of concern, the incidence of testicular cancer around the world has been steadily increasing, basically doubling in the past 30-40 years.

Symptoms

Most testicular cancer cases are found through a self-examination. The testicles are smooth, oval-shaped, and rather firm. Men who examine themselves routinely become familiar with the way their testicles normally feel. Any changes in the way they feel from month-to-month should be checked by a doctor. (See below for self-exam instructions.)

In about 90% of cases, men have a lump on a testicle that is often painless but slightly uncomfortable, or they may notice testicular enlargement or swelling. Men with testicular cancer often report a sensation of heaviness or aching in the lower abdomen or scrotum. In rare cases, men with germ cell cancer notice breast tenderness or breast growth. This symptom occurs because certain types of germ cell tumors secrete high levels of a hormone called human chorionic gonadotropin (HCG), which stimulates breast development. Blood tests can measure HCG levels. In the rarer non-germ cell testicular cancers, Leydig cell tumors produce androgens (male sex hormones) or estrogens (female sex hormones). These hormones may cause symptoms such as breast growth or loss of sexual desire, symptoms of estrogen-producing tumors. Androgen-producing tumors may not cause any specific symptoms in men, but in boys they can cause growth of facial and body hair at an abnormally early age.

Even when testicular cancer has spread to other organs, only about 1 man in 4 may experience symptoms related to the metastases prior to diagnosis. Lower back pain is a frequent symptom of later-stage testicular cancer. If the cancer has spread to the lungs and is advanced, shortness of breath, chest pain, cough, or bloody sputum may develop. Occasionally, men will complain of central abdominal discomfort, due usually to enlargement of abdominal lymph nodes. Rarely, men will complain of headache, which is associated with brain metastases (an uncommon pattern of spread, and usually associated with a certain type of testicular cancer called choriocarcinoma).

It is important to know that a number of noncancerous conditions, such as testicle injury or infection, can produce symptoms similar to those of testicular cancer. Inflammation of the testicle, known as orchitis, can cause painful swelling. Causes of orchitis include viral or bacterial infections.

Listed below are warning signs that men should watch for:

• A lump in either testicle; the lump typically is pea-sized, but sometimes it might be as big as a marble or even an egg;
• Any enlargement of a testicle;
• A significant shrinking of a testicle;
• A change in the consistency of a testicle (hardness);
• A feeling of heaviness in the scrotum;
• A dull ache in the lower abdomen or in the groin;
• A sudden collection of fluid in the scrotum;
• Pain or discomfort in a testicle or in the scrotum;
• Enlargement or tenderness of the breasts.

A testicular self-exam is best performed after a warm bath or shower. Heat relaxes the scrotum, making it easier to spot anything abnormal. The National Cancer Institute recommends following these steps every month:

• Stand in front of a mirror. Check for any swelling on the scrotum skin.
• Examine each testicle with both hands. Place the index and middle fingers under the testicle with the thumbs placed on top. Roll the testicle gently between the thumbs and fingers. Don’t be alarmed if one testicle seems slightly larger than the other which is normal.
• Find the epididymis, the soft, tubelike structure behind the testicle that collects and carries sperm. If you are familiar with this structure, you won’t mistake it for a suspicious lump. Cancerous lumps usually are found on the sides of the testicle but can also show up on the front.
• If you find a lump, see a doctor right away. The abnormality may not be cancer, but if it is, the chances are great it can spread if not stopped by treatment. Only a physician can make a positive diagnosis.

Diagnosis

Various tests are necessary to make the diagnosis of testicular cancer. Your doctor may order several imaging tests and also draw blood to aid in the diagnosis. If a mass is seen in the testicle, these tests are usually followed by surgery to remove the affected testicle(s). A summary of the tests and procedures are below:

Ultrasound

An ultrasound can help doctors tell if a testicular mass is solid or fluid filled. This test uses sound waves to produce images of internal organs. The images can help distinguish some types of benign and malignant tumors from one another. This test is very easy to take and uses no radiation. When you have an ultrasound exam, you simply lie on a table and a technician moves the transducer over the part of your body being examined. Usually, the skin is first lubricated with jelly. The pattern of echoes reflected by tissues can be useful in distinguishing fluid buildup around the testicle (called a hydrocele) and certain benign masses from cancers. If the mass is solid, then it is probably either a tumor or cancer but still could be some form of infection, and thus it is essential to follow up with further tests.

Blood Tests

Certain blood tests are sometimes helpful in diagnosing testicular tumors. Many testicular cancers make high levels of certain proteins, such as alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG). The tumors may also increase the levels of enzymes such as lactate dehydrogenase (LDH). These proteins are important because their presence in the blood suggests that a testicular tumor is present. However, they can also be found in conditions other than cancer.

Nonseminomas can sometimes raise AFP and HCG levels. Seminomas occasionally raise HCG levels, but never AFP levels. LDH is a non-specific blood test, and occasionally a very high LDH often (but not always) indicates widespread disease. Sertoli or Leydig cell tumors do not produce these substances. These proteins are not usually elevated in the blood if the tumor is small. Therefore, these tests are also useful in estimating how much cancer is present and in evaluating the response to therapy to make sure the tumor has not returned.

Surgery

If a suspicious mass is present in the testicle, the testicle is usually removed in a procedure called a radical orchiectomy. Through an incision in the groin, the surgeons remove the entire tumor together with the testicle and spermatic cord. The spermatic cord contains blood and lymph vessels that may act as a pathway for testicular cancer to spread to the rest of the body. The entire specimen will be sent to the laboratory where a pathologist (a doctor specializing in laboratory diagnosis of diseases) examines the tissue under a microscope. If cancer cells are present, the pathologist sends back a report describing the type and extent of the cancer. The entire operation takes less than an hour and is usually an outpatient procedure. At the time of radical orchiectomy, a testicular prosthesis can be placed if desired by the patient.

Imaging Tests

Chest x-ray: This is a “plain” x-ray of your chest and can be taken in any outpatient setting. This test is done to see if your cancer has spread to your lungs or the lymph nodes in an area of the chest known as the mediastinum.
Computed tomography (CT): The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, as does a conventional x-ray, a CT scanner takes many pictures of the part of your body being studied as it rotates around you. A computer then combines these pictures into an image of a slice of your body.
CT scans are helpful in staging the cancer (determining the extent of its spread), to help tell if your cancer has spread into your abdomen, lungs, liver, or other organs. They show the lymph nodes and distant organs where metastatic cancer might be present.

Once cancer of the testicle has been found, more tests will be done to find out if the cancer has spread from the testicle to other parts of the body (staging). A doctor needs to know the stage of the disease to plan treatment. The following stages are used for cancer of the testicle:

Stage I
Cancer is found only in the testicle.

Stage II
Cancer has spread to the lymph nodes in the abdomen (lymph nodes are small, bean-shaped structures that are found throughout the body; they produce and store infection-fighting cells).

Stage III
Cancer has spread beyond the lymph nodes in the abdomen. There may be cancer in parts of the body far away from the testicles, such as the lungs and liver.

Treatment

Stage I Testicular Cancer

Treatment depends on what the cancer cells look like under a microscope (cell type).

If the tumor is a seminoma, treatment will probably be surgery to remove the testicle (radical inguinal orchiectomy), followed by either 1.) external-beam radiation to the lymph nodes in the abdomen, 2.) surveillance – i.e. close observation with chest x-rays, CT scans, and blood tests, or 3.) chemotherapy usually in the form of a drug called carboplatin.

If a tumor is a nonseminoma, treatment will be radical orchiectomy followed by one of the following:

• Removal of some of the lymph nodes in the abdomen (retroperitoneal lymph node dissection). This surgery removes the lymph nodes where the testicular cancer usually spreads. The surgery can be performed so that fertility is preserved.
  • • • If there is no cancer found in these lymph nodes, then blood tests and imaging exams will be done on a regular basis to make sure that the cancer does not recur.
      • If there is a small amount of cancer found in the lymph nodes (e.g. less than or equal to 2 lymph nodes with cancer), then the surgery is usually completely therapeutic; in other words, removing this small amount of cancer in the lymph nodes oftentimes cures the patient without further therapy. Of course, routine visits for blood tests and imaging exams are necessary in this case.
      • If a larger amount of tumor is found in the lymph nodes (e.g. greater than 2 nodes), chemotherapy is usually given after the patient recovers from surgery.
• Surveillance: careful testing to see if the cancer comes back (i.e. surveillance). The doctor must check the patient and do blood tests and x-rays very frequently, for example every 1-2 months for 2 years. This option is often chosen if the tumor has certain features to suggest a low chance of occult spread and if the patient is very reliable/compliant
• Immediate chemotherapy. This is sometimes preferred in select patients who have cancer confined to the testicle, however, the doctors worry that there is a high likelihood that the cancer has spread, but the cancer is too small to detect by our imaging exams.

Stage II Testicular Cancer

Again, treatment depends on whether the cancer is a seminoma or nonseminoma.

If the tumor is a seminoma and the spread of cancer is felt to be small volume, then treatment will probably be surgery to remove the testicle (radical inguinal orchiectomy), followed by external-beam radiation to the lymph nodes in the abdomen. If the spread to the abdomen is felt to be more bulky (larger nodes), then the treatment will probably be a radical inguinal orchiectomy followed by systemic chemotherapy.

If a tumor is a nonseminoma, treatment will be radical orchiectomy followed by one of the following:

• If low volume lymph nodes, then possibly removal of the lymph nodes in the abdomen (lymph node dissection) followed by the same protocol as in Stage I testicular cancer treated by lymph node dissection (see above). The other primary alternative is chemotherapy instead of surgery. If the tumor markers remain abnormal, then the recommendation should be chemotherapy.
• If high volume lymph node spread on CT scan, then the patient is administered systemic chemotherapy.
  • • • If there is a “complete response” to chemotherapy (i.e. complete shrinkage of the metastasis so that there is no evidence of metastases, ie. normal CT scan), then the patients are usually followed closely with blood tests and imaging exams.
      • If x-rays following chemotherapy show that there are still lymph nodes that remain enlarged with potential cancer, then surgery may be done to remove these masses. If there is still residual cancer in these masses, then your doctor may recommend more chemotherapy. If there is no cancer in these masses, the doctor will check the patient at regular intervals with blood tests, chest x-rays, and CT scans.

Stage III Testicular Cancer

Stage III disease is universally treated with systemic chemotherapy. The number of cycles and exact chemotherapy regimen depends on whether the tumor is a seminoma or nonseminoma, how extensive the disease is, and presence/extent of tumor marker (AFP, HCG) elevation. Doctors will follow how the tumor is responding to the chemotherapy with multiple imaging exams. Oftentimes in Stage III testicular cancer, there are masses remaining after completion of the chemotherapy. Usually, these masses are removed, as they may harbor residual cancer or teratoma. If there is residual cancer in these masses after full chemotherapy, then your doctor may recommend more chemotherapy, sometimes even a different chemotherapy drug combination.

Survival

The survival rates for testicular cancer are excellent. Specifically, the survival rate for men diagnosed with Stage I seminoma is about 99%. The survival rate for men with Stage I non-seminoma is about 98%. Cure rates for Stage II tumors range above 90%, while cure rates for Stage III tumors vary between 50-80%. In addition to Stage, a variety of institutions have created classifications of Good and Poor risk tumors. Good risk tumors are generally those that have not spread outside of the retroperitoneal lymph nodes or lungs and do not have overly elevated tumor markers. Poor risk tumors generally have very high tumor markers or have spread outside of the lungs and lymph nodes. As you might expect, the survival rate for good risk tumors is high (more than 90%), while the survival rate for poor risk tumors is lower (50-60%).