Testicular cancer is a type of cancer exclusive to males, which develops in the testicles- also known as the testes or gonads. Housed in the scrotal sac which hangs below the penis for optimal temperature regulation, the testicles manufacture sperm and produce critical male hormones, such as testosterone, which regulates facial and body hair, voice deepness, development of muscle mass and sexual function. Healthy testicles are critical to the overall sexual and physical health of men.
Although testicular cancer is rare in comparison to other types of cancer, it is the leading form of cancer in males of peak reproductive age- 15 to 34. Approximately 8,000 new cases of testicular cancer are diagnosed annually in the United States and 2,000 in the United Kingdom. Of the cases diagnosed, the cure rate is very high.
Types of Testicular Cancer
The majority of testicular cancer tumors are forms of Germ Cell tumors. Germ cells are responsible for sperm production and account for 90% of all testicular cancer. Within this category, there are two specific categories of cancer cells.
Seminoma germ cell tumors are identified mainly in men in their late 30s to 50s. In a fifth of cases, pain is an initial symptom and for approximately 89%, there is a palpable mass upon physical examination.
This form accounts for approximately half of germ cell cancers and can be treated with external radiation treatment instead of chemotherapy if detected early. Statistics show a 99% Success rate with early (stage I) intervention. Seminomas have a relatively slow growth rate compared to Nonseminomas and the risk of the cancer spreading to other parts of the body is less than with other forms of cancer.
Nonseminomas Germ Cell tumors differ from Seminomas in that they are harder to treat, being less responsive to radiation treatment and require chemotherapy. This form is found in much younger males, beginning in the late teens to around forty. Nonseminomas germ cell tumors come in four forms:
- Embryonal Carcinoma– derives its name from the fact that the cells in question are left over from when the individual was an embryo and can appear similar to the tissue of an early embryo when viewed under a microscope. This form accounts for 3-10% of all germ cell tumors, but these cells can also be found mixed with other cells in up to 40% of tumors under different classifications. A primarily Embryonal carcinoma tumor can progress relatively fast. This form has the potential to spread outside of the testicles, with two thirds of cases spreading to other parts of the body. Embryonal carcinoma tumors are primarily found in men prior to middle age, with the average age being 31.
- Yolk Sac carcinoma– these cancer cells resemble the yolk sac of a human embryo and is the most common form of Testicular Cancer in children. When diagnosed in a child, there is a very high success rate. When found in adults, this form can present more of a danger and is treated with aggressive chemotherapy.
- Choriocarcinoma– is a rare, but very serious form of cancer. It is extremely aggressive and can quickly spread to other areas of the body, including the bones, brain, lungs and other organs. Prompt and aggressive treatment is required in this case.
- Teratoma- originates fromgerm cells and mimics the three layers of the human embryo. There are three types of Teratoma, which are Mature Teratomas, Immature Teratomas and Teratomas with Malignant transformation. Mature Teratomas can usually be cured by surgery to remove the testicle, however, the other two types are likely to spread to other parts of the body and require chemotherapy.
It is quite normal for there to be two types of Nonseminoma cancer cells involved in one patient. This however, does not affect the course of treatment.
Causes of Testicular Cancer
As with many cancers, the exact cause of Testicular Cancer is unknown. Cancer itself occurs when usually healthy cells become compromised and altered, affecting how they divide and proliferate. A normal cell divides at a set rate, but cancerous cells divide furiously, until there is a mass of altered cells attached to a healthy organ or tissue Researchers do not possess definitive answers about what causes Testicular Cancer, however, there are theories and initial evidence of how tumors of the testes come about, including the following:
- Genetics may play a role in developing testicular cancer, as men who have a family history are more likely to develop cancer of the testes in their lifetime.
- Exposure to excessive Pesticides has been implicated in the development of Testicular Cancer.
- Suffering from an undescended testicle in early life, which can lead to insufficient sperm production and cancer in one or both testicles.
- The HIV virus has also been documented as a risk factor for Testicular Cancer.
- Klinefelter Syndrome can also place one at risk for Testicular Cancer. This condition is the existence of an extra X chromosome in males (female chromosome), which leads to enlarged breast, smaller testicles and infertility.
- Carcinoma in Situ is a gathering of abnormal cells that are usually detected during biopsies in fertility treatment and usually require the removal of the affected testicle.
Additional Risk Factors
- A previous case of Testicular Cancer provides a 3-4% chance of cancer occurring in the opposite testicle.
- White males are more likely than other ethnic groups to be diagnosed with Testicular Cancer.
- This form of cancer is also more prevalent in higher end socio-economic groups.
- Testicular cancer seems to appear more often in taller men.
- Smoking increases the risk of developing Testicular Cancer by 50%.
Symptoms of Testicular Cancer
Although cases of Testicular Cancer may present with no recognizable symptoms, it is more common for the patient to complain of one or more of the following:
- A discernable lump in the testicle
- Pain or discomfort in the testicle or scrotum
- Swelling of one or both testicles
- Lower back, chest or abdominal pain due to the cancer spreading through the lymph nodes
- Breast tenderness or swelling due to hormonal secretions of the cancer cells
Diagnosing Testicular Cancer
While in some cases, the patient presents with symptoms that are very indicative of testicular cancer, other cases are not that apparent. In order for a physician to make an accurate diagnosis, there are a number of diagnostic tools available. The initial evaluation will likely be performed by your family physician, with a referral to an oncology specialist if necessary.
In order to help the doctor assess your condition, have a list of any symptoms, duration, frequency and severity of pain, any recent accidents, medication currently being taken, as well as documentation of any family history of cancer.
In the physical examination, the physician will examine the testicle for swelling, redness, heat and pain upon touch. Additional testing to determine the likelihood of testicular cancer includes:
An Ultrasound will be performed to provide a more accurate picture of the testicle and any lumps. In this procedure, a clear gel is applied to the testicles and a small device that emits sound waves is passed over the scrotum. This provides a picture of the testicles and any abnormalities. If there are any lumps, they should be evident on the ultrasound. The doctor will be able to tell if there is likely cancer evident or if the lump is a fluid filled cyst instead. The physician will also be able to tell if the mass is centralized inside or outside of the testicle.
Additional Blood Tests may be ordered to make a definitive analysis of cancer. The test will look for elevated levels of tumor markers that may be indicative of active cancer. Although not evident in all cases of testicular cancer, elevated tumor markers can confirm a suspected case of cancer. The common markers the physician will look for are:
AFP (alpha-fetoprotien) – This test may be by far the most indicative of malignant cancer. Although this element occurs naturally in the body, it is highly elevated in cases of cancer, specifically in Teratoma germ cell tumors.
HCG Levels (human chorionic gonadotrophin)- This is another test that provides information regarding a possible testicular tumor. HCG levels are noticeably elevated in 80-85% of cancer cases and the test can also provide an indication of the size of the tumor. HCG levels can be high in seminomas and nonseminomas
LDH (lactic dehydrogenase)– High LDH levels represent in increased amount of enzyme in the blood that is a result of damage to healthy cells. LDH levels can be elevated in many types of cancer and provide the physician with a general cancer diagnosis, while more tests are required to ascertain the specific type of cancer and the extent of the damage. This test can also help to gauge whether the cancer has spread to other parts of the body.
PLAP (placental alkaline phosphatase)- Elevated PLAP levels can be indicative of a seminoma tumor. Studies have shown that PLAP levels are elevated in 78% of men with seminomas.
Tumor marker tests are often conducted in order to confirm testicular cancer and also to monitor the progress of recovery after treatment.
Biopsies are another diagnostic option. In this procedure, a small piece of the testicle will be removed and examined in a laboratory for cancerous cells. There are two ways to perform the biopsy- an open biopsy, or a needle biopsy.
In both types of biopsy, the testicles are cleaned with a sterile solution and a local anesthesia is administered to numb the area. The surrounding area is carefully covered with a sterile cloth. In an open biopsy, the doctor makes a small incision in the testicle and removes a small piece of tissue from the testicle. One or two small stitches are required to close the incision. In a needle biopsy, the tissue is extracted by a surgical needle inserted into the testicle and no cuts or stitches are required. Both are outpatient procedures that can usually be performed in the physician’s office. However, it is important to note that a biopsy will not always be offered, because of the likelihood of spreading the cancerous cells.
Testicular Cancer Treatment
Once a high likelihood of Testicular Cancer is confirmed, surgery must be performed to remove the affected testicle. This is the only way to verify the existence of cancer 100% and will often be coupled with follow-up treatment to prohibit a reoccurrence of cancer. These treatments may also be required to treat other areas of the body, to which the cancer has spread.
The surgical procedure to remove the testicle is called an Orchiectomy. In this procedure, the patient is given a local anesthesia and an incision is made in the lower groin, above the affected testicle. The testicle is gently moved up towards the incision, pushed out and removed. If necessary, nearby lymph nodes will be removed at this time as well. If desired, a prosthetic testicle can be placed into the scrotum to even out the appearance of the testicles.
The surgery is usually done within an hour and the patient is released to go home. A small number of cases may require a short hospital stay, but this is usually an outpatient procedure. The patient can usually resume normal activities within two weeks, although it may take up to four weeks or all discomfort and other signs of surgery to disappear.
Although an Orchiectomy is a relatively low risk procedure, there are still the risks associated with surgery, such as excessive bleeding, adverse reaction to anesthesia and infection. If the patient needs to have both testicles removed, there is the additional risk of a loss of testosterone, which can cause the following:
- Reduced Libido
- Erectile and ejaculation dysfunction
- Weight gain
- Increase in breast tissue
- Loss of muscle tissue
Hormone therapy can be prescribed to alleviate some of the symptoms above. While it may seem a drastic procedure, removal of the affected testicle is the most reliable way to treat testicular cancer. In some cases, additional therapies will be implemented to fight cancer that has spread to other parts of the body. The type of additional treatment depends on the stage of the cancer.
Stages of Testicular Cancer
Once the testicle is removed, it is examined under a microscope by a pathologist to definitively diagnose cancer, as well as the type of cancer cells and provide information about what stage the cancer is in. The stage indicates whether the cancer has spread to other parts of the body and how far. In addition to the pathology report, a CAT scan will be ordered to provide a detailed look at the various organs and systems to identify additional tumors and cancerous cells.
During the CAT scan, the patient will be required to drink barium sulfate, a milky liquid that may cause some stomach discomfort. Additionally, the patient will likely receive an IV filled with contrast dye, which allows for a better image of the inside of the body. There may be some side affects of the dye, including a metallic taste in the mouth, nausea, warmth throughout the body and itching. These are routine and mild side affects, however difficulty breathing or swelling of the throat or other body parts should be reported immediately, as some people may be allergic to the iodine in the contrast dye.
The physician will usually examine images of the pelvis, abdomen and chest area in search of additional cancer cells. Based on the existence of additional cells and their location, a stage will be determined. The stage will determine the treatment plan for the patient going forward.
There are three specific stages, as follows:
In this stage, the cancer is restricted to the testicles and has not spread to the lymph nodes or other areas of the body. 72% of Testicular cancer cases are classified as stage I.
Also known as the Regional stage, this classification is for cases where the cancer has gravitated into the lymph nodes in the abdomen. Stage II accounts for approximately 19% of all cases.
In this stage, not only are the lymph nodes affected, but the cancer has spread to other organs further away, including the heart, lungs, bones or brain. Stage III cancer accounts for 9% of all Testicular Cancer cases.
Treatment Based on Stage
Stage 1 Treatment
For localized cases, often the removal of the testicle is sufficient to cure the cancer. After successful surgery, the patient will enter a period called “surveillance”, in which they are closely monitored for a reoccurrence of cancer. During the surveillance period, the doctor will routinely check the patient’s tumor markers for signs of cancerous activity.
Also, based on the blood analysis and examination of the testicle after removal, some stage I patients will also receive external localized radiation treatment targeting lymph nodes in the abdomen. This is especially the case if the cancer is classified as a Seminoma and is used as a measure to prevent a reoccurrence of cancer. The patient will be monitored closely to detect any relapse.
If the stage I cancer is classified as Nonseminoma, more aggressive treatment is applied. The patient will likely be advised to have additional surgery to remove the lymph nodes in the pelvis and abdomen. Also, the patient must undergo blood testing on a monthly basis for a period of one year, and bimonthly the following year. A followup CAT scan may also be done during that time. If additional cancer cells are detected, the patient will likely have to undergo chemotherapy.
Stage 2 Treatment
In stage II cases that have spread to the lymph nodes, there are two options. The physician may elect to remove the affected testicle, then follow up with external radiation treatment of the lymph nodes. This is usually the case for tumors that are found to be Seminomas. In the case of NonSeminomas tumors, the lymph nodes will be surgically removed, followed by chemotherapy to combat any remaining cancer cells.
There have also been cases where the physician is able to clearly identify stage II testicular cancer based on physical examinations and ultrasound images. In this case, the patient may be offered the option of undergoing chemotherapy, instead of surgery to remove the testicle. In this case, the patient will receive systemic chemotherapy treatments, along with ongoing blood work and x-rays to evaluate the success of the treatment. However, it the doctor does not see sufficient progress, or the cancer seems to be spreading, surgery will be advised.
Stage 3 Treatment
In stage III Testicular Cancer, if Seminoma cancer cells are found, then the testicle will be removed, with a high probability that the lymph nodes will be removed as well. The patient will then undergo systemic chemotherapy treatment and will be monitored continuously to gauge progress. In Nonseminoma stage III cases, which means that the cancer has spread to other parts of the body, more aggressive treatment is required. The patient will immediately undergo systemic chemotherapy treatment. The patient’s tumor markers, CAT scans and other indicators will be reviewed regularly for signs of progress or additional cancer proliferation.
After the determined number of chemotherapy treatments, the oncologist may order surgery to remove any remaining tumors that remain in the body. In some cases, additional chemotherapy treatment is ordered after surgery to eradicate any lingering cancer cells.
Chemotherapy treatment is administered in cases where the oncologist wants to provide extra assurance against cancer returning, to fight cancer that has spread to other parts of the body or to treat reoccurring cancer that has returned after the initial treatment. There are numerous mixtures of drugs that may be administered which depend on the stage, but the most common by far is a mixture of Cisplatin, Etoposide and Bleomycin, known as BEP chemotherapy.
Chemotherapy drugs are administered via an intravenous drip or injection directly into the veins of the patient. The usual administration points are in the arm (a PICC line), or into the main vein in the chest (a central line). If this chest is chosen, local anesthesia will be given before the infusion line is inserted.
Side Affects of Chemotherapy
- Some chemotherapy patients experience acute anemia, with symptoms such as lethargy, breathlessness, and dizziness. This is due to chemotherapy reducing the red blood cell count. Medication can be given to combat anemia and blood transfusions can be administered in severe cases.
- Low platelet counts may affect the blood’s ability to clot effectively, which may cause excessive bleeding from even small wounds, as well as easy bruising.
- The risk of infection increases, due to the reduction of white blood cells.
- Nausea and vomiting may occur, but can be controlled by medication.
- Hair loss is a common side affect of chemotherapy, with the onset at about two to three weeks after the first round of treatment. The amount of hair lost will vary, but should fully return once treatment is completed.
- Loss of appetite is a common side affect of chemotherapy, as well as dry mouth and mouth soreness.
- Shortness of breath and excessive coughing can be caused by the drugs used for chemotherapy.
Outcomes for Testicular Cancer
Testicular Cancer is highly curable. With early detection and prompt intervention, the success rates are impressive, but do vary by stage.
- For Stage 1 Testicular Cancer the cure rate is 99% for Seminoma tumors and 98% for Nonseminomas.
- Stage 2 Testicular Cancer cure rates are 95% for both Seminoma and Nonseminoma cancers.
- Stage 3 Testicular cure rates are lower, but still impressive at 90% for Seminoma and 76% for Nonseminoma.
To ensure the best outcome, patients should make all of their appointments and treatment sessions and report any adverse reactions to their doctor.
Fertility after Testicular Cancer
Removal of one testicle does not translate into infertility, as semen can be produced by the remaining one. However, if the patient is required to have the lymph nodes in their abdomen removed, this can cause a problem with fertility, called Retrograde Ejaculation.
Retrograde Ejaculation means that instead of semen emitting from the penis during ejaculation, it is instead unable to descend and actually moves backwards into the bladder. In this case, a male will still be able to sustain an erection, but will experience a dry climax and is unable to impregnate his mate. However, if a patient desires children, the semen can be removed and inserted into his mate via in-vitro fertilization.
Chemotherapy can also cause infertility. For most individuals, it will cause temporary infertility while undergoing treatment. Some individuals are able to become fertile again after chemotherapy is discontinued. Overall, 80% of men with Testicular Cancer are able to conceive after treatment and 70% of those that received chemotherapy go on to successfully have children.
If you are concerned about the possibility of infertility and would like to have more children, there is the possibility to bank some of your sperm for later use in impregnating your partner. To achieve this, the patient will be tested to ensure that their sperm count is sufficient, however if the sperm count is low, there are techniques to salvage usable sperm if there is sufficient time. Once testing is complete, the sperm are removed and frozen in the hospital. When you desire to have children, the sperm are then thawed and the process will begin to inseminate your partner. Note, however that some sperm do die upon thawing and it may take multiple attempts before your partner becomes pregnant.
Possible Testicular Cancer Complications
With Testicular Cancer, early detection is best. Possible complications differ based on the patient’s overall health, whether both testicles are affected, the stage of the cancer and the overall treatment plan and success thereof. Possible complications include:
- Cancer cells can spread to other areas of the body, including the spine, lungs and abdomen.
- There is the possibility of infertility from chemotherapy.
- Removal of the lymph glands in the abdomen or both testicles can also cause infertility.
- Complications of surgery to remove one or both testicles include excessive bleeding and infection.
- If both testicles are removed, hormone replacement therapy may be required.
- During chemotherapy, patients may experience fatigue, nausea, hair loss and skin issues.
Preventing Testicular Cancer
There is no documented means of preventing Testicular Cancer. Researchers state that the best defense is to do routine self examinations and report any abnormalities to your physician for early intervention.
Testicle Self Examination
A self examination is best performed in the shower, under warm running water. This allows the testicles to be fully relaxed.
Check the entire scrotum to see if it feels of normal weight and size. Then, use your fingers to check each testicle individually for size and shape, taking care to look for any swelling or hard masses. It is normal for one testicle to be lower and larger than the other. If you encounter any abnormalities, report them to your physician, who can perform a thorough examination.
If you are a smoker, eliminating this habit reduces the risk of developing Testicular Cancer by 50%.
- National Cancer Institute. Testicular Cancer: http://www.cancer.gov/cancertopics/types/testicular
- US National Library of Medicine. Klinefelter Syndrome: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001420/
- US National Library of Medicine. Testicular Cancer: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002266/
- US National Library of Medicine. Undescended Testicle: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001968/
- Macmillan Cancer Support. Testicular Cancer
- Macmillan Cancer Support. Chemotherapy
- Mayo Clinic. Testicular Cancer: http://www.mayoclinic.com/health/testicular-cancer/DS00046
- Cancer Research UK. Fertility-Having Children after Testicular Cancer
- Testicular Cancer Information and Support. Testicular Cancer Treatment: http://www.tc-cancer.com/treatment.html
- Testicular Cancer Research Center. Testicular Cancer Info-Staging: http://tcrc.acor.org/staging.html
- Staging of Testicular Cancer: http://www.kantrowitz.com/cancer/staging.html
- UK NHS. Testicular Cancer-Prevention: http://www.nhs.uk/Conditions/Cancer-of-the-testicle/Pages/Prevention.aspx
- American Cancer Society. What is Testicular Cancer