What is testicular cancer?

Testicular cancer (sometimes called germ cell tumor) begins when cells within the testicle become cancerous and begin to grow out of control. Testicular cancer is classified as one of two types, seminoma, which account for 30% to 40% of all testicular cancers, and nonseminoma, which includes four sub-types. The nonseminomas include: choriocarcinoma, embryonal carcinoma, teratoma, and yolk sac tumors. A tumor can contain a mixture of both cell types; these are called mixed germ-cell tumors. The types have different prognoses and treatments.

The American Cancer Society estimates that 7,600 new cases of testicular cancer will be diagnosed in 2003, accounting for only 1% of cancers in men. It is the most common form of cancer in men ages 15 to 35. In addition, the disease is five times more common in whites than in blacks or Asians.

Am I at risk for testicular cancer?

The cause of testicular cancer is still unknown, but a few things have been linked to a higher risk of developing the disease. An undescended testicle (also called cryptorchidism) is a condition where the testicle did not move into the scrotum before birth. Surgery can be performed to correct the problem, but this does not seem to lower the risk of developing testicular cancer. Men whose testicles did not develop normally are also at higher risk. Klinefelter's Syndrome is a disorder characterized by low levels of male hormones, sterility, breast enlargement, and small testes, which carries with it an increased risk of testicular cancer. Men who have already had testicular cancer have a two to five percent chance of developing cancer in the opposite testicle during the 25 years following diagnosis.

How can I prevent testicular cancer?

Unfortunately, the factors listed above that increase risk, cannot be prevented. The best outcomes for patients with testicular cancer occur when the disease is found early, so early detection is important. This is best done by testicular self-exam.

What screening tests are available?

Most testicular cancers are found by the men themselves, or during a routine exam by a physician. The best method of examination is known as testicular self-exam or TSE. TSE includes regular inspection and palpation of the testicles. Men (and boys) should be familiar with the normal weight, texture and consistency of their testicles. Examination should be done once a month after a warm bath or shower, when the scrotal sac is relaxed. Each testicle should be rolled between the thumb and forefinger to examine for any lumps. Any lumps or abnormalities should be reported to a doctor immediately.

What are the signs of testicular cancer?

Some men find a lump in their testicle before any other symptoms are present, so a lack of other symptoms does not mean a lump is normal. Some symptoms that may be present are:

• Painless lump or swelling in either testicle, or a change in the way it feels
  
• A feeling of heaviness in the scrotum
  
• A sudden collection of fluid in the scrotum
  
• Pain or discomfort in the scrotum

These symptoms can be a sign of conditions other than cancer. If any are present, a doctor should evaluate them.

How is testicular cancer diagnosed and staged?

If the doctor suspects testicular cancer he may perform several tests to clarify the diagnosis. These tests include an ultrasound of the affected scrotum to identify a mass in the testicle or blood tests that measure substances known as tumor markers (which are found in higher than normal amounts when a tumor is present). If these tests point to a diagnosis of cancer, the next step is to remove the affected testicle surgically. This then allows pathologists to examine the tumor closely, determining what type of testicular cancer it is. Once the tumor is identified, the next step is to determine how far the cancer has spread - this is known as staging.

Staging may include surgery to remove lymph nodes in the groin and lower abdominal area to test for spread of the cancer and/or CT scans of the chest, abdomen, and pelvis to look for tumor spread, depending on the cell type (seminoma versus nonseminoma). Stage I disease is confined to the testicle, stage II has spread to the abdominal lymph nodes, and stage III represents more advanced disease.

What are the treatments for testicular cancer?

The treatment of testicular cancer is determined by the type and stage of the tumor. Seminomas and nonseminomas are treated differently, as are stage I, II, and III tumors.

Surgery

Initially, all patients will require removal of the affected testicle (orchiectomy). This may cause concerns related to fertility and sexuality, and these should be discussed with your doctor before the surgery. Many men with testicular cancer have fertility problems before diagnosis, and this may or may not improve after the surgery. One testicle produces enough hormones and sperm to have an erection or father a child. Other surgery, chemotherapy, and radiation may affect sperm production and the ability to ejaculate of sperm, so this should be discussed before surgery.

A second surgery, called retroperitoneal lymph node dissection (RPLND), removes the lymph nodes that the tumor typically spreads to. This surgery is often performed in nonseminomas to evaluate tumor spread, but in seminomas, CT scans give adequate results and therefore are used instead.

Radiation Therapy

Once again, the choice of treatment with radiation depends on the tumor type. Seminomas are very sensitive to radiation, and therefore are usually treated with radiation. Nonseminomas are not very sensitive to radiation, and therefore are not usually treated with radiation.

The remaining testicle can be shielded during treatment to prevent it from receiving radiation and losing the ability to produce sperm. Sperm counts may fall after radiation, but typically return to normal within one to two years after treatment.

Chemotherapy

In some cases, chemotherapy is given to patients after surgery to kill any remaining tumor cells in the body. This is often referred to as adjuvant (meaning after surgery) chemotherapy.

The regimen of chemotherapy that is given varies from doctor to doctor.ﾠ The regimen is chosen based on the tumor type and stage, the patient?s general health, and his ability to tolerate expected side effects.ﾠ The most commonly used chemotherapy medications include: cisplatin, bleomycin, etoposide, and ifosfamide. As with surgery, sexuality and fertility issues should be discussed before treatment is started.

Follow-up testing

Follow-up testing is very important because of the risk of recurrence or the development of a second tumor. Although most recurrences occur within two years for seminomas and five years for nonseminomas, some patients have recurred many years later, so follow-up is very important. This should include: a physical exam by an oncologist, tumor markers (a blood test whose levels are found in higher than normal amounts when a tumor is present), and chest x-ray, with or without a CT scan (depending on the case). These tests are performed every one to two months for the first year after therapy, every four to six months for the second year, every six months for years three through five, and yearly thereafter. These are guidelines only, and may vary from case to case and hospital to hospital.