Testicular Cancer

Testicular cancer primarily affects men between the ages of 15 and 35. However, men of any age can develop the disease. The good news is that when found early, testicular cancer is highly treatable and curable.

Testicular cancer is a type of cancer that develops in the testicle(s) of men. It is not a common cancer, accounting for only 1%-2% of cancers in men, with about 8,400 men diagnosed each year and about 350 men will die of the disease each year.  

Because of its high cure rate, testicular cancer is considered the model of successful treatment for cancer originating in a solid organ. In 1970, 90% of men with metastatic testicular cancer died of the disease. By 1990, that figure had almost reversed nearly 90% of men with metastatic testicular cancer were cured.

In rare cases it might not be Testicular Cancer, it might be

Testicular Mesothelioma is the rarest form of mesothelioma. It occurs in less than one percent of all mesothelioma diagnoses.

Mesothelioma typically presents itself in the chest or abdomen, but in rare circumstances, it can develop in the testicles. Testicular mesothelioma occurs when mutated cells in the lining surrounding the testicle begin replicating uncontrollably.

For more information visit http://www.mesotheliomaguide.com/mesothelioma/testicular-mesothelioma/

Below is what your Testicle looks like

How to check yourself

All men (specifically those 18-44 years of age) should perform monthly testicular self-examinations. The point of these examinations is not to find a cancer but to get familiar with how your testicles feel so that you will notice if something changes.

The best time to do the exam is after a warm bath or shower, when the muscles are most relaxed.

Stand in front of a mirror that allows full view of the scrotum.

Examine each testicle, one at a time.

Use two hands: Hold the testicle between the thumbs and first two fingers of both hands, with the thumbs in front and the fingers behind. Gently roll the testicle around between these fingers, carefully feeling the testicle and the cord, trying not to miss a spot.

Locate the epididymis, the soft tube at the back of each testicle that carries the sperm. Refer to above picture.

Men should not feel any pain during the exam.

If a person finds anything that alarms or concerns them, have it checked out by your primary care provider or an urologist.

Causes and Risk Factors of Testicular Cancer

Although researchers cannot pinpoint exactly what causes testicular cancer, they have identified several known risk factors for the disease. A risk factor is something that increases the likelihood that you may develop a disease, but is not a guarantee you will get it. Risk factors for testicular cancer include

Having had an undescended testicle, although if this is corrected early in life, the risk is reduced

Having had abnormal development of the testicles

Having a personal or family history of testicular cancer

Being diagnosed with Klinefelter’s Syndrome

Being infected with HIV

Being Caucasian  

 

Testicular Cancer Symptoms

Painless lump in the testicle or both testicles

Less commonly, the lump will cause pain

Heaviness or feeling of swelling in the scrotum

Discomfort or pain in the scrotum

Ache in lower back, pelvis or groin area

Collection of fluid in the scrotum  

 

Blood tests

If you have testicular cancer, you may have a higher than normal amounts of several chemicals in your blood. These are called Tumoe markers. The chemicals are

 Alpha-fetoprotein (AFP)

Human chorionic gonadotrophin (HCG)

Lactase dehydrogenase (LDH).

Tests for these chemicals can help your doctor find out what type of testicular cancer you have seminomas or nonseminomas. For example, if you have seminomas, you'll have normal levels of AFP. If you have nonseminomas, such as teratoma, you may have raised levels of AFP.

However a blood test on its own isn't enough for your doctor to say for certain you have caancer.  Not all men with testicular cancer have high levels of these chemicals, and it's possiable to have increased levels of Tumor  markers in your blood without having testicular cancer.

You'll have more blood tests as you go on with your treatment. If the level of these chemicals in your blood drops, it's a sign that your treatment is working.

 

There are two types of germ cells tumors,

Seminomas and  Nonseminomas.

Seminomas arise from only one type of cell: immature germ cells that have not yet differentiated. These constitute about 40% of all testicular cancers.

Nonseminomas are composed of mature cells that have already specialized. Thus, these tumors often are "mixed," that is, they are made up of more than one tumor type. Typical components include choriocarcinoma, embryonal carcinoma, immature teratoma, and yolk sac tumors. These tumors tend to be faster growing and to spread more aggressively than seminomas.

Nonseminomas tend to grow and spread more quickly than seminomas. Seminomas are more sensitive to radiation. A testicular tumor that contains both seminomas and nonseminoma cells is treated as a nonseminoma.

 

Testicular cancer is most common in whites and least common in blacks and Asians.

The cure rate is greater than 90% for all stages. In men whose cancer is diagnosed in an early stage, the cure rate is nearly 100%. Even those with metastatic disease have a cure rate of greater than 80%.

These figures apply only to men who receive appropriate treatment for their cancer. Prompt diagnosis and treatment are essential.

What is a Tumor 

Testicular Cancer occurs when normal cells transform and begin

to grow and multiply without normal controls.

This uncontrolled growth results in a mass of abnormal cells called a tumor.

Some tumors grow quickly, others more slowly.

Tumors are dangerous because they overwhelm surrounding healthy tissue, taking not only its space but also the oxygen and nutrients it needs to carry out its normal functions.

Not all tumors are cancer. A tumor is considered cancer if it is malignant. This means that, if the tumor is not treated and stopped, it will spread to other parts of the body. Other tumors are termed benign because their cells do not spread to other organs. However, almost all tumors start to cause symptoms when they get large enough.

Malignant tumors can spread to neighboring structures, usually lymph nodes. They encroach on and invade these healthy tissues, impairing their function and eventually destroy them.

Tumor cells sometimes enter the bloodstream and spread to distant organs. There, they can grow as similar but separate tumors. This process is called metastasis.

The most common places for testicular cancer to spread are the lymph nodes in the area near the kidneys, called the retroperitoneal lymph nodes. It also can spread to the lungs, liver, and rarely to the brain.

Metastatic cancers are more difficult to cure than benign tumors, but still have very high cure rates.

Testicular cancers can be comprised of one or several different types of tumor cells. The types are based on the cell type from which the tumor arises.

By far the most common type is germ cell carcinoma. These tumors arise from the sperm forming cells within the testes.

Other rarer types of testicular tumors include Leydig cell tumors, Sertoli cell tumors, primitive neuroectodermal tumors (PNET), leiomyosarcomas, rhabdomyosarcomas, and mesotheliomas. None of these tumors is very common.

 

Tumor Stages

Tumor Stage is a critical measure of how much the cancer has spread. Knowing the stage is important because it guides treatment. Preliminary staging is based on the results of the imaging studies and lab tests. Testicular cancer typically spreads in a step-by-step fashion. If it spreads from the testicle, the first place it typically goes is in the area near the kidneys, called the retroperitoneum. It then can spread to the lungs, brain, or liver.

Stage I

Tumor is limited to testicle without any evidence of disease in the abdomen, chest, or brain.

Seminomas: Orchiectomy with or without radiation to the retroperitoneum

There is a 15% chance that tumor will spread to the retroperitoneum.

Because radiation can eliminate this cancer 99% of the time and is generally very well tolerated, radiation therapy is typically recommended.

Stage I seminomas has a 99% cure rate. Stage I nonseminomas has about a 97%-99% cure rate.

Stage IIA

Tumor is in the testicle and has spread to a small number of retroperitoneal lymph nodes measuring less than 2 cm in greatest diameter.

Seminomas: Orchiectomy followed by radiation therapy,

although chemotherapy is also effective

Stage IIA seminomas have a 95% cure rate.

Nonseminomas: Chemotherapy or RPLND

Stage IIA nonseminomas have a 98% cure rate.

Stage IIB

Tumor is in the testicle and has spread to a retroperitoneal lymph node(s) measuring between 2 cm and 5 cm in greatest diameter.

Seminomas: Either radiation or chemotherapy

Stage IIB seminomas have an 80% cure rate.

Nonseminoma: Either chemotherapy or RPLND

Stage IIB nonseminomas have a 95% cure rate.

Stage IIC

Tumor is in the testicle and has spread to the retroperitoneal

lymph nodes measuring greater than 5 cm in greatest diameter.

Stage III

Tumor has spread beyond the retroperitoneal lymph nodes, typically to the lungs or brain.

Seminomas: Chemotherapy followed by post-chemotherapy RPLND,if needed

Stage III seminomas have about an 80% cure rate.

Nonseminoma: Chemotherapy followed by post-chemotherapy RPLND, if needed

Stage III nonseminomas have about an 80% cure rate.

Most non-germ cell testicular tumors usually require no further treatment after Orchiectomy. If there is a high-risk of metastases or if metastases are present, further surgery is often recommended.

Staging can only be estimated from imaging studies and tumor markers. The only way to confirm the diagnosis of testicular cancer is through surgical removal of suspected tumor tissue that is biopsied; often it means that a testicle is removed.

The testicle is removed in a procedure called radical Orchiectomy, which requires an incision in the groin (inguinal region) and complete removal of the testicle and spermatic cord.

A small piece of the tumor (biopsy) is examined by a physician who specializes in diagnosing disease by examining cells and tissues (pathologist).

Removing the tumor without removing the testicle (partial Orchiectomy) is rarely an option in adults, since this carries a risk of leaving residual cancer cells in the testicle that could spread to the other testicle or other parts of the body.

What is the treatment for testicular cancer

Treatment options which may be considered include surgery, chemotherapy and radiotherapy. The treatment advised for each case depends on various factors such as the stage of the cancer, the type of cancer (seminomas or nonseminomas), and your general health.

Surgery

Orchiectomy: This operation removes the entire testicle and the attached cord.  A small incision is made where the leg meets the abdomen on the side of the testicle with the tumor. The testicle and attached cord are gently moved up out of the scrotum and out of the incision. Only a few stitches are needed.

Typically, the surgery takes 20-40 minutes. It can be done with a general, spinal, or local anesthetic.

Absorbable stitches are usually used, and the patient can go home the same day as surgery.

Many urologists recommend that men bank their semen prior to the surgery, because it can take months to years after therapy to return to full fertility.

This surgery is recommended for all men with testicular cancer. It is the first and, for some men, the only treatment needed.

This surgery should not interfere with normal erection, ejaculation, orgasm or fertility.

This alone may be curative if the cancer is in an early stage and has not spread. (Radiotherapy may also be advised for seminomas even at an early stage.)

Chemotherapy

Chemotherapy is a treatment of cancer by using anti-cancer drugs which kill cancer cells, or stop them from multiplying.

Chemotherapy is often given after surgery, even if the cancer has not spread.

Radiotherapy

Radiotherapy is a treatment which uses high energy beams of radiation which are focused on cancerous tissue. This kills cancer cells, or stops cancer cells from multiplying.

Radiotherapy is sometimes given to men with seminomas to prevent the cancer coming back after surgery or to treat any cancer cells that have spread to the lymph nodes at the back of the abdomen.

Further surgery may also be needed for some men after radiotherapy or chemotherapy, to remove any cancer cells present in the lymph nodes of the abdomen or chest.


When chemotherapy or radiotherapy is used in addition to surgery

it is known as 'adjuvant chemotherapy' or 'adjuvant radiotherapy'.

 

What is RPLND

Cancer usually spreads via a very predictable route through the lymph nodes upwards to the lungs, and then outward to the liver, brain, and elsewhere. The affected lymph nodes are called the "retroperitoneal lymph nodes" and they are located behind all of the major organs in the belly, basically between the kidneys and along the vena cava and aorta.

In certain situations it makes sense to remove these nodes. In other situations the RPLND is simply not done. So, who might need an RPLND?  

When a patient has Stage 1 nonsemionas, it may make sence to remove the lymph nodes to determine whether in fact the cancer really is gone.  If it isn't the surgery alone may cure them or they can proactively receive a short course of chemotherapy that will essentially cure them.  Before the 1980's this surgery was almost always done whenever testicular cancer was diagnosed.  But now with the increased effectivness of chemotherapy it is used much less offen today.A patient with Stage II nonseminoma, may also choose to have the surgery if their nodes are small enough. The reason here is either it might not be cancer and they don't want to get chemotherapy if they do not need it or if only a small amount of cancer is found, the surgery alone might cure it or  removing the lymph nodes first may reduce the amount of chemo required to cure the cancer.

A number of people may need this surgery after chemotherapy. The chemo may kill the cancer, but one of the things left behind, teratoma, must be removed. Teratoma is a benign tumor with a tendency to grow or degenerate back into another cancer. Anything left after chemo that is large enough (perhaps more than 1-2cm), it is likely that the doctors will want to remove it. In a few cases it is possible that the chemo did not completely kill all the cancer. In these cases, removing the lymph nodes might also be therapeutic and cure the cancer.

So who does not need an RPLND or is not likely to be offered an RPLND? In general, if you don't fall into one of the categories mentioned above, you should not be thinking about the RPLND. Here is a list of situations where you do not want or will not be offered an RPLND.

The RPLND is almost never done for seminomas.  It is more difficult to do and radiation or chemotherapy are preferred treatments.  The most common reason to preform this surgery on a seminomas patient is to remove any large or bulky masses that might be left over after chemo or radiation that are getting in the way of the normal operation of the organs around it.

If their is no visible spread of the cancer but you have rising tumor markers after the Orchiectomy you should not have a RPLND and should go directly to chemotherapy. 

Nonseminomas patients with lymph nodes that are larger than 3 cm are not normaly offered a RPLND as they most likely have cancer and need to go on chemotherapy.

There are always exceptions, a patient who has teratoma in the tumor with a 4 cm lymph node has a better chance that the teratoma is also in his lymph nodes.  In this case the RPLND could cure him in half the time and cut the number of chemotherapys needed to cure his cancer.

Patients with clinical stage I cancer who had their Orchiectomy more than 6 weeks before the scheduled RPLND date should consider canceling the surgery. The RPLND is most beneficial if it is done soon after the Orchiectomy. If you wait too long before having an RPLND, or if they do find cancer during the surgery, it is less likely that they will have caught it before it spread outside of the surgical boundary. Unless there is a very good reason for delay, try to have the surgery done quickly. 

What is the operation like? We're talking serious surgery. The RPLND involves an incision from just below your sternum to below the belly button. Your intestines and associated organs are literally lifted out of the way, nerves are identified and hopefully moved out of the way, and then the surgeons remove all the lymph nodes that were connected to the testicle containing the tumor.

The operation itself can take 3-6 hours. They usually check the lymph nodes on the same side as the affected testicle first, and if they find anything suspicious, they may check the other side as well for additional spreading.  

This is a great surgical procedure if done right you should be testicular cancer free. 

If they do find cancer, you've most likely got a date with chemotherapy in the near future.

This is a complicated and delicate procedure. Few doctors do more than a couple of these surgeries a year, so do not worry about hurting your urologist's feelings and look for someone who has alot of experience. If you need a post-chemo RPLND, find someone who has done the procedure many times before.  

This is what your RPLND scar might look like

What are some of the risks with RPLND surgery

Infertility due to retrograde ejaculation. If the doctor cuts a nerve during the surgery, and it is very easy to do this, you will lose the ability to ejaculate normally.

Prolonged bowel inactivity  

Bowel obstruction

Large scar and possible infection

Pain management, the effects of the operation should last for 2-3 months.

Interior damage to surrounding organs, blood vessels, etc.

Infection from blood transfusions

General infections

Recent developments in the field include the laparoscopic RPLND. This is a new, very difficult, time consuming operation. It does substantially reduce morbidity and recovery time. But most doctors do not recommend it because they do not feel that it is a curative operation. In other words, since it won't cure you, it will not eliminate the need for chemotherapy. If it doesn't do this, then why bother doing it at all?  Learn all you can about Testicular Cancer.  The more you know about your cancer and your treatment options, the more confident you'll feel as you make decisions about your treatment. Write down any questions you might have and ask them at your next doctor's appointment. Ask your doctor or other members of your health care team to recommend reputable sources for further information. Some good places to start include the National Cancer Society's Cancer Information Service at 800-4-CANCER (800-422-6237), or the American Cancer Society at 800-ACS-2345 (800-227-2345).

 

 

 
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