TESTICULAR CANCER

What is it?

Cancer of the testes is a relatively rare form of cancer, accounting for approximately one percent of cancers in men. The great majority of these cancers, however, occur in males between the ages of 20 and 44, precisely the time when a man may be most concerned about sexual fertility and planning for a family. Most patients treated for early stage disease can retain sexual function and fertility.

Almost all testicular tumors occur in the cells that produce sperm and are known as germ cells. These tumors, which are usually malignant, are grouped into two main classes: seminomas and nonseminomas.

Seminoma - This is the most common type of testicular cancer, accounting for 30 to 40 percent of all such tumors. It occurs most often in men between the ages of 25 and 45 and is usually slow growing.

Nonseminoma - The nonseminomas tend to be more aggressive than seminomas. Although 75 percent of seminomas have not spread beyond the testes when first diagnosed, 60 to 70 percent of patients with nonseminomas are found at the time of diagnosis to have cancer that has already spread to the lymph nodes. Nonseminomas can be further divided into four types, although they sometimes occur in combination and are then known as mixed tumors.

1. Embryonal cell carcinomas, 20 to 25 percent of all testicular tumors.
2. Teratomas, 5 to 10 percent.
3. Teratocarcinomas, 20 to 25 percent.
4. Choriocarcinomas, just 1 to 3 percent.

Who gets it?

During the past 40 years, the rates among white men have nearly doubled and are now more than four times greater than among black men. The rates for Hispanics, American Indians, and Asians are higher than those for blacks, but still less than those for whites.

The major risk factor for testicular cancer is undescended testes - that is, the testes, which are formed up in the body near the kidneys, fail to descend into the scrotum. This condition increases by five times the risk of developing testicular cancer. It can be easily corrected by surgery, however, and if done before a boy is six years old, the risk is reduced to normal.

Although physical injury to the testes has sometimes been associated with testicular cancer, it may just be that the injury prompted the person to have his testes checked, leading to a diagnosis of an already existing tumor, rather than actually causing the cancer.

What are the symptoms?

The most common finding leading to a diagnosis of testicular cancer is a hard lump in the testicle. The lump might be as small as a pea or as large or larger than the testicle. Other signs include painless swelling and a feeling of heaviness in the groin area or scrotum. In most cases, there is no pain unless the patient also has an inflamed epididymis. These symptoms can also be caused by other conditions, but even the mildest symptom should be checked by a doctor.

What tests will the Doctor want to do?

New tests make it easier to distinguish between cancer of the testes and other conditions. Such techniques might include ultrasound, which is a painless and harmless test using high frequency sound waves that bounce off body tissue to produce images of the internal structures. Any cancerous tumors found are projected on a small screen.

When a suspicious mass is present and other conditions are ruled out, the testis is removed through the groin. The procedure is known as orchiectomy. Tissue is then studied under a microscope. Because testicular tumors often are of a mixed type, many different sections of the removed testes will be examined to make a complete and accurate diagnosis.

Once a diagnosis has been made, other parts of the body where testicular cancer is likely to spread are also examined. Methods used include:

• Chest x-ray.
• Tomograms of the lungs. Tomograms are x-rays that show one thin layer of the lung at a time. They may reveal a small tumor not visible on a standard x-ray. These have been largely replaced by CAT scans of the lung.
• CAT Scans of the abdomen and lung. Computerized Axial Tomography Scans use x-ray beams that rotates around the body to produce a series of x-rays taken from different angles. This information is then processed by a computer to produce a complete picture of a cross-section of a selected body area.
• Blood tests to determine the levels of serum markers, proteins that in abnormally high levels indicate the presence of certain cancers. Measuring serum levels not only helps in making an accurate diagnosis, but comparing readings taken at different times can show if a patient is responding to treatment, or if a relapse occurs.

What is the treatment?

Surgical removal of the affected testis is both part of the diagnostic process and the first step in treatment of the disease. Testicular cancer rarely occurs in both testes and the remaining testicle can maintain a man's fertility and hormone production. Further treatment depends on the type of testicular cancer and whether it has spread beyond the testes.

Although testicular cancer is considered highly curable, proper treatment does require the expertise of cancer specialists. To maximize chances for a cure, patients should seek treatment at medical facilities with health professionals experienced in managing testicular cancer. Even if considered cured, patients should continue to receive follow up examinations in case any long-term after effects occur.

Surgery

Because there may be metastasis when most nonseminomas are first diagnosed, further surgery may be required to remove nearby lymph nodes. These nodes are then checked for evidence of the disease. If none is apparent, no further treatment may be needed. In more advanced cases, chemotherapy may be used.

Chemotherapy

Combinations of several different anticancer drugs have greatly improved survival rates, achieving complete remission in 80 percent of patients with nonseminomas and limited metastasis. Newer drug combinations can help save additional patients who don't respond to the initial drug therapy or who later have a relapse.

Side effects of chemotherapy depend on the drugs used and may include hair loss, nausea and vomiting, a feeling of tiredness, and changes in the patient's blood count. The hair grows back and most other side effects end when chemotherapy is stopped.

Radiation

Radiation therapy is the treatment of choice for patients with seminomas and may be used at times for those with nonseminomas. The aim of radiation therapy is to destroy cancer cells by injuring their ability to divide. For patients with testicular cancer, radiation is usually beamed at the abdomen and pelvis, and sometimes the chest and neck. Chemotherapy or the surgical removal of nearby lymph nodes may also be part of the treatment.

Side effects of radiation therapy include a general feeling tiredness that usually leaves within a week after treatment is completed, nausea and vomiting, and skin irritations.