General Information / Anatomy / Function / Statistics

• Male genital glands (gonads) that produce the male reproductive cells, or spermatozoa, and the male hormone testosterone
• Each testis is surrounded by a thick fibrous capsule and is composed of many small, thin, coiled tubes called seminiferous tubules
• Testicular cancers usually grow from cells in the gonads that actually create the sperm
• Tumours of both testicles are uncommon
• Tend to occur in younger men
• Testicular cancers are uncommon but can be very malignant
• Death is unusual now but may be caused by bulky, wide-spread disease
• Early detection can result in a complete cure and less treatment
• Very few benign tumours are found in the testes so all lumps should be checked immediately
• Often lumps are confused with inflammatory conditions of the adjacent epididymis

Symptoms / Signs

• Painless lump in the testis
• Enlarged testicle (most common)
• Feeling of heaviness in the scrotum
• Hormonal imbalance that causes breast enlargement (rare)
• Back pain or abdominal mass of nodes (uncommon)
• Shortness of breath from spread to lungs (uncommon)

Etiology / Carcinogens / Risks

• The cause is unknown
• Patient with a history of undescended testicle
• Rarely there may be a family predisposition
• Age range 15 to 35 (but has been found in newborns and older men)
• Ranks first in cancer incidence for men between 20 and 34 years old
• Ranks second in cancer incidence for men aged 35 to 39 years old
• Ranks third in cancer incidence for those between ages 15 and 19
• Previous cancer of the other testis

Prevention

• Testicular self-examination performed monthly may help detect testicular cancer. Easy to learn and takes a couple of minutes. This is important for individuals with a history of abnormal descent of the testicle, a close family member affected or a previous cancer of the other testis.

Diagnosis / Staging / Grading / Types

• Complete medical history
• Physical examination
• Laboratory tests on blood particularly. Three main tumour markers are:
  • HCG (Human chorionic gonadotropin)
  • AFP (Alpha feto protein)
    • both detect substances secreted by the cancer which act as "tumour markers".  Also tell whether or not patient is responding to treatment
  • LDH (Lactate dehydrogenase) not as specific for testis cancer as HCG and AFP
• Ultrasound scanning of the scrotum may be helpful
• Once the diagnosis is confirmed the extent of disease elsewhere needs assessment:
  • Chest X-ray
  • CAT scan of abdomen (usually after removal of the affected testicle)
  • A dissection of the nodes in the retro peritoneum may be advised if scans are ambiguous
• Orchiectomy is the removal of the testicle
• Biopsy is not done until the actual surgery for removal of the testicle

Staging

• Stage 1 - Tumuor confined to the testis
• Stage II - Involvement of the retroperitoneal lymph nodes (back portion of the abdomen)
• Non-bulky
• Bulky - extensive retroperitoneal lymph node involvement with more than five nodes generally greater than 2 cm (3/4 in)
• Stage III - Extension beyond retroperitoneal lymph nodes

Types

• Germ cell - tumours are divided into two groups:
• Seminomas
  • Most common form (50%), usually confined to the testicle
  • Very sensitive to radiation and/or chemotherapy (25 to 45 yrs. age group)
• Nonseminomas
  • Rest of group
  • Spread through bloodstream
  • Usually occur in men in their mid-twenties
  • Less sensitive to radiation but very sensitive to chemotherapy
  • Nonseminomas are composed of various cell types:
    • Teratomas
    • Embryonal-cell tumor (aggressive tumor)
    • Yolk sac carcinoma - very rare except in children under 15 which accounts for 90% of cases
    • Choriocarcinomas (rare but very malignant)
    • Teratocarcinoma - mixture of embryonal cell carcinoma and teratoma
    • Some may be mixed-cell types
• Non Germ Cell Tumors
  • these tumors are rare and usually treated surgically

Treatment

• Sperm count and analysis, if fertility is an issue
• Sperm banking may be sought in some cases

Surgery

• Usually the first step and is required for diagnosis
• Radical Orchiectomy:
  • The affected testicle is removed
  • Incision is made through the groin
  • If cancer has not involved the scrotum an artificial testicle may be inserted, usually in a subsequent operation
  • If both testicles are removed (rare) the patient will become infertile and will also require male hormone replacement
• Once the cancer diagnosis is confirmed a dissection of the nodes in the retro peritoneum may be advised if scans are ambiguous.
• Lymphadenectomy: Sometimes performed with nonseminomas. Consists of removing all of the lymph nodes on one side of the abdomen up to the kidneys. If necessary, it may be done on both
sides
• A frequent complication is failure of ejaculation. A patient with one testis may continue to produce sperm but they do not make their way out of the penis at the time of
ejaculation, hence the patient becomes infertile. New surgical techniques can sometimes avoid this problem
• Chemotherapy may be required if cancer is present in the lymph nodes at the time of surgery

Radiation

• Steps can be taken to minimize the risk of infertility, e.g. sperm banking, design of radiation fields and shielding
• Standard treatment after a radical orchiectomy for Stage I and non-bulky Stage II seminomas
• Directed to the abdominal lymph nodes
• Cure rates in early seminomas approach 100%
• If advanced, systemic chemotherapy may be given with or without radiation with good cure rates
• Recurrences detected early are very curable

Chemotherapy

• Nonseminomas: chemotherapy may be used, radiation is rarely used
• One of the great breakthroughs in cancer medicine
• Cure rate for patients with low stage nonseminoma approaches 100%
• Patients with advanced seminoma also have a good prognosis, but with a cure rate of approximately 65%
• Chemotherapy required is vigorous and some side effects are unavoidable, but program is short (3-4 months) and patient should not be intimidated
• Alopecia (hair loss) will occur but hair will return within two to six months after chemotherapy is stopped
• Chemotherapy may temporarily or permanently decrease the sperm count
• Results of treatment from BCCA are among the best in the world 
• 75% of recurrences happen in first year after treatment
• Monthly checkups will be scheduled (physical examination, chest X-ray, blood tests)

Revised September 2001