Testicular Cancer

Introduction Testicular Cancer

Cancer of the testicles, also known as testicular cancer, is an uncommon type of cancer that primarily affects younger men. The most common symptom of testicular cancer is a painless lump or swelling in the testicles. Other symptoms can include

  • A dull ache in the scrotum
  • A feeling of heaviness in the scrotum

The testicles are the two oval-shaped male sex organs that sit inside the scrotum on either side of the penis. The testicles are an important part of the male reproductive system because they produce sperm and the hormone testosterone, which plays a major role in the male sexual development.

 

Types of testicular cancer

The different types of testicular cancer are classified by what type of cells the cancer first begins in. The most common type of testicular cancer is known as ‘germ cell testicular cancer’, which accounts for around 95% of all cases. Germ cells are a type of cell that the body uses to help create sperm.

There are two main subtypes of germ cell testicular cancer . They are:

  • Seminomas, which accounts for 40% of all cases
  • Non-seminomas, which accounts for the remaining 60% of cases

In practical terms, the only important difference between the two subtypes is that seminomas tend to respond better to radiotherapy (treatment that uses radiation to kill cancer cells) and non-seminomas tend to respond better to chemotherapy (treatment that uses medication to kill cancer cells)

Less common types are:

  • Leydig cell tumours, which account for 1-3% of cases
  • Sertoli cell tumours, which account for  1% of cases.

How common is testicular cancer?

Testicular cancer is relatively uncommon, accounting for just 1% of all cancers that occur in men. Each year in England, it is estimated that   there are three to six new cases of testicular cancer for every 100,000 men.

Testicular cancer is unusual compared to other types of cancer because it tends to affect younger men who are between 20 to 55 years of age. As a result, although relatively uncommon overall, testicular cancer is the most common type of cancer to affect young men (20 to 30 years of age).

Rates of testicular cancer are five times higher in white men than in black men. The reason for this is unclear.

The number of cases of testicular cancer that are diagnosed each year has roughly doubled over the last two decades, both in England and in other European and North American nations.

The cause or causes of testicular cancer are unknown, but a number of risk factors have been identified that increase the chance of developing the condition . These include:

  • Having a family history of testicular cancer
  • Being infertile
  • Being born with un-descending testicles (cryptorchidism). About 3-5% of boys born with their testicles located inside their abdomen, which usually descends into the scrotum during the first four months of life.

Outlook

The outlook for testicular cancer is very good because it is one of the most treatable types of cancer. Over 95% of man with early stage testicular cancer will be completely cured. Even cases of advanced cancer, where the cancer has spread outside the testicles to nearby tissue, have an 80% chance of being cured. Compared to other cancers, deaths from testicular cancer are rare.

Treatment for testicular cancer includes the surgical removal of affected

Testicle (which should not affect the fertility or ability to have sex) chemotherapy and radiotherapy.

Symptoms of testicular cancer

The most common symptom of testicular cancer is a lump or swelling in one of your testicles. Testicle lumps are most commonly found on the front or the side of the testicle. They often feel like a hard, pea-sized swelling.

When to see a GP

Never ignore a lump or swelling in your testicles . It is very important to visit a GP as soon as you notice any lump or swelling on your testicles.

Your GP will examine your testicles to help determine whether or not the lump is cancerous. Most testicular lumps are not a sign of cancer. For example varicoceles (swollen blood vessels) are a common cause of testicular lumps.

Research has shown that less than 4% of testicular lumps are cancerous. In the unlikely event that you do have testicular cancer , the sooner  treatment begins, the greater the likelihood that you will be completely cured.

Associated symptoms

As well as a lump or swelling, testicular cancer can cause other symptoms including:

  • A dull ache or sharp pain in your testicles or scrotum, which may come and go.
  • A feeling of heaviness in your scrotum
  • A dull ache in your lower abdomen (stomach area)
  • A sudden collection of fluid in your scrotum (hydrocele)
  • Fatigue
  • A general feeling of being unwell.

Metastatic cancer

If testicular cancer has spread to other parts of your body, you may also experience a variety of other symptoms. Cancer that has spread to other parts of the body is known as matastatic cancer. Around 5% of people with testicular cancer will experience symptoms of mestastatic cancer.

The most common place for cancer to spread is to the nearby lymph nodes in your abdomen or your lungs, lymph nodes are glands that make up your immune system. Less commonly, the cancer can spread to your liver, brain or bones.

Symptoms of mestastatic cancer can include:

  • A persistent cough
  • Coughing or spitting up blood
  • Shortness of breath
  • Swelling and enlargement of male breasts
  • A lump or swelling in your neck
  • Lower back pain

Cancer

Cancer begins with an alteration of the structure of the DNA that’s found in all humans cells. This is known as a genetic mutation. The DNA provides the cells with a basic set of instructions, such as when to grow and reproduce. The mutations in the DNA changes these instructions so that the cells carry on growing. This causes the cells to reproduce uncontrollably, producing a lump of tissue known as a tumour.

How cancer spreads

Most cancers grow and spread to other parts of the body through the lymphatic system. The lymphatic system is a series of glands (nodes) that are located throughout your body is a similar way to the blood circular system. The lymph glands produce many of the specialised cells that are needed by your immune system (the body’s natural defence against disease and infection). Left untreated, testicular cancer will first spread into nearby blood vessels and lymph nodes. Over time, the cancer can spread throughout the lymphatic system into other parts of the body, such as the lungs, liver, bones and brain.

Risk factor

It is not known what triggers the onset of testicular cancer. However, research has identified a number of factors which may increase your chances of developing the condition.

If you have had surgery to move your testicles down your scrotum, your risk of developing testicular cancer may be increased

Un-descending testicles

When male babies grow in the womb, their testicles develop inside their abdomen. The testicles then normally move down into the scrotum when the baby is born or during their first year of life. However, for some children, the testicles fail to descend into the scrotum. Surgery is usually required to move the testicles down.

You should not father children while you are receiving chemotherapy and for a year after treatment has finished. Chemotherapy medications can temporarily damage your sperm, increase your risk of fathering a baby with serious birth defects. Therefore, you will need to use a reliable methods of contraception, such as a condom, during this time.

Age and race

Unlike most types of cancer, testicular cancer is more common in young and middle-aged  men than in older or elderly men. It more commonly  affects men between 20 and 44 years of age, with 90% of testicular cancer cases affecting men under the age of 55. testicular cancer is more common in white men than other ethnic groups. It is also more common in northern and western Europe compared with other parts of the world.

Family history

Having a close relative with a history of testicular cancer increases your risk of developing it. If your father had testicular cancer, you are four to six times more likely to develop it then a person with no family history . If your brother had testicular cancer, you are eight to ten times more likely to develop it (having an identical twin with testicular cancer means you are 75 times more likely to develop it). The fact that testicular cancer appears to run in families has led researchers to speculate that there may be one or more genetic mutations that make a person more likely to develop testicular cancer. A promising piece of research that was carried out in 2009 identified mutations in two genes (known as the KITLG and SPRY4 Genes) that appear to increase the risk of a person developing testicular cancer.

Testicular dysgenesis syndrome

Over the last 20 years, rates of testicular cancer have doubled, both in England and in other western countries.  Rates of three other conditions that affect the male genitals have also been increasing.

These are:

  • Low sperm count
  • Un-descending testicles
  • Hypospadias, where the urethra (the tube in the penis through which urine passes) is not located in the correct position.

Some researches believe that these conditions, as well as testicular cancer, are interrelated and that rather that being separate conditions they are all different forms of an underlying syndrome, (testicular dysgenesis syndrome) (TDS).

If TDS exists, it may be caused by exposure to chemicals during pregnancy that disrupt the normal balance of hormones. This may Interfere with the normal development of the male genitals, increasing the chances of the cells of the testicles becoming more cancerous. Chemicals that are known to disrupt hormonal balance are called endocrine disruptors.

Endocrine disruptors

Examples of endocrine disruptors include:

  • Some types of pesticide
  • Polychlorinated biphenyis (PCBs), chemical compounds used in coolants
  • Dibutyl phthalate, a chemical used to manufacture cosmetics, such as nail polish.

Infertility

Men who are infertile are three times more likely to develop testicular cancer that fertile men. It is uncertain whether this is due to testicular dysgenesis syndrome or other underlying cause.

Smoking

Research has found that long-term smokers (people who have been smoking a pack of 20 a day for 12 years or 10 cigarettes a day for 24 years) are twice as likely to develop testicular cancer than non-smokers.

Height

A study that was carried out in 2008 found that a man’s height affects his chances of developing testicular cancer. Men who are 190-194cm (6`1—6`3ft) tall are twice as likely to develop testicular cancer than men of average height. Very tall men, 195cm ( 6`4ft) or above are three times more likely to develop cancer. Being shorter, less than 170cm (5`6ft tall), decreases your risk of getting testicular cancer by around 20%.

Diagnosing testicular cancer

Visiting your GP

See your GP if you notice a lump or abnormality on or in your testicles. Most testicular lumps are not cancerous, but it is essential you have the abnormality checked. This is because the treatment for testicular cancer is much more effective when it starts a s soon as possible after the condition is diagnosed.

Physical examination

As well as asking you about your symptoms and consulting your medical history, your GP will usually need to carry out a physical examination of your testicles. Your GP may hold a small light or torch against the lump in your testicles to see whether light passes through it. Cancerous lumps tend to be solid, which means that light is unable to pass through them.

Scrotal ultrasound

A scrotal ultrasound scan is a painless procedure that uses high-frequency sound waves to produce an image of the inside of your testicles. This is one of the main ways that your radiologist (a doctor who specialises in using imaging equipment such as ultrasound scans) will be able to determine whether or not your lump is cancerous. During a scrotal ultrasound, your specialist will be able to determine the position and size of the abnormality in your testicle. It will also give them a clear indication of whether the lump is solid or whether it is filled with fluid. A lump that is filled with fluid is known as a cyst and is usually harmless. A more solid lump may be a sign that the swelling is cancerous.

Blood tests

To help confirm your diagnosis, you may require a series of blood tests. These tests will be used to detect certain hormones in your blood, which are known as ‘markers’. Testicular cancer often produces these markers, so having them in your blood may be a strong indication that you have the condition.

The markers in your blood that will be tested for include:

  • AFP (alpha fete protein)
  • HCG (human chronic gonadotrophin)
  • LDH (lactate dehydrogenate)

Biopsy

The only way to definitively confirm a case of testicular cancer is to have a biopsy of the tumour taken. The cells from the tumour can be examined in a laboratory to determine whether it is cancerous (malignant) or non-cancerous (benign). A biopsy usually involves taking a small sample of cells from the tumour. For most cases of testicular cancer, the only way to be safely take a biopsy is to remove the affected testicle completely. This is because specialists often think that the risk of the cancer spreading is to high for a conventional biopsy to be taken. Your specialist will only recommend removing your testicle if they are relatively certain that your lump is cancerous. Losing a testicle will not affect your sex life of ability to have children. The removal of a testicle is known as an orchidectomy. The main form of treatment for testicular cancer is removing the affected testicle, so if you have testicular cancer it is likely that you will need to have an orchidectomy at some point.

Other tests

If your specialist feels it is necessary, you may require further tests to check whether testicular cancer has spread to any other parts of your body. When cancer of the testicles spreads, it most commonly affects the lungs. Therefore, you may require a chest X-ray to check for any signs of a tumour. You may also require a scan of your entire body, such as a magnetic resonance imaging (MRI) scan or a computerised tomography  (CT) scan to check for signs of the cancer spreading.

Staging

Once the above tests have been completed, it is usually possible to determine the stage of your cancer, as well as any resulting implications, both in terms of your treatment and the possibility of achieving a complete cure.

There are two ways that the staging of testicular cancer can be categorised. The first is known as the TNM staging system:

  • T indicates the size of the tumour
  • N indicates whether the cancer has spread to nearby lymph nodes
  • M indicates whether the cancer has spread to other part of the body (metastasis)

While widely used, the TNM system can sometimes be difficult for someone with little or no medical expertise to understand. Therefore, for the sake of clarity, the rest of this booklet will use the second staging system, where the stages of testiculars cancer are described numerically.

In the numerical system, there are four main stages

  • Stage 1: the cancer is contained inside your testicles
  • Stage 2: the cancer has spread from the testicles into the lymph nodes in your abdomen and pelvis
  • Stage 3: the cancer has spread into the lymph nodes in your upper chest.
  • Stage 4: the cancer has spread into other organs, such as your lungs.

Treating testicular cancer

Your treatment plan

If you have testicular cancer, your recommended treatment plan will depend on two factors:

  • Whether you have seminomas or non-seminomas testicular cancer
  • The stage of your cancer

The first treatment option for all cases of testicular cancer, what ever stage, is to surgically remove the affected testicle (an orchidectomy). In cases of stage 1 seminomas cancer, after the testicle ahs been removed, a short course of radiotherapy may be given to prevent the cancer returning, in stage 1 non-seminomas , chemotherapy may be given.

In stages 2 & 3 , further surgery will be required to remove the affected lymph nodes. Three to four cycles of chemotherapy will be given using a combination of different medications.

A similar treatment plan is used to treat stage 4 cancer . Additional surgery my also be required to remove tumours from other parts of the body, such as the lungs.

Deciding what treatment is best for you can be difficult. Your cancer team will make recommendations, but the final decision will be yours.

Orchidectomy

An orchidectomy is the medical term for the surgical removal of a testicle.  If you have a testicular cancer, it is necessary to remove the whole testicle because only removing the  tumour may lead to the cancer spreading. Bu removing the  entire testicle, your chances of making a full recovery are greatly improved. If you have testicular cancer that is detected in it’s very early stages, an orchidectomy may be the only treatment you require.

The operation is performed under general anaesthetic. A small incision (cut) is made in your groin and the whole testicle is removed through the incision. If you want, you can have an artificial (prosthetic) testicle inserted into your scrotum so that the appearance of your testicles is not greatly affected. The artificial testicle is usually made from silicone (a soft type of plastic).

After an orchidectomy, you will need to stay in hospital for a few days. If you only have one testicle removed , there should not be any lasting side effects. Your sex life and your ability to father children will not be affected.

If you have both testicles removed (a bi-lateral orchidectomy), you will be infertile. However, it is only necessary to remove both testicles in 1 in every 100 cases. You may be able to bank sperm before having a bi-lateral orchidectomy to allow you to father children if you decide to.

Testosterone replacement therapy

Having both testicles removed will also stop you from producing testosterone. This means that you will have a low libido (decreased sex drive) and you will not be able to get or maintain an erection. In this case, you will require testosterone replacement therapy. Testosterone is usually given either as injections or skin patches. If you have injections, you will usually need to have them every two to three weeks. If you have  this treatment you will be able to maintain an erection and your sex drive. Side effects are usually uncommon or very mild.

  • Oily skin, which sometimes triggers the onset of acne
  • Enlargement and swelling of the breasts
  • A change in your normal urinary patterns, such as needing to urinate more frequently or having problems passing urine (caused by an enlarged prostate gland which puts pressure on your bladder)

Lymph node surgery

If your testicular cancer is more advanced, it may spread to your lymph nodes. Your lymph nodes are part of your body’s immune system, which help to protect it against illness and infection.

Lymph node surgery is carried out under general anaesthetic. The lymph nodes in your chest and abdomen are the most  likely nodes that will need to be removed.

In some cases, the nerves that are near to the lymph nodes can become damaged, which means that rather than ejaculating semen out of your penis during sex or masturbation, the semen instead travels back into your bladder. This is known as retrograde ejaculation. If you have retrograde ejaculation, you will still experience the sensation of having an orgasm during ejaculation, but you will not be able to father a child. As with orchidectomy, you may want to bank sperm before your operation, in case you become infertile.

Nerve-sparing retroperitoneal lymph nodes dissection

A new type of lymph node surgery, called nerve sparing retroperitoneal lymph node dissection (RPLND), is increasingly being used because it carries lower risk of causing retrograde ejaculation and infertility.

There may be a long waiting list for nerve-sparing RPLND. However, in many cases, it may be too dangerous to delay surgery and ‘traditional lymph node surgery’ may be required.

Laparoscopic retroperitoneal lymph node dissection

Laparoscopis (LRPLND) is a new type of ‘keyhole’ surgery that can be used to remove the lymph nodes. During LRPLND, the surgeon will make a number of small incisions in your abdomen. A special instrument called an endoscope is inserted into one of the incisions. The endoscope is a long thin tube that has a light source and a video camera at one end, enabling images of the inside of your body to be relayed to an external television monitor. Small surgical instruments can be passed down the endoscope and can be used to remove the affected lymph nodes. The advantage of this procedure is less post-operative pain and a faster recovery time.

Radiotherapy

Radiotherapy is a form of cancer therapy that uses high-energy beams of radiation to help destroy cancer cells. Most seminomas types of testicular cancer require radiotherapy as well as surgery. This is to help prevent the cancer from returning.

The side effects from radiotherapy can include:

  • Reddening and soreness of the skin, which is similar to sunburn
  • Nausea
  • Diarrhoea
  • Fatigue

These side effects are usually temporary and should improve after you have completed your treatment.

Chemotherapy

Chemotherapy is a type of treatment that uses anti-cancer medicines to kill the malignant (cancerous) cells in your body or stop them from

multiplying. If you have advanced testicular cancer or it has spread to other places in your body, you may require chemotherapy. It is also used to help to prevent the cancer returning. Chemotherapy is most commonly used to treat non-seminoma tumours.

Chemotherapy medicines are usually injected or given orally (by mouth). Sometimes, chemotherapy can attack your body’s normal, healthy cells. This is why chemotherapy can have many different side effects. The most common are

  • Vomiting
  • Hair loss
  • Nausea
  • Sore mouth
  • Loss of appetite
  • Breathlessness
  • Infertility (usually temporary)
  • Ringing in your ears
  • Skin that bleeds or bruises easily
  • Increased vulnerability to infection
  • Numbness and tingling (pins and needles) in hands and feet

These side effects are usually temporary and should improve after you have completed your treatment.

You should not father children while you are receiving chemotherapy and for a year after treatment has finished. Chemotherapy medications can temporarily damage your sperm, increase your risk of fathering a baby with serious birth defects. Therefore, you will need to use a reliable methods of contraception, such as a condom, during this time.

Condoms should be also used during the first 48 hours after having a course of chemotherapy. This is to protect your partner from any potential harmful effects of the chemotherapy medication in your sperm.

Follow-up

Even if your cancer has been completely cured, there is a risk that it will later return. Around 25-30% of people will experience a return of cancer, usually within the first two years after their treatment has finished.

Due to this risk, you will require regular tests to check whether the cancer has returned. These tests include:

  • A physical examination
  • Blood tests
  • Chest X-ray
  • Computerised tomography (CT) scan

Testing is usually recommended every three months during the first year after treatment. And after the first year, the tests will be less frequent, decreasing to twice a year, and then annually.

If the cancer does return and is diagnosed at an early stage, it will usually be possible to cure it using radiotherapy and chemotherapy. Some types of recurring testicular cancer have a cure rate of almost 100%

Sperm bank

Some treatments for testicular cancer can cause infertility. For some treatments, such as chemotherapy, infertility is usually temporary.

For other treatments, such as a bi-lateral orchidectomy or a ‘traditional’ lymph node removal, infertility will be permanent.

Before your treatment begins, you may want to consider sperm banking. Sperm banking is where a sample of your sperm is frozen so that it can be used at a later date to impregnate your partner during artificial insemination.

Not all men are suitable for sperm banking. For the technique to work, the sperm has to be of a reasonable high quality. There may also be circumstances where it is considered too dangerous to delay treatment in order for sperm banking to take place.

Some NHS cancer treatment centres offer free sperm banking services. Other centres may not have the facilities available, so you may have to pay a fee to a private company. Prices vary but, on average, it will cost £200-400 to have your sperm extracted and frozen, plus a further £125 a year to store the sperm.