Testicular Cancer

 

Testicular cancer happens when cells in the testicle grow to form a tumor. This is rare. More than 90 percent of testicular cancers begin in the germ cells, which produce sperm. There are two types of germ cell cancers (GCTs). Seminoma can grow slowly and respond very well to radiation and chemotherapy. Non-seminoma can grow more quickly and can be less responsive to those treatments. There are a few types of non-seminomas: choriocarcinoma, embryonal carcinoma, teratoma and yolk sac tumors.

 

There are also rare testicular cancers that don’t form in the germ cells. Leydig cell tumors form from the Leydig cells that produce testosterone. Sertoli cell tumors arise from the Sertoli cells that support normal sperm growth. Testicular tumors can be made of more than one type of cell.

 

The type of testicular cancer cell found, symptoms and other factors will help guide your treatment.

 

 

Male Anatomy

 

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Symptoms

 

The symptoms of testicular cancer may be hard to notice, especially at first. Symptoms of a testicular tumor include:

 

• A painless lump in the testicle, which is the most common sign
• Swelling of the testicle, with or without pain
• A feeling of weight in the testicles
• A dull ache or pain in the testicle, scrotum or groin
• Tenderness or changes in the male breast tissue

 

If you find any lump or firm part of the testicle, you should see a doctor to find out if it is a tumor. It should be tested as soon as possible. About 75 out of 100 men with swelling or a lump in the testicle have cancer. Most masses in the scrotum outside of the testicle, are not cancer. No matter what, if you find a lump, tell Dr. Tubre.

 

On average, most men don’t tell anyone about signs or symptoms like these. They instead wait for five or more months before saying anything.

 

If you wait, the cancer can spread. It’s of great value to talk with Dr. Tubre or urologist if you find a lump that lasts longer than two weeks. The urologist will want to test if cancer is growing or if there’s some other issue, like:

 

• Epididymitis: swelling of the epididymis. Often treated with antibiotics.
  
  
• Testicular torsion: twisting of the testicles. Often treated with surgery.
  
  
• Inguinal hernia: when part of the intestine pokes through a weak part of the stomach muscles near the groin. Often treated with surgery.
  
  
• Hydrocele: when fluid builds up in the scrotum. This is not dangerous but can be treated with surgery if bothersome.

 

 

Causes

 

It is not always known why cells grow to form a tumor. Also, you may not be able to avoid the risk factors of testicular cancer. The best plan is to catch this problem early.

 

Who Gets Testicular Cancer?

 

The risk for getting testicular cancer rises for men with:

 

• Family history: If your father or brother had testicular cancer.
  
  
• Undescended testicles: If your testicles did not drop before birth. This can also be called cryptorchidism and is when a testicle did not drop from the abdomen into the scrotum before birth, as it should. A tumor is more likely to grow after this issue. Surgery can fix the testis, but cancer can still develop. About 8 out of 100 of these patients get cancer.
  
  
• GCNIS: These are odd cells in the testicle called germ cell neoplasia in situ (GCNIS) and they are typically found during an infertility test. Microlithiasis, or small calcifications in the testicle, is not a risk factor for testicular cancer (unless you have one of the risk factors above).

 

 

Diagnosis

 

Understanding how testicular cancer could affect you starts with a conversation. Dr. Tubre will ask you questions about your general health and talk about your concerns. Many men are able to identify a problem with their testicles by doing a self-exam. Testicular cancer is one of the most treatable cancers. When caught early, the cure rate is close to 100 percent. This is true for men with early stage testicular cancer, where it has not spread past the testicle. For men with stage II or III testicular cancer, the cure rate is still higher than other cancers. If you notice a lump, or feel discomfort, swelling, pain or other changes in your testicles or scrotum, see a doctor. Ideally, you can meet with a urologist.

 

Testicular Self-Exam

 

The best time to do a monthly testicular self-exam is after a warm bath or shower, while standing, when the scrotum is relaxed. It only takes a few minutes. To start:

 

1. Check each testicle. Gently but firmly roll each testicle between the thumb and forefingers. Feel the whole surface. The firmness of the testis should be the same all around. It’s normal for one testis to be slightly larger than the other.
   
   
2. Find the epididymis and vas deferens. These are soft tube-like structures above and behind the testicle. These tubes collect and carry sperm. Just become familiar with how these cords feel.
   
   
3. Look for lumps, swelling or things that don’t seem right. Lumps or bumps are not normal (even if they cause no pain). Pain is not normal.
   
   
4. Check yourself at least once per month. Always look for changes in size, shape or texture. If you notice a lump or any changes over time, you should seek medical help. It may be nothing, but if it is testicular cancer, it can spread very quickly. When found early, testicular cancer is curable. If you have any questions or concerns, talk to your urologist.

 

 

Medical Exams

 

Dr. Tubre will talk with you about your symptoms, your overall health and will do a medical exam. If the doctor suspects something is not normal, they will run more tests.

 

Health Record and Physical Exam

 

Your urologist will talk with you about your health. They’ll examine your scrotum, belly, lymph nodes and other parts to look for signs of cancer. They’ll look for lumps, firmness or signs of swelling. Tell them if you have a history of undescended testicles.

 

Testicular Ultrasound

 

This imaging test is used to see inside the scrotum and check a suspicious lump. Other scans or x-rays may be done if Dr. Tubre would like to see inside your chest or abdomen. This is done to see if cancer has spread to lymph nodes, the lungs or liver. MRIs are rarely used, but in some cases are needed to check the brain and spinal cord.

 

Blood Test

 

A blood test is taken to check tumor markers. These are proteins and hormones made by some testicular cancers. AFP, ACG and LDH tumor markers rise with some cancers but many testicular cancers will not produce tumor markers. In other words, just because tumor markers are normal does not mean you are free of cancer. It’s of great value to ask Dr. Tubre about your tumor marker levels and learn what’s normal vs. not normal.

 

Serum Tumor Marker Test

 

Tumor markers (AFP, HCG, and LDH) should be measured before any treatment, such as surgery. If cancer is found, tumor marker tests will be repeated after treatment to track how well you’re doing over time. Some medicines and marijuana can create false positive levels of HCG. Tell Dr. Tubre about your medicine and/or marijuana use. It is also worth noting that:

 

• Pure seminomas can raise HCG levels but never AFP levels
• Non-seminomas often raise AFP and/or HCG levels
• Over the counter urinary pregnancy tests do check for HCG levels in the urine but are not reliable tests for testicular cancer

 

 

Stages

 

If your urologist finds cancer through these exams, they will want to learn the exact cancer cell-type and if it has spread. This is called staging. This process helps the doctor learn which treatments are best.

 

Testicular cancer is not found with a standard biopsy (tissue sample). With this cancer, cells are examined after the cancerous tissue is removed in surgery.

 

Testicular Cancer is grouped into the following stages:

 

Stage 0: This is also called “Germ Cell Neoplasia In Situ (GCNIS)”. This is not yet cancer, but a warning that cancer could grow. GCNIS may be found in the seminal tubules and nowhere else.

 

Stage I (IA, IB, IS): Cancer is found only in the testicle. It has not spread to nearby lymph nodes or anywhere else in the body.

 

Stage II (IIA, IIB, IIC): Cancer has spread to one or more lymph nodes in the belly (often the first site of testicular cancer spread). It has not spread to other parts of the body.

 

Stage III (IIIA, IIIB, IIIC): Cancer has spread beyond the lymph nodes in the belly. Cancer may be found far away from the testicles, such as distant lymph nodes or the lungs. Tumor marker levels are high.

 

 

Treatment

 

Often, a team of doctors, such as a urologist, oncologist or a radiation oncologist, will work together to find the best plan to treat each patient. Choices will be based on the exact diagnosis and health of the patient. Before treatment, men should talk with their urologist about whether or not they want to have children. Not being able to have children and changes in male hormones are common after certain treatments. Sperm banking may be useful before treatment, especially if you hope to have children in the future. Men can also ask about a testicular prosthesis before surgery. This is a way to make the scrotum look more “normal” after a testis is removed.

 

Surveillance

 

Surveillance is a way to look for changes with normal checkups. These include a physical exam, tumor marker tests and imaging tests. Imaging tests start with an ultrasound of the scrotum. They can also involve chest x-rays or CT scans. Most men may be checked for signs of low testosterone as well.

 

Surveillance is recommended for patients with Stage 0 and some Stage I cancers as described below.

 

Stage I seminoma. Surveillance is one option for stage I seminoma after surgery. It should involve a physical exam and imaging and may include tumor markers. It is generally every six months for the first two years and then every six to 12 months in years three through five. Surveillance may be less frequent for stage I cancers treated with adjuvant chemotherapy or radiation.

 

Stage I non-seminoma germ cell tumors (NSGCT). Surveillance is one option for stage I NSGCT after surgery. It should include a physical exam, imaging and tumor marker test. The timing may be every two months during the first year; every three months in year two; every four to six months in year three and every six to 12 months in years four through five. This timing may be more frequent for patients with additional risk factors.

 

Standard surveillance by cell-type. This surveillance can be broken down into two categories:

 

Seminoma – Active surveillance is often used after initial orchiectomy for low stage seminomas. In later stages, this cancer is often treated successfully with surgery, radiation and chemotherapy.

Non-seminomas – Treatment for this type of cancer may involve surveillance after initial orchiectomy for low stages. Later stages may be treated with chemotherapy or surgery. The treatment used depends on the exact diagnosis and whether the disease has spread.

If the cancer shows signs of growth, or if hormone levels change, then more treatment may be offered.

 

Surgery

 

Surgery is the main treatment for testicular cancer. Based on the diagnosis, other choices may be offered. Changes in fertility should be discussed before surgery.

 

Orchiectomy

 

Orchiectomy is used to diagnose and treat early-stage or later-stage cancer. This surgery removes the entire testicle and mass through a small cut in the groin. The spermatic cord is also removed. A pathologist will stage the cell type after surgery. Routine surveillance is done after surgery to make sure the cancer doesn’t return. If one testicle is removed and the other is normal, testosterone levels should be fine. The remaining testicle should make enough testosterone. Also, if a man is worried about the way he looks, a testicular prosthesis (fake testicle) is an option.

 

Testis Sparing Surgery

 

Testis-sparing surgery (TSS) is sometimes recommended for some men. This surgery removes just the tumor tissue, not the entire testis. For TSS, the mass must be very small and tumor markers must be negative. TSS is best for men who have benign tumors rather than cancer. If the tumor is cancerous and the patient has a normal testicle on the other side, TSS is not recommended. Surveillance after surgery is important to check for cancer.

 

Retroperitoneal Lymph Node Dissection

 

Retroperitoneal lymph node dissection (RPLND) is a complex surgery, helpful for some men. It needs a skilled surgeon to remove lymph nodes in the back of the abdomen to ensure limited side effects. This surgery is an option for patients with a more forceful Stage I cancer. It is typically used for men with non-seminomatous germ cell tumors that may return. It can be used rather than chemotherapy for stage IIA or IIB non-seminoma tumors. After RPLND surgery, either chemotherapy or surveillance is offered based on the cancer location, type and the risk that it can return.

 

Radiation

 

Radiation is used to kill cancer cells in the testis or in nearby lymph nodes. It is only used in seminoma because some forms of non-seminoma are resistant to radiotherapy. It may be an option if testicular cancer (either type) has spread to far organs like the brain. There are a few radiation therapy types used.

 

Chemotherapy

 

Chemotherapy is used for cancers that spread beyond the testicles, or if tumor markers rise after surgery. Serum tumor markers and imaging tests help guide how much chemotherapy to use, and if it can help. These drugs travel around the body through the bloodstream and may cause side effects. They can wipe out cancer cells that may have traveled to lymph nodes. Chemotherapy is also used to help lower the risk of cancer coming back after surgery. One, two or three chemotherapies may be combined for testicular cancer treatment. These drugs are given in three or four three-week cycles. Sometimes more surgery will be done to remove tumors after chemotherapy is complete.

 

Further Treatment

 

Beyond basic surgery, care depends on the type of cell and follow-up tests. Even if cancer was found early and treated, follow-up tests are recommended. If, after time, cancer returns, then more treatment will be needed.

 

 

Treatment for Children

 

Testicular tumors in children are rare. If they are found early, treatment is often successful. If a tumor is found after it has spread, it’s harder to treat. As with men, this cancer often begins as a painless lump.

 

Get Children Diagnosed

 

The most common type in boys are yolk sac tumors and teratomas. The cancer cell-types found in children are:

 

• Yolk Sac Tumors. These are often treated successfully and are rare in adults.
  
  
• Teratomas. These germ cells grow in hard-to-predict ways and do not respond to chemotherapy. They can be treated with surgery.
  
  
• Gonadal Stromal Tumors. These are more likely to spread and require a chest x-ray if found.
  
  
• Gonadoblastoma and Dysgerminoma. These are rare and they happen in children with testicles that did not grow normally before birth.
  
  
• Gonadoblastomas. These cells are benign and they can become cancer in 50 percent of cases.

 

Treatment for Children

 

The most common treatments for children with testicular tumors are:

 

• Inguinal Exploration. For this surgery, a cut on the skin crease just above the pubic bone is made and the testicle is guided out of the scrotum. Dr. Tubre then looks at the gland to decide next steps. This is recommended for any child with a testicular tumor. It is most often an outpatient service.
  
  
• Testis Sparing Surgery (TSS). This is a choice when Dr. Tubre thinks the tumor is benign. A surgeon decides on TSS based on how the tumor looks and on normal tumor markers. In this case, just the tumor tissue is removed (biopsy) and sent to a pathologist for testing.
  
  
• Total Orchiectomy. Surgery to remove the testis is needed if biopsy results show cancer. This may be recommended in patients with large tumors, high tumor markers or those whose tumors are found after puberty.
  
  
• Further treatment is offered if the cancer is more aggressive. These options include a RPLND, radiation or chemotherapy.

 

Children after Treatment

 

After treatment, children are checked for at least two years to make sure all is well. Physical exams, tumor marker tests and chest x-rays are common follow-up tests. Most often boys do not look different if a testicle is removed. The scrotum is not cut and the other testicle keeps growing. If a boy does not like the result, a prosthesis is an option. This is most often done after puberty. Most boys who’ve been treated for testicular cancer will be healthy and can have children when they grow up.

 

 

After Treatment

 

Risk for Return

 

The risk of testicular cancer coming back depends on the stage at diagnosis, but it’s very small, at 5 percent or less. There is also a very small (about 2 percent) risk of cancer growing in the other testicle. Still, it is of great value to learn how to do a testicular self-exam. Also, regular followup visits with your urologist will be important. How often, and for how long follow-up care is needed is based on your diagnosis. If cancer returns, the doctor will want to find it and treat it quickly. Additional treatment depends on the cancer type and location. RPLND surgery, radiation and chemotherapy are options.

 

Sex Life and Fertility

 

The removal of one testicle should not change your sexual energy or fertility (chances of having a child). Most men can have a normal erection after surgery. Still, men diagnosed with testicular cancer have a higher risk of infertility and low testosterone. You may also have a decrease in sperm growth after chemotherapy or radiation that will usually recover. If lymph nodes were removed, it may be harder to ejaculate. If you have problems, there are treatments that can help with ejaculation. If you are worried, talk with Dr. Tubre.

 

As you heal, your body will find balance. Over time, the healthy testicle will usually make enough testosterone to help you return to normal. Dr. Tubre may check hormone levels on an annual basis as part of your check-up.

 

Treatment Risk

 

Patients who’ve had radiation and/or chemotherapy should pay attention to their heart health. Their risk for cardiovascular disease rises after treatment. Simple lifestyle changes can prevent problems. For example, strive to exercise regularly, eat less processed food and stop smoking/ vaping. Be sure to ask for regular check-ups to test your blood pressure, lipid and glucose levels.

 

Patients who’ve had radiation and/or chemotherapy may be at higher risk of developing different cancer in the future. You should make sure you follow with a primary care physician to ensure you get appropriate screening.

 

Testosterone levels in men treated for testicular cancer can also be lower. Patients should be watched for signs and symptoms of lower testosterone and can be checked with a blood test if symptoms develop.