Testicular Cancer

Overview
Are there different types of testicular cancer?
What are some of the symptoms of testicular cancer?
What are my treatment options if I am diagnosed?
What is the prognosis for testicular cancer?

Overview
Testicular cancer develops in the testicles (testes), the male reproductive glands. The testicles are located in the membranous pouch below the penis (scrotum) and are suspended from the body by the spermatic cord. They produce male reproductive cells (sperm) and testosterone. Testicular cancer is treated successfully in more than 95% of cases.

Incidence of testicular cancer is rising. According to the American Cancer Society, approximately 7600 cases are diagnosed and about 400 men die of the disease each year in the United States. The disease is most prevalent in men between the ages of 18 and 32 and is approximately 5 times more common in Caucasians than African Americans.

Are there different types of testicular cancer?
Most (95%) testicular cancer originates in undeveloped cells (germ cells) that produce sperm. These tumors, called germ cell tumors (GCTs), are most common in men between the ages of 20 and 40 and are curable in more than 95% of cases. There are two main types: seminomas and nonseminomas. A third type, called stromal tumors, develops in the supporting tissues of the testicle.

Approximately 40% of GCTs are seminomas, which are classified as either typical or spermatocytic. Typical seminomas account for 90% of this type. They often cause unilateral (i.e., on one side) testicle enlargement or more often a painless lump in the testicle. Spermatocytic seminomas grow slowly, usually do not spread to other parts of the body (metastasize), and are most common around age 65.

Nonseminomas account for 60% of GCTs and develop in younger men (usually between 15 and 35). Most nonseminomas contain cells from at least two subtypes, including the following:

  • Choriocarcinoma (rare; aggressive; likely to metastasize)
  • Embryonal carcinoma (accounts for 20% of cases; likely to metastasize)
  • Teratoma (usually benign in children; rarely metastasize)
  • Yolk sac carcinoma (most common in young boys; rare in men)

Testicular cancer may also develop in the supportive, hormone-producing tissue of the testicles (stroma). This type accounts for 4% of testicular cancer in men and 20% in boys. Types of stromal tumors include Leydig cell tumors and Sertoli cell tumors.

Seventy-five percent of Leydig cell tumors develop in men and 25% develop in boys. Most tumors of this type are benign and are treated successfully with surgery. If the tumor metastasizes, it often does not respond well to radiation or chemotherapy and the prognosis is poor.

Sertoli cell tumors develop in Sertoli cells that nourish the sperm-producing germ cells. These tumors are usually benign; metastatic tumors of this type are rare, yet resistant to treatment.

Secondary tumors in the testicles usually migrate from the lymph or lymph nodes. Testicular lymphoma is more common than primary testicular cancer in men over 50. Other cancers (e.g., prostate, lung, skin) may also spread to the testicles.

What are some of the symptoms of testicular cancer?

Testicular cancer does not always produce symptoms. A mass or lump in the testicle is usually the first sign of the disease. The mass may or may not be painful. Other symptoms include testicular swelling, hardness, and a feeling of heaviness or aching in the scrotum or lower abdomen.

Some types of testicular cancer (e.g., choriocarcinoma, Leydig cell tumors, Sertoli cell tumors) produce high levels of hormones (e.g., human chorionic gonadotropin [HCG], estrogen, testosterone). Increased levels of HCG may cause breast tenderness and abnormal growth of breast tissue (gynecomastia). Increased levels of estrogen may cause a loss of sexual desire (libido) and increased levels of testosterone may cause premature growth of facial and body hair in boys.

Testicular cancer that has spread to other organs (metastasized) may cause low back pain, shortness of breath, chest pain, and cough.

What are my treatment options if I am diagnosed?
Treatment for testicular cancer depends on the stage of the disease. Surgery to remove the testicle is sometimes combined with radiation and/or chemotherapy. Some patients choose to store frozen sperm in a sperm bank before treatment to ensure fertility.

Surgery
Radical inguinal orchiectomy is the surgical removal of the testicle and the spermatic cord through an incision in the groin. Surgery is performed under general or regional anesthesia and takes approximately 1 hour. Most patients remain in the hospital overnight.

If CT scan indicates that testicular cancer has metastasized to the lymph nodes, retroperitoneal lymph node dissection is often performed. All of the lymph nodes connected to the affected testicle are removed in this procedure. Such dissection is usually done at a later date.

Retroperitoneal lymph node dissection is performed under general anesthesia, requires a large incision, and usually takes 4 to 6 hours.

Complications associated with surgery include the following:

  • Adverse reaction to anesthesia
  • Bowel obstruction and inactivity
  • Damage to surrounding organs, blood vessels, and nerves
  • Infection
  • Infertility (caused by nerve damage that results in retrograde ejaculation)
  • Lymph-filled cyst (lymphocele)

Following surgery, patients are usually encouraged to get up as soon as possible. Pain at the incision site and numbness in the area surrounding the incision are common, and pain relievers are often prescribed. Driving and heavy lifting should be avoided for a several weeks.

Men who have had an orchiectomy may choose to have a testicular prosthesis surgically implanted into the scrotum. The prosthesis is filled with saline and is made to look and feel natural.

Radiation
Radiation uses high energy x-rays to destroy cancer cells. In testicular seminoma, external beam radiation (from a machine outside of the body) is primarily used after orchiectomy (called adjuvant therapy) to destroy cancer cells that have spread (metastasized) to lymph nodes. Testicular seminoma typically requires a lower dose of radiation than other types of cancer. During treatment, a shield is placed over the remaining testicle to preserve fertility.

Side effects of radiation include the following:

  • Diarrhea
  • Fatigue
  • Nausea
  • Skin irritation that resembles sunburn

Chemotherapy
Chemotherapy is a systemic (i.e., circulates throughout the body via the bloodstream) cancer treatment that uses toxic drugs to destroy cancer cells. In testicular cancer cases, it is used to destroy cancer cells that remain after surgery. Chemotherapy may be administered intravenously (IV), taken in pill form, or injected into muscle.

Drugs used alone or in combination to treat testicular cancer include the following:

  • Cisplatin (Platinol®)
  • Vinblastine (Velban®)
  • Bleomycin (Blenoxane®)
  • Cyclophosphamide (Cytoxan®)
  • Etoposide (Etopophos®)
  • Ifosfamide (Ifex®)

Side effects of chemotherapy are often severe and include gastrointestinal disturbances, low blood count, skin disorders, and neurological disorders.

What is the prognosis for testicular cancer?
Prognosis for testicular cancer depends on the stage of the disease at diagnosis. More than 95% of cases are treated successfully.

Anatomy of the Testicle
The testicles are primarily made up of a mass of seminiferous tubules in which sperm develop. The tubules are lined with Sertoli cells, which protect and supply nutrients to developing sperm. Sertoli cells also secrete the hormone inhibin, which is involved in the regulation of sperm production.

Leydig cells, located in tissue between the seminiferous tubules, secrete testosterone and androsterone. These hormones stimulate the development of male sex organs, beard growth, muscle mass, and deepening of the voice.