Testicular cancer is cancer that develops in the testicles, a part of the male reproductive system. Symptoms may include a lump in the testicle or swelling or pain in the scrotum. Treatment may result in infertility.
Risk factors include an undescended testis, family history of the disease, and previous history of testicular cancer. More than 95% are germ cell tumors which are divided into seminomas and non-seminomas. Other types include sex-cord stromal tumors and lymphomas. Diagnosis is typically based on a physical exam, ultrasound, and blood tests. Surgical removal of the testicle with examination under a microscope is then done to determine the type.
Testicular cancer is highly treatable and usually curable. Treatment options may include surgery, radiation therapy, chemotherapy, or stem cell transplantation. Even in cases in which cancer has spread widely, chemotherapy offers a cure rate greater than 80%.
Globally, testicular cancer affected about 686,000 people in 2015. That year it resulted in 9,400 deaths up from 7,000 deaths in 1990. Rates are lower in the developing than the developed world. Onset most commonly occurs in males 20 to 34 years old, rarely before 20 years old. The five-year survival rate in the United States is about 95%. Outcomes are better when the disease remains localized.
Signs and symptoms
One of the first signs of testicular cancer is often a lump or swelling in the testicles. The U.S. Preventive Services Task Force (USPSTF) recommends against routine screening for testicular cancer in asymptomatic males, including routine testicular self-exams. However, the American Cancer Society suggests that some men should examine their testicles monthly, especially if they have a family history of cancer, and the American Urological Association recommends monthly testicular self-examinations for all young men.
Symptoms may also include one or more of the following: a lump in one testis which may or may not be painful sharp pain or a dull ache in the lower abdomen or scrotum a feeling often described as "heaviness" in the scrotum firmness of the testicle breast enlargement (gynecomastia) from hormonal effects of β-hCG low back pain (lumbago) due to the cancer spreading to the lymph nodes along the back
It is not very common for testicular cancer to spread to other organs, apart from the lungs. If it has, however, the following symptoms may be present: shortness of breath (dyspnea), cough or coughing up blood (hemoptysis) from metastatic spread to the lungs a lump in the neck due to metastases to the lymph nodes
Testicular cancer, cryptorchidism, hypospadias, and poor semen quality make up the syndrome known as testicular dysgenesis syndrome.
Causes A major risk factor for the development of testis cancer is cryptorchidism (undescended testicles). It is generally believed that the presence of a tumor contributes to cryptorchidism; when cryptorchidism occurs in conjunction with a tumor, then the tumor tends to be large. Other risk factors include inguinal hernias, Klinefelter syndrome, and mumps orchitis. Physical activity is associated with decreased risk and sedentary lifestyle is associated with increased risk. Early onset of male characteristics is associated with increased risk. These may reflect endogenous or environmental hormones.
Higher rates of testicular cancer in Western nations have been linked to the use of cannabis.Testicular Cancer Risk Linked To Marijuana Smoking Medical News Today 2 September 2009.Cannabis linked to testicular cancer . The Independent 2 September 2009.Smoking Marijuana Tied to Testicular Cancer Web MD 9 October 2012. A mounting pattern of studies over time suggesting this possible, but still inconclusive linkage has convinced some doctors and researchers to recommend younger men, especially those with a family history of cystic fibrosis or indirect hernias, to quit or avoid cannabis use as an extra precaution.
Mechanisms Most testicular germ cell tumors have too many chromosomes, and most often they are triploid to tetraploid. An isochromosome 12p (the short arm of chromosome 12 on both sides of the same centromere) is present in about 80% of testicular cancers, and also other cancers usually have extra material from this chromosome arm through other mechanisms of genomic amplification.
Diagnosis
The main way testicular cancer is diagnosed is via a lump or mass inside a testis. More generally, if a young male has a single enlarged testicle, which may or may not be painful, this should give doctors reason to suspect testicular cancer.
Other conditions may also have symptoms similar to testicular cancer:
Epididymitis or epididymo-orchitis Hematocele Varicocele Orchitis Prostate infections or inflammations (prostatitis), bladder infections or inflammations (cystitis), or kidney (renal) infections (nephritis) or inflammations which have spread to and caused swelling in the vessels of the testicles or scrotum Testicular torsion or a hernia Infection, inflammation, retro-peritonitis, or other conditions of the lymph nodes or vessels near the scrotum, testicles, pubis, anorectal area, and groin Benign tumors or lesions of the testicles Metastasis to the testicles from another primary tumor site(s)
The nature of any palpated lump in the scrotum is often evaluated by scrotal ultrasound, which can determine the exact location, size, and some characteristics of the lump, such as cystic vs solid, uniform vs heterogeneous, sharply circumscribed, or poorly defined. The extent of the disease is evaluated by CT scans, which are used to locate metastases.
The differential diagnosis of testicular cancer requires examining the histology of tissue obtained from an inguinal orchiectomy—that is, surgical excision of the entire testis along with attached structures (epididymis and spermatic cord). A biopsy should not be performed, as it raises the risk of spreading cancer cells into the scrotum.
Inguinal orchiectomy is the preferred method because it lowers the risk of cancer cells escaping. This is because the lymphatic system of the scrotum, through which white blood cells (and, potentially, cancer cells) flow in and out, links to the lower extremities, while that of the testicle links to the back of the abdominal cavity (the retroperitoneum). A trans-scrotal biopsy or orchiectomy will potentially leave cancer cells in the scrotum and create two routes for cancer cells to spread, while in an inguinal orchiectomy, only the retroperitoneal route exists.
Blood tests are also used to identify and measure tumor markers (usually proteins present in the bloodstream) that are specific to testicular cancer. Alpha-fetoprotein, human chorionic gonadotropin (the "pregnancy hormone"), and LDH-1 are the typical tumor markers used to spot testicular germ cell tumors.
A pregnancy test may be used to detect high levels of chorionic gonadotropin; however, the first sign of testicular cancer is usually a painless lump. Note that only about 25% of seminomas have elevated chorionic gonadotropin, so a pregnancy test is not very sensitive for making out testicular cancer.
Stressful experiences The stressful event of testicular cancer not only affects the patient who is diagnosed but also affects the caregiver. The psychological stress model consists of stressful experiences that a patient with testicular cancer may go through after diagnosis, that caregivers may want to look out for. The stressful experiences consist of 4 main categories:
Late side-effects Fear of tumor relapse Fertility problems Social and workplace issues
These side effects may need physical and emotional care, which in turn, can cause the caregiver an emotional burden.
Screening The American Academy of Family Physicians recommends against screening males without symptoms for testicular cancer.
Staging After removal, the testicle is fixed with Bouin's solution because it better conserves some morphological details such as nuclear conformation. Then the testicular tumor is staged by a pathologist according to the TNM Classification of Malignant Tumors as published in the AJCC Cancer Staging Manual. Testicular cancer is categorized as being in one of three stages (which have subclassifications). The size of the tumor in the testis is irrelevant to staging. In broad terms, testicular cancer is staged as follows: Stage I: the cancer remains localized to the testis. Stage II: the cancer involves the testis and metastasis to retroperitoneal and/or paraaortic lymph nodes (lymph nodes below the diaphragm). Stage III: the cancer involves the testis and metastasis beyond the retroperitoneal and paraaortic lymph nodes. Stage 3 is further subdivided into non-bulky stage 3 and bulky stage 3.
Further information on the detailed staging system is available on the website of the American Cancer Society.
Classification
Although testicular cancer can be derived from any cell type found in the testicles, more than 95% of testicular cancers are germ cell tumors (GCTs). Most of the remaining 5% are sex cord–gonadal stromal tumours derived from Leydig cells or Sertoli cells. A correct diagnosis is necessary to ensure the most effective and appropriate treatment. To some extent, this can be done via blood tests for tumor markers, but definitive diagnosis requires examination of the histology of a specimen by a pathologist. Testicular tumors are best classified by radical inguinal orchiectomy, which allows for histologic evaluation of the whole testicle and provides local tumor control.
Most pathologists use the World Health Organization classification system for testicular tumors: Germ cells derived from germ cell neoplasia in situ Noninvasive germ cell neoplasia Germ cell neoplasia in situ Specific forms of intratubular germ cell neoplasia Gonadoblastoma Germinoma family of tumors Seminoma Nonseminomatous germ cell tumors Embryonal carcinoma Yolk sac tumor, postpubertal type Choriocarcinoma Placental site trophoblastic tumour Epithelioid trophoblastic tumour Teratoma, postpubertal type Teratoma with somatic-type malignancy Mixed germ cell tumors of the testis Mixed germ cell tumors Polyembryoma Diffuse embryoma Germ cell tumors of unknown type Regressed germ cell tumors Germ cell tumors unrelated to germ cell neoplasia in situ Spermatocytic tumor Teratoma, prepubertal type Dermoid cyst Epidermoid cyst Yolk sac tumor, prepubertal type Testicular neuroendocrine tumor, prepubertal type Mixed teratoma and yolk sac tumor, prepubertal type Sex cord-stromal tumors of the testis Leydig cell tumor Leydig cell tumor Sertoli cell tumor Sertoli cell tumor Large cell calcifying Sertoli cell tumor Granulosa cell tumor Adult granulosa cell tumor Juvenile granulosa cell tumor The fibroma thecoma family of tumors Thecoma Fibroma Mixed and other sex cord-stromal tumors Mixed sex cord-stromal tumor Signet ring stromal tumor Myoid gonadal stromal tumor Sex cord-stromal tumor not otherwise specified Secondary tumors of the testis
Treatment The three basic types of treatment are surgery, radiation therapy, and chemotherapy.
Surgery is performed by urologists; radiation therapy is administered by radiation oncologists; and chemotherapy is the work of medical oncologists. In most patients with testicular cancer, the disease is cured readily with minimal long-term morbidity. While treatment success depends on the stage, the average survival rate after five years is around 95%, and stage 1 cancer cases, if monitored properly, have essentially a 100% survival rate.
Testicle removal