Testicular cancer occurs when cancerous cells develop in one or both testicles, which are the male reproductive glands located in the scrotum, a loose skin sac that hangs directly beneath the penis.
Testicular cancer is the most common cancer in young men and has become one of the most curable cancer types. More than 95% of men diagnosed with testicular cancer are successfully treated.
Types of Testicular Cancer
Types of Testicular Cancer Approximately 95% of testicular cancers develop from a type of cell called germ cells, so they are referred to as testicular germ cell tumors.
1. Seminoma and Non-Seminomatous Germ Cell Tumors
• There are two main types of testicular germ cell tumors: seminomas and non-seminomatous germ cell tumors (NSGCTs). Approximately one-third of all testicular germ cell tumors are seminomas, with the rest being NSGCTs. Both seminomas and NSGCTs typically affect men between the ages of 15 and 35, although seminomas tend to occur in a slightly older age group.
2. Other Types of Testicular Cancer
• In about 5% of cases, cancer can originate from testicular tissues other than germ cells. This category includes testicular "sex cord-stromal tumors," such as Leydig cell tumors, Sertoli cell tumors, and granulosa cell tumors.
Symptoms of Testicular Cancer /h3>
For most men, the initial symptom of testicular cancer is a painless lump or swelling in the scrotum. Some men may also experience a dull ache or a heavy sensation in the lower abdomen, anus, or around the scrotum. Pain is an initial symptom in about 10% of men.
Diagnosis of Testicular
Men who detect a lump in their testicles should seek medical attention as soon as possible if testicular cancer is suspected. Several tests may be ordered to confirm the diagnosis, but the only definitive way to diagnose testicular cancer is by removing the testis.
Diagnostic tests for testicular cancer may include:
• Testicular ultrasound: This imaging test uses sound waves to measure the size and characteristics of the testis and any mass (lump). It can determine if the mass is inside or outside the testis and whether it contains fluid or is solid. Ultrasonography is strongly recommended in most cases of suspected testicular cancer.
• Orchiectomy: The surgical removal of the testis is necessary to confirm the diagnosis of testicular cancer. This procedure is known as radical inguinal orchiectomy.
Staging and Classification of Testicular Cancer
Staging is used to determine whether cancer has spread beyond the testis (metastasized).
• Stage I testicular cancer is defined as cancer that is limited to the testis.
• Stage II testicular cancer has spread to retroperitoneal lymph nodes (nodes located in the abdomen).
• Stage III testicular cancer has spread to other organs.
Staging involves blood tests and imaging (e.g., computed tomography [CT] scans). Blood tests measure substances produced by testicular cancer, known as tumor markers, including alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (beta-hCG), and lactate dehydrogenase (LDH).
High levels of these tumor markers in the blood suggest testicular cancer and can help determine the specific type of testicular cancer. These tumor markers are also used to monitor a patient's response to treatment during and after therapy.
Computed tomography (CT) scans are commonly performed on men with suspected testicular cancer. Chest X-rays or CT scans are also often done. These tests are used to determine if the cancer has spread beyond the testis, with the most common site of metastasis being the lymph nodes in the abdomen. Metastasis to the lungs, liver, bones, and brain is also possible.
Prognostic Classification: Men with Stage II or Stage III testicular cancer (both seminomas and NSGCTs) can be classified as having good, intermediate, or poor prognosis (chance of survival and cure). Stage I testicular cancer patients have an excellent prognosis and are not included in this classification system.
After radical inguinal orchiectomy, testicular cancer is treated based on tumor type (seminoma or NSGCT), cancer stage, and prognosis. Seminoma patients are classified as having either a good or intermediate prognosis. NSGCT patients can have good, intermediate, or poor prognoses, depending on the stage of their disease:
• Good prognosis: Seminoma patients with no metastasis beyond the lungs and normal AFP levels have a good prognosis. NSGCT patients with tumors originating in the testis or behind the abdominal wall (retroperitoneal) and no metastasis to organs outside the lungs and only mildly elevated tumor markers also have a good prognosis
• Intermediate prognosis: Seminoma patients with metastasis beyond the lungs and normal AFP levels or slightly elevated AFP levels have an intermediate prognosis. NSGCT patients with tumors originating in the testis or behind the abdominal wall (retroperitoneal) and no metastasis to organs outside the lungs but with higher elevations in tumor markers have an intermediate prognosis.
• Poor prognosis: NSGCT patients with tumors located in the middle of the chest between the lungs (mediastinum), metastasis to organs outside the lungs, or the presence of multiple tumor markers markedly elevated beyond normal levels have a poor prognosis. In these cases, aggressive treatment can still result in cure in about half of the patients.
Treatment of Testicular Cancer
The treatment of both seminomas and NSGCTs generally includes the surgical removal of the affected testis, a procedure known as radical inguinal orchiectomy. This surgery is required for diagnosis and is the initial step in treatment.
The need for further treatment depends on the cancer type, stage, and prognosis. Chemotherapy and radiation therapy (RT) are often used in conjunction with surgery and can increase the chances of curing cancer.
1. Radical Inguinal Orchiectomy: The removal of the entire testis is typically required for diagnosis, and it serves as the first step in treatment. During the surgery, the entire testis is usually removed to minimize the risk of the tumor spreading to the scrotum. Testicular tissue is then examined under a microscope.
2. Chemotherapy: Chemotherapy is the use of drugs to stop or slow down the growth of cancer cells. Chemotherapy targets rapidly dividing cells by interfering with their ability to divide and multiply. Since most of an adult's normal cells are not actively dividing, they are less affected by chemotherapy. However, cells in the bone marrow (where blood cells are produced), hair follicles, and the digestive tract continue to grow. This is why chemotherapy can cause side effects such as hair loss, nausea, anemia (a decrease in red blood cells), an increased risk of infection (a decrease in white blood cells), and bleeding (a decrease in platelets).
Chemotherapy
Most chemotherapy drugs are administered intravenously (IV), not orally. They are typically given in cycles, not daily, and a chemotherapy cycle refers to the time between doses of drugs and the time required for the body to recover.
For testicular cancer, chemotherapy may be given to some men with early-stage disease. Men with more advanced cancer or those who have experienced recurrence after RT often undergo multiple cycles of combination chemotherapy.
Adjuvant Chemotherapy: The term "adjuvant chemotherapy" refers to additional anti-cancer treatment given after surgery to eliminate any remaining tumor cells in the body, often referred to as micrometastases. Adjuvant chemotherapy reduces the chances of cancer coming back (or recurring) and also increases the likelihood of recovering from cancer. As a result, adjuvant chemotherapy has become a significant component of cancer treatment.
Lymph Node Dissection: The most common site of spread for testicular cancer is the retroperitoneal lymph nodes, located behind the abdomen. Surgical removal of these nodes, known as retroperitoneal lymph node dissection (RPLND), is sometimes recommended.
Periodic physical examinations and computerized tomography (CT) scans (referred to as active surveillance or careful waiting) offer alternatives to RPLND, along with short courses of chemotherapy or low-dose radiation therapy (RT) in the case of seminoma.
Men with stage II or III testicular cancer may not undergo RPLND at all or may only be recommended for RPLND if cancer persists after chemotherapy.
RPLND requires specialized knowledge and training. Men in need of this procedure should seek care at a facility where the surgeon is experienced in RPLND. The risks of the procedure depend on the extent of the surgery required to remove lymph nodes and whether chemotherapy has been administered.
Radiation Therapy: RT involves exposing a tumor to high-energy X-rays to slow down or stop its growth. Exposure to X-rays damages cells. Unlike normal cells, cancer cells cannot repair the damage caused by radiation, especially when radiation is delivered over several days. This prevents cancer cells from further growth and eventually leads to their death.
For testicular cancer, RT is delivered as external beam RT, where radiation beams are generated by a machine while the patient lies on a table underneath or in front of the machine. High-energy beams are directed at the pelvic lymph nodes rather than the scrotum.
Exposure to radiation typically lasts only a few seconds (similar to taking an X-ray). Generally, treatment is repeated for about five to six weeks, five days a week.
To reduce the risk of recurrence, RT is often recommended after orchiectomy (removal of the testicle) in seminoma cases. RT can also be used after orchiectomy in stage II seminoma cases described as "bulky" (meaning the tumor is larger than 5 cm).
Testicular Cancer Treatment Recommendations
Seminoma:Seminomas generally grow slowly and do not rapidly spread to other parts of the body. For all men with early-stage seminomas, surgical treatment (radical inguinal orchiectomy) is recommended. After surgery, three treatment options are possible, all of which have excellent cure rates (around 98%). Treatment options include surveillance (careful waiting), RT, and chemotherapy.
RPLND is used in some cases after chemotherapy but is generally not applied initially. For stage I seminoma patients who are not candidates for active surveillance, sometimes a single dose of RT or a chemotherapy called carboplatin is used.
Not all treatments are suitable for every patient; doctors will work with you to determine the most appropriate option based on your condition.
Non-Seminomatous Germ Cell Tumors (NSGCTs): Surgical treatment (radical inguinal orchiectomy) is recommended for all men with NSGCTs. NSGCTs are less sensitive to RT than seminomas. NSGCTs have a higher likelihood of spreading to other parts of the body, such as the liver, lungs, and brain.
Generally, treatment for NSGCTs involves chemotherapy with drugs like cisplatin and additional chemotherapy agents. For patients with more advanced disease, multiple cycles of treatment with multiple agents are often considered. The regimen and number of cycles may vary depending on the extent of the disease and patient characteristics.
Men with residual masses after chemotherapy may require surgery to remove them. Patients requiring this type of surgical treatment are best served by seeking care at a cancer center that treats a high volume of patients.
Please note that treatment options may vary based on individual patient circumstances, and it's essential to consult with a healthcare professional for a comprehensive evaluation and guidance regarding any testicular cancer diagnosis or treatment plan.
