Testicular Cancer

Testicular cancer can develop in one or both of the testicles. It is the most common cancer in young men. Fortunately, testicular cancer is one of the most curable cancers and more than 95% of patients survive their disease.

Types & Stages

The most common type of testis cancer is a germ cell tumor (GCT). There are two main types of GCT: seminoma and nonseminomatous germ cell tumors (NSGCT). Both seminoma and NSGCT occur at about the same rate, and men can have seminoma, NSGCT or a combination of both. There are also rare stromal tumors. 

• Seminomas tend to grow and spread more slowly than NSGCT, although some seminomas can grow very rapidly. Subtypes of seminoma include classic seminoma, which account for 95 percent of seminomas, and spermatocytic seminoma, which tend to occur in older men and have an excellent prognosis. Seminomas can secrete human chorionic gonadotropin (HCG) but don’t secrete other tumor markers.
   
• Nonseminomatous germ cell tumors (NSGCT) are very variable in appearance and prognosis. There are four main types of NSGCT that can appear alone, but most often appear as a “mixed” NSGCT, with more than one type present:
   
  • Embryonal carcinoma, which are present in about 40% of tumors and among the most rapidly growing and potentially aggressive tumor types. Embryonal carcinoma can secrete HCG or alpha fetoprotein (AFP).
     
  • Yolk sac carcinoma is the most common type of tumor in children and responds well to chemotherapy in children and adults. They almost always secrete AFP.
     
  • Choriocarcinoma is a very rare and very aggressive form of testis cancer and can secrete HCG.
     
  • Teratoma most often appear as a mixed NSGCT. They usually grow locally but can appear in retroperitoneal lymph nodes. Teratoma is chemotherapy- and radiation-resistant and best treated with surgical removal.
     
• Stromal tumors develop from the supportive tissues around the germ cells in the testicle. These tumors are rare, making up less than 5% of testis cancers, and have an excellent prognosis if surgically resected. There are two types of stromal tumors: 
   
  • Leydig cell tumors make the male hormone testosterone and are most often cured with surgery.
     
  • Sertoli cell tumors support and nourish the developing sperm and are usually benign tumors.

Signs & Symptoms

Most testicular cancers present as a mass confined to the testicle. Therefore, the most common presentation is a painless testicular mass. Other symptoms are:

• Pain is the first symptom in 10 percent of men
• Painless lump or swelling in the scrotum
• Ache or heavy sensation in the belly, anus or scrotum

Diagnosis

The initial evaluation of a possible testis cancer should involve:

• Scrotal ultrasound, which often demonstrates an intratesticular, hypoechoic (dark) mass. Testis cancers are often vascular (or hypervascular), although the absence of blood flow doesn’t rule out a testis cancer.
   
• Testicular tumor markers. Testicular cancer is one of the few cancers associated with tumor markers, which are well established to help in the diagnosis, prognosis, treatment and monitoring of testis cancer. Tumor markers include alphafetoprotein (AFP), human chorionic gonadotropin (hCG) and lactate dehydrogenase (LDH).
   
• Advanced imaging can be performed before or after the diagnosis of cancer is confirmed, based on the strength of suspicion for cancer. CT, MRI and X-ray can be used for staging.
   
• Orchiectomy. A biopsy isn’t recommended for testis cancers, as this can spread the cancer and changes lymphatic drainage patterns. Therefore, surgical removal of the testicle is diagnostic and therapeutic in most cases.

Treatment

Treatment of testicular cancer will be determined by the stage and grade of cancer, and your overall health and can include:

• Radical inguinal orchiectomy, which is surgical removal of the entire testicle and is the first step for diagnosis and treatment.
   
• Chemotherapy to kills cancer cells or stops them from growing.
   
• Lymph node removal, surgical removal of lymph nodes in the back of the abdomen.
• Radiation therapy, which is the use of high-energy X-rays to remove or stop the growth of a tumor.
   
• Surveillance. Men with small stage I cancer may only need regular follow-up appointments after orchiectomy.

Causes & Risk Factors

There are four well-established risk factors for testis cancer:

• Cryptorchidism (also known as an undescended testicle) is the most common risk factor for testis cancer. Boys with a history of cryptorchidism have an increased risk. The risk of cancer is not directly related to the fact that the testicle doesn’t descend, but it’s believed that the abnormality in descent likely indicates an abnormality in the testicle that makes cancer more likely.
   
• Family history of testicular cancer is another common risk factor, with an eight- to twelvefold risk if a man has a brother with testis cancer and a two- to fourfold risk if his father has testis cancer. While there is not a specific gene linked to testicular cancer, the disease is highly heritable and can be passed from generation to generation. In addition, the average age at diagnosis is two to three years younger than the general population if a first-degree relative has testicular cancer. However, it should be remembered that this cancer is rare so it is also rare for it to run in families.
   
• A personal history of testicular cancer is the highest risk of developing another cancer. Fortunately, only 2 percent of men will develop cancer in both testicles, but that risk is twelvefold higher than men without testis cancer. In addition, men who develop testis cancer in their 20s or earlier, men with seminoma, and men with ITGCN have a higher risk of developing a second testis cancer.
   
• Intratubular germ cell neoplasia (ITGCN) is a precursor lesion, formerly known as carcinoma in situ, CIS or ITGCN, which is present adjacent to testis cancer in 80 to 90 percent of patients. For men in whom GCNIS is found for other reasons, the risk of subsequent testis cancer is 50 percent at five years and 70 percent at seven years. 

Screening

There is no standard or routine screening test used for early detection of testicular cancer. Most often, testicular cancer is first found by men themselves, either by chance or during self-exam. Sometimes the cancer is found by a doctor during a routine physical exam.