Testicular Cancer

Testicular cancer occurs in the testicles (testes), which are located inside the scrotum, a loose bag of skin underneath the penis. The testicles produce male sex hormones and sperm for reproduction. As compared to other cancers, testicular cancer is rare. It is more common in whites than Asian or African men. India has one of the lowest incidence of testicular cancer with less than 1 man per 100, 000 population affected by this condition. It is the most common cancer in 20- to 35-year-old men.

Testicular cancer is highly treatable, even when cancer has spread beyond the testicle. Regular testicular self-examinations can help identify growths early, when the chance for successful treatment of testicular cancer is highest.

What are the risk factors of Testicular Cancer ?

Factors that may increase your risk of testicular cancer include:

• An undescended testicle (cryptorchidism).The testes form in the abdominal area during fetal development and usually descend into the scrotum before birth. Men who have a testicle that never descended are at greater risk of testicular cancer in either testicle than are men whose testicles descended normally. The risk remains elevated even if the testicle has been surgically relocated to the scrotum.Still, the majority of men who develop testicular cancer don’t have a history of undescended testicles.
• Abnormal testicle development.Conditions that cause testicles to develop abnormally, may increase your risk of testicular cancer.
• Family history.If family members have had testicular cancer, you may have an increased risk.
• A personal history of testicular cancer in the other testis.
• Infertile men have higher incidence of testicular tumor.
• Testicular cancer affects teens and younger men, particularly those between ages 15 and 35. However, it can occur at any age.

What are the signs and symptoms of testicular cancer a person should be aware of ?

• The most common presentation of testicular cancer is painless testicular mass.
• Acute pain is less common and is either the result of bleeding within the tumor or due to rapid tumor growth.
• Testicular cancer may also present as a casual finding on ultrasound or is revealed by a scrotal trauma. Patient may report a history of scrotal trauma, although incidental trauma is likely responsible for bringing the testicular mass to patient’s attention for the first time.
• Patient may also complain of vague scrotal discomfort or heaviness.
• Rarely, in patients who have widespread disease in body, presenting symptom may be related to various organs or sites affected by the disease such as flank pain, back pain, breathing difficulty or cough etc.
• Approximately 2% of men affected have gynaecomastia (enlargement of male breasts). Although more than half of men with germ cell tumors have diminished fertility, it is uncommon initial presentation.

How is the diagnosis of testicular cancer made?

• Physical exam and history.
• Ultrasound exam.
• Serum tumor marker test (Blood test) :Alpha-fetoprotein (AFP), Beta-human chorionic gonadotropin (β-hCG) and LDH.
• Tumor marker levels are measured before inguinal orchiectomy to help diagnose testicular cancer.
• Needle Biopsy directly from scrotum is contraindicated as it may lead to spread of tumor cells.
• Inguinal orchidectomy: A procedure to remove the entire testicle through an incision in the groin.
• CT Chest & Abdomen/: A procedure to findmalignant tumor elsewhere in the body.

What is the treatment for Testicular Cancer?

Surgery

Surgery to remove the testicle is usually the first treatment for testicular cancer.

Types of surgery

Removing a testicle (High inguinal orchidectomy)

• Removing the testicle is usually the first treatment for testicular cancer. Your surgeon usually removes the whole testicle through incision in groin. The operation is called high inguinal orchidectomy or orchiectomy. This also helps in diagnosing the type of cancer the cancer.

Removing lymph nodes (retroperitoneal lymph node dissection)

• Lymph nodes form a network of glands throughout your body. Every organ in our body drain to particular group of lymph nodes which form the regional lymph nodes for that particular organ. Whenever tumor spreads out of the primary organ, it usually spreads to these regional lymph nodes first before metastasising to distant sites. However rarely tumor may spread to distant organs skipping regional nodes. The regional nodes for testis are retroperitoneal nodes which are situated along major vessels i.e along inferior vena cava(IVC) & Aorta in the abdomen. These nodes include paracaval, precaval, interaortocaval, preaortic and paraaortic.Testicular cancer can spread to these lymph nodes and make them get bigger (enlarge).
• Usually if there are enlarged lymph nodes in a patient with testicular tumor, they are treated with chemotherapy after orchidectomy especially in non seminoma type of tumors. If you have non seminoma cancer and still have enlarged lymph nodes in your abdomen after chemotherapy, you might have an operation to remove them. This operation is called retroperitoneal lymph node dissection (RPLND). Now a days this operation can be done robotically which has reduced the morbidity of this extensive surgery to a great extent.
• Advantages of Robotic RPLND: please see advantages of Robotic surgery in Robotic surgery section.

Chemotherapy

Chemotherapy uses anti cancer (cytotoxic) drugs to destroy cancer cells. The drugs circulate around your body in the bloodstream. They work by disrupting the growth of cancer cells.

You might have chemotherapy to:

• treat cancer that has spread outside the testicle especially retroperitoneum.
• help prevent the cancer coming back after you’ve had a testicle removed (called adjuvant chemotherapy).
• treat cancer that has come back after initial treatment.

Side effects

Common chemotherapy side effects include:

• feeling sick
• loss of appetite
• losing weight
• feeling tired
• a lower resistance to infections
• bleeding and bruising easily

Radiotherapy

Radiotherapy uses high energy x-rays to kill cancer cells. If you have seminoma testicular cancer you might have radiotherapy to the retroperitoneal lymph nodes.

Radiotherapy works very well for seminoma. Almost all men with this type of cancer are completely cured. The treatment area is usually a strip down the middle of your abdomen.

Usually radiotherapy is given in short sessions (called fractions) each weekday from Monday to Fridaywith a break at the weekend. The whole course normally lasts from 3 to 4 weeks.

Fertility and Sperm banking

Most men have one testicle removed to treat their cancer. Usually men can still father children after this treatment. But if you have chemotherapy or surgery to remove the lymph glands in your abdomen you have a risk of permanent infertility and might not be able to father children.

Your doctor will offer you the chance to collect and store sperm (sperm banking) before you start treatment.

You give 2 or 3 semen samples over a few days at the clinic.The hospital freezes and stores the samples.

Chemotherapy and fertility

Chemotherapy for testicular cancer causes temporary infertility in most men who have it.

Usually fertility goes back to normal some months after the chemotherapy ends but for some men it doesn’t recover. This is most likely if you have had very high doses of chemotherapy.

About 7 out of 10 (70%) men who have chemotherapy for testicular cancer are later able to father children.

Surgery and fertility

Very rarely, the lymph glands in your abdomen might need to be removed by surgery to treat non seminoma cancer. This surgery can make you ejaculate backwards (retrograde ejaculation). Your semen and sperm go back into your bladder instead of coming out of your penis.If you have retrograde ejaculation you won’t be able to have children by natural sexual intercourse. But it may be possible to take sperm directly from your testicles or from your urine after you have had sex. The sperm can be used to fertilise your partner directly or with in vitro fertilization (IVF).

Radiotherapy and fertility

Your doctors will advise you not to try to father a child when having radiotherapy treatment, and for up to a year afterwards.

When treating the lymph nodes in the abdomen, the radiotherapy beams are directed at an area down the middle of the stomach or abdomen, and sometimes at the groin. There is a small risk of the remaining testicle receiving a dose of radiation, as it is quite close by. The testicles are where sperm are made. Your radiographer uses a lead shield to protect the testicle from the radiotherapy beams but there is still a small chance of damage.

In a healthy testicle, sperm are constantly being made, so any effects from the radiotherapy should usually only last for a few months after treatment ends.