Testicular cancer

What is testicular cancer?

Testicular cancer starts as an abnormal growth or tumour in a testis. A cancer will usually appear as a painless lump in a testis. If a man sees a doctor as soon as a lump, swelling or pain in a testis is noticed, the cancer can remain localised (remain within the testis). However, if not treated, the cancer typically spreads to other parts of the body via the blood or lymphatic system. Testicular cancer has a very good cure rate (about 95 per cent).

British Testicular Tumour Panel Classification:

  • Seminomas.
  • Teratomas, which are subdivided into:
    • Teratoma differentiated.
    • Malignant teratoma intermediate.
    • Malignant teratoma undifferentiated.
    • Malignant teratoma trophoblastic (choriocarcinoma is the most lethal form and it is the least common at 1% of the non-seminomatous type).
  • Yolk sac tumours:
    • Yolk sac tumours are also known as endodermal sinus tumours and are the most common prepubertal germ cell tumours.
    • They may be benign but they are most often malignant.
    • Most require surgery and chemotherapy because of their aggressive nature but the overall prognosis is excellent.

How common is testicular cancer?

  • Testicular cancer is a relatively rare cancer with an incidence of 7.0 per 100,000 population. The lifetime risk of developing testicular cancer is about 1 in 199 for men.
  • There has been a steady increase in incidence over previous decades in industrialised countries.
  • Testicular cancer can occur at any age but is most common between the ages of 15 and 40 years. Testicular tumours are the most common malignancy in men aged between 20 and 35 years.
  • Testicular tumours are far more common in adults than in children. Seminoma is rare in boys younger than 10 years of age but is the most common testicular tumour in men older than 60.

What are the risk factors for testicular cancer?

Young men (about 20 to 40 years of age) are most at risk of developing testicular cancer.

Due to the higher risk of testicular cancer in men with a history of undescended testes, it is important for families to share details of medical history with boys in early adolescence so they are aware of the need to regularly check their testes.

Undescended testes (cryptorchidism) A condition when one or both of the testes have not descended (lowered) into the scrotum at birth but stay in the abdomen or only move part way down into the scrotum
Found in three to five boys in every 100
Men with a history of undescended testes have about ten times the chance of testicular cancer; the risk may be lower if surgery to fix the problem happened before one year of age. Where there has been a single undescended testis, the risk of cancer is usually only in that testis.
Previous testicular cancer About 1 in 25 men who have had testicular cancer in one testis develop cancer in the other testis
Previous male infertility Men diagnosed with fertility problems, particularly those with a history of undescended testes, may have a greater chance of developing testicular cancer
Pre-cancer cells (ITGCN) are sometimes found in testicular biopsies from infertile men (not all pre-cancer cells will develop into cancer)
Family history Having a father, brother or uncle with testicular cancer is a minor risk factor
Down syndrome Men with Down syndrome may be at higher genetic risk of testicular cancer, gastrointestinal cancer and leukaemia.

Can I do anything to prevent testicular cancer?

As the causes of testicular cancer are largely unknown, there are no known ways to prevent it.

There is no evidence that injury or sporting strains, life-style (for example smoking or diet), or sexual activity are linked with testicular cancer. However, an injury to the groin area may sometimes prompt men to check or notice a problem with the testes that needs further investigation by a doctor.

What are the symptoms of testicular cancer?

  • More than 95% present with a lump in the body of the testis, which is usually painless. See the separate article on Lumps in the Groin and Scrotum.
  • Testicular pain and/or abdominal pain.
  • Dragging sensation.
  • Recent history of trauma; it is probably the trauma that leads the man to examine himself and find the tumour rather than being the cause of malignant change.
  • Hydrocele.
  • Gynaecomastia from beta human chorionic gonadotrophin (beta-hCG) production.
  • Metastasis – seminomas metastasise to para-aortic nodes and produce back pain; teratomas undergo blood-borne spread to the liver, lung, bone and brain.
  • A lump is palpable in nearly all cases.
  • Whereas the normal testis is rather delicate and the inflamed testis is very tender, the malignant testis tends to lack the normal level of sensation.
  • Lymphatics from the scrotum drain to the inguinal nodes but from the testes they go deeper. Hence, inguinal lymph nodes are unlikely to be enlarged.

Patients presenting with a swelling in the scrotum should be examined carefully and an attempt made to distinguish between lumps arising from the testis and other intrascrotal swellings. An ultrasound scan should be performed to make a distinction

Investigations should not delay referral. Patients should be referred urgently to be seen within two weeks if malignancy is suspected. Pre-operative investigations should include assay of tumour markers, bilateral testicular ultrasound, and X ray.

  • Diagnosis is usually confirmed by ultrasound.
  • Tissue histology can follow an inguinal orchidectomy.
  • Disease can be staged by thoraco-abdominal CT scanning.
  • Elevation of tumour markers supports the diagnosis but normal marker levels do not exclude testicular cancer and these markers are raised in other cancers and some benign conditions:
    • Alpha-fetoprotein (AFP) is produced by yolk sac elements but not produced by seminomas.
    • Beta-hCG is produced by trophoblastic elements and so there may be elevated levels both in teratomas and in seminomas.
  • I – no evidence of disease outside the testis.
  • IM – as above but with persistently raised tumour markers.
  • II – infradiaphragmatic nodal involvement.
    • IIA – maximum diameter <2 cm.
    • IIB – maximum diameter 2-5 cm.
    • IIC – maximum diameter >5-10 cm.
    • IID – maximum diameter >10 cm.
  • III – supradiaphragmatic and infradiaphragmatic node involvement:
    • Abdominal nodes A, B, C, as above.
    • Mediastinal nodes M+.
    • Neck nodes N+.
  • IV – extralymphatic metastases:
    • Abdominal nodes A, B, C, as above.
    • Mediastinal or neck nodes as for stage III.
    • Lungs:
      • L1 <3 metastases.
      • L2 multiple metastases <2 cm maximum diameter.
      • L3 multiple metastases >2 cm in diameter.
    • Liver involvement H+.
    • Other sites specified.

Management is dependent on the type of tumour and stage .Approximately 90% of patients classified as having a good prognosis achieve a durable complete remission with treatment. Even metastatic disease should be seen as potentially curable. When treating young adults with a highly curable disease, possible long-term toxicity of treatment is an important consideration. Following confirmation of a germ cell tumour, all patients should be referred to a specialist centre for the management of testicular tumours.

  • Where possible, a radical orchidectomy should be performed. A testicular prosthesis should be offered to all patients. When appropriate, sperm storage should be offered to men who may require chemotherapy or radiotherapy.
  • Patients with metastases where the diagnosis is not in doubt (high tumour markers and the presence of a testicular mass) should be referred for immediate chemotherapy.

Management of stage 1 disease

  • Seminoma:
    • Post-orchidectomy management options following assessment of the extent of disease include surveillance, single-dose adjuvant carboplatin and adjuvant radiotherapy.
  • Stage I NSGCT and mixed seminoma/NSGCT:
    • Patients with stage I NSGCT or mixed seminoma/NSGCT of the testis with no high-risk features (blood vessel and/or lymphatic invasion) should be managed by surveillance following inguinal orchidectomy.
    • In low-risk patients under surveillance, CT scanning at three and 12 months post-orchidectomy is recommended.
    • Two courses of adjuvant bleomycin, etoposide and cisplatin (BEP) chemotherapy should be offered to patients with stage I NSGCT or mixed seminoma/NSGCT of the testis following inguinal orchidectomy if high-risk features are present or if the patient is unable or unwilling to comply with a policy of surveillance

Carcinoma in situ (CIS)

Of all patients with unilateral testicular tumours, approximately 2-5% have CIS in their contralateral testis. CIS develops into invasive malignancy in 70% of the cases in seven years and probably all patients over a longer period of time. CIS can be successfully treated with a low dose of radiotherapy or unilateral orchidectomy.

Management of metastatic disease

  • Seminoma:
    • In stage IIA seminoma, both chemotherapy and radiotherapy treatment options should be considered.
    • For patients with stage IIC and IID seminoma, chemotherapy is the recommended initial treatment.
    • Patients with stage III and IV seminoma should be treated with cisplatin-based chemotherapy. In patients with stage III and IV seminoma, carboplatin should only be used as an alternative to cisplatin in exceptional circumstances.
  • NSGCT:
    • Patients with good-prognosis metastatic NSGCT should receive three cycles of BEP chemotherapy. (The International Germ Cell Consensus Classification (IGCCC) prognostic grouping is mainly based on the presence on the site of the primary, presence of non-pulmonary metastases and levels of tumour markers.)
    • Patients with good-prognosis metastatic NSGCT and in whom bleomycin is contra-indicated should receive chemotherapy with etoposide and cisplatin.
    • Standard initial chemotherapy for patients with intermediate and poor-risk germ cell tumours is four courses of BEP.

Management of residual masses after chemotherapy

  • Patients with NSGCT who have residual masses after chemotherapy and whose markers have normalised should be treated by complete excision.
  • Patients with seminoma who have residual masses following chemotherapy can generally be managed by a policy of observation rather than radiotherapy.

Other

  • Counselling and support organisations.
  • Fertility issues and sperm storage (semen quality is reduced after orchidectomy and samples should be taken before surgery).
  • Testicular prosthesis should be offered to all patients.
  • Follow-up visits for early detection and treatment of relapse during the first 5-10 years.
  • Most survivors of testicular cancer regain a normal quality of life. Some patients become hypogonadal after orchidectomy and fertility may be reduced after chemotherapy.
  • Peripheral neuropathy, Raynaud’s phenomenon, and hearing loss caused by chemotherapy may persist for years.
  • The risk of developing a second (non-germ cell) cancer is doubled in those who were treated in the past with standard chemotherapy regimens or radiotherapy.
  • Radiotherapy causes a risk of damage to organs in the radiation field. Increased risks following chemotherapy include leukaemias, lung cancer and melanoma.
  • There is an increased risk of cardiac events. The increased risk of cardiovascular disease and a second cancer is similar to the risk seen from long-term smoking.
  • Overall quality of life scores are similar to those in the general population, but anxiety associated with fear of recurrence, economic worries, alcohol misuse, and sexual difficulties are common in survivors.
  • Late relapse (new tumour growth more than two years after at least three cycles of chemotherapy) occurs in 2-3% and does not have a good response to chemotherapy.

There has been decline in mortality rates reported in Western countries. The prognosis is dependent on stage, tumour type and presence of low, medium or high levels of markers.

  • If the tumour is diagnosed early, over 95% of men are cured and treatment can be less intensive.
  • For NSGCTs, the overall results are less favourable than for seminomas.
  • Choriocarcinomas have the worst prognosis of any of the testicular malignancies.

Does testicular cancer treatment affect sexual function?

Many men find that testicular cancer and its treatment do not affect their sexual performance in any way. However, the stress and anxiety of cancer can affect sexual function. Concerns about changes in body image may also cause sexual problems and anxiety.

Can testicular cancer cause infertility?

Cancer in a single testis may not affect the chance of having children. After a cancerous testis is removed, in many men the remaining testis continues to make testosterone and sperm.

However, some men who have had testicular cancer may have trouble having children. Men who are diagnosed with testicular cancer are more likely to have lower fertility before any treatment starts. Fertility can be further affected by cancer treatments such as radiotherapy and chemotherapy.

Why is sperm storage important?

All men who are going to have chemotherapy or radiotherapy should speak to their doctors about their fertility before treatment begins. It is highly recommended that men produce semen samples (through masturbation) for sperm storage (also known as sperm banking). Sperm storage should take place before chemotherapy or radiotherapy starts.

Semen can be frozen, using special equipment, and stored long-term for future use. If a man wants to father a child at a later stage, the frozen semen is thawed and used in fertility treatments such as IVF (in vitro fertilisation). Modern IVF treatments can be successful with just a few moving sperm.