Fortunately, testis cancer is an eminently curable disease, provided patients are compliant with treatment and follow up. Testis cancer is a perfect example of how the interplay of different treatment modalities has resulted in excellent outcomes.
The testis consists of predominantly seminiferous tubules, which produce sperm, and these drain to the epididymis. Its blood supply is from the spermatic artery and its venous drainage is to the pampiniform plexus of gonadal veins. Its lymphatic drainage is to the retroperitoneal lymph nodes.
Testicular cancer usually affects one testicle only, however, in a small percentage of patients testis cancer can occur in both testicles either at the same time or at some time in the future.
Most patients who present with testicular cancer will have noticed a swelling in one testicle. The swelling is usually painless but in about 10% of patients, pain in the testicle is the initial presenting symptom.
Rarely patients may present with symptoms related to the spread of the cancer to other areas of the body, such as, swollen lymph nodes in the neck, shortness of breath, or abdominal or low back pain.
Cryptorchidism or undescended testicle is thought to be a risk factor for the development of testis cancer.
Any patient who suffers from persistent pain in the testicle or notices a lump in the body of the testicle should see their general practitioner for review. A scrotal ultrasound is a painless examination and the most reliable way of detecting testicular tumours.
Testicular self examination on a monthly basis is a sensible recommendation allowing early detection of testicular abnormalities.
Two thirds of testicular tumours produce proteins that can be measured in the blood called tumour markers. Alpha feto protein (AFP) and beta human chorionic ganatoprophin (HCG) are the most common markers produced.
If testicular cancer is suspected, the testicle will need to be removed through a small incision in the groin. Provided the remaining testicle is normal this operation will have no impact on a patient’s libido or erectile function. Unfortunately, infertility is not uncommon in patients suffering from testicular cancer. Patients should have sperm collected and frozen prior to treatment. Fortunately in the vast majority of patients, simply removing the testicle will result in cure of their disease. The majority of testicular tumours arise from germ cells within the testicle.
There are essentially 2 different types of testicular cancers, seminoma, and non seminoma. Within the non seminomatous group there are 4 sub types namely embryonal carcinoma, choriocarcinoma, yolk sack tumour, and teratoma. Commonly testicular tumours will consist of multiple different germ cell types (e.g., embryonal carcinoma, yolk sack tumour and teratoma, i.e. a mixed germ cell tumour).
The spread of testicular cancer is relatively predictable based upon the lymphatic drainage of the testicle. The most common sites of spread are to the lymph nodes within the abdomen, the lungs, and the lymph nodes in the chest. Rarely testicular cancer can spread to the brain or bones.
The TNM classification system is used to stage testicular tumours. This system uses the microscopic examination of the testicular tumour, the size and number of abdominal lymph nodes involved with tumour and the presence of spread elsewhere to stage testicular cancer.
TNM staging system
- T (Tumour) indicates the depth of the tumour invasion – the higher the number (between 1 and 4), the further the cancer has spread.
- N (Nodes) indicates whether the lymph nodes are affected – a number between 0 and 3 describes how much the cancer has spread to lymph nodes near the bladder.
- M (Metastasis) indicates whether the cancer has spread to other parts of the body – M1 means the cancer has spread to other organs or lymph nodes that are not near the bladder; M0 means there is no sign of the cancer spreading to other parts of the body.
This information is combined to describe the stage of the cancer from stage I to stage IV
Once the diagnosis of testicular cancer is made, patients require measurement of their testicular tumour markers and CT scans of their chest, abdomen and pelvis to adequately stage their disease.
Staging is important as it dictates treatment options.
As already indicated, the vast majority of patients with testicular cancer are cured simply by removing the testicle, however, diligent follow up is required in order to detect a recurrence of disease at the earliest possible time. Treatment options are dependent on both the type of testicular cancer (seminoma or non seminoma) and the stage of the disease. In patients with seminoma, treatment options include surveillance radiotherapy and/or chemotherapy.
For patients with non seminomatous testicular cancer, treatment options include surveillance, surgical removal of the abdominal lymph nodes and/or chemotherapy. Surgical removal of the abdominal lymph nodes (RPLND – retroperitoneal lymph node dissection), often resulted in the inability to ejaculate because the post-ganglionic sympathetic nerves were damaged. Today, in experienced hands, these nerves can be preserved and ejaculation maintained in the majority of patients.
To ensure the best possible outcome, patients with testicular cancer need to be managed in centres that offer multi disciplinary treatment clinics and in units that treat large volumes of patients with the disease.
Radical inguinal orchiectomy
Treatment of testicular cancer usually starts with surgery to remove the affected testicle, called radical inguinal orchiectomy. This is done through an incision in the groin (along the beltline). It is used to diagnose and treat both early-stage and later-stage testicular cancer, regardless of the type of tumor. In stage I non-seminoma testicular cancer, a man’s blood serum markers should return to normal after this surgery. For later-stage cancer, a radical inguinal orchiectomy may, occasionally, be delayed until after treatment with chemotherapy is finished.
Retroperitoneal lymph node dissection (RPLND)
This is surgery to remove the retroperitoneal lymph nodes that lie at the back of the abdomen. RPLND may be considered for men with clinical stage I and IIa non-seminomas and men with retroperitoneal masses that remain after finishing chemotherapy for late-stage disease. In men with non-seminomas, any masses larger than 1 cm that remain after chemotherapy are removed if it is surgically feasible, but for men with pure seminomas, masses smaller than 3 cm are usually left in place and monitored for changes with CT scans.RPLND is usually performed as an open operation with an incision down the middle of the abdomen.
Chemotherapy is the use of drugs to kill cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time.
Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. For testicular cancer, the radiation is generally directed at lymph nodes in the abdomen. Often, the radiation is also targeted at lymph nodes on the same side of the pelvis as the testicle where the cancer started.
After having a radical inguinal orchiectomy, one option for clinical stage I seminomas and non-seminomas may be active surveillance. Active surveillance will only be considered as an option if the serum tumor markers are normal or return to normal after the cancerous testicle is removed. This option involves regular doctor appointments for CT scans, chest x-rays, physical examinations, and blood tests for tumor markers.