What Is Testicular Cancer

What Is Testicular Cancer 2

What Is Testicular Cancer 4

What Is Testicular Cancer 5

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What Is Testicular Cancer?

Testicular cancer is cancer that typically develops in one or both testicles in young men. It is a highly treatable and usually curable form of cancer.
The testicles (also called the testes; a single testicle is called a testis) are a part of the male reproductive system. These 2 organs, each normally somewhat smaller than a golf ball in adult males, are contained within a sac of skin called the scrotum, which hangs beneath the base of the penis.

The testicles manufacture the male hormones, most of which is testosterone. They also produce sperm. Sperm cells are carried from the testicle by the vas deferens to the seminal vesicles, where they are mixed with fluid produced by the prostate gland. During ejaculation, sperm cells, seminal vesicle fluid, and prostatic fluid enter the urethra, the tube in the center of the penis through which both urine and semen are passed.

The testicles contain several types of cells, each of which may develop into one or more types of cancer. It is important to distinguish these types of cancers from one another because they differ in their prognosis (the course of disease and the outlook for cure) and in the ways they are treated.
Germ Cell Tumors

Over 90% of cancers of the testicle develop in certain cells known as germ cells. (Germ means seed; these are the cells that produce sperm.) The 2 main types of germ cell tumors (GCTs) that occur in men are seminomas (60%) and nonseminomas (40%). (The suffix -oma means tumor.) Seminomas and nonseminomas are recognized by their appearance under the microscope. They also have different patterns of spread.

These 2 kinds of cancer occur in about equal numbers. Some cancers contain both nonseminoma and seminoma cells. These are classified as nonseminomas because they grow and spread like nonseminomas
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Invasive testicular germ cell cancers can begin as a noninvasive form of the disease called carcinoma in situ or intratubular germ cell neoplasia. Researchers have estimated that it takes about 5 years for carcinoma in situ to progress to the invasive form of germ cell cancer. There is no practical way to detect carcinoma in situ before it develops into cancer, because it causes no symptoms. The only way to diagnose testicular carcinoma in situ is to have a biopsy. Some cases are found incidentally in men who have a testicular biopsy for some other reason, such as infertility. However, testicular carcinoma in situ is so rare that it is not reasonable to consider testicular biopsies as a screening test. Also, carcinoma in situ may not always progress to cancer.

When a testicular cancer becomes invasive, its cells have penetrated the surrounding tissues and may have spread through either the blood circulation or the lymph nodes (small, bean-shaped collections of white blood cells that fight infection) and lymphatic channels (fluid-filled vessels that connect the series of lymph nodes) to other parts of the body.

Seminomas: Seminomas develop from the sperm-producing germ cells of the testicle. The 2 main subtypes of these tumors are classical (or typical) seminomas and spermatocytic seminomas. Doctors can tell them apart by how they look under the microscope. Over 95% of seminomas are classical. These usually occur in men when they are between their late 30s and early 50s. This is an older population than those with nonseminomas.

The average age of men diagnosed with spermatocytic seminoma is about 55, which is 10 to 15 years older than the average age of men with typical seminomas. Spermatocytic tumors are different from classical seminomas. They grow very slowly and usually do not spread to other parts of the body.

Nonseminomas: These germ cell cancers tend to develop earlier in life than seminomas, usually occurring in men between their late teens and early 40s. The main types of nonseminomas are embryonal carcinoma, yolk sac carcinoma, choriocarcinoma, and teratoma. Most tumors are mixed with at least 2 different types, but this does not change treatment. All nonseminoma germ cell cancers are treated the same way, so the exact type of nonseminoma is not that important, except that they do have different patterns of spread.

Embryonal carcinoma: In this type of nonseminoma germ cell cancer, the embryonal cell type is the most plentiful. It is present in about 40% of testicular tumors. Pure embryonal carcinomas occur only 3% to 4% of the time. Seen under a microscope, these tumors can resemble tissues of very early embryos, with a diffuse pattern of disorganized and irregular, small rounded cells without specific organization into organ-like structures. This type of nonseminoma is more likely to grow rapidly and spread outside the testicle.

Yolk sac carcinomas: These are so named because their cells resemble the yolk sac of an early human embryo. Other names for this cancer include endodermal sinus tumors, infantile embryonal carcinoma, or orchidoblastoma. Yolk sac carcinoma is the most common form of testicular cancer in children. When they occur in children, these tumors usually are successfully treated. When yolk sac tumors develop in adults, however, they are more dangerous, especially if they are "pure" (that is, they do not contain other types of nonseminoma cells), although they still respond very well to chemotherapy if they have spread. This type of tumor releases a protein into the bloodstream known as alpha-fetoprotein (AFP). The presence of AFP helps confirm the diagnosis (see below).

Choriocarcinomas: This is a very rare and aggressive type of testicular cancer occurring in adults. Such cancers are likely to spread rapidly to distant organs of the body, including the lungs, bone, and brain. Pure choriocarcinoma does not often occur in the testicles. More often, choriocarcinoma cells are present with other types of nonseminoma cells in a mixed germ cell tumor. This type of tumor is classically associated with the production of another protein, human chorionic gonadotrophin (HCG), as discussed below.

Teratomas: Teratomas are germ cell tumors with areas that, when viewed under the microscope, resemble each of the 3 layers of a developing embryo: the endoderm (innermost layer), mesoderm (middle layer), and ectoderm (outer layer). The 3 main types of these tumors are the mature teratoma, immature teratoma, and teratoma with malignant transformation.

- Mature teratomas are tumors formed by cells similar to cells of adult tissues. They rarely spread to nearby tissues and distant parts of the body. They are usually treated by surgical removal, which is curative. Sometimes deposits of mature teratoma are found after chemotherapy to treat a nonseminomatous mixed germ cell tumor is finished. It is thought that these deposits represent elements of a tumor that are left behind after chemotherapy has killed the other components of the tumors.

- Immature teratomas are less well-developed cancers that may also spread to other organs. Their cells resemble those of an early embryo. Unlike mature teratomas, this type has a greater potential to invade and occasionally to metastasize, and it is this type that is sometimes found to relapse years after treatment.

- Teratoma with malignant transformation is a very rare cancer. These cancers contain some areas that look like mature teratomas and other areas that resemble types of cancers that develop outside of the testicle, in tissues such as muscles, the lungs or intestines, or the brain.

Stromal Tumors

Tumors can also arise in the supportive and hormone-producing tissues, or stroma, of the testicles. Such tumors are known as gonadal stromal tumors. They account for less than 4% of adult testicle tumors and up to 20% of childhood testicular tumors. The 2 main types are Leydig cell tumors and Sertoli cell tumors.

Leydig cell tumors: Leydig cell tumors develop from normal Leydig cells (also called interstitial cells) of the testicle. These are the cells that normally produce androgens (male sex hormones, like testosterone). Leydig cell tumors may develop in adults (75% of cases) or children (25% of cases). They often produce androgens but sometimes produce estrogens (female sex hormones). Most Leydig cell tumors do not spread beyond the testicle and are cured by surgical removal but a few spread to other parts of the body. Metastatic Leydig cell tumors have a poor prognosis because they do not respond well to chemotherapy or radiation therapy.

Sertoli cell tumors: These tumors develop from normal Sertoli cells, which support and nourish the sperm-producing germ cells. Like the Leydig cell tumors, they are usually benign; however, if they spread, they tend to be resistant to chemotherapy and radiation therapy.
Secondary Testicular Tumors

Secondary testicular tumors are those that start in another organ and then spread to the testicle. Lymphoma is the most common secondary testicular cancer. Among men older than 50, testicular lymphoma is more common than primary testicular tumors. Their prognosis depends on the type and stage of lymphoma. The usual treatment is surgical removal, followed by radiation and/or chemotherapy. In children with acute leukemia, the leukemia cells can sometimes form a tumor in the testicle.

Cancers of the prostate, lung, skin (melanoma), kidney, and other organs can secondarily spread to the testicles. The prognosis for these cancers is usually poor because these cancers generally spread widely to other organs as well. Treatment depends on the specific type of cancer.

What Are the Risk Factors for Testicular Cancer?

A risk factor is anything that increases a person's chance of getting a disease such as cancer. Different cancers have different risk factors. For example, exposing skin to strong sunlight is a risk factor for skin cancer. Smoking is a risk factor for cancers of the lung, mouth, larynx, bladder, kidney, and several other organs. But having a risk factor, or even several, does not mean that a person will get the disease.

Scientists have found a few risk factors that make a man more likely to develop testicular cancer. Even if a man has one or more risk factors for this disease, it is impossible to know for sure how much that risk factor contributes to developing the cancer. Also, most men with testicular cancer do not have any of the known risk factors
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This cancer is not common; a manÂ’s lifetime chance of developing testicular cancer is about 1 in 300. A small increase in risk still makes the chance of ever getting it low, and the risk of dying from this cancer is 1 in 5,000.

Cryptorchidism: The main risk factor for testicular cancer is a condition called cryptorchidism, or undescended testicle(s). This term comes from the Greek words kryptos, meaning hidden, and orchis, meaning testicle. In a fetus, the testicles normally develop inside the abdomen and descend into the scrotum before birth. In about 3% of boys, however, the testicles do not make this descent. Sometimes the testicle remains in the abdomen. In other cases, the testicle starts to descend but remains stuck in the groin area.
About 14% of cases of testicular cancer occur in men with a history of cryptorchidism. The risk of testicular cancer is somewhat higher for men whose testicle stayed in the abdomen as opposed to one that has descended at least partway. In men with a history of cryptorchidism, most cancers develop in the undescended testicle, but up to 25% of cases occur in the normally descended testicle. Based on these observations, some doctors conclude that cryptorchidism is not the direct cause of testicular cancer but that some other disorder is responsible for increasing the testicular cancer risk and preventing normal positioning of one or both testicles.

Most cryptorchid testicles eventually descend on their own in the child's first year. Sometimes a surgical procedure known as orchiopexy is necessary to bring the testicle down into the scrotum. Some experts believe that performing orchiopexy before puberty may reduce the risk of developing certain types of germ cell tumors.
Family history: A family history of testicular cancer increases the risk. If a man has the disease, there is an increased risk that one or more of his brothers or sons will also develop it. However, very few cases of testicular cancer are actually found to occur in families, so that most men are unlikely to pass this disorder on to their children.
Multiple atypical nevi: Two recent studies have shown that an unusual condition, in which multiple pigmented spots or moles are found particularly on the back, chest, abdomen and face, is associated with an increased risk of developing testicular cancer. This condition also increases the risk for a form of skin cancer called melanoma, and it has been shown that patients cured of testicular cancer have an increased risk of developing a melanoma later in life.

HIV infection: Some evidence has shown that men infected with the human immunodeficiency virus (HIV), particularly those with AIDS, are at increased risk. No other infections have been shown to increase testicular cancer risk.

Carcinoma in situ: This condition does not produce a mass or cause any symptoms. Carcinoma in situ (CIS) in the testicles often progresses to cancer. In some cases, CIS is detected in men who undergo a testicular biopsy during medical evaluation of infertility or have a testicle removed because of cryptorchidism. As noted previously, the criteria to make this diagnosis are controversial, and the figures for diagnosis and progression to cancer are lower in the United States than in parts of Europe.

Cancer of the other testicle: A history of testicular cancer is another risk factor. Men who have been cured of cancer in one testicle have an increased risk (about 3% to 4%) of eventually developing cancer in the other testicle.

Age: Most testicular cancers occur between the ages of 15 and 40. But this cancer can affect males of any age, including infants and elderly men.

Race and ethnicity: The risk of testicular cancer among white men is about 5 to 10 times that of black men and more than twice that of Asian-American men. The risk for Hispanics falls between that of Asians and non-Hispanic whites. The reason for this difference is not known. The testicular cancer rate has increased in both whites and blacks although the rate of increase is greater in white men. Worldwide, the risk of developing this disease is highest among men living in the United States and Europe and lowest among men living in Africa or Asia.

Body size: A recent study from Sweden found that body size was a risk factor; the highest risk was seen in tall, slim men. Because it is such an uncommon disease, the health benefits of being slim, however, outweigh any concern about testicular cancer.

Can Testicular Cancer Be Prevented?

Some of the known risk factors -- cryptorchidism, white race, body size, and a family history of the disease -- are unavoidable because they are present at birth. Also, many men with testicular cancer have no known risk factors. For these reasons, it is not currently possible to prevent most cases of this disease. But, it is wise to correct cryptorchidism in male children. A study of children who had the orchiopexy operation found that their rate of testicular cancer was not increased as long as the operation was done before they were 11 years old. This also means that the doctor and parents should be checking male children to make sure the testes are descended. Furthermore, knowing he has a risk factor such as cryptorchidism may lead a male to be more watchful and to practice testicular self-examination to allow an earlier diagnosis.
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Can Testicular Cancer Be Found Early?

Most cases of testicular cancer can be found at an early stage. In some cases, early testicular cancers cause symptoms that lead men to seek medical attention. Most of the time a lump on the testicle is the first sign. Unfortunately, however, some testicular cancers may not cause symptoms until after reaching an advanced stage.

Most doctors agree that examination of a man's testicles should be part of a general physical examination. The American Cancer Society (ACS) recommends a testicular examination as part of a routine cancer-related checkup.

The ACS advises men to be aware of testicular cancer and to seek prompt medical evaluation if a mass is found. Because regular testicular self-examinations have not been studied enough to show a reduction in the death rate from this cancer the ACS does not recommend regular testicular self-examinations for men without specific testicular cancer risk factors.

However, some doctors think that not noticing masses promptly is an important factor in delaying treatment, and they recommend that all men perform monthly testicular self-examinations after puberty.

The choice of whether to perform a monthly self-examination should be made by each man, so instructions for testicular examination are included in this section. If you have certain risk factors that increase your chance of developing testicular cancer (such as cryptorchidism, previous germ cell tumor in one testicle, or a family history), you should seriously consider monthly examinations and discuss this issue with your doctor.

The best time to perform the self-exam is during or after a bath or shower, when the skin of the scrotum is relaxed. To perform a testicular self-exam:

Hold the penis out of the way and examine each testicle separately.

Hold the testicle between the thumbs and fingers with both hands and roll it gently between the fingers.

Look and feel for any hard lumps or nodules (smooth rounded masses) or any change in the size, shape, or consistency of the testes.

You should be aware that each normal testis has an epididymis, which appears as a small "bump" on the upper or middle outer side of the testis. Normal testicles also contain blood vessels, supporting tissues, and tubes that conduct sperm. Some men may confuse these with cancer. If you have any doubts, ask your doctor. Sometimes, the testicle can be enlarged because fluid has collected around it. This is called a hydrocele. Other times, the veins in the testicle can dilate and cause enlargement and lumpiness around the testicle. This is called a varicocele. To be sure you have one of these conditions and not a tumor, you need to have a doctor examine you.

How Is Testicular Cancer Diagnosed?

Signs and Symptoms of Testicular Cancer

In about 90% of cases, men have a lump on a testicle that is often painless but slightly uncomfortable, or they may notice testicular enlargement or swelling. Men with testicular cancer often report a sensation of heaviness or aching in the lower abdomen or scrotum.
In rare cases, men with germ cell cancer notice breast tenderness or breast growth. This symptom occurs because certain types of germ cell tumors secrete high levels of a hormone called human chorionic gonadotropin (HCG), which stimulates breast development. Blood tests can measure HCG levels. These tests are important in diagnosis, staging, and follow-up of some testicular cancers.

Leydig cell tumors and Sertoli cell tumors also result in a mass that can only be distinguished by examining the germ cell tumor under a microscope. However, Leydig cell tumors produce androgens (male sex hormones) or estrogens (female sex hormones). These hormones may cause symptoms that provide clues to the correct diagnosis. Breast growth or loss of sexual desire is a symptom of estrogen-producing tumors. Androgen-producing tumors may not cause any specific symptoms in men, but in boys they can cause growth of facial and body hair at an abnormally early age.

Even when testicular cancer has spread to other organs, only about 1 man in 4 may experience symptoms related to the metastases prior to diagnosis. Lower back pain is a frequent symptom of later-stage testicular cancer. If the cancer has spread to the lungs and is advanced, shortness of breath, chest pain, cough, or bloody sputum may develop. Occasionally men will complain of central abdominal pain, due either to enlargement of lymph nodes or spread to the liver. Rarely, men will complain of headache, which is associated with brain metastases (an uncommon pattern of spread, usually only found in patients with choriocarcinoma).

Some men with testicular cancer have no symptoms at all, and their cancer is found during medical testing for other conditions. Sometimes imaging tests done to find the cause of infertility can uncover a small testicular cancer. Testicular biopsies to evaluate infertile men may find carcinoma in situ.

A number of noncancerous conditions, such as testicle injury, can produce symptoms similar to those of testicular cancer. Inflammation of the testicle, known as orchitis, can cause painful swelling. Causes of orchitis include viral or bacterial infections. About 1 man in 5 who contracts mumps as an adult experiences orchitis in one or both testes.

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