Testicular cancer is the most common malignancy in men between the age of 15 to 35 years. Fortunately, it is one of the most curable cancers due to early diagnosis, new treatment such as cisplatin chemotherapy and a greater understanding of the nature of the disease.
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Paul L. Crispen, MD
Professor
Pete and Carolyn Newsome Urologic Oncology Professorship
UF Health Cancer Center Associate Director for Clinical Research
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Department of Urology
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Padraic G. O’Malley, MD
Associate Professor
Chief, Division of Urologic Oncology
Department of Urology
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Epidemiology & Etiology
There are approximately 8,000 newly diagnosed cases of testicular cancer each year in the United States. The probability that an American white male will develop testicular cancer in his lifetime is approximately 0.2%. Most tumors occur in late adolescence or early adulthood. However, occasionally tumors are seen in infancy and in patients over the age of 60 years. The incidence of testicular tumors in African Americans is dramatically less than that in American whites.
Types of Testicular Cancer
- Seminoma
- Non-seminoma
- Embryonal carciroma
- Choriocarcinoma
- Yolk sac tumor
- Teratoma
The cancer type determines its biological behavior, thus distinguishing the type (seminoma vs. non-seminoma) is important in making treatment recommendations. It is not unusual to have multiple cell types in a given testicular cancer (i.e., embryonal carcinoma and teratoma together).
Some testicular tumors produce proteins which can be detected in the blood and can be used as tumor markers to detect and survey disease. The most common tumor markers produced by testicular cancer are alpha fetoprotein (AFP), human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH). These tumor markers should normalize following successful treatment, and persistently elevated markers usually indicate presence of active disease. Most testis cancers (70%) are diagnosed at an early stage (while still confined to the testicle). However, nearly 20% of cases present with regional lymph node (retroperitoneal) involvement and approximately 10% present with distant metastasis. In general, survival rates are excellent following treatment; 5-year survival for local, regional and distant disease is 99%, 96% and 71%, respectively.
Signs & Symptoms
Most patients notice a mass, pain or swelling in one testicle. In about 10% of patients, acute pain is a presenting symptom. In a very small percentage of patients, the first symptoms are from metastases, including neck mass, problems with breathing (cough or shortness of breath), difficulty eating, abdominal pain, back pain or pain in the bones
Diagnosis
Typically the patient or a physician feels a mass within the testicle. It is not unusual to have small lumps in the epididymis, however, any unusual mass should be evaluated by a physician. Other diseases that can cause swelling or tenderness in the testicles include infection, fluid around testicles, hernia or testicular torsion. An ultrasound examination of the scrotum and testicle is the most reliable technique to evaluate the presence of a testicular tumor.
Early detection is important, so monthly self-examination is recommended. This is best performed in a warm shower. Any suspicious areas should be examined by a physician. If an intratesticular mass is present a radical orchiectomy – removal of affected testicle and spermatocord – should be performed.
Staging for Testicular Cancer
Testicular tumors are staged using the TNM system. Tumors are staged based on the findings at the surgery to remove the testicle including: the microscopic examination, serum tumor markers, chest x-ray, CAT scan and other studies as indicated. Staging helps in assessing risk and in making treatment recommendations.
TNM System (Tumor, Lymph Nodes, and Metastasis)
| TNM SYSTEM | Status |
|---|---|
| T0 | No evidence of primary testicular tumors |
| T1 | Tumor confined to the testicle without lymphovascular invasion |
| T2 | Tumor invading outside the capsule of the testicle or with lymphovascular invasion |
| T3 | Tumor invading the spermatic cord |
| T4 | Tumor invading the scrotum |
| Nx | Regional lymph nodes cannot be assessed |
| N0 | No regional lymph node metastases |
| N1 | Lymph node metastases 2 cm or less in greatest dimension, less than 5 positive nodes |
| N2 | Lymph node metastases more then 2 cm but not more than 5 cm in greatest dimension, or greater than 5 positive lymph nodes |
| N3 | Lymph node metastases greater than 5 cm in greatest dimension |
| Mx | Distant metastasis cannot be assessed |
| M0 | No distant metastasis |
| M1 | Distant metastasis |
| M1a | Nonregional nodal or pulmonary metastasis |
| M1b | Distant metastasis other than to nonregional lymph node and lungs |
| Sx | Marker studies not available |
| S0 | Markers within normal limits |
| S1 | LDH < 1.5 x Normal AND hCG < 5000 mIu/mL AND AFP < 1000 ng/mL |
| S2 | LDH 1.5-10 x N OR hCG 5,000 to 50,000 mIu/mL OR AFP 1000-10,000 ng/mL |
| S3 | LDH > 10 x N OR hCG > 50,000 mIu/mL OR AFP > 10,000 ng/mL |
Testis tumors can spread by one of three routes. First and most commonly, they may spread through the lymph nodes in the back and abdomen. Right-sided tumors tend to spread to the right side of the lymph nodes and left-sided lymph nodes in the back. Second, they may spread to adjacent tissue through the wall of the testicle into the blood supply or tubes that transport sperm. Finally, testicular tumors can initially spread by the bloodstream to distant organs such as the lung, bone or brain.
Treatment
Where testicular cancer is probable, it is best to treat it initially by removing the testicle through an incision in the groin. Once the tumor is removed, any elevated tumor markers should return to the normal range. If they do not normalize, one should suspect that cancer is still present. Depending upon the examination, tumor markers, results of x-rays and type of tumor present on microscopic evaluation, a variety of different treatment options may be recommended.
In patients with low stage seminoma, removing the testicle and radiation to the back may be appropriate. With other types of tumors, initial chemotherapy or surgery to remove the lymph nodes in the back may be necessary.
Traditional surgery removes the retroperitoneal lymph nodes located in back of the abdomen. For low stage disease, the lymph nodes can be observed, treated with a short course of chemotherapy, or treated with a lymph node dissection. Most often, surgery is performed through an open incision to allow complete removal of all potentially involved lymph node tissue. In some cases, laparoscopic surgery may be used to remove the lymph nodes.
