TESTICULAR CANCER

Testicular cancer is a disease in which malignant (cancer) cells form in the tissues of one or both testicles.

The testicles are 2 egg-shaped glands located inside the scrotum (a sac of loose skin that lies directly below the penis). The testicles are held within the scrotum by the spermatic cord, which also contains the vas deferens and vessels and nerves of the testicles.

The testicles are the male sex glands and produce testosterone and sperm. Germ cells within the testicles produce immature sperm that travel through a network of tubules (tiny tubes) and larger tubes into the epididymis (a long coiled tube next to the testicles) where the sperm mature and are stored.

Almost all testicular cancers start in the germ cells. The two main types of testicular germ cell tumours are seminomas and nonseminomas. These 2 types grow and spread differently and are treated differently. Nonseminomas tend to grow and spread more quickly than seminomas. Seminomas are more sensitive to radiation. A testicular tumour that contains both seminoma and nonseminoma cells is treated as a nonseminoma.

Testicular cancer is the most common cancer in men 20 to 35 years old.

Health history can affect the risk of developing testicular cancer.

Anything that increases the chance of getting a disease is called a risk factor. Risk factors for testicular cancer include:

* Having had an undescended testicle.
* Having had abnormal development of the testicles.
* Having a personal or family history of testicular cancer.
* Having Klinefelter's syndrome.
* Being white.

Possible signs of testicular cancer include swelling or discomfort in the scrotum.

These and other symptoms may be caused by testicular cancer. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:

* A painless lump or swelling in either testicle.
* A change in how the testicle feels.
* A dull ache in the lower abdomen or the groin.
* A sudden build-up of fluid in the scrotum.
* Pain or discomfort in a testicle or in the scrotum.

Tests that examine the testicles and blood are used to detect (find) and diagnose testicular cancer.

The following tests and procedures may be used:

* Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. The testicles will be examined to check for lumps, swelling, or pain. A history of the patient's health habits and past illnesses and treatments will also be taken.

* Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.

* Serum tumour marker test: A procedure in which a sample of blood is examined to measure the amounts of certain substances released into the blood by organs, tissues, or tumour cells in the body. Certain substances are linked to specific types of cancer when found in increased levels in the blood. These are called tumour markers. The following 3 tumour markers are used to detect testicular cancer:
o Alpha-fetoprotein (AFP).
o Beta-human chorionic gonadotropin (β-hCG).
o Lactate dehydrogenase (LDH).
Tumour marker levels are measured before radical inguinal orchiectomy and biopsy, to help diagnose testicular cancer.

* Radical inguinal orchiectomy and biopsy: A procedure to remove the entire testicle through an incision in the groin. A tissue sample from the testicle is then viewed under a microscope to check for cancer cells. (The surgeon does not cut through the scrotum into the testicle to remove a sample of tissue for biopsy, because if cancer is present, this procedure could cause it to spread into the scrotum and lymph nodes.) If cancer is found, the cell type (seminoma or nonseminoma) is determined in order to help plan treatment.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

* Stage of the cancer (whether it is in or near the testicle or has spread to other places in the body, and blood levels of AFP, β-hCG, and LDH).
* Type of cancer.
* Size of the tumour.
* Number and size of retroperitoneal lymph nodes.

Testicular cancer is often curable.

Treatment for testicular cancer can cause infertility.

Certain treatments for testicular cancer can cause infertility that may be permanent. Patients who may wish to have children should consider sperm banking before having treatment. Sperm banking is the process of freezing sperm and storing it for later use.

Stages of Testicular Cancer

Key Points for This Section

* After testicular cancer has been diagnosed, tests are done to find out if cancer cells have spread within the testicles or to other parts of the body.
* The following stages are used for testicular cancer:
o Stage 0
o Stage I
o Stage II
o Stage III

After testicular cancer has been diagnosed, tests are done to find out if cancer cells have spread within the testicles or to other parts of the body.

The process used to find out if cancer has spread within the testicles or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:

* Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.

* CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerised tomography, or computerised axial tomography.

* Lymphangiography: A procedure used to x-ray the lymph system. A dye is injected into the lymph vessels in the feet. The dye travels upward through the lymph nodes and lymph vessels, and x-rays are taken to see if there are any blockages. This test helps find out whether cancer has spread to the lymph nodes.

* Abdominal lymph node dissection: A procedure to examine lymph nodes in the abdomen. Lymph nodes are removed and a pathologist checks them for cancer cells. For patients with nonseminoma, removing the lymph nodes may help stop the spread of disease. Cancer cells in the lymph nodes of seminoma patients can be treated with radiation therapy.

* Radical inguinal orchiectomy and biopsy: A procedure to remove the entire testicle through an incision in the groin. A tissue sample from the testicle is then viewed under a microscope to check for cancer cells. (The surgeon does not cut through the scrotum into the testicle to remove a sample of tissue for biopsy, because if cancer is present, this procedure could cause it to spread into the scrotum and lymph nodes.)

* Serum tumour marker test: A procedure in which a sample of blood is examined to measure the amounts of certain substances released into the blood by organs, tissues, or tumour cells in the body. Certain substances are linked to specific types or cancer when found in increased levels in the blood. These are called tumour markers. The following 3 tumour markers are used in staging testicular cancer:
o Alpha-fetoprotein (AFP)
o Beta-human chorionic gonadotropin (β-hCG).
o Lactate dehydrogenase (LDH).
Tumour marker levels are measured again, after radical inguinal orchiectomy and biopsy, in order to determine the stage of the cancer. This helps to show if all of the cancer has been removed or if more treatment is needed. Tumour marker levels are also measured during follow-up as a way of checking if the cancer has come back.

The following stages are used for testicular cancer:

Stage 0

In stage 0, abnormal cells are found only in the tiny tubules where the sperm cells begin to develop. The cells do not invade normal tissues. This is sometimes called a "precancerous condition." Stage 0 cancer is also called carcinoma in situ. All tumour marker levels are normal.

Stage I

Stage I is divided into stage IA, stage IB, and stage IS and is determined after a radical inguinal orchiectomy is done.

* In stage IA, the cancer is in the testicle and epididymis and may have spread to the inner layer of the membrane surrounding the testicle. All tumour marker levels are normal.

* In stage IB, the cancer:
o is in the testicle and the epididymis and has spread to the blood or lymph vessels in the testicle; or
o has spread to the outer layer of the membrane surrounding the testicle; or
o is in the spermatic cord or the scrotum and may be in the blood or lymph vessels of the testicle.
All tumour marker levels are normal.

* In stage IS, the cancer is found anywhere within the testicle, spermatic cord, or the scrotum and either:
o all tumour marker levels are slightly above normal; or
o one or more tumour marker levels are moderately above normal or high.

Stage II

Stage II is divided into stage IIA, stage IIB, and stage IIC and is determined after a radical inguinal orchiectomy is done.

* In stage IIA, the cancer:
o is anywhere within the testicle, spermatic cord, or scrotum; and
o has spread to up to 5 lymph nodes in the abdomen, none larger than 2 centimeters.
All tumour marker levels are normal or slightly above normal.

* In stage IIB, the cancer is anywhere within the testicle, spermatic cord, or scrotum; and either:
o has spread to up to 5 lymph nodes in the abdomen; at least one of the lymph nodes is larger than 2 centimeters, but none are larger than 5 centimeters; or
o has spread to more than 5 lymph nodes; the lymph nodes are not larger than 5 centimeters.
All tumour markers levels are normal or slightly above normal.

* In stage IIC, the cancer:
o is anywhere within the testicle, spermatic cord, or scrotum; and
o has spread to a lymph node in the abdomen that is larger than 5 centimeters.
All tumour marker levels are normal or slightly above normal.

Stage III

Stage III is divided into stage IIIA, stage IIIB, and stage IIIC and is determined after a radical inguinal orchiectomy is done.

* In stage IIIA, the cancer:
o is anywhere within the testicle, spermatic cord, or scrotum; and
o may have spread to one or more lymph nodes in the abdomen; and
o has spread to distant lymph nodes or to the lungs.
The level of one or more tumour markers may range from normal to slightly above normal.

* In stage IIIB, the cancer:
o is anywhere within the testicle, spermatic cord, or scrotum; and
o may have spread to one or more nearby or distant lymph nodes or to the lungs.
The level of one or more tumour markers may range from normal to high.

* In stage IIIC, the cancer:
o is anywhere within the testicle, spermatic cord, or scrotum; and
o may have spread to one or more nearby or distant lymph nodes or to the lungs or anywhere else in the body.
The level of one or more tumour markers may range from normal to very high.

Recurrent Testicular Cancer

Recurrent testicular cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back many years after the initial cancer, in the other testicle or in other parts of the body.

Treatment Option Overview

Key Points for This Section

* There are different types of treatment for patients with testicular cancer.
* Testicular tumours are divided into 3 groups, based on how well the tumours are expected to respond to treatment.
o Good Prognosis
o Intermediate Prognosis
o Poor Prognosis
* Three types of standard treatment are used:
o Surgery
o Radiation therapy
o Chemotherapy
* New types of treatment are being tested in clinical trials. These include the following:
o High-dose chemotherapy with stem cell transplant
* Lifelong follow-up exams are very important for men who have had testicular cancer.

There are different types of treatment for patients with testicular cancer.

Different types of treatments are available for patients with testicular cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.

Clinical trials are taking place in many parts of the country. Information about ongoing clinical trials is available from the NCI Web site. Choosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team.

Testicular tumours are divided into 3 groups, based on how well the tumours are expected to respond to treatment.

Good Prognosis

For nonseminoma, all of the following must be true:

* The tumour is found only in the testicle or in the retroperitoneum (area outside or behind the abdominal wall); and
* The tumour has not spread to organs other than the lungs; and
* The levels of all the tumour markers are slightly above normal.

For seminoma, all of the following must be true:

* The tumour has not spread to organs other than the lungs; and
* The level of alpha-fetoprotein (AFP) is normal. Beta-human chorionic gonadotropin (β-hCG) and lactate dehydrogenase (LDH) may be at any level.

Intermediate Prognosis

For nonseminoma, all of the following must be true:

* The tumour is found in one testicle only or in the retroperitoneum (area outside or behind the abdominal wall); and
* The tumour has not spread to organs other than the lungs; and
* The level of any one of the tumour markers is more than slightly above normal.

For seminoma, all of the following must be true:

* The tumour has spread to organs other than the lungs; and
* The level of AFP is normal. β-hCG and LDH may be at any level.

Poor Prognosis

For nonseminoma, at least one of the following must be true:

* The tumour is in the center of the chest between the lungs; or
* The tumour has spread to organs other than the lungs; or
* The level of any one of the tumour markers is high.

There is no poor prognosis grouping for seminoma testicular tumours.

Three types of standard treatment are used:

Surgery

Surgery to remove the testicle (radical inguinal orchiectomy) and some of the lymph nodes may be done at diagnosis and staging. (Refer to the General Information and Stages sections of this summary.) Tumours that have spread to other places in the body may be partly or entirely removed by surgery.

Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy or radiation therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to increase the chances of a cure, is called adjuvant therapy.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

New types of treatment are being tested in clinical trials. These include the following:

High-dose chemotherapy with stem cell transplant

High-dose chemotherapy with stem cell transplant is a method of giving high doses of chemotherapy and replacing blood-forming cells destroyed by the cancer treatment. Stem cells (immature blood cells) are removed from the blood or bone marrow of the patient or a donor and are frozen and stored. After the chemotherapy is completed, the stored stem cells are thawed and given back to the patient through an infusion. These reinfused stem cells grow into (and restore) the body’s blood cells.

Lifelong follow-up exams are very important for men who have had testicular cancer.

Men who have had testicular cancer have an increased risk of developing cancer in the other testicle. A patient is advised to regularly check the other testicle and report any unusual symptoms to a doctor right away.

Lifelong clinical exams are very important. The patient will probably have checkups once per month during the first year after surgery, every other month during the next year, and less often after that.

Treatment Options by Stage

Stage I Testicular Cancer

Treatment of stage I testicular cancer depends on whether the cancer is a seminoma or a nonseminoma.

Treatment of seminoma is usually surgery to remove the testicle, with or without radiation therapy to lymph nodes in the abdomen after the surgery, with lifelong follow-up.

Treatment of nonseminoma may include the following:

* Surgery to remove the testicle and lymph nodes in the abdomen, with lifelong follow-up.
* Surgery to remove the testicle, followed by chemotherapy and lifelong follow-up.
* Surgery to remove the testicle, with lifelong follow-up.

Stage II Testicular Cancer

Treatment of stage II testicular cancer depends on whether the cancer is a seminoma or a nonseminoma.

Treatment of seminoma may include the following:

* When the tumour is 5 centimeters or smaller, treatment is usually surgery to remove the testicle followed by radiation therapy to lymph nodes in the abdomen and pelvis, with lifelong follow-up.
* When the tumour is larger than 5 centimeters, treatment is usually surgery to remove the testicle followed by combination chemotherapy or radiation therapy to lymph nodes in the abdomen and pelvis, with lifelong follow-up.

Treatment of nonseminoma may include the following:

* Surgery to remove the testicle and lymph nodes, with lifelong follow-up.
* Surgery to remove the testicle and lymph nodes, followed by combination chemotherapy and lifelong follow-up.
* Surgery to remove the testicle followed by combination chemotherapy and a second surgery if cancer remains, with lifelong follow-up.
* Combination chemotherapy before surgery to remove the testicle, for cancer that has spread and is thought to be life-threatening.
* A clinical trial of combination chemotherapy instead of removing the lymph nodes.

Stage III Testicular Cancer

Treatment of stage III testicular cancer depends on whether the cancer is a seminoma or a nonseminoma.

Treatment of seminoma may include the following:

* Surgery to remove the testicle followed by combination chemotherapy. Any tumour remaining after treatment will need lifelong follow-up.
* A clinical trial of a new therapy.
* A clinical trial of high-dose chemotherapy with bone marrow transplant.

Treatment of nonseminoma may include the following:

* Surgery to remove the testicle, followed by combination chemotherapy.
* Combination chemotherapy followed by surgery to remove any remaining tumour. Additional chemotherapy may be given if the tumour tissue removed contains cancer cells that are growing.
* Combination chemotherapy combined with radiation therapy to the brain for cancer that has spread to the brain.
* Combination chemotherapy before surgery to remove the testicle, for cancer that has spread and is thought to be life-threatening.
* A clinical trial of a new therapy.
* A clinical trial of high-dose chemotherapy with bone marrow transplant.

Treatment Options for Recurrent Testicular Cancer

Treatment of recurrent testicular cancer may include the following: