Testicular cancer

Definition

Testicular cancer is a disease in which cancer cells are discovered in one or both testicles. The testicles, also known as testes or gonads, are located in a pouch beneath the penis called the scrotum.

Description

The testicles make up one portion of the male reproductive system. Normally, they are each somewhat smaller than a golf ball in size and are contained within the scrotum. The testicles are a man's primary source of male hormones, particularly testosterone. They also produce sperm.

There are several types of cells contained in the testicles, and any of these may develop into one or more types of cancer. Over 90% of all testicular cancers begin in cells called germ cells. There are two main types of germ cell tumors in men: seminomas and nonseminomas. Seminomas make up about 40% of all testicular germ cell tumors. Nonseminomas make up a group of cancers, which include choriocarcinoma, yolk sac tumors, embryonal carcinoma, and teratoma.

Although testicular cancer accounts for less then 2% of all cancers in men, it is the most commonly seen cancer in young men aged 15 to 35. It is also one of the most curable.

The American Cancer Society estimates that approximately 7,200 new cases of testicular cancer will be diagnosed in 2001. In addition, about 400 men will die of the disease during that year. Though the incidence of testicular cancer is rising, having doubled in the last 30 years, it is still rare. Scandinavian countries have the highest rate in the world. Germany and New Zealand also have high rates. The lowest incidences of testicular cancer are in Asia and Africa.

— Deanna Swartout-Corbeil, R.N.

Key Terms: Cryptorchidism, Metastatic testicular cancer, Radical inguinal orchiectomy.

Definition

Testicular cancer is a disease in which cancer cells are discovered in one or both testicles. The testicles, also known as testes or gonads, are located in a pouch beneath the penis called the scrotum.

Description

The testicles make up one portion of the male reproductive system. Normally, they are each somewhat smaller than a golf ball in size and are contained within the scrotum. The testicles are a man's primary source of male hormones, particularly testosterone. They also produce sperm.

There are several types of cells contained in the testicles, and any of these may develop into one or more types of cancer. Over 90% of all testicular cancers begin in cells called germ cells. There are two main types of germ cell tumors in men: seminomas and nonseminomas. Seminomas make up about 40% of all testicular germ cell tumors. Nonseminomas make up a group of cancers, which include choriocarcinoma, yolk sac tumors, embryonal carcinoma, and teratoma.

Although testicular cancer accounts for less then 2% of all cancers in men, it is the most commonly seen cancer in young men aged 15 to 35. It is also one of the most curable.

Demographics

The American Cancer Society estimates that approximately 8, 980 new cases of testicular cancer will be diagnosed in American men in 2004. In addition, about 360 men will die of the disease during that year. Although the incidence of testicular cancer is rising, having doubled since 1975, it is still rare. Scandinavian countries have the highest rate in the world. Germany and New Zealand also have high rates. The lowest incidences of testicular cancer are in Asia and Africa.

Causes and Symptoms

The exact causes of testicular cancer are unknown. However, there is research showing that some men are more likely to acquire it than others. The risk for testicular cancer is much higher for boys born with one or both of their testicles located in the lower abdomen rather than in the scrotum. This condition is called cryptorchidism or undescended testicles. The lifetime risk of getting testicular cancer is four times higher for boys with cryptorchidism than the risk in the general population. This risk factor remains even if surgery is done to place the testicle back into the scrotum.

Boys born with Down syndrome are also at higher risk of developing testicular cancer, although the reasons for this increased risk are not yet fully understood as of 2004.

There are other risk factors as well. Men who have had abnormal development of their testicles are at increased risk, as are men with Klinefelter's syndrome (a disorder of the sex chromosomes). A family history of testicular cancer increases the possibility of getting the disease. Men infected with the human immunodeficiency virus (HIV), especially those with AIDS, have a higher incidence, as do infertile men. Certain testicular tumors appear more frequently among men who work in certain occupations, like miners, oil workers, and utility workers. There is no conclusive evidence that injuries to the testicles, or environmental exposure to various chemicals causes the disease.

Testicular cancer usually shows no early symptoms. It is suspected when a mass or lump is felt in the testes, although a testicular mass does not always indicate cancer and is usually painless.

Symptoms of testicular cancer include:

• a lump in either testicle (usually pea-sized, but may be as large as a marble or an egg)
• any enlargement or significant shrinking of a testicle
• a sensation of heaviness in the scrotum
• a dull ache in the groin or lower abdomen
• any sudden collection of fluid in the scrotum
• tenderness or enlargement of the breasts
• pain or discomfort in a testicle or in the scrotum

Diagnosis

When a man exhibits symptoms that suggest a possibility of testicular cancer, several diagnostic steps will occur before a definitive diagnosis is made.

History and Physical

The physician takes a personal and family medical history and a complete physical examination is performed. The doctor will examine the scrotum as well as the abdomen and other areas to check for additional masses.

Imaging Studies

If a mass is found, the physician will likely have an ultrasound performed. Through the use of sound waves, ultrasounds can help visualize internal organs and may be useful in telling the difference between fluid-filled cysts and solid masses. If the tumor is solid, it is most likely cancerous.

Computed tomography as well as ultrasound may be used to diagnose malignant germ cell tumors in undescended testes.

Blood Tests

Certain blood tests can be helpful in diagnosing some testicular tumors. Tumor markers are substances often found in higher-than-normal amounts in cancer patients. Some testicular cancers secrete high levels of certain proteins such as alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and enzymes like lactate dehydrogenase (LDH). These markers may help find a tumor that is too small to be felt during a physical examination. In addition, these tests are also helpful in determining how much cancer is actually present, and in evaluating the response to treatment to make sure the tumor has not returned.

Surgery

If a suspicious growth is found, a surgeon will need to remove the tumor and send it to the laboratory for testing. A pathologist examines the testicular tissue microscopically to determine whether cancer cells are present. If cancer cells are found, the pathologist sends back a report describing the type and extent of the cancer. In almost all cases, the surgeon removes the entire affected testicle through an incision in the groin, though not through the scrotum. This procedure is called radical inguinal orchiectomy.

Once testicular cancer is determined, further tests are necessary to find out if the cancer has metastasized (spread) to other parts of the body, and to ascertain the stage or extent of the disease. This information helps the doctor plan appropriate treatment. These tests may include computed tomography (CT scan), lymphangiography (x rays of the lymph system), bone scans, and chest x rays.

Treatment Team

From diagnosis through treatment and follow-up, several health care professionals participate in the care of the person with testicular cancer. Patients usually seek help from their primary physician after first noticing the lump or other suspicious symptom. A referral to the urologist will follow. The urologist usually performs any diagnostic tests as well as any necessary surgery. A pathologist makes the definitive cancer diagnosis by looking at the cells under a microscope. After the diagnosis is made, the patient will usually see a medical oncologist. If it is determined that radiation therapy is appropriate treatment, a visit to the radiation oncologist is recommended as well. Specially trained nurses will administer chemotherapy if necessary.

Clinical Staging, Treatments, and Prognosis

Staging

One method the cancer treatment team uses to describe the scope of a patient's cancer is the use of a staging system. Testicular cancer is classified using the TNM system. However, in order to simplify and summarize this information, the TNM description can be grouped according to stages.

Stages of testicular cancer:

• Stage I. This stage refers to a cancer found only in the testicle, with no spread to the lymph nodes or to distant organs.
• Stage II. This indicates that the cancer has spread to the lymph nodes in the abdomen, but not to lymph nodes in other parts of the body.
• Stage III. In this stage, the cancer has spread beyond the lymph nodes in the abdomen, and/or the cancer is in parts of the body far away from the testicles, such as the lungs or the liver.

• Recurrent. Recurrent disease indicates that the cancer has come back after it has already been treated. Testicular cancer can come back in the same testicle (if it was not surgically removed) or in some other body part.

Treatment

The treatment decisions for testicular cancer are dependent on the stage and cell type of the disease, as well as the patient's age and overall health. The four kinds of treatment most commonly used are surgery, radiation therapy, chemotherapy, and bone marrow or stem cell transplantation.

Surgery is normally the first line of treatment for testicular cancer and involves the removal of the affected testicle. This procedure is known as a radical inguinal orchiectomy. Depending on the type and stage of the cancer, some lymph nodes may also be removed at the same time, or possibly in a second operation. This procedure is called a retroperitoneal lymph node dissection, and can be a major operation. Some patients will experience temporary complications after surgery, including infections and bowel obstruction. If both of the testicles are taken out, a man will have no ability to produce sperm cells and will become infertile (unable to father a child). Surgery removing the lymph nodes may cause some damage to nearby nerves, which may interfere with the ability to ejaculate. Men undergoing surgery for testicular cancer may wish to discuss nerve-sparing surgery with their doctor, as well as sperm banking.

Radiation therapy for testicular cancer is delivered from a machine and is known as external beam radiation. One potential problem with this type of radiation is that it can also destroy nearby healthy tissue as well as cancer cells. Other potential side effects include nausea, diarrhea and fatigue. A special device can be used to protect the unaffected testicle to preserve fertility.

Chemotherapy refers to the use of drugs in treating cancer. Since the drugs enter the bloodstream and circulate throughout the body, chemotherapy is considered a systemic treatment. The drugs primarily used in the treatment of testicular cancer are cisplatin, vinblastine, bleomycin, cyclophosphamide, etoposide, and ifosfamide. These drugs are given in various combinations, since the use of two or more drugs is considered more effective than using only one drug.

Since chemotherapy agents can affect normal as well as cancerous cells, several side effects are possible. These side effects include:

• nausea and vomiting
• changes in appetite (anorexia)
• temporary hair loss (alopecia)
• mouth sores
• increased risk of infections
• bleeding or bruising
• fatigue
• diarrhea or constipation

Several drugs are available to assist in treating these side effects, most of which will disappear after the treatment is completed. However, some of the chemotherapy agents used during treatment of testicular cancer may cause long-term side effects. These include hearing loss, nerve damage, and possible kidney or lung damage. Another potentially serious long-term complication is an increased risk of leukemia. This is a rare side effect, however, as it occurs in less than 1% of testicular cancer patients who receive chemotherapy. Chemotherapy may also interfere with sperm production. This may be permanent for some, but many will regain their fertility within a few years.

Studies are ongoing to determine whether high doses of chemotherapy combined with stem-cell transplantation will prove effective in treating some patients with advanced testicular cancer. In this treatment, blood-forming cells called stem cells are taken from the patient (either from the bone marrow or filtered out of the patient's blood). These cells are kept frozen while high-dose chemotherapy is administered. After receiving the chemotherapy, the patient is given the stem cells through an infusion. This treatment enables the use of extra large doses of chemotherapy that might increase the cure rate for some testicular cancers.

Preferred Treatment Plans By Stage of Disease

Stage I: Stage I seminomas are normally treated with a radical inguinal orchiectomy followed by radiation treatment aimed at the lymph nodes. More than 95% of Stage I seminomas are cured through this method. Another approach is to perform surgery only. Patients are then followed closely for several years with blood tests and imaging studies. If the cancer spreads later on, radiation or chemotherapy can still be used. Stage I nonseminomas are also highly curable with surgery, followed by one of three options. These options include the performance of a retroperitoneal lymph node dissection, two cycles of chemotherapy, or careful observation for several years.

Stage II: Stage II seminomas and non-seminomas are cured in 90% to 95% of the cases. For the purposes of treatment, stage II testicular cancers are classified as either bulky or nonbulky. Nonbulky seminomas (no lymph nodes can be felt in the abdomen) are treated with an orchiectomy followed by radiation to the lymph nodes. Men with bulky seminomas have surgery, which may be followed by either radiation or a course of chemotherapy. Nonbulky Stage II non-seminomas are treated with surgery and lymph node removal, with possible chemotherapy. Men with bulky disease have surgery followed by chemotherapy.

Stage III: Stage III seminomas and non-seminomas are treated with surgery followed by chemotherapy. This produces a cure in about 70% of the cases. Those who are not cured may be eligible to participate in clinical trials of other chemotherapy agents.

Recurrent: Treatment of recurrent testicular cancer is dependent upon the initial stage and the treatment given. This might include further surgery and chemotherapy. Many men whose disease comes back after chemotherapy are treated with high-dose chemotherapy followed by bone marrow or stem cell transplantation.

Alternative and Complementary Therapies

There are currently no scientifically proven alternative treatments known for testicular cancer. Nothing has been shown to be as successful as conventional treatment. However, some patients may find certain alternative or complementary treatments supportive while undergoing surgery, chemotherapy or radiation. For example, meditation and relaxation exercises may prove effective in reducing nausea and vomiting. Some dietary modifications and nutritional supplements may be helpful in assisting with recovery after surgery. The testicular cancer patient considering alternative treatments should talk it over with members of the cancer care team. They may be able to offer additional information.

Coping With Cancer Treatment

Coping with the effects of cancer treatment can often prove challenging. One of the most common effects of treatment is fatigue. The man going through treatment for testicular cancer should allow time for recovery, and not rush back to normal activities. Eating a balanced diet of healthy foods may be helpful as well. Enlisting friends and family members to aid with transportation and responsibilities at home is another way of coping. Most of the side effects of treatment for testicular cancer can be alleviated. In addition, many men experience some levels of anxiety and/or depression during diagnosis and treatment. These can also be treated through medication and/or counseling.

Clinical Trials

Important research into testicular cancer is ongoing at many medical institutions around the country. Scientists are examining the changes that occur to the DNA of testicular cancer cells, in order to improve their understanding of the causes of the disease, and to find more effective treatments. Clinical trials are a method for doctors to explore new treatment options. For example, stem cell transplantation is being studied as one way to help men with recurrent cancer or a poor prognosis. Various chemotherapy regimens are being tested to find out if changing doses or specific drugs might reduce the incidence of side effects without reducing the effectiveness of treatment. For information on specific clinical trials, patients may ask the cancer care team or get a list of current clinical trials from the National Cancer Institute (see Resources.)

Prevention

The main risk factors associated with testicular cancer—cryptorchidism, family history of the disease, and being Caucasian—are unavoidable since they are present at birth. In addition, many men diagnosed with the disease have no known risk factors. Because of these reasons, it is not possible to prevent most incidences of testicular cancer.

Special Concerns

For many men, testicles are symbolic of manhood, and the removal of one can lead to embarrassment, or fear about a partner's reaction. Indeed, after surgical removal, the affected side of the scrotum does look and feel empty. To correct this, a patient can have a testicular prosthesis implanted in his scrotum. This prosthesis looks and feels like a real testicle, and the surgical procedure usually leaves only a small scar.

Questions to Ask the Doctor

• How do I perform a testicular self examination?
• What kind of testicular cancer do I have?
• What treatment choices do I have?
• What side effects can I expect from my treatment?
• How long will it take me to recover?
• What are the chances that the cancer will come back?
• Is there a chance I will become infertile?

As of 2004, there is growing evidence that men treated with cisplatin for testicular cancer are at increased risk of coronary artery disease ten years or longer after treatment. In addition, men who have had an orchiectomy followed by external beam radiation therapy have a significantly increased risk of dying from heart disease or a second cancer.

Resources

Books

Beers, Mark H., MD, and Robert Berkow, MD, editors. "Testicular Cancer." Section 17, Chapter 233 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

Nichols, Craig R., et al. "Neoplasms of the Testis." In Cancer Medicine. 5th ed. Hamilton, Ontario: American Cancer Society, 2000.

Periodicals

Mercer, E. S., B. Broecker, E. A. Smith, et al. "Urological Manifestations of Down Syndrome." Journal of Urology 171 (March 2004): 1250–1253.

Muttarak, M., W. C. Peh, and B. Chaiwun. "Malignant Germ Cell Tumours of Undescended Testes: Imaging Features with Pathological Correlation." Clinical Radiology 59 (February 2004): 198–2004.

Nuver, J., A. J. Smit, D. T. Sleijfer, et al. "Microalbuminuria, Decreased Fibrinolysis, and Inflammation as Early Signs of Atherosclerosis in Long-Term Survivors of Disseminated Testicular Cancer." European Journal of Cancer 40 (March 2004): 701–706.

Zagars, G. K., M. T. Ballo, A. K. Lee, and S. S. Strom. "Mortality after Cure of Testicular Seminoma." Journal of Clinical Oncology 22 (February 18, 2004): 640–647.

Organizations

American Cancer Society. (800) ACS-2345.

National Cancer Institute. Cancer Information Service. (800) 4-CANCER.

Other

American Cancer Society (ACS). Cancer Facts & Figures 2004..

National Cancer Institute CancerNet. [cited June 19, 2001]. .

The Testicular Cancer Resource Center. [cited June 19, 2001]. .

—Deanna Swartout-Corbeil, R.N.; Rebecca J. Frey, PhD

For more information on testicular cancer, visit Britannica.com.

This article may require cleanup to meet Wikipedia's quality standards. Please improve this article if you can. (June 2007)

Testicular Cancer
Classification and external resources
7.4 x 5.5-cm seminoma in a radical orchiectomy specimen.
ICD-10	C62.
OMIM	273300
DiseasesDB	12966
eMedicine	med/2250 med/863
MeSH	D013736

Testicular cancer is cancer that develops in the testicles, a part of the male reproductive system.

In the United States, between 7,500 and 8,000 diagnoses of testicular cancer are made each year.^[1][2] Over his lifetime, a man's risk of testicular cancer is roughly 1 in 250 (0.4%). It is most common among males aged 15–40 years, particularly those in their mid-twenties. Testicular cancer has one of the highest cure rates of all cancers: in excess of 90 percent; essentially 100 percent if it has not metastasized. Even for the relatively few cases in which malignant cancer has spread widely, chemotherapy offers a cure rate of at least 85 percent today. Not all lumps on the testicles are tumors, and not all tumors are malignant; there are many other conditions such as testicular microlithiasis, epididymal cysts, appendix testis (hydatid of Morgagni), and so on which may be painful but are non-cancerous.

Contents 1 Prevalence and distribution 2 Signs and symptoms 3 Diagnosis 4 Management 5 Classification 5.1 Staging 5.2 Histology 5.2.1 Germ cell tumors of the testis, by frequency 5.2.2 Non-germ cell tumors of the testis 5.2.3 Secondary tumors of the testis 6 Treatment 6.1 Surgery 6.1.1 Orchiectomy 6.1.2 Retroperitoneal Lymph Node Dissection (RPLND) 6.2 Radiation therapy 6.3 Chemotherapy 7 Actions after treatment 7.1 Surveillance 7.2 Fertility 7.3 Genetics 8 In animals 9 References 10 External links

Prevalence and distribution

Testicular cancer is most common among caucasian men and rare among men of African descent.^[3] Testicular cancer is uncommon in Asia and Africa. Worldwide incidence has doubled since the 1960s, with the highest rates of prevalence in Scandinavia, Germany, and New Zealand.

Incidence among African Americans doubled from 1988 to 2001 with a bias towards seminoma. The lack of significant increase in the incidence of early-stage testicular cancer during this timeframe suggests that the overall increase was not due to heightened awareness of the disease.

Although testicular cancer is most common among men aged 15–40 years, it has three peaks: infancy through the age of four as teratomas and yolk sac tumors, ages 25–40 years as post-pubertal seminomas and nonseminomas, and from age 60 as spermatocytic seminomas.^[4]

Germ cell tumors of the testis are the most common cancer in young men between the ages of 15 and 35 years.^[5]

A major risk factor for the development of testis cancer is cryptorchidism (undescended testicles). It is generally believed that the presence of a tumor contributes to cryptorchidism; when cryptorchidism occurs in conjunction with a tumor then the tumor tends to be large. Other risk factors include inguinal hernia^[6], mumps orchitis ^[7]. Physical activity is associated with decreased risk and sedentary lifestyle is associated with increased risk. Early onset of male characteristics is associated with increased risk. These may reflect endogenous or environmental hormones.

Signs and symptoms

A testicular mass can often be palpated. Because testicular cancer is curable when detected early (stage one can have a success rate of >98%), experts recommend regular monthly testicular self-examination after a hot shower or bath, when the scrotum is looser. Men should examine each testicle, feeling for pea-shaped lumps. The testicle should normally feel smooth to the touch. Ridges may be felt because of enlarged blood vessels or tumor growth. Additionally the entire testicle may feel hard and bumpy to the touch.The U.S. Preventive Services Task Force (USPSTF) recommends against routine screening for testicular cancer in asymptomatic adolescent and adult.^[8]

Symptoms may include one or more of the following:

• a lump in one testis or a hardening of one of the testicles
• abnormal sensitivity (either numbness or pain)
• loss of sexual activity or interest
• sexual withdrawal
• A burning sensation, specially following physical activity.
• build-up of fluid in the scrotum or tunica vaginalis, known as a hydrocele
• a dull ache in the lower abdomen or groin, sometimes described as a "heavy" sensation
• lumbago - lower back pain
• An increase, or significant decrease, or sudden decrease in the size of one or both testes. The testicle with a tumor may be severely enlarged, as much as 3 times the original size. Simultaneously the other testicle may be shrunken in size, due to the tumor taking up the majority of the blood supply to the scrotum.
• blood in semen
• general weak and tired feeling

The nature of any palpated lump in the scrotum is evaluated by scrotal ultrasound, which can determine exact location, size, and some characteristics of the lump, such as cystic vs solid, uniform vs heterogeneous, sharply circumscribed or poorly defined. The extent of the disease is evaluated by CT scans, which are used to locate metastases. Blood tests are also used to identify and measure tumor markers that are specific to testicular cancer. AFP alpha1 feto protein, Beta-HCG, and LDH are the typical markers used to identify testicular cancer. The diagnosis is made by performing an inguinal orchiectomy, surgical excision of the entire testis along with attached structures epididymis and spermatic cord; the resected specimen is evaluated by a pathologist. A biopsy should not be performed, as it raises the risk of migrating cancer cells into the scrotum. The reason why inguinal orchiectomy is the preferred method is that the lymphatic system of the scrotum links to the lower extremities and that of the testicle links to the retroperitoneum. A transscrotal biopsy or orchiectomy will potentially leave cancer cells in the scrotum and create two vectors for cancer spread, while in an inguinal orchiectomy only the retroperitoneal route exists.

Diagnosis

Micrograph (high magnification) of a seminoma. H&E stain.

The cardinal diagnostic finding in the patient with testis cancer is a mass in the substance of the testis. Unilateral enlargement of the testis with or without pain in the adolescent or young adult male should raise concern for testis cancer.

An incorrect diagnosis is made at the initial examination in up to 25% of patients with testicular tumors and may result in delay in treatment or a suboptimal approach (scrotal incision) for exploration.

• Epididymitis or epididymoorchitis
• Hematocele
• Varicocele

The differential diagnosis of testicular cancer requires examining the histology of tissue obtained from an inguinal orchiectomy specimen. Orchiectomy, rather than transcrotal biopsy, is preferred to reduce the risk of spill and thus the risk of metastasis, in the event that the tumor is malignant. For orchiectomy, an inguinal surgical approach is preferred.

Management

Before 1970, the young man with recurrent testicular cancer was destined to have rapid progression and death from disseminated disease. Currently, although 7000 to 8000 new cases of testicular cancer occur in the United States yearly, only 400 men are expected to die of the disease. Much of this improvement is due to advances in adjuvant therapy.

Due to the risk of subsequent metastasis, post-surgical adjuvant therapy may be offered to the patient following orchiectomy. The type of adjuvant therapy depends largely on the histology of the tumor and the stage of progression at the time of surgery. These two factors contribute to the risk of recurrence, including metastasis. Adjuvant treatments may involve chemotherapy, radiotherapy or careful surveillance by frequent CT scans and blood tests by oncologists.

Classification

Main article: Germ cell tumor

Although testicular cancer can be derived from any cell type found in the testicles, more than 95% of testicular cancers are germ cell tumors. Most of the remaining 5% are sex cord-gonadal stromal tumours derived from Leydig cells or Sertoli cells. Thus, the focus of diagnosis is on determining which germ cell tumor is present. Correct diagnosis is necessary to ensure the most effective and least harmful treatment. To some extent, this can be done via blood tests for tumor markers, but differential diagnosis requires examination of the histology of a specimen by a pathologist.

Staging

After removal, a testicular tumor is staged by a pathologist according to the TNM Classification of Malignant Tumors as published in the AJCC Cancer Staging Manual. Testicular cancer is categorized as being in one of three stages (which have subclassifications). The size of the tumor in the testis is irrelevant to staging. [2] In broad terms, testicular cancer is staged as follows:

• Stage I: the cancer remains localized to the testis.
• Stage II: the cancer involves the testis and metastasis to retroperitoneal and/or Paraaortic lymph nodes (lymph nodes below the diaphragm).
• Stage III: the cancer involves the testis and metastasis beyond the retroperitoneal and Paraaortic lymph nodes. Stage III is further subdivided into nonbulky stage III and bulky stage III. ^[9]
• Stage IV: if there is liver and/or lung secondaries

Histology

After removal, a testicular tumor is classified by a pathologist according to its histology.

Germ cell tumors of the testis, by frequency

Main article: Germ cell tumor

It contained the following materials

• 40% mixed (usually teratoma plus another)
• 35% seminoma (germinoma of the testis)
• 20% embryonal carcinoma
• 5% teratoma (pure)
• <1% choriocarcinoma
• Endodermal sinus tumor
• Gonadoblastoma

Also: Intratubular germ cell neoplasms (the in situ stage of germ cell tumors)

Non-germ cell tumors of the testis

• Sex cord-gonadal stromal tumour (usually benign)

Secondary tumors of the testis

• Lymphoma
• Leukemic infiltration of the testis
• Metastatic tumors (prostate, lung, GI, renal, melanoma) ^[10]

Treatment

The three basic types of treatment are surgery, radiation therapy, and chemotherapy.^[11]

Surgery is performed by urologists; radiation therapy is administered by radiation oncologists; and chemotherapy is the work of medical oncologists.The UK are offering injections for boys in Secondary school

In most patients with testicular cancer, the disease is cured readily with minimal long-term morbidity.

Surgery

Orchiectomy

While it may be possible, in some cases, to remove testicular cancer tumors from a testis while leaving the testis functional, this is almost never done, as the affected testicle usually contains pre-cancerous cells spread throughout the entire testicle. Thus removing the tumor alone without additional treatment greatly increases the risk that another cancer will form in that testicle . Since only one testis is typically required to maintain fertility, hormone production, and other male functions, the afflicted testis is almost always removed completely in a procedure called inguinal orchiectomy. (The testicle is almost never removed through the scrotum; an incision is made beneath the belt line in the inguinal area.) Most notably, since removing the tumor alone does not eliminate the precancerous cells that exist in the testis, it is usually better in the long run to remove the entire testis to prevent another tumor. A plausible exception could be in the case of the second testis later developing cancer as well.

Retroperitoneal Lymph Node Dissection (RPLND)

In the case of nonseminomas that appear to be stage I, surgery may be done on the retroperitoneal/Paraaortic lymph nodes (in a separate operation) to accurately determine whether the cancer is in stage I or stage II and to reduce the risk that malignant testicular cancer cells that may have metastasized to lymph nodes in the lower abdomen. This surgery is called Retroperitoneal Lymph Node Dissection (RPLND). However, this approach, while standard in many places, especially the United States, is out of favor due to costs and the high level of expertise required to perform the surgery. The urologist may take extra care in the case of males who have not fathered children, to preserve the nerves involved in ejaculation.

Many patients are instead choosing surveillance, where no further surgery is performed unless tests indicate that the cancer has returned. This approach maintains a high cure rate because of the growing accuracy of surveillance techniques.

Lymph node surgery may also be performed after chemotherapy to remove masses left behind, particularly in the cases of advanced initial cancer or large nonseminomas.

Radiation therapy

Radiation may be used to treat stage II seminoma cancers, or as adjuvant (preventative) therapy in the case of stage I seminomas, to minimize the likelihood that tiny, non-detectable tumors exist and will spread (in the inguinal and para-aortic lymph nodes). Radiation is never used as a primary therapy for nonseminoma.

Chemotherapy

As an adjuvant treatment, use of chemotherapy as an alternative to radiation therapy in the treatment of seminoma is increasing, because radiation therapy appears to have more significant long-term side effects (for example, internal scarring, increased risks of secondary malignancies, etc.). Two doses, or occasionally a single dose of carboplatin, typically delivered three weeks apart, is proving to be a successful adjuvant treatment, with recurrence rates in the same ranges as those of radiotherapy. However, very long term data on the efficacy of adjuvant carboplatin in this setting does not exist. Since seminoma can recur decades after the primary tumor is removed, patients receiving adjuvant chemotherapy should remain vigilant and not assume they are cured 5 years after treatment.

Chemotherapy is the standard treatment for non-seminoma when the cancer has spread to other parts of the body (that is, stage IIb or III). The standard chemotherapy protocol is three, or sometimes four, rounds of Bleomycin-Etoposide-Cisplatin (BEP). This treatment was developed by Dr. Lawrence Einhorn at Indiana University.^[12] An alternative, equally effective treatment involves the use of four cycles of Etoposide-Cisplatin (EP).

While treatment success depends on the stage, the average survival rate after five years is around 95%, and stage I cancers cases (if monitored properly) have essentially a 100% survival rate (which is why prompt action, when testicular cancer is a possibility, is extremely important).

Actions after treatment

Surveillance

For stage I cancers that have not had any adjuvant (preventative) therapy, close monitoring for at least a year is important, and should include blood tests (in cases of nonseminomas) and CT-scans (in all cases), to ascertain whether the cancer has metastasized (spread to other parts of the body). For other stages, and for those cases in which radiation therapy or chemotherapy was administered, the extent of monitoring (tests) will vary on the basis of the circumstances, but normally should be done for five years (with decreasing intensity). For the first year blood tests for tumor markers should be done monthly, and decreasing to once every three months in the years after. CT scans should be performed once every three months in the first year and decreasing to once every six months thereafter. The high cost of CT scans and the relative danger of the radiation involved both being factors in the relative infrequence with which tests are performed. CT-scans are performed on the abdomen (and sometimes the pelvis) whereas chest x-rays are preferred for the lungs as they give sufficient detail combined with a lower false-positive rate and significantly smaller radiation dose.

Fertility

A man with one remaining testis can lead a normal life, because the remaining testis takes up the burden of testosterone production and will generally have adequate fertility.[3] However, it is worth the (minor) expense of measuring hormone levels before removal of a testicle, and sperm banking may be appropriate for younger men who still plan to have children, since fertility may be lessened by removal of one testicle^{[citation needed]}, and can be severely affected if extensive chemotherapy and/or radiotherapy is done.

Less than five percent of those who have testicular cancer will have it again in the remaining testis. A man who loses both testicles will normally have to take hormone supplements (in particular, testosterone, which is created in the testicles), and will be infertile, but can lead an otherwise normal life.

Genetics

Most testicular germ cell tumors have too many chromosomes, and most often they are triploid to tetraploid. An isochromosome 12p (the short arm of chromosome 12 on both sides of the same centromere) is present in about 80 % of the testicular cancers, and also the other cancers usually have extra material from this chromosome arm through other mechanisms of genomic amplification. ^[13]

In animals

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Testicular tumors occur also in animals. In horses, these include interstitial cell tumors and teratomas. Typically, the former are found in older stallions (affected stallions may become extremely vicious, suggesting excessive production of androgen), and the latter are found in young horses and are large.^[14]

References

1. ^ Cancer Facts and Figures 2003, Atlanta, GA: American Cancer Society, 2003, http://www.cancer.org/downloads/STT/CAFF2003PWSecured.pdf, retrieved 2008-04-24 
2. ^ Cancer Facts and Figures 2007, Atlanta, GA: American Cancer Society, 2007, http://www.cancer.org/downloads/STT/CAFF2007PWSecured.pdf, retrieved 2008-04-24 
3. ^ "Cancer of the testicle Causes - Health encyclopaedia - NHS Direct". http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=85&sectionId=5. Retrieved 2007-12-13. 
4. ^ Leendert H. J. Looijenga; J. Wolter Oosterhuis (May 1999). "Pathogenesis of testicular germ cell tumours" (pdf). Reviews of Reproduction (England: Journals of Reproduction and Fertility) 4 (2): 90–100. ISSN 1359-6004. PMID 10357096. http://ror.reproduction-online.org/cgi/reprint/4/2/90. Retrieved July 31, 2009. 
5. ^ Holmes L; Escalante C, Garrison O, Foldi BX, Ogungbade GO, Essien EJ, Ward D (September 2008). "Testicular cancer incidence trends in the United States (1975−2004): Plateau or shifting racial paradigm?". Public Health (England: Elsevier) 122 (9): 862–872. doi:10.1016/j.puhe.2007.10.010. 
6. ^ Forman, D; M C Pike, G Davey, S Dawson, K Baker, C E D Chilvers, R T D Oliver, C A C Coupland (28 May 1994). "Aetiology of testicular cancer: association with congenital abnormalities, age at puberty, infertility, and exercise". BMJ (England: BMJ Publishing Group) 308 (6941): 1393–1399. ISSN 0959-8138. PMID 7912596. http://www.bmj.com/cgi/content/full/308/6941/1393. Retrieved 2008-01-23. 
7. ^ Swerdlow, AJ; Huttly SR, Smith PG. (January 1987). "Testicular cancer and antecedent diseases". British Journal of Cancer (England: Nature Publishing Group on behalf of Cancer Research UK) 55 (1): 97–103. ISSN 0007-0920. PMID 2880604. 
8. ^ [1]
9. ^ "Testicular Cancer Resource Center's Staging Page". http://tcrc.acor.org/staging.html. Retrieved 2007-12-13. 
10. ^ "Secondary Tumors of the Testis -Genital Tumors". http://www.health.am/cr/more/secondary-tumors-of-the-testis/. Retrieved 2007-12-13. 
11. ^ "Testicular Cancer Treatment (PDQ)". National Cancer Institute. 2009-01-15. http://www.cancer.gov/cancertopics/pdq/treatment/testicular/HealthProfessional/page8. Retrieved 2009-02-13. 
12. ^ "Chemotherapy - BEP and EP". http://www.tc-library.com/chemotherapy-bep-and-ep/. Retrieved 2009-02-16. 
13. ^ Specific chromosome change, i(12p), in testicular tumours?, 1982, http://www.ncbi.nlm.nih.gov/pubmed/6128640?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum 
14. ^ Jones, T. C., R. D. Hunt, and N. W. King (1997). Veterinary pathology (6th ed.). Wiley-Blackwell. pp. 1392. ISBN 0683044818, 9780683044812. http://books.google.com/books?id=8fXzJrDfFgUC.  page 1210.

External links

• Testicular Cancer: Survival High with Early Treatment
• National Institute of Health information and links
• Testicular Cancer Resource Center
• Understanding Testicular Cancer from The Cancer Council Australia
• Testicular Cancer at UK NHS

v • d • e Tumors: urogenital neoplasia · genital neoplasia (C51-C63/D25-29, 179-187/218-222) Female Ovaries Glandular and epithelial Clear cell adenocarcinoma · Endometrioid tumor CMS: Krukenberg tumor · Serous cystadenoma/Mucinous cystadenoma · Cystadenocarcinoma/Papillary serous cystadenocarcinoma Sex cord-gonadal stromal Leydig cell tumour · Sertoli cell tumour · Sertoli-Leydig cell tumour · Thecoma · Granulosa cell tumour · Luteoma Connective tissue Fibroma (Meigs syndrome) · Surface epithelial-stromal tumor (Brenner tumour) Germ cell Dysgerminoma · Embryonal carcinoma · Gonadoblastoma · Teratoma · Choriocarcinoma Fallopian tube Adenomatoid tumor Uterus Uterine sarcoma · Leiomyosarcoma Endometrium (Endometrioid tumor), (Uterine papillary serous carcinoma), (Clear cell carcinoma) Adenomyoma Cervix (SCC, Cervical intraepithelial neoplasia) Vagina SCC · Botryoid rhabdomyosarcoma · Adenocarcinoma/Clear cell adenocarcinoma Vulva Papillary hidradenoma · Extramammary Paget's disease Placenta Choriocarcinoma Male Testicles Sex cord-gonadal stromal Sertoli-Leydig cell tumour (Sertoli cell tumor, Leydig cell tumor) Germ cell G Seminoma (Spermatocytic seminoma) · Intratubular germ cell neoplasia NG Embryonal carcinoma · Endodermal sinus tumor · Gonadoblastoma · Teratoma · Choriocarcinoma · Embryoma Prostate Adenocarcinoma · Prostatic intraepithelial neoplasia (HGPIN) · Small cell carcinoma · Transitional cell carcinoma Penis Carcinoma (Extramammary Paget's disease) · Bowen's disease · Bowenoid papulosis · Erythroplasia of Queyrat reproductive system navs: anat female,male/physio/dev, noncongen/congen/neoplasia, symptoms+signs/eponymous, proc

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