Testicular cancer, or cancer of the testis, is one of the commonest cancers in young adult males. Besides the usual pressures that a cancer patient faces, there can also be the added factor of embarrassment for the patient to be stricken with cancer in the genital area.

This cancer spreads to distant areas of the body via the lymphatic system and the blood stream. The areas of spread include the lymph nodes, lungs, liver, bones and even the brain. The more aggressive the tumour, the faster and wider the spread and the poorer the prognosis (outcome).

To understand testicular cancer, it is essential to know the different main types of cells the testis contains. They are:

1. Sertoli cells are found in the tubules of the testis, providing support and nutrition to the immature sperms.
2. Leydig cells secrete androgens (male hormones), mainly testosterone.
3. Germ cells are capable of dividing and replication. They are the ones that give rise to the sperm cells.

Types of Testicular Cancers

1. Seminoma

Seminomas are the commonest type of testicular cancers. They occur most commonly in men between the ages of 35 and 45 years. They are produced by the germ cells and can result in large testicular cancers.

2. Teratoma

Teratomas may occur at any age but are commonest between 20 and 35 years of age. Hair, skin and even teeth may be found in these cancers.

3. Combined seminoma and teratoma

The tumour has elements of both seminoma and teratoma.

4. Lymphomas

This is the most common form of testicular cancer in elderly men. It is a cancer of lymph tissue, and the outcome is extremely bad.

5. Interstitial Tumours

i) Leydig cell tumours

ii) Sertoli cell tumours

These tumours may secrete testosterone. Some also secrete oestrogen (female hormones), leading to gynaecomastia, i.e. the development of feminine breasts in an adult male.

6. Other Tumours

Some other types of testicular cancers are yolk sac tumour, choriocarcinoma and embryonal carcinoma.

There are also several pre-disposing factors that may place some men in the higher risk category.

1. Undescended testis

Both testes descend into the scrotum during foetal development. When there is a developmental defect, one or both testes fail to descend and remain in the abdomen.

2. Existing cancer in a testis

The risk of cancer occurring in the normal remaining testis increases when there is already testicular cancer in one testis.

3. Genetic factors

Although there is no obvious pattern of inheritance, there appears to be genetic involvement.

Signs and Symptoms

1. Enlargement of the testis

i) Painless

This is the most common symptom. If the cancerous mass is large, there may be a heavy dragging sensation in the scrotum.

ii) Painful
This is rare.

2. Chest pain, shortness of breath, cough (with or without blood in the sputum)

These symptoms are due to the fact that the cancer has spread to the lungs.

3. Abdominal pain or masses may be present when the cancer has spread to the abdomen
4. Lower back pain



5. Enlarged lymph nodes in the region just above the clavicle (collar bone)
6. Pain and swelling of the testis (rare)
7. Gynaecomastia

This means the development of female breasts.

Testicular Self-examination

Now, armed with a basic knowledge of testicular cancer, males should examine their testes monthly for early detection of testicular cancer, especially since the testes are in so accessible a site. The earlier the cancer is detected, the higher the survival rate.

It is best to examine the testes when the scrotal skin is relaxed, such as after a warm bath. While standing, examine the testes one at a time. Hold the testis gently in one hand, with the thumb on the front and the index and middle fingers at the back of the scrotum. Feel the testicular surface for lumps. A mass due to testicular cancer is usually not painful.

Do not be alarmed if one testis is larger than the other. This is normal.

Continue by feeling the epididymis and vas deferens for unusual swellings and tenderness. The epididymis is a cord-like structure, which store the sperms, located on the top and back of the testis. The vas deferens is a tube that transports the sperms from the epididymis to the penis.

Staging

Staging involves undergoing several tests to find out whether the cancer has spread and how far it has spread. Only after an accurate staging can the appropriate treatment be instituted.

1. Ultrasound of the testes to establish the size and assess local spread of the cancer.
2. Blood tests to determine the presence and level of tumour markers such as AFP (alpha-foetoprotein) and beta HCG (human chorionic gonadotropin).

These tumour markers (proteins) are produced by germ cell testicular cancers. Raised levels of these proteins would cause one to suspect the presence of testicular cancer. They help in the staging and in the follow-up of the patient. Levels of these proteins fall after treatment and rise if the cancer recurs.

3. Radiography

Chest X-rays, bone scans, CT-scans (computerised axial scans) of the chest, abdomen or brain may be required.

4. Biopsy to determine type and spread of testicular cancer.

Treatment

Treatment involves surgical removal of the cancerous testis and accessible cancerous lymph nodes. Depending on the histology and spread of the cancer, radiotherapy and/or chemotherapy follows soon after surgery.

Radiotherapy is used to irradiate affected lymph nodes that have not been surgically removed. It is given over a course of four to six weeks. The side effects include vomiting, nausea, loss of appetite, fever and lowered blood cell counts.

Chemotherapy is prescribed when organs such as the lungs, liver and bones are involved. It is usually given over three to four months, for three to five days each month. Side effects are temporary loss of hair, severe vomiting, loss of weight, diarrhoea (may contain blood), lowered blood cell counts or numbness of hands and feet.

Seminomas are very radiosensitive, i.e. they respond very well to radiotherapy and have the best prognosis. Generally, non-seminomas are more sensitive to chemotherapy. Sometimes a combination of chemotherapy and radiotherapy is required.

Outcome (Prognosis)

There are two main factors that determine how the patient fares after treatment.

1. Microscopic type of the testicular cancer
2. Presence and extent of spread of the disease.

The more aggressive and wider the extent of spread, the worse the outcome. The five-year survival rate for an early stage seminoma is more than 90% after treatment. It is up to 60% for advanced seminomas.

That of early stage non-seminomas is about 80-90%. With more advanced highly aggressive non-seminomas such as choriocarcinoma, the outlook is pessimistic.

Even after successful initial treatment, regular follow-ups are necessary to detect recurrence or the development of a cancer in the other testis. The frequency of follow-ups will depend on the type and stage of the cancer.

Given the nature of testicular cancer, many men are naturally concerned as to sexual function after treatment. This will depend on the number of testes removed and the success of the treatment.

When both testes have been removed (surgical castration), no sexual ability remains. Otherwise, upon successful treatment, sexual function will return to normal after 12-24 months. There is no risk of genetic damage to the offspring if they have not been conceived during periods of radiotherapy and chemotherapy.

Testicular cancer is generally a treatable disease. When an abnormal testis is detected, it is wise to consult a general practitioner or polyclinic doctor as soon as possible where the patient will be referred to a surgeon (urologist).

Many patients in Singapore go to the National Cancer Centre, which is one-stop centre for the treatment of cancer patients.

References

1. Robbins & Kumar (1987) Basic Pathology. International edition. W.B. Faunders. Philadelphia, USA.
2. Rains, Mann (1988) Bailey & Love's Short Practice of Surgery. 20th edition. London, Great Britain.
3. The Singapore Cancer Society website. Singapore.

Date reviewed: 16 January 2000