Testicular cancer is cancer that develops in the testicles, a part of the male reproductive system. 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 tumors derived from Leydig cells or Sertoli cells. Over man's lifetime, his risk of testicular cancer is roughly 1 in 250 (0.4%). It is the most common cancer in males aged 20–39 years, the period of peak incidence, and is rarely seen before the age of 15 years. Children born with an undescended testicle have an increased risk of getting testicular cancer regardless of whether surgery is done to correct the problem.
Testicular cancer has one of the highest cure rates of all cancers with an average five-year survival rate of 95%. If the cancer has not spread outside the testicle, the 5-year survival is 99% while if it has grown into nearby structures or has spread to nearby lymph nodes, the rate is 96% and if it has spread to organs or lymph nodes away from the testicles, the 5-year survival is around 74%. Even for the relatively few cases in which cancer has spread widely, chemotherapy offers a cure rate of at least 80%.
Treatment depends on the type of testicular tumor and stage of the tumor. To determinate which type of tumor is it, it needs to be examinated under microscope. Staging is used to distinguish if the cancer is only in testicles, or if it spreads to other parts of body:
Depending on the type and size of tumor different treatments can be used:
Two sets of tumors were defined depending on their ability to invade neighboring tissue or metastasize: malignant vs. benign tumors. Malignant tumors represents a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. On the other hand, benign tumors consist of a mass of cells that lacks the ability to invade neighboring tissue or metastasize. Malignats are - seminoma, embryonal carcinoma, trophoblastic tumor, carcinoid, granulosa cell tumor, yolk sac tumor, spermatocytic seminoma. Strictly benign are ganodoblastomas and thecoma, then there are tumors, that are mostly benign but some percent are malignant such as teratomas, Sertoli cell tumors and Leydig cell tumors.
1. Germ cell tumors
Seminomas
(also known as pure seminoma or classical seminoma) is a germ cell tumor of the testicle or, more rarely, the mediastinum or other extra-gonadal locations. It is a malignant neoplasm and is one of the most treatable and curable cancers, with a survival rate above 95% if discovered in early stages.
Testicular seminoma originates in the germinal epithelium of the seminiferous tubules. About half of germ cell tumors of the testicles are seminomas. Treatment usually requires removal of one testicle. However, fertility isn't affected. All other sexual functions will remain intact.
Embryonal carcinomas
In the testis pure embryonal carcinoma is also uncommon, and accounts for approximately ten percent of testicular germ cell tumors. However, it is present as a component of almost ninety percent of mixed nonseminomatous germ cell tumors. The average age at diagnosis is 31 years, and typically presents as a testicular lump which may be painful. One fifth to two thirds of patients with tumors composed predominantly of embryonal carcinoma have metastases at diagnosis.
Teratomas
The tissues of a teratoma, although normal in themselves, may be quite different from surrounding tissues and may be highly disparate; teratomas have been reported to contain hair, teeth and bone. Because they are encapsulated, teratomas are usually benign, although several forms of malignant teratoma are known and some of these are common forms of teratoma. A mature teratoma is typically benign and found more commonly in women, while an immature teratoma is typically malignant and is more often found in men.
Yolk sac tumors
Endodermal sinus tumor (EST), also known as yolk sac tumor (YST), is a member of the germ cell tumor group of cancers. It is the most common testicular tumor in children under 3, and is also known as infantile embryonal carcinoma. This age group has a very good prognosis. In contrast to the pure form typical of infants, adult endodermal sinus tumors are often found in combination with other kinds of germ cell tumor, particularly teratoma and embryonal carcinoma. While pure teratoma is usually benign, endodermal sinus tumor is malignant.
Trophoblastic tumors
Choriocarcinoma is widely known as a malignant, trophoblastic cancer, usually of the woman's placenta. However, they rarely exist in men, accounting for less than 1% to 3% of all the testicular neoplasms. They can also be found in combination with other germ cell tumor elements in 8% of testicular germ cell tumors. Tumors are mostly found in patients in their second to fourth decade of life. Choriocarcinomas are highly malignant lesions with the potential for early, hematogenous metastases to the lung, liver, gastrointestinal tract, and brain. Choriocarcinoma has the worst prognosis of all germ cell tumors.
Spermatocytic seminoma
The name of the tumor comes from the similarity (under the microscope) between the small cells of the tumor and secondary spermatocytes. Spermatocytic seminoma is a rare tumor, comprising only one to two percent of all testicular germ cell tumors. Men presenting with this tumor are generally 50 to 60 years old, and its occurrence is rare in men under 30 years old. Most present with slow, painless testicular enlargement, which may involve both testes.
2. Sex cord/Gonadal stromal tumors
Granulosa cell tumor
Although granulosa cells normally occur only in the ovary, granulosa cell tumors occur in both ovaries and testicles. These tumors should be considered malignant and treated in the same way as other malignant tumors of ovary.
Sertoli cell tumor
This tumor produces Sertoli cells, which are normally found in the testicle. Sertoli cell tumor occurs in both men and women. Due to excess estrogen secreted by these tumors, one-third of male patients may present with a recent history of progressive feminization.
Thecoma
Thecomas or theca cell tumors are benign neoplasms composed only of theca cells. Histogenetically they are classified as sex cord-stromal tumors. Males with these tumors may present with signs and symptoms of estrogen or androgen excess, including gynecomastia, impotence or decreased libido. The most common presentation in males remains a painless testicular mass.
Leydig cell tumor
The majority of Leydig cell tumors are found in men, usually at 5–10 years of age or in middle adulthood (30–60 years). Children typically present with precocious puberty. Adults with Leydig cell tumors have testicular swelling, and decreased libido (20%) some of them could suffer from gynecomastia (15-30%). Pseudoprecocity is usually seen in children. Most of tumors are unilateral and only 3% are bilateral. The tumor is well-circumscribed and occasionally encapsulated. Hemorrhage or necrosis are present in 25% of the cases, and extraparenchymal extension is in 10-15 % of cases.
3. Mixed Germ Cell and Sex Cord/Gonadal Stromal Tumor
Gonadoblastoma
A gonadoblastoma is a complex neoplasm composed of a mixture of gonadal elements, such as large primordial germ cells, immature Sertoli cells or granulosa cells of the sex cord, and gonadal stromal cells. Most gonadoblastomas are benign.
4. Miscellaneous tumors of the testis
Carcinoid
Carcinoid tumors are the most commonly encountered small bowel malignancy and are believed to arise from neuroendocrine cells. They are classically found at the tip of the vermiform appendix or the terminal ileum although they have also been described to occur in the lungs, pancreas, rectum, and genitourinary tract. Carcinoid tumors of the testis are a rare entity comprising less than one percent of all testis tumors. Carcinoid tumors of the testis can arise as a metastasis from an extratesticular primary, as a component of a teratoma, or as a primary tumor, with primary tumor being most common. Their presence should be considered particularly when evaluating a testicular lesion in an older male patient. Primary carcinoid tumors of the testis are associated with an excellent prognosis; however, surveillance is important given rare reports of delayed metastases.
Associated disease
Complications
Malignant testicular tumors may spread to some other parts of the body. After the tumor cells come to rest at another site, they re-penetrate the vessel or walls and continue to multiply, eventually forming another clinically detectable tumor. This new tumor is known as a metastatic (or secondary) tumor. Metastasis is one of three hallmarks of malignancy (contrast benign tumors). The most common metastasis location are lungs, abdomen, spine and retroperitoneal area.
Risk factors
The exact cause of testicular cancer is usually not known. Risk factors for developing testicular cancer may include family history of testicular cancer, previous cancer in one testicle, tobacco use and undescended testis.
If the physicians detect a tumor, it is necessary to get rid of an abnormal tissue of testicle. Tumor could be removed surgically, or it could be destroyed chemotherapy or radiotherapy. When the cancer is not spread in both testicles, a man with one remaining testis may maintain fertility. Thus might be due to the fact that the tissue still can produce a healthy sperm. This sperm can be capable of insemination. However, sperm banking may be appropriate for men who still plan to have children, since fertility may be adversely affected by chemotherapy and/or radiotherapy or in case that cancer relapses. A man who lost both testicles is infertile and sperm donation should be considered.
Maintaining a healthy lifestyle and avoiding exposure to known cancer-causing substances such as tabacco, alcohol, obesity and radiation.
In the treatment of testicular cancer, nutrition therapy is individualized personally, based on body fat, immune system, staging and medical history. It usually involves an increase of fruits, vegetables and whole grains as well as yogurt, fish and poultry.
Pharmacotherapy
Chemotherapy is the standard treatment for nonseminoma when the cancer has spread to other parts of the body. The standard chemotherapy protocol includes three, or sometimes four, rounds of Bleomycin-Etoposide Cisplatin (BEP). An alternative, equally effective treatment involves the use of four cycles of Etoposide-Cisplatin (EP). The increase in survival and cure rate in the last decades has been due mainly to effective chemotherapy.
Lymph node surgery may also be performed after chemotherapy to remove masses left behind (stage 2 or more advanced), particularly in the cases of large nonseminomas.
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 f radiotherapy. Since seminoma can recur decades after the primary tumor is removed, patients receiving adjuvant chemotherapy main vigilant and not assume they are cured 5 years after treatment.
Psychotherapy
Cancer support groups provide a setting in which cancer patients can talk about living with cancer with others who may be having similar experiences. Much of the sociological construction of these groups is similar to other kinds of other types of support groups.
Although the experience of people diagnosed with cancer varies greatly from one person to another, they all need a good support system in order to cope throughout the different stages of the process. Different support systems have thus been developed including community support groups, on line cancer support groups, networks, forums, and charitable organizations. Community support groups are usually led by psychologists, social workers, and medical professionals and can take place in churches, hospitals, or community centers. Online support groups and forums are a good option for those patients who find it difficult to leave their home during treatment. People participating in such forums have the possibility to maintain their anonymity.
Support systems range from those that address patients suffering from specific types of cancer to those that support patients suffering from any kind of cancer.
Surgical therapy
The initial treatment for testicular cancer is surgery to remove the affected testicle (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 he 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.
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 hat malignant testicular cancer cells that may have metastasized to lymph nodes in the lower abdomen.
This surgery is called retroperitoneal lymph node dissection (RPLND). Sperm banking is frequently carried out prior to the procedure (as with chemotherapy), as there is a risk that RPLND may damage the nerves involved in ejaculation, causing ejaculation to occur internally into the bladder rather than externally.
Other therapy
Seminoma cells are extremely radiosensitive, and radiation therapy has been widely used for more than 60 years, and has an excellent long-term track record. Radiation may be used to treat stage 2 seminoma cancers, or as adjuvant (preventative) therapy in the case of stage 1 seminomas, to minimize the likelihood that tiny, non-detectable tumors exist and will spread (in the inguinal and para-aortic lymph nodes). Radiation is ineffective against and is therefore never used as a primary therapy for nonseminoma.
Sperm function is affected after chemotherapy or radiotherapy, so lot of man use sperm bank that collects and stores human sperm. Man's own sperm obtained by microsurgical methods (TESE, micro-TESE, etc.) may be also used but this approach is generally not suggested due to very high risk of their genetic damage after chemotherapy/radiation treatment. Otherwise, it is recommended to perform PGS on resulting embryos. Sperm donation is another option to bear in mind if a man wishes to have a child and his sperm are not in a sufficient number or quality. Then, the IVF or IVF-ICSI procedure can be done.
In the case of cryptorchidism one or both testes are absent from the scrotum. It is is the most common etiologic factor of azoospermy in the adult.
Complete absence of sperm in the ejaculate due to testicular failure.
An accumulation of clear fluid in the tunica vaginalis, the most internal of membranes containing a testicle.
Male gonads which produce both sperm and androgens, such as testosterone, and are active throughout the reproductive lifespan of the male.
The cell found in interstitial tissue of testicles responsible for production of androgens - male hormones.
The cell in seminiferous epithelium responsible for nutrition and development of germ (sperm) cells.
An undifferentiated male germ cell with self-renewing capacity representing the first stage of spermatogenesis.
Steroid hormone, secreted by the ovaries, whose function is to prepare the uterus for the implantation of a fertilized ovum and to maintain pregnancy.
The physiological process by which a penis becomes erect by being engorged with blood.
The fusion of an ovum with a sperm to initiate the development of a new individual organism.
Process in which spermatozoa are produced from male primordial germ cells in testicles by way of mitosis and meiosis.
Long-lasting inhalation of the smoke of burning tobacco.
A pain that occurs between the chest and pelvic regions.
A not-temporary condition in which the testes diminish in size and may be accompanied by loss of function.
A pain is felt anywhere in the chest area from the level of shoulders to the bottom of ribs.
The condition of having at least three loose or liquid bowel movements each day.
The onset of puberty before the average age in boys (9 years).
A disorder of the endocrine system in which there is a non-cancerous swelling of the breast tissue in boys or men.
A common painful disorder involving the muscles and bones of the back.
A discomfort felt in the testicles (testes) or scrotum.
A therapeutic option for testicular cancer, which uses anti-cancer drugs.
Process by which a woman donates eggs for purposes of assisted reproduction or biomedical research.
A micromanipulative fertilization technique in which a single sperm is injected directly into an egg.
Surgical removal of one or both testes.
The term PGS is used to denote procedures that do not look for a specific disease but to identify embryos at risk of de-novo occurring aneuploidies
A therapy of testicular cancer, which uses ionizing radiation to shrink tumors and kill cancer cells.
The procedure in which a man (sperm donor) provides his sperm for fertility treatment.
A process in which an egg is fertilised by sperm outside the body: in vitro. Own or donated gametes may be used.
