Causes
The exact cause of most testicular cancers is not known. But scientists have found that the disease is linked with a number of other conditions.
Researchers are learning how certain changes in a cell’s DNA can cause the cell to become cancer. Genes tell our cells how to function. They are packaged in chromosomes, which are long strands of DNA in each cell. Most cells in the body have two sets of 23 chromosomes (one set of chromosomes comes from each parent). Cancers can be caused by changes in chromosomes that turn on oncogenes or turn off tumor suppressor genes.
Most testicular cancer cells have extra copies of a part of chromosome 12 (called isochromosome 12p or i12p). Some testicular cancers have changes in other chromosomes as well, or even abnormal numbers of chromosomes (often too many). Scientists are studying these DNA and chromosome changes to learn more about which genes are affected and how this might lead to testicular cancer.
Risk Factors
Age
Young men between the ages of 15-35 are at the highest risk for testicular cancer. However, it can occur in men of any age.
Race
Testicular cancer is 4.5 times more common in white men verses black men. The risk for Hispanics, American Indians and Asians falls between that of white and black men.
Non-Descending Testicle (Cryptochidism)
Normally, after birth, the testicles descend from inside the abdomen down into the scrotum. In some men one or both testicles fail to descend into the scrotum. Men with a history of a non-descending testicle are three to 17 times more likely to develop testicular cancer than men whose testicles descended normally. Surgery to correct the non-descended testicle (orchiopexy) may not reduce the risk of testicular cancer but may allow for better observation of the testicle for abnormalities.
Gonadal Dysgenesis
Abnormal development of a gonad (testicle) which is usually part of a genetic syndrome increases the risk of testicular cancer.
Klinefeter Syndrome
A genetic syndrome where males are born with an extra X chromosome increases the risk of testicular cancer.
Personal or family history of testicular cancer
Having a father, brother or uncle with testicular cancer may slightly increase one's risk of developing testicular cancer.
Weaker evidence suggests that infertility, testicular atrophy, twinship or abnormal semen parameters may increase one's risk for testicular cancer.
Carcinoma in situ (CIS) also called intratubular germ cell neoplasia
The presence of carcinoma in situ in the testicle increases the risk for testicular cancer.
Types
There are two main types: Germ cell tumours and stromal tumours. Both have multiple subtypes, but germ cell tumours account for 95% of all cases. This may be too granular for a landing page, but ultimately up to you if you would like to include.
Diagnosis
Physical Exam
Your physician will examine your testicles by gently rolling them between two fingers and thumb to identify any abnormal lumps. Your physician may also check your groin area, abdomen, armpits and neck to look for swollen lymph nodes. The doctor may also exam you for breast tenderness or enlargement and listen to your lungs.
Scrotal Ultrasound
The scrotal ultrasound is a painless non-invasive procedure in which high frequency sound waves are used to produce images of inside the scrotum and testicles. It is the same technology that is used in pregnant women when they get a sonogram. The images will show if there are any solid masses, swelling or fluid collections within the scrotum.
Radical Orchiectomy
Orchiectomy means removal of one or both of the testicles. Radical means that the removal is done by making an incision high up in the groin area. The incision is not made on the scrotum itself. The reason the testicle is removed from higher up is so that there are no changes made to the lymph drainage system. The reason is similar to why the transscrotal biopsy is condemned. Contrary to rumors the removal of a testicle does not affect the ability to achieve an erection and seldom interferes with the ability to father children. Once the testicle is removed a biopsy or a small sample of the tumor is sent to the laboratory to determine if the cells are cancerous (malignant) or non-cancerous (benign).
Chest X-ray
A front and side chest x-ray are done to see if the cancer has spread to the lungs or chest cavity.
CT Scan
CT-Scans create three-dimensional pictures of the inside of the body with an x-ray machine. They usually require you to drink a dye and also have a contrast dye injected into you veins in order to see the internal structures better. CT-scans are the most common imaging tests used for testicular cancer. A CT-scan of the abdomen/pelvis is done to see if any lymph nodes in the retroperitoneal area (stomach area) or pelvis have been affected by the cancer. The CT-scan is the most effective imaging test to determine if the cancer has spread and scans may also be done of the chest and/or brain.
MRI, Bone Scan
PET Scans. CT-scans are the preferred imaging test for testicular cancer patients. However, other tests such as a MRI, Bone Scan or PET scan may be needed in certain situations. If your doctor orders one of the tests you should discuss with him why the test is needed.
Blood Tests or Tumor Markers
Testicular cancer or germ cell tumors can secrete proteins or hormones into the bloodstream. The levels of these proteins/hormones in the blood can be measured in the laboratory and are often called tumor markers. The levels of the tumor markers can help verify that a diagnosis is correct and/or that a patient is responding to certain treatments. These tumor markers include: AFP (alpha-Fetoprotein), beta-hCG (beta-Human Chorionic Gonadotropin) and LDH (Lactic Acid Dehydrogenase). Not all forms of testicular cancer produce tumor markers or elevate their levels and you can have testicular cancer even if your tumor markers are normal.
AFP (alpha-Fetoprotein)
AFP may be produced by pure embryonal carcinoma, yolk sac tumor or combined tumors. It is not secreted by pure seminoma or choriocarcinoma. If a diagnosis of seminoma is made but the APF is elevated then the pathology specimen should be reviewed again.
Beta-hCG (beta-Human Chorionic Gonadotropin)
Beta-hCG is the same substance that helps identify if women are pregnant. However, some testicular cancers can also secrete the substance. These tumors include embryonal carcinoma and choriocarcinoma. Only 5-10% of seminomas secrete beta-hCG and if secreted it is usually done so at lower levels.
LDH (Lactic Acid Dehydrogenase)
LDH is the least specific tumor marker for testicular cancer. The levels may be elevated for reasons other than testicular cancer. However, monitoring the LDH levels can give your physician more information about your cancer and treatment.
Transscrotal Biopsy
The procedure of taking a biopsy from outside the scrotum and into the testicle.
Treatment
Active Surveillance
If a patient has early stage testicular cancer and their tumor markers are normal or return to normal after surgery then an active surveillance program may be a treatment option. This option involves regular doctor visits with CT-scans, x-rays and blood work to closely monitor for the cancer returning. This option requires great dedication by the patient and the doctor to follow the surveillance schedule so that any recurrence can be detected early. Many men (70-80%) may be able to avoid additional chemotherapy/radiation after the orchiectomy and active surveillance allows for this option but the follow up schedule does require a lot of dedication and needs to be discussed with your doctor. Some schedules may require check-ups every one-two months.
Radiation Therapy
Radiation therapy uses high-energy beams of radiation to help destroy any cancer cells that were left behind after the orchiectomy. These left over cancerous cells can spread through the lymph system to other areas of the body. The external radiation is aimed at the lymph nodes in the abdominal and/or groin area to kill any cancer cells. Radiation therapy is usually done daily for five days a week for 3-4 weeks. Normal cells are also killed by the radiation and can lead to side effects.
Side effects of radiation therapy include: fatigue, skin changes/burns, loss of appetite, nausea, diarrhea, stiff joints/muscles. These side effects are usually only temporary and should improve once treatments are over. Radiation therapy can also interfere with sperm production despite the use of shields to reduce the amount of radiation that the remaining testicle receives.
Chemotherapy
Chemotherapy are drugs that are given intravenously to kill any remaining cancer cells and to keep the cancer from returning. Chemotherapy is usually used more for non-seminomas that seminomas. Chemotherapy is usually given in cycles meaning that it is given daily for 5 days and then none is given for the next two weeks and then the cycle is repeated.
Chemotherapy also kills healthy cells and can lead to side effects. Side effects of chemotherapy include: nausea, vomiting, hair loss, loss of appetite, fatigue, mouth sores, fever, chills, numbness. Chemotherapy can also interfere with sperm production which can be permanent.
Retroperitoneal Lymph Node Dissection (RPLND)
This is a surgery to remove the retroperitoneal lymph nodes that are located at the back of the abdomen. The surgery involves an incision down the middle of the abdomen to remove the lymph nodes. A RPLND is a complex operation that requires substantial experience and technical skill in order to remove the lymph nodes and reduce the likelihood of side effects. A RPLND should only be done by a surgeon who is highly experienced with this operation.