Testicular Cancer

Testicular Cancer Overview

Testicular cancer is an abnormal growth of cells in the testicles. The testicles are the male reproductive organs (gonads) where sperm are produced.

• The two small testicular glands lie in a pouch of skin behind the penis called the scrotal sac, or scrotum.
• They are attached to the ejaculatory duct in the lower pelvis by cords called spermatic cords, which contain the vas deferens, the narrow tube through which the sperm moves out of the testis.
• Besides producing and storing sperm, the testicles (or testes) are the main source of male hormones such as testosterone, which control reproduction and sex drive (libido) and impart male physical traits such as deep voice and body and facial hair.
• Cancer usually occurs in only one testicle. Less than 5% of the time, it occurs in both testicles. (Usually, the two tumors are found at different times, the second perhaps years later.)

Cancer occurs when normal cells transform and begin to grow and multiply without normal controls.

• This uncontrolled growth results in a mass of abnormal cells called a tumor.
• Some tumors grow quickly, others more slowly.
• Tumors are dangerous because they overwhelm surrounding healthy tissue, taking not only its space but also the oxygen and nutrients it needs to carry out its normal functions.

Not all tumors are cancer. A tumor is considered cancer if it is malignant. This means that, if the tumor is not treated and stopped, it will spread to other parts of the body. Other tumors are termed benign because their cells do not spread to other organs. However, almost all tumors start to cause symptoms when they get large enough.

• Malignant tumors can spread to neighboring structures, usually lymph nodes. They encroach on and invade these healthy tissues, impairing their function and eventually destroy them.
• Tumor cells sometimes enter the bloodstream and spread to distant organs. There, they can grow as similar but separate tumors. This process is called metastasis.
• The most common places for testicular cancer to spread are the lymph nodes in the area near the kidneys (located in the retroperitoneum area), called the retroperitoneal lymph nodes. It also can spread to the lungs, liver, and rarely to the brain.
• Metastatic cancers are more difficult to cure than benign tumors, but still have very high cure rates.

Testicular cancers can be comprised of one or several different types of tumor cells. The types are based on the cell type from which the tumor arises.

• By far the most common type is germ cell carcinoma. These tumors arise from the sperm forming cells within the testes.
• Other rarer types of testicular tumors include Leydig cell tumors, Sertoli cell tumors, primitive neuroectodermal tumors (PNET), leiomyosarcomas, rhabdomyosarcomas, and mesotheliomas. None of these tumors is very common.
• Most of the information presented here concerns germ cell tumors.

There are two types of germ cells tumors, seminomas and nonseminomas.

• Seminomas arise from only one type of cell: immature germ cells that have not yet differentiated. These constitute about 40% of all testicular cancers.
• Nonseminomas are composed of mature cells that have already specialized. Thus, these tumors often are "mixed," that is, they are made up of more than one tumor type. Typical components include choriocarcinoma, embryonal carcinoma, immature teratoma, and yolk sac tumors. These tumors tend to be faster growing and to spread more aggressively than seminomas.

Testicular cancer is the most common type of cancer in young men 15-35 years of age, but it can occur at any age.

• It is not a common cancer, accounting for only 1%-2% of cancers in men.
• The American Cancer Society estimated that about 8,400 new cases of testicular cancer would be diagnosed in the United States and about 350 men would die of the disease in 2010.
• Testicular cancer is most common in whites and least common in blacks and Asians.

Testicular cancer is one of the most curable of all cancers.

• The cure rate is greater than 90% for all stages. In men whose cancer is diagnosed in an early stage, the cure rate is nearly 100%. Even those with metastatic disease have a cure rate of greater than 80%.
• These figures apply only to men who receive appropriate treatment for their cancer. Prompt diagnosis and treatment are essential.
• Because of its high cure rate, testicular cancer is considered the model of successful treatment for cancer originating in a solid organ. In 1970, 90% of men with metastatic testicular cancer died of the disease. By 1990, that figure had almost reversed -- nearly 90% of men with metastatic testicular cancer were cured.

Testicular Cancer Treatment

Medical Treatments

The initial treatment for testicular cancer is orchiectomy (surgical removal of the testicle and the attached cord). This is the standard therapy and is recommended for all men with testicular cancer.
Whether a patient has additional therapy following surgery depends on a number of factors: the tumor type, the location and extent of the cancer (whether it is limited to the scrotum or has spread to the abdominal cavity or other sites), and the serum tumor marker levels (AFP and beta-HCG). Men should discuss their urologist's recommendations and the risks and benefits of each therapy before making a decision. Some individuals may want to consider getting a second opinion before beginning treatment.
For germ cell tumors, the following options are available for treatment after orchiectomy.
Surveillance: This is sometimes called "watchful waiting" or "observation." What it means is that the patient receives no further treatment after orchiectomy but must adhere to a very strict schedule of follow-up visits with a urologist. The idea is to detect any potential residual or recurrent cancer and then proceed with treatment at that point.

• Surveillance protocols vary by physician, but a typical protocol would require visits every two months for the first year, with tumor markers, chest X-ray, and CT scan of the abdomen done at every visit or every other visit.
• Follow-up is lifelong, gradually (over five or more years) tapering the frequency of the visits and tests to once per year (as long as no cancer is detected).
• Surveillance is a calculated gamble. The patient is betting that they have no residual disease but that, if they do, it will be found early while still highly curable. The advantage to this choice is that patients are avoiding the potential side effects of and lengthy recovery from chemotherapy or radiation therapy.
• If a patient is concerned about being able to stick with the rigorous surveillance schedule, immediate surgery, radiation, or chemotherapy may be the best choice.
• Surveillance is not recommended for all men with testicular cancer. Generally, it is reserved for men with stage I disease at low-risk of recurrence.
• Statistically, men who choose surveillance for select stage I cancer have just as good a chance of ultimate cure as men who proceed with immediate treatment.
• The risks and benefits are complex. These should be discussed in great detail with the physician before making a decision.

Chemotherapy: Combinations of drugs are the standard, whether a cancer is good risk or poor risk. The revolution in treatment of testicular cancer is attributed to the use of these regimens. The drugs are given in cycles consisting of about five days of intense treatment followed by a recovery period of approximately three weeks.

• Chemotherapy is the standard treatment for stage III disease.
• Patients will be referred to a cancer specialist (oncologist) for chemotherapy.
• Good-risk tumors (as determined by blood tumor marker levels and the radiographic extent of disease) are treated with a combination called BEP (bleomycin [Blenoxane], etoposide [VePesid], and cisplatin [Platinol]) for three cycles or a combination of etoposide and cisplatin for four cycles.
• Poor-risk tumors are also treated with BEP but for four cycles. Another option is VIP (etoposide [VP-16], ifosfamide [Ifex], and cisplatin).
• Each cycle lasts three to four weeks, although the next cycle may be postponed if the person has severe side effects.
• In rare cases of very aggressive cancer, high-dose chemotherapy with stem cell transplant is used. This is not offered unless regular chemotherapy has not worked to control the disease.
• Side effects may include kidney dysfunction, alterations in skin sensation (17%-45% of men), hearing changes (30%-40%), decreased blood circulation to extremities (25%-50%), cardiovascular disease (18%), testosterone deficiency (15%), lung damage, infertility (30%), and a slight increase in the incidence of secondary solid tumors.

Radiation therapy: Radiation is the targeting of high-energy radiation beams directly at the tumor. In testicular cancer, the beam is targeted mainly at the lower abdomen to destroy any residual disease in lymph nodes.

• Radiation is usually offered for stage I or low-volume stage II seminoma. It is not recommended for nonseminoma.
• Patients will be referred to a specialist in radiation therapy (radiation oncologist) for this treatment.
• The radiation is given in a series of brief treatments five days a week, usually for three to four weeks. The repeated treatments help destroy the tumor.
• The remaining testicle is shielded to prevent damage to healthy tissue.
• Side effects include nausea (50%), vomiting (6%), diarrhea, loss of energy, irritation or mild burning of the skin exposed to the radiation beam, impaired fertility, and slightly increased risk of other cancers.

Surgery and Treatment by Stage

Surgery: A second more complex surgery is offered to some men. This surgery is designed to remove any residual cancer in the retroperitoneal lymph nodes and is called a retroperitoneal lymph node dissection, or RPLND.

• This surgery is not offered to all men with testicular cancer. It is usually offered to men with stage I or II nonseminoma who are thought to have a high risk of cancer in the retroperitoneum. It is also commonly recommended following chemotherapy if abnormally enlarged lymph nodes are present in the retroperitoneum. It is almost never offered to men with seminoma.
• The decision to go ahead with RPLND is based on tumor marker levels and findings of CT scan of the abdomen after orchiectomy. Rising or persistently high tumor marker levels or enlarged lymph nodes on the CT scan after orchiectomy strongly suggest residual cancer. Most experts recommend chemotherapy in these cases, not RPLND.
• In some cases, both RPLND and chemotherapy are recommended.

Summary of treatment by stage
Stage I

• Seminoma: Orchiectomy with or without radiation to the retroperitoneum
• There is a 15% chance that tumor will spread to the retroperitoneum.
• Because radiation can eliminate this cancer 99% of the time and is generally very well tolerated, radiation therapy is typically recommended.
• Single dosage of chemotherapy (carboplatin [Paraplatin]) may be an effective alternative treatment but is not commonly recommended in the United States.
• For those who choose surveillance, frequent visits (every one to two months) and tests are essential.
• Nonseminoma: Orchiectomy followed by RPLND or chemotherapy
• Of men who have no evidence of cancer spread on CT scan, 30%-50% do have microscopic spread. This risk can be predicted by a pathologic evaluation of the testicular tumor and depends on the presence of embryonal carcinoma or invasion of the cancer into the lymphatic/blood vessels.
• Treatment options include surgery to remove the lymph nodes in the retroperitoneum (RPLND), chemotherapy, or surveillance.

Stage IIA

• Seminoma: Orchiectomy followed by radiation therapy, although chemotherapy is also effective
• Nonseminoma: Chemotherapy or RPLND

Stage IIB

• Seminoma: Either radiation or chemotherapy
• Nonseminoma: Either chemotherapy or RPLND

Stage IIC, III

• Seminoma: Chemotherapy followed by post-chemotherapy RPLND, if needed
• Nonseminoma: Chemotherapy followed by post-chemotherapy RPLND, if needed

Most non-germ cell testicular tumors usually require no further treatment after orchiectomy. If there is a high-risk of metastases or if metastases are present, further surgery is often recommended.