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Testicular Cancer

Anatomical facts

The testicles are a pair of male sex glands located under the penis in a sac-like pouch called the scrotum. The testicles have two main functions: to produce and store sperm and to produce the male hormone testosterone, which controls the development of the reproductive organs, sexual function, and other male physical characteristics.

Types:
The most common type of testicular cancer is germ cell cancer, which accounts for 90% of all testicular tumors. Germ cell tumors grow in the cells that make sperms and are divided into two principal subtypes.
Seminomas: occur mostly in men between their late 30s and early 50s.

Non seminomas: occur in younger men between their late teens and early 40s. There are four main subtypes of non seminomas. Most tumors are mixed, having at least two different types; however, all non seminoma germ cell cancers are treated the same. Tumors may contain both seminoma and non seminoma cells. In that case, they will be treated as non seminoma.

Stromal tumors account for less than 10% of testicular cancers. The two main types are Leydig cell tumors and Sertoli cell tumors. These tumors usu ally do not spread beyond the testicle and can be cured by surgery. If they do
metastasize, they have a worse prognosis than germ cell tumors because they do not respond well to chemotherapy or radiation.

Lymphoma and childhood leukemia may spread to the testicles, but these tumors are not considered testicular cancer but rather a metastatic form of
the primary cancer.

Testicular Cancer Treatment:
Since the 1970’s cure and survival rates for testicular cancer have changed dramatically. This change is attributed to the use of the chemotherapy drug cisplatin, which is particularly effective against this cancer. Today, patients with early-stage testicular cancer have a five-year survival rate of 90%, and patients with advanced disease have a 70% chance to be alive five
years after diagnosis.

Surgery
Surgery is the primary treatment for this type of cancer. Removal of the testicle is called orchiectomy and is done through an incision in the groin. Sometimes lymph nodes from the retro peritoneum (an area in the abdomen near the back) need to be removed and tested for the presence of tumor cells. This procedure, called retroperitoneal lymph node dissection, may be done at the same time as the orchiectomy or during a second operation.
Radiation therapy may also be used in addition to chemotherapy. Men whose cancer
has recurred after treatment with chemotherapy sometimes receive high dose chemotherapy followed by an autologous stem cell transplantation.
Treatment for testicular cancer may sometimes impair sexual function, and fertility Since most testicular cancer patients are young men, these issues affect almost all of them. Infertility may be caused by damage to nerves during a retroperitoneal lymph node dissection or if both testicles are removed in surgery. It is very important that patients discuss the options of a nerve- sparing surgery (to maintain erection) and sperm banking before treatment. Men who lose only one testicle usually retain normal sexual function; however, the loss of a testicle causes a change in the look and feel of the scrotum. A prosthesis implanted at the time of surgery restores a more natural look.
Orchidectomy
The surgical removal of a cancer affected testicle is called orchidectomy. No half measures are taken. The whole testicle is removed to avoid spreading of the cancer. This treatment is highly effective for patients who are diagnosed early with testicular cancer. The operation is done by making an incision in the groin area. Artificial testes made with plastic can be inserted in the scrotum to replace the one removed. If one testicle is removed the patient can still be a father.
Bi-lateral orchidectomy
The surgical removal of both testicles is called bi-lateral orchidectomy. This surgery will make the person infertile, but is done in rare cases. The patient may want to bank his sperm for becoming a father in future.
Removal of lymph nodes
Lymph nodes in the abdomen or chest are removed when the cancer has advanced to Stage II and III testicular cancer. If nerves near the affected lymph nodes get damaged while removing the lymph nodes, then a condition called retrograde ejaculation arises. The person will not be able to ejaculate the sperm – rather it will enter the urinary bladder.
–Nerve-sparing retroperitoneal lymph node dissection
This is a new kind of surgery to remove lymph nodes in which the chances of damaging the nerves and causing retrograde ejaculation and infertility are decreased. The technique requires specialists in this field of surgery.
–Laparoscopic retroperitoneal lymph node dissection
This is another modern form of surgery to remove lymph nodes. An endoscope with a video camera is inserted through a small hole made in the skin and the images guide the doctor to perform the surgery.
–Additional surgery for stage IV patients
Stage IV testicular patients (patients who are diagnosed very late) may have to undergo additional operations to remove tumors that have formed in other organs due to the spread of cancer cells to other organs.
Testosterone replacement therapy
Testosterone is a hormone which is produced in the testicles. Removal of both testicles by surgery can result in complete absence of the hormone in the body. The main function of testosterone is to control the male libido, erectile function and other reproductive functions. Therefore, testosterone replacement is required for maintenance of a normal healthy life after surgery. This kind of therapy is called testosterone replacement therapy. The patient is given a synthetic form of testosterone. It can function like natural testosterone in the body and compensate for the loss of natural testosterone. Synthetic testosterone is given in the form of injections or skin patches. The person can have a normal sex life after testosterone replacement therapy. There are some mild side effects which can be managed.
Radiotherapy
Radiation therapy refers to the use of high energy x-rays to kill cancer cells. It can be done in two ways:

  • External radiation therapy: A beam of radiation from a machine outside the body is aimed at the affected site of the patient’s body.
  •  Internal radiation therapy or brachytherapy: Radioactive substance sealed in small pellets is placed near the affected region. Cancer cells are killed by the radiations emitted from the radioactive substances.

Radiation therapy can be used before or after surgery. Seminomas of the testicles are often treated with radiation after surgery. This prevents the cancer from coming back. Radiotherapy is also recommended when the cancer has spread to lymph nodes or other tissues and organs.
There are several side effects of radiation, but these effects are temporary.
Chemotherapy
Chemotherapy is the use of drugs for the treatment of cancer. It can be used alone or in combination with radiation therapy. When drugs are administered through a vein or by mouth, then this kind of chemotherapy is called systemic chemotherapy. Direct administration of drugs to the affected region is called regional chemotherapy.
Chemotherapy can be given for the treatment of non-seminoma tumours. It can also be used at an advanced stage to relieve symptoms, inhibit the progression of cancer and reduce the chances of recurrence of cancer.
Side effects from drugs depend on the kind of drugs used and the dosage. There can be several side effects, but they are usually temporary. The drugs can also damage the sperm and it is safer to use reliable contraceptive methods while the patient is treated. This will also protect the partner from the harmful effects of chemotherapy drugs.

Treatment on the basis of stage:
Stage I seminoma: Treated with surgery and radiotherapy
Stage I non-seminoma: Treated with surgery and chemotherapy
Stage II and III seminoma and non-seminoma: Treated with more invasive surgery to remove testicles and surrounding tissues and chemotherapy
Stage IV seminoma and non-seminoma: Treated with more invasive surgery to remove all the cancerous tissues, including some of those that have spread to distant organs and chemotherapy
Clinical trials
Clinical trials refer to those kinds of treatment which are not yet standardized. It is a part of research that aims to develop better strategies for the treatment of cancer. The patients may willingly participate in clinical trials.
References:

Chieffi P. Potential new anticancer molecular targets for the treatment of human testicular seminomas. Mini Rev Med Chem. 2011 Oct; 11(12):1075-81.
Warde P, Huddart R, Bolton D, Heidenreich A, Gilligan T, Fossa S. Management of localized seminoma, stage I-II: SIU/ICUD Consensus Meeting on Germ Cell Tumors (GCT), Shanghai 2009. Urology. 2011 Oct; 78(4 Suppl):S435-43.

Reiners C, Hänscheid H, Luster M, Lassmann M, Verburg FA. Radioiodine for remnant ablation and therapy of metastatic disease. Nat Rev Endocrinol. 2011 Aug 9; 7(10):589-95.

Additional Resources:

Testicular Cancer Resource Center. Access at: tcrc.acor.org  This comprehensive Website is provided by a testicular cancer survivor and a medical advisory board of well-known testicular cancer physicians. In addition to information about diagnosis and treatment options, it also contains sections on sexuality, fertility, and testicular implants.
American Cancer Society. Learn about Testicular Cancer. Access at: www.cancer.org and select from the menu under “Choose a Cancer Topic.”
National Cancer Institute. Testicular Cancer. Access at: www.cancer.gov  and click on “Types of Cancer.” The top page of the section links to patient versions of PDQ@ statements, clinical trial information, and other NCI publications on this topic.
People Living with Cancer. Testicular Cancer. Access at: www.plwc.org and click on “Cancer Type.” The PLWC oncologist-approved testicular cancer guide can be printed in its entirety or by subtopic.

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