Testicular Cancer

Testicular cancer is a growth of abnormal cells within a testicle. Doctors do not know the exact cause of testicular cancer. It accounts for only 1 percent of all cancers in men. However, it is the most common cancer in men aged 15 to 34. Testicular cancer is about four times more common in white men than in African American men, with rates for Hispanic, Native American, and Asian men between those two groups. Thanks to dramatic advances in therapeutic drugs, along with better diagnostic tests, survival rates for the cancer have been boosted significantly. Today, testicular cancer is frequently curable, especially with early diagnosis and treatment.

There are two different types of testicular cancer: seminomatous and non-seminomatous. Seminomas, which account for about 40 percent of all testicular cancers, are made up of a single type of immature germ cell (probably arising from the cells that produce sperm). Seminomas are usually slower growing and usually are found before they spread to other parts of the body.

Nonseminomas (also called teratomas) consist of a mix of different cell types. They account for about 55 percent of testicular cancers, tend to grow more rapidly, and often spread before they are discovered. An estimated 60 to 70 percent of men diagnosed with nonseminomas have cancer that has spread to nearby lymph nodes.

The risk of testicular cancer is three to 17 times higher than average for boys born with undescended testicles (see page 162)—a condition called cryptorchidism. The risk increases if the condition is not surgically corrected before puberty. Other conditions associated with testicular cancer include:

• Klinefelter syndrome—a chromosomal disorder in males characterized by small testicles, enlarged breasts, and a lack of secondary sex characteristics such as beard growth and voice change

• gonadal aplasia—failure of the testicles to develop

• hermaphroditism—development of both male and female sex characteristics

• low birth weight

• fetal alcohol syndrome (mother's use of alcohol during pregnancy)

Most testicular cancers are found by men themselves, either by chance or while performing a self-examination of the testicles (see page 91). Symptoms of testicular cancer include the following:

• a lump in either testicle

• enlargement of a testicle

• a feeling of heaviness in the scrotum

• a dull ache in the lower abdomen or in the groin area (where the thigh meets the abdomen)

• a sudden collection of fluid in the scrotum

• discomfort in a testicle or in the scrotum

• enlargement or tenderness of the breasts

If you notice any of these symptoms, see a doctor immediately. Cancer of the testicles usually does not cause pain, although some men may experience soreness or discomfort in the scrotum or in the groin area.

Men with suspected testicular cancer usually undergo a complete medical checkup, including a careful examination of the testicles. If the physical examination and laboratory tests do not show an infection or other disorder, additional tests will be conducted to find or rule out cancer. Various imaging methods are used to diagnose testicular cancer. One method is ultrasound, in which high-frequency sound waves are used to create images of the testicle. This procedure is painless and noninvasive.

The only way to determine whether a tumor is malignant (cancerous) is to examine a small sample of tissue from the testicle under a microscope. The tissue must be obtained by removing the entire affected testicle using a surgical procedure called a radical inguinal orchiectomy. The testicle is removed through a small incision in the lower abdomen.

The surgeon cannot simply cut through the scrotum or remove just part of the testicle because, if cancer is present, cutting through the outer layer of the testicle might cause the cancer to spread to surrounding tissues and lymph nodes. Removing the testicle can prevent the cancer from spreading to other parts of

Disorders of the Reproductive System

Reproductive System the body. Removal of one testicle does not interfere with fertility or the ability to have an erection.

Cancer Stages Doctors measure the extent of the cancer by conducting tests that categorize, or "stage," the disease. These staging tests include blood analyses, imaging techniques, and, sometimes, additional surgery. Staging allows doctors to plan the most appropriate treatment. There are three stages of testicular cancer:

• stage I—cancer of the testicle is confirmed

• stage II—cancer has spread to lymph nodes located toward the back of the abdomen below the diaphragm (the muscular wall separating the chest cavity from the abdomen)

• stage III—cancer has spread beyond the lymph nodes to sites away from the abdomen

Through blood tests, a doctor can check for tumor-associated markers, which are substances often present in abnormal amounts in people who have cancer. By comparing levels of these markers before and after surgical treatment, a doctor can determine if the cancer has spread beyond the testicles. Likewise, measuring marker levels before and after chemotherapy treatment can help show how well the treatment is working.

Treatment Treatment of testicular cancer will depend on what cell type (semi-nomatous or nonseminomatous) is present, how advanced the cancer is, and the patient's age and overall health. If caught early enough, the initial removal of the testicle may also be the treatment for a seminoma. In some cases, radiation therapy directed to the lymph nodes is used to kill cancer cells that have spread there.

Surgery to remove the lymph nodes into which the testicles drain is often necessary for patients with testicular cancer. Doctors examine lymph tissue under a microscope to help determine the stage of the disease. Also, removing the tissue helps control further spread of the cancer.

Because seminomas tend to be slow growing and tend to stay in one area, they generally are diagnosed in stage I or II. Treatment is usually a combination of testicle removal, radiation, and chemotherapy. Surgical removal of lymph nodes usually is not necessary for patients with seminomas because this type of tumor responds very well to radiation treatment. Most stage III seminomas are treated with multidrug chemotherapy and radiation.

Even though nonseminomas grow more rapidly and often spread before they are caught, the cure rate is very high. Surgical removal of the lymph nodes is often necessary after the cancer has spread beyond the testicle, because non-seminomas do not respond as well to radiation therapy. Treatment of nonsemi-

nomas also can include chemotherapy with various drug combinations. Patients with stage II nonseminoma who have had a testicle and lymph nodes removed may need no further therapy, but some doctors recommend a short course of multidrug chemotherapy to reduce the risk of recurrence. Most stage III non-seminomas can be cured with drug combinations.

All men must be carefully monitored by their physician for at least 2 years after treatment for testicular cancer because about 10 percent experience recurrences, which are then treated with chemotherapy. Each method of treatment has different side effects, which can vary from one person to another. The loss of one testicle does not affect a man's ability to engage in sexual intercourse and does not cause infertility. A man with one healthy testicle can have a normal erection and produce sperm. Some men may choose to have an artificial testicle implanted into the scrotum for cosmetic purposes.

To be sure the cancer is completely gone, regular follow-up examinations are necessary. Testicular cancer seldom recurs after a man has been cancer-free for 3 years. Men who have been treated for cancer in one testicle have about a 1 percent chance of developing cancer in the remaining testicle. If cancer develops in the second testicle, it is almost always a new disease rather than the result of cells that have spread from the first tumor. These men should be conscientious about doing a testicular self-examination every month.

Disorders of the Reproductive System

Side Effects Any kind of cancer treatment can cause undesirable side effects. However, not all people react the same way or to the same extent to any particular treatment. One of the main concerns of young men is how their treatment might affect their sexual or reproductive capabilities.

Removing one testicle does not impair fertility or sexual function. The remaining testicle can produce sperm and hormones adequate for reproduction. Removal of lymph nodes usually does not affect the ability to have erections or orgasms. It can, however, disrupt the nerve pathways that control ejaculation, causing infertility.

Modern "nerve-sparing" surgical techniques have increased the odds of retaining fertility. Many surgeons are abandoning procedures that involve total lymph node removal. By limiting the amount of surgery necessary to achieve a cure without disrupting the nerves, surgeons are now able to preserve the ejaculation function in as many as 90 percent of men.

Chemotherapy can cause increased risk of infection, nausea or vomiting, and

Self-Examination of the Testicles

Men of all ages, not just those at high risk for testicular cancer, should perform a testicular self-examination at least once a month. Most cases of testicular cancer can be caught in the early stages, when it is most curable, with a routine testicular self-examination. It is a simple procedure that takes only a few minutes. The best time to do a testicle self-examination is immediately after a warm bath or shower because the skin of the scrotum is relaxed, making it easier to find anything unusual. For how to perform a self-examination of your testicles, see page 91.

hair loss. Not all men experience these side effects. Some drugs may cause infertility, but many men recover their fertility within 2 to 3 years after therapy ends. Men who are receiving radiation therapy may experience fatigue or have lowered blood cell counts. Infertility also may result from radiation treatments, but it is temporary.

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