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Testicular Cancer

How common is testicular cancer?

It is the most common solid tumour in men between the ages of 15 and 40 years. The incidence is about 4.5 per 100,000 per year and the lifetime risk of developing testicular cancer is 1 in 500. All young men should regularly do self-examination of their testicles.

What are the risk factors?

The exact causes are unknown but there are a few risk factors for testicular cancer.

  • History of undescended testis:

    • An undescended testis has a 3% - 5% chance of developing cancer, with the risk increasing the higher the testis location.

    • Previous testicular cancer in the other testis.

    • Family history of testicular cancer (father or brother).

    • Poorly developed testes associated with an intersex disorder.

What are the symptoms?

Possible symptoms include:

  • Painless mass or swelling in the testis.

  • Back pain from spread of cancer to the abdomen (retroperitoneum).

  • Breast swelling or enlargement (uncommon).

In most cases, only one testicle is affected; about 1% - 3% of cancers occur in both testicles.

What are the other causes of testicular swelling?

Even though testicular cancer is rare, medical attention should be sought if one has symptoms. This is because some of the other possible diagnoses may require urgent medical treatment and they can also occur together with cancer.

  • Epididymo-orchitis:

    • This is an infection of the testicle, which can present as a painful testicular swelling often associated with urinary symptoms and a bladder or prostate infection.

    • 10% of testicular cancers present with infection.

  • Hydrocele:

    • This is a fluid-filled swelling around the testicle, which can happen when there is an infection, trauma or cancer (5% - 10%) in the testicle.

  • Testicular torsion:

    • The testicle can twist upon itself, cutting off its own blood supply and causing pain and eventual dying off of the testicle if it is not surgically untwisted soon enough.

    • It is considered a medical emergency.

  • Haematoma:

    • A collection of blood can happen when there is a history of trauma to the testicle.

  • Epididymal cyst or spermatocele:

    • This is a benign fluid collection located on the epididymis (long coiled tube that lies above and behind each testis).

What tests are needed?

A scrotal ultrasound is the most important test to visualise the tumour. Most of the time, it can differentiate cancer from some of the other causes of testicular swelling. If cancer is suspected, the following tests are needed:

  • Blood tests:

    • Tumour markers (AFP, HCG, LDH) are helpful in determining what type of testicular cancer and how advanced it is likely to be.

    • Red blood cell count, kidney function test and liver function test are all part of the blood tests.

  • CT scan of the abdomen and pelvis:

    • Testicular cancer can spread to the abdominal lymph nodes. Depending on the type of testicular cancer as determined after surgical removal and analysis of the testicle, some patients may need further surgery to remove the abdominal lymph nodes if present.

  • Chest X-ray or CT scan of the chest:

    • To look for spread of cancer to the lungs.

  • MRI scan of the brain or bone scan (optional):

    • To look for spread of cancer to the brain or bones if suspected.

Why is sperm banking offered to some patients?

Even though a single testicle can produce enough sperm, many patients often already have lower sperm counts due to some underlying disorder of the testicle (e.g. undescended testis), which predisposes them to having testicular cancer. Subsequent treatments may be needed after surgical removal of the testicle and these interventions can lower the sperm count (chemotherapy) or cause ejaculatory dysfunction (major abdominal surgery - see below). Sperm banking is especially important in men who have not had children.

How is testicular cancer treated?

Testicular surgery

All patients should undergo surgical removal of the testicle (radical orchidectomy) as the first step. A testicular biopsy is almost always never done because of the risk of spreading the cancer cells along the needle tract.

Surgery is done through a groin incision from which the testicle and the spermatic cord are delivered out of the body and surgically removed. The testicle specimen can then be analysed to find out what type of cancer it is. There are a few subtypes of testicular cancer, some of which can behave more aggressively. Therefore, some patients may need further treatment after the surgery. Each case is always discussed in a multi-disciplinary meeting involving other cancer specialists.

Chemotherapy

Some subtypes of cancer may respond to chemotherapy. In advanced cancers, chemotherapy is usually the main treatment option. This is coordinated by a medical oncologist (cancer specialist). Different combinations and doses of chemotherapy drugs are catered individually to the patient. Side effects include nausea, fatigue, suppression of the immune system, infertility, small risk of secondary cancer, hair loss, lung complications, hearing damage and kidney damage.

Radiotherapy

Some subtypes of testicular cancer can respond to radiotherapy. Side effects include nausea, vomiting, fatigue, skin irritation, bone marrow suppression and long-term increased risks of heart disease and secondary cancer. A radiation oncologist (cancer specialist who arranges radiotherapy) supervises these treatments.

Major abdominal surgery

Some patients with spread of cancer to the abdominal lymph nodes may need to have them surgically removed (retroperitoneal lymph node dissection). This is a major surgery done through a large midline abdominal incision and is invasive. Side effects and possible complications include bleeding, bowel obstruction, ejaculatory dysfunction and injury to abdominal organs.

Careful observation (surveillance)

After removal of the testicle, some patients may be suitable for surveillance with regular scans, blood tests and physical examinations, especially if the cancer is still in the early stages. This is because some early cancers may never recur and the patient will not have to put up with treatment side effects of radiotherapy or chemotherapy. Strict compliance and intensive follow up are required. Patients may also have more psychological stress, worrying about possible recurrence.

What is the prognosis?

With effective treatment options available nowadays, testicular cancer is very much a treatable condition in most patients. The prognosis depends on the subtype of testicular cancer and how advanced it is on presentation. The 5-year survival for early and moderate stage cancers are >95%.