Testicular cancer

Testicular cancer represents 1% of the total cancers found in females and males in the UK each year; it tends to affect men aged between 15 and 49 years of age but is most common in the 30 - 34 age group. Many men believe that it is a form of cancer more often found in older men but as we can see it is the young to middle age that is more at risk.

The incidence of testicular cancer is one the rise and has risen by 24% since the 1990s

Finding a lump in the testicles is the moment that every man dreads but the good news is that it is eminently treatable and in England and Wales 99% of men survive for a year after diagnosis and 98% of men survive for more than 5 years

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What are testicles?

Also known as tests, testicles are part of the male reproductive system; they are held in a sack known as the scrotum. They have two main functions:

They produce the male hormones or androgens; testosterone is produced in the testes
Testicles also produce spermatozoa (sperm). They are required in order that a man may fertilise a woman and subsequently produce a child. They are stored in a small coiled tube behind each testicle called the epididymis

So what is testicular cancer?

Testicular cancer is a condition that occurs when normally healthy cells begin to reproduce uncontrollably within the testicles

Types of testicular cancer

There are many types of cells found in the testes, each of which can develop into a different form of cancer. The reason that we need to know which form of cancer has manifested is that treatment and prognosis may differ between the types

Germ cell tumours

This is the most common form of testicular cancer representing 90% of cancers of the testicle. They are called germ cell tumours because they are the cells that make sperm and there are two types, seminomas and nonseminomas which occur more or less equally. Many cases of testicular cancer contain both types and are treated as non-seminomas because they grow and spread in the same way as non-seminomas.

The fact that some seminomas can cause the rise of human chorionic gonadotropin (HCG) in the bloodstream, it can be considered a marker for some types of testicular cancer

Stromal tumours

Some testicular tumours begin in the hormone-producing and supportive areas of the testicles known as stroma - they are known as gonadal stromal tumours.

Less than 5% of adult testicular tumours are gonadal stromal tumours but up to 20% of childhood testicular tumours. There are two types of stromal tumours:

Leydig cell tumours - these tumours begin in the cells of the testicle that make male sex hormone; they are known as Leydig cells. Leydig cell tumours can develop in adults and children; they often produce androgens (male hormones) but sometimes make oestrogens (female sex hormones). Most Leydig cell tumours are benign (not cancerous) and can be removed with surgery, however, a small number of these tumours will spread and these cases tend to have a poor prognosis as they do not respond well to chemotherapy or radiation therapy
Sertoli cell tumours - these tumours begin in the Sertoli cells which support and nourish the germ cells. In much the same way as the Leydig cell tumours, they are mainly benign but if they spread they also do not respond well to treatment

Risk factors associated with testicular cancer

Whilst most cancers have some strong risk factors associated with them (eg. smoking and lung cancer), there are few serious risk factors associated with testicular cancer. There are however some risk factors that can be associated with a small number of cases:

Males born with an undescended testicle, also known as cryptorchidism. Normally the testicles of a male foetus form in its abdomen during development and during birth or soon afterwards they will descend into the scrotum. It has been observed that around 10% of men diagnosed with testicular cancer have a history of cryptorchidism. Even though the condition may have been corrected the risk of developing testicular cancer still remains higher
The existence of precancerous cells in the testicle known as ‘carcinoma in situ’. There is a 50% chance that these cells may become cancerous within 5 years
If a father or brother has had testicular cancer there is a greater chance of developing the disease; some research has suggested that genetic factors may contribute to the risk
If there is a history of previous testicular cancer there is a chance that it will return
Men that have had problems with sperm production, only being able to produce poor or abnormal sperm, have been shown to have a greater risk of developing testicular cancer
Caucasian men have a greater chance of developing testicular cancer than men from other ethnic groups
If a man suffers from HIV he is more likely to develop testicular cancer
It has been suggested that taller men have a slightly higher risk of developing the disease
Twins, especially those who are identical, have a greater risk of having testicular cancer

Symptoms of testicular cancer

Signs of a testicular tumour are:

The most common indication seen in about 90% of cases is the presence of a painless lump which can be felt in the testicle
There may be swelling of the testicle and a sensation of heaviness in the scrotum.
Pain or a dull ache in the testicle, scrotum or groin
Recent history of trauma to the area
Swelling or tenderness of the breasts (gynecomastia). Although this is not a common symptom it is associated with hormones produced by some types of testicular cancer
Enlarged lymph nodes in the back may cause pain

Testicular self-examination

The testicular self-examination should be routinely carried out by all men. It involves an examination of the testicles and scrotum. It is important that men know what a normal testicle feels like in their case; it is normal for one to hang lower than the other and not unusual for one to be slightly larger than the other. It is important they are of similar size and smooth to the touch

Men should:

Perform self-examination regularly
Get to know what their testicles feel like
If anything out of the ordinary is discovered they should consult their GP sooner rather than later; early diagnosis improves the chances of successful treatment. It is worth noting that around 96% of testicular abnormalities that are investigated do not turn out to be cancerous

Non-cancerous conditions

There are several non-cancerous conditions which may present like testicular cancerous but are not cancer:

Varicocele - this is best described as a collection of dilated veins found in the scrotum which may affect men in the 15 - 25 year age group. The veins can be found next to or above one or both testicles; the spermatic cord, which delivers the sperm from the testes to the urethra, has blood vessels and it is these that become dilated.

Varicoceles may be found in different sizes and whilst they are not painful they may cause a dragging sensation. They are associated with male infertility and affect approximately 15% of men in the UK

Epididymal-orchitis - this occurs when an infection causes inflammation of the epididymis and/or testicle. It is seen mainly in males aged 15 - 30 years and may be caused by a sexually transmitted infection or a urinary infection. It is a painful condition and swelling may come on quickly and it is normal for a 2-week course of antibiotics to be given
Hydrocele - The testes are enclosed by a protective bag of tissue; the tissue produces a lubricating fluid that allows the tests to move freely within the scrotum. Any excess lubricating fluid normally drains away via the veins in the scrotum but if this route becomes blocked the fluid will accumulate and this is known as a hydrocele. It may be uncomfortable with aching pain and may feel like a small balloon filled with fluid. The condition can be surgically treated if it becomes an issue
Epididymal cysts - these are small cysts, usually about the size of a pea that is filled with fluid and may contain semen. They may take years to form and are seen in men around 40 years old. They are benign and only tend to be removed if they become too big or painful.

Diagnosis of testicular cancer

If you detect changes or a lump in your scrotum it is rare that they will be cancerous but it is important to seek advice from your healthcare professional as soon as possible. Should it be that you have developed testicular cancer it can be treated much sooner and so with much more success

Firstly the GP will carry out a full physical examination of the tests; they may use a torch to shine a light through the scrotum; tumours will present as a dense mass which will not allow light to pass through. Any fluid in the scrotum will allow light to pass through.

If your GP has any concerns he will refer you for testing. The tests that may be carried out include:

Scrotal ultrasound - the ultrasound scan will be used to produce an image of the inside of the scrotum. This will make it possible to determine if any abnormalities or lumps are fluid-filled which are usually harmless or if they are a solid mass which is much more likely to be cancerous
Blood tests - these need to be carried out in order that the presence of a cancerous lump can be confirmed. The blood will be tested for hormone markers; some testicular cancer will produce these hormone markers but the absence of the markers does not confirm that the lump is not cancerous.
Histological tests - these tests involve first taking a biopsy of the lump and then the examination of the suspect tissue under the microscope. This is the only way to confirm absolutely whether the tissue is cancerous or benign.

Treatment for testicular cancer

It is usual that the biopsy and histological testing is carried out after performing an orchidectomy. This is because it is usual that after ultrasound and blood tests it is already considered that the lump is cancerous and the actual process of taking a biopsy can spread cancer onto the scrotum which was initially unaffected.

Doing the biopsy is the only way to be 100% sure that the lump is cancerous; removing one testicle will not affect sex life or fertility

Other treatment for cancer may be required depending on what stage the disease has reached:

Chemotherapy
Radiotherapy
Removing the relevant lymph nodes
High dose chemotherapy with stem cell support

Effects of testicular cancer on sex and fertility

Fertility after treatment is unlikely to be affected provided only one testicle has to be removed. It may be advised however that sperm be placed in a sperm bank before treatment
Whilst any changes in a persons sex life after treatment may not be as a result of physical issues, having the disease itself may give rise to many emotions that in turn may impact on the libido. Counselling and emotional support may help with any issues that arise

Conclusion

As mentioned previously, testicular cancer is every man’s nightmare and something that most men do not want to think about.

What men need to remember however is that it is always a possibility and it is important to perform regular self-examination and if any issues such as a lump or abnormality in the groin area are found that they do not ignore it and have it investigated as soon as possible.

Early treatment is the best and most effective treatment!