What is testicular cancer?

Testicular cancer is a cancer which affects the testes, organs responsible for the production of sperm and hormones and is unique to males.  The testes (testicle) is located within the scrotum which a small muscular sac that is located underneath the penis.

In the United States, testicular cancer is the most common solid malignant tumour in men aged between 20 to 35 years.  In addition, the frequency of testicular cancer has been increasing by 1.2% per year.  The most common symptom is a painless swelling in one testicle.  The American Cancer Society (ACS) estimates that about 9560 new cases of testicular cancer was diagnosed during the year 2019.

There are several treatment options available to treat testicular cancer and seeking medical help early is important to prevent complications.

What are the causes of testicular cancer?

The exact cause of testicular cancer is not known.  Your body’s cells divide and grow in an orderly manner to repair or renew itself.  In cancer, this process is impaired and your cells divide even when it is not needed resulting in a mass.  Genetic factors are involved in the development of the cancer.

What are the risk factors for testicular cancer?

There are several factors which may increase your risk of developing testicular cancer and these include:

• Family history: If one of your parents or sibling is affected by testicular cancer, your chance of developing the disease increases.
• Race: White people are 5 times more at risk of developing testicular cancer than African Americans.
• Age: Testicular cancer is more common in men aged between 20 to 35 years.
• Cryptorchidism: This is also known as undescended testes.  It occurs when your testes does not reach your scrotum and the affected testes can develop into a cancer if left untreated.
• Infertility: infertile males are 3 times more at risk of developing testicular cancer.
• Environmental exposure: being exposed to diethylstilbestrol (DES) in utero (when you are still inside your mother’s womb) increases your risk of developing testicular cancer.

What are the signs and symptoms of testicular cancer?

 The signs and symptoms of testicular cancer include:

• Painless mass in one testicle.
• Heavy sensation in the scrotum.
• Dull ache in the lower abdomen.

When testicular cancer spreads you can have the following signs and symptoms:

• Neck mass
• Loss of appetite
• Nausea
• Vomiting
• Back pain
• Cough
• Chest pain
• Haemoptysis (coughing up of blood)
• Shortness of breath

Your doctor will have to differentiate between the following diseases as they may have similar signs and symptoms:

• Epididymo-orchitis: This is inflammation of the contents of the scrotum, usually the epididymis and testicle.  It usually occurs after an infection.
• Testicular torsion: This is when the tissue surrounding your testes is not attached well and twist on itself, compromising the blood supply to your testes.  It causes extreme pain and swelling which is a surgical emergency.  If not treated on time it may result in permanent damage to the affected testes.
• Hernia: A hernia is an abnormal protrusion of your bowel through the wall of the cavity in which it normally resides.
• Hydrocele: A hydrocele occurs when fluid accumulates around your testes which may result from a recent injury or inflammation.
• Spermatocele: A spermatocele is when a cyst develop in the coiled tube located above your testicle (epididymis).
• Varicocele: This is an enlargement of the veins within the scrotum which may lead to infertility.  It is often described as a bag of worms.

Making a diagnosis

To make a diagnosis, your doctor will first take a detailed history from you to know more about your symptoms.  After the history taking, he/she will perform a thorough physical examination to look for signs of testicular cancer.  Your doctor may order some tests in order to confirm the diagnosis and this include:

• Serum alpha-fetoprotein (AFP): High levels of this protein indicates that there is a testicular tumour.  It is also known as a tumour marker.
• Serum beta subunit of human chorionic gonadotropin (beta-HCG): Beta-HCG is another tumour marker for testicular cancer and is never found in normal men.
• Lactate dehydrogenase (LDH): LDH is less specific than beta-HCG or AFP but elevated levels indicate a testicular tumour.
• Testicular ultrasound: This test uses sound waves to obtain an imaging of the testicles and scrotum.  It can be used to differentiate between a solid or cystic mass (a fluid-filled mass).  A cystic mass is unlikely to be cancerous.  However, this test is not reliable for staging of the cancer.
• Computed Tomography (CT) scan: CT scan of the abdomen and pelvis are done only after the diagnosis of testicular cancer is made in order to assess if the cancer has spread and to stage it.  If your chest x-ray is abnormal, then your doctor may order a chest CT scan as well.
• Magnetic Resonance Imaging (MRI) scan: MRI scan is used if your doctor suspects that the cancer has spread to your bones or brain.
• Radical inguinal orchiectomy: This is a surgical procedure during which the mass is removed and sent to the laboratory to determine if it is cancerous.  It is also done to prevent the cancer to spread.

What are the treatments for testicular cancer?

The treatments for testicular cancer involves:

• Chemotherapy: This treatment involves taking drugs to kill cancer cells.  You may experience side effects such as hair loss, fatigue and nausea.  It may unfortunately lead to infertility in some people.
• Surgery: Radical inguinal orchidectomy is the surgical treatment of choice that involves complete removal of your testicle by making an incision in your scrotum.  In addition, your doctor may perform retroperitoneal lymph node dissension- this is the removal of the lymph nodes found within your abdomen.
• Radiotherapy: This technique uses high-powered energy beams to kill cancer cells.  It is usually used after surgical treatment to kill any remaining cancer cells.  Some side effects may include nausea, skin redness and fatigue.
• Sperm bank: If you want to preserve your fertility, you may go to a fertility centre to store your sperm prior to the treatment.

Prognosis

Testicular cancer is highly treatable even in people with metastatic disease-that is when the cancer has spread beyond your testicles.  The overall 5-year survival rate is 95.2%.

J. Alastair, I. and Simon, M., 2016. Davidson's Essentials of Medicine. 2nd ed. London: ELSEVIER.

Parveen, K. and Michael, C., 2017. Kumar & Clarks Clinical Medicine. 9th ed. The Netherlands: ELSEVIER.

Sachdeva, K., 2020. Testicular Cancer Workup.