April 21, 2014


TESTICULAR CANCER

Overview Signs & Symptoms Screening and diagnosis Treatments Related Links Faculty Clinical Trials

OVERVIEW

Several diseases can effect the testicle and associated structures. When pain or a mass develops in the testicle or scrotum, one should be evaluated by a physician to rule out infection or, less commonly, a tumor. In patients where pain persists, despite antibiotic therapy, an ultrasound is usually recommended to rule out a tumor.

A varicocele is common in young men and usually seen in the left scrotum. It is a dilation of the veins which drain the left testicle. These veins may cause enlargement of the left scrotum and feel like a bag of worms under the skin. In most instances, these are of no clinical concern, however, they potentially can cause problems with infertility and pain. In these instances, surgical correction is possible.

Occasionally, fluid will develop around the testicle and this condition is known as a hydrocele. These are common in newborns and usually spontaneously resolve within the first year of life. In the adult, a hydrocele may develop after trauma or infection. A hydrocele may need to be drained or surgically removed if it causes problems with pain or discomfort.

Torsion of the testicle is a condition where the testicle twists upon itself. When the testicle twists on itself, this will result in blockage of the blood flow to the testicle and ultimately, testicular death. This phenomenon usually is seen in boys up to age 16 years, however, it can also occur in adults. It presents with a sudden onset of excruciating testicular pain. If left untreated for more than eight hours, the testicle is usually permanently damaged. If a patient is seen within a few hours of the onset of pain then the testicle should be surgically untwisted.

Infections in the epididymis are common. This condition is called epididymitis. Epididymitis may be recurring and cause chronic pain in the scrotum. The usual treatment is with antibiotics, however, a prolonged course may be necessary in select individuals. In severe cases that do not respond to medication, surgery may be necessary to remove nerves going to the testicle or to actually remove the testicle in an effort to relieve pain.

Cysts are very common on the epididymis. On ultrasound evaluation, these can be differentiated from testicular tumors. No treatment is necessary unless there is persistent pain.


CANCER OF THE TESTICLE: INCIDENCE

Testicular cancer is the most common malignancy in men between the ages of 15 to 35 years. It, fortunately, is one of the most curable cancers due to early diagnosis, new techniques for treatment and a greater understanding of the nature history of the disease.

The probability that an American white male will get testicular in his lifetime is approximately 0.2%. Most tumors occur in late adolescence or early adulthood, however, tumors are also seen in infancy and in patients over the age of 6o years. The incidence of testicular tumors in African Americans is much less than that in American whites. There does not appear to be a great genetic predisposition for testicular cancer to develop in family members. Testicular cancer usually occurs in one testicle, however, 2-3% of tumors can occur in both testicles, either simultaneously or at a later date.

TYPES OF TESTICULAR CANCER

There are several different types of testicular cancers. The most common type is seminoma, followed by embryonal carciroma, teratocarcinoma, teratoma and pure carcinoma. The type of tumor determines its biological behavior, thus, is important in making treatment recommendations. It is not unusual to have multiple cell types in a given testicular cancer (i.e. embryonal carcinoma and teratoma)

Some testicular tumors produce proteins, which can be detected in the blood called tumor markers. The two most common tumor markers produced by testicular cancer are alphafetoprotein(AFP) and human chorionic gonadotropin(hCG). If testicular tumors are removed and thereis persistent elevation of one of these tumor markers then one has to assume that there is tumor remaining in the patient.

SIGNS AND SYMPTOMS

Most patients notice a mass or a pain or swelling in one testicle. In about 10% of patients, acute pain is presenting symptom. In a small percentage of patients, the first symptom are from metastases, including neck mass, problems with breathing (cough or shortness of breath), difficulty eating, abdominal pain, back pain or pain in the bones. Five percent of patients may have swelling of breast due to a hormonal affect from the tumor.

SCREENING AND DIAGNOSIS

On examination, one feels a mass within the testicle. It is not unusual to have small lumps in the epididymis, which is a tube adjacent to the testicle, which helpstransport sperm, however, any unusual mass should be evaluated by physician. Other diseases that can both cause swelling or tenderness in the testicles, includes infection, fluid around testicles, hernia or testicular torsion (twisting of the testicle or one of its parts). An ultrasound examination of the scrotum and testicle is the most reliable technique to evaluate for testicular tumors.

Early detection is important, so annual examination by a physician is recommended. This is the best done in a warm shower and any suspicious areas examined by a physician.

STAGING

Staging is a classification system for testicular tumors that helps in making recommendations for treatment.

Testicular tumors are staged using the TNM system. Tumors are staged based on the findings at the surgery to remove the testicle including; the microscopic examination, X-ray, CT scan and other studies as indicated.

Tumors (T) are definitively staged based on findings at surgery to remove the testicle and or lymph nodes in the abdomen. Tools used to determine the stage of the testicular cancer include a microscopic examination of the removed testicle and lymph nodes, CT scan, and other studies as indicated. The various stages of testicular cancer are:

T0 – No evidence of primary testicular tumors
T1 – Tumor confined to the testicle
T2 – Tumor invading outside the capsule of the testicle
T3 – Tumor invading the tubes which transport sperm
T4 – Tumor invading blood vessels which supply the testicles
T4B – Invades the scrotum
N0 – No tumor in any lymph nodesN1 – Less than 6 nodes positive for cancer, no nodes greater than 2 cm
N2 – Greater than 6 positive nodes, any node greater than 2 cm
N3 – Masses, disease and lymph nodes in the back
N+ – Tumor has spread to multiple sites outside the lymph nodes

Testis tumors can spread by one of three routes. First, they may spread to adjacent tissue through the wall of the testicle into the blood supply or tubes that transport sperm. Secondly and most commonly, the majority of testicular cancers spread through the lymph nodes in the back of the abdomen. Right-sided tumors tend to spread to the right side of the lymph nodes and left-sided lymph nodes in the back. Finally, testicular tumors can initially spread by the blood stream to distant organs such as the lung, bone or brain.

SURVIVING TESTICULAR CANCER

If one suspects cancer of the testicle, is best to treat it initially by removing the testicle through an incision in the groin. At this point, the testicle and its blood supply is removed, as close to the abdomen as possible. Once the tumor is removed, any elevated tumor markers should return to the normal range. If they do not normalize, one should suspect that cancer is still present. Depending upon the examination, tumor markers, results of X-rays and type of tumor present on microscopic evaluation, a variety of different treatment options may be recommended.

In patients with low stage seminoma, removing the testicle and radiation to the back may be the first lane of treatment. With other types of tumors, initial chemotherapy or surgery to remove the lymph nodes in the back may be recommend.

Traditional surgery has involved a large open incision to remove the lymph nodes in the back often associated with prolonged recovery and discomfort. Recently, several centers, including ours, have developed techniques to remove lymph nodes laparoscopically through 3-4 small holes in the abdomen. Click here for more details. With this approach, hospitalization, postoperative pain, postoperative recovery and cosmetic results are markedly improved over traditional open node dissection. At our institution, with this approach, the same number of the nodes has been obtained compared with open node dissection.


 

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