Testicular cancer

Testicular cancer can cause several symptoms that affect your health. It is possible to experience more than one symptom at the same time.

• Feeling a lump or swelling in either testicle
• Feeling of heaviness in the scrotum
• Collection of fluid in the scrotum
• Experiencing pain or discomfort in one testicle or the scrotum
• Testicular atrophy (shrinking of the testicles)
• Experiencing a dull ache in the abdomen or groin region
• Enlargement or tenderness of the breasts
• Lower back pain
• Swelling of one or both legs or shortness of breath due to a blood clot. For some young or middle-aged men, developing a blood clot may be the first sign of testicular cancer
• Shortness of breath, chest pain, and blood in sputum or phlegm can be symptoms of later stages of testicular cancer due to spread to the lungs
• Headaches and confusion in case the tumor spreads to the brain

Here are some common signs and symptoms that could be suggestive of cancer.

It's not exactly clear what leads to the development of testicular cancer. Typically, healthy cells in our body undergo division and growth to maintain optimal body function. However, sometimes these cells may develop abnormalities. Such mutations can cause previously healthy cells to start dividing and growing out of control. These cancerous cells continue dividing despite the body not needing them. Slowly, these cancerous cells accumulate, taking up space and nutrients that healthy cells require. This results in a cancerous mass that can be felt as a lump in the testicle.

There are specific cells in the testicles that produce immature sperm. Some researchers have found that most testicular cancer cells have an extra pair of chromosome number 12. They have also detected the presence of other chromosomes or an abnormal number of chromosomes in some testicular cancers. Experts are studying these chromosomes and the DNA further to learn more about the genes that become affected and lead to the development of testicular cancer.

The following factors are associated with a high risk of testicular cancer:

• Age group of 15 to 44 years
• Failure of testicle to descend from the abdomen into the scrotum (cryptorchidism)
• Personal history of testicular cancer
• Family history of testicular cancer
• Incidence is highest in the white race, most rapidly increasing in the Hispanic population, and lowest amongst African American individuals
• Infertility or difficulty conceiving a baby
• Abnormal testicular development in conditions like Klinefelter syndrome
• Congenital defects such as hypospadias (abnormality of the penis) and inguinal hernia (a lump in the groin)
• Issues before birth related to the mother’s pregnancy, such as abnormal bleeding and estrogen or hormone therapy
• HIV infection or AIDS

Your doctor will consider your symptoms and carry out some tests to rule out diseases that mimic the symptoms of testicular cancer. In many cases, men discover the presence of testicular cancer themselves when they unintentionally find a lump in their testicles. Your doctor can determine whether a lump is cancerous or not.

1. Clinical Examination

Your doctor will perform an examination of the affected testis and the contralateral normal testis to look for any abnormalities. Many tumors will have a hard consistency, while some tumors may show testicular atrophy.

The doctor will also examine the abdomen, neck, upper chest, armpits, and groin for any evidence of enlarged lymph nodes to evaluate any spread of cancer.

The breasts and nipples will be examined for any growth.

The legs will be examined for swelling from blood clots in the veins of the legs, pelvis, or abdomen.

2. Ultrasound

A testicular ultrasound is an examination modality that uses sound waves to create an image of the scrotum and testicles. A doctor or health provider uses a handheld probe and moves it over the scrotum to conduct the ultrasound. This process generates a digital image on the screen that can be viewed by the doctor. An ultrasound test helps determine the size, nature, and location of the lump, identifying whether the lump is filled with fluid or is solid. It will also assist your doctor in determining the presence of lumps inside or outside the testicle.

3. Blood Tests

Your health provider may request blood tests depending on your signs and symptoms. This will help determine the levels of tumor markers present in the blood. Tumor markers are compounds that normally occur in the body; however, in certain conditions such as testicular cancer, these markers are elevated in the blood. The final diagnosis will be provided by your doctor based on your results and other tests. Blood tests to measure the levels of tumor markers such as serum alpha-fetoprotein (AFP), lactate dehydrogenase (LDH), and beta-human chorionic gonadotropin (beta-hCG) are recommended for patients suspected of having testicular cancer.

AFP is elevated in 60-70% of patients with non-seminoma. Since AFP is not produced by seminomas, an increased level of AFP indicates that the tumor is not a pure seminoma. A falsely elevated AFP may be observed in patients with liver disease or a condition called hereditary persistence of AFP, where patients may have baseline AFP levels that are mildly elevated.

Beta-hCG may be elevated in both non-seminomas and seminomas. However, beta-hCG levels above 1,000 IU/L generally indicate that the cancer is a non-seminoma rather than a seminoma. False positive elevation of hCG may occur secondary to hypogonadism or marijuana use.

LDH is a nonspecific marker primarily used to help assess how much chemotherapy to administer for metastatic non-seminoma. Many other cancers and non-cancerous conditions can increase LDH levels, and it is not used specifically to diagnose testicular cancer.

Although elevated serum tumor markers support the diagnosis of testicular cancer, it is important to note that most patients with seminoma and up to a third of patients with non-seminomas do not have elevated levels. The levels of these markers are measured before a biopsy is taken to help determine testicular cancer.

4. Imaging Tests

• CECT Abdomen: This test is usually performed to evaluate the abdominal area. It assesses the presence, size, and location of a tumor along with associated lymph nodes.
• Chest X-ray: A chest x-ray is used to ascertain any metastasis to the lungs. If a more detailed picture of the lungs is needed, the doctor may recommend a CECT of the chest. However, in many cases, an x-ray is preferred due to lower radiation exposure.
• CECT Chest: This should be performed if metastasis to the lung is suspected or if lung nodules are identified on a chest x-ray.

5. Surgical Removal of Testicle (Orchidectomy or Orchiectomy)

Surgical removal of the affected testicle is performed to examine it in the laboratory. In most cases, only one testicle is removed, as both testicles are rarely affected by cancer simultaneously. For most types of cancer, a biopsy is done by removing and examining some tissue from the tumor. However, a biopsy from the testicle is not performed due to the risk of causing cancer cells to spread to the lymph nodes.

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Unfortunately, researchers have not yet found a way to prevent testicular cancer. However, early diagnosis can prevent the spread of cancer and offers a good prognosis. Men are advised to perform a testicular self-examination (TSE) once a month.

Performing a TSE can be done while taking a shower or warm bath. A warm bath will help the scrotum relax, making it easier to detect unusual lumps.

To perform the examination:

• Use both hands to examine each testicle.
• Place your index and middle fingers underneath your testicles while placing your thumb on top.
• Gently roll each testicle between your fingers and thumb.

Your testicles may vary in size, which is normal. As you move your testicles between your fingers, look out for the epididymis, a tube that stores and transports sperm. It feels like a cord on the top and back of your testicle; do not confuse it with a lump.

You may feel lumps that can be the size of peas or larger. They are often painless.

If you feel a lump or notice a change in the size of your testicle, contact your doctor for a medical opinion.

Testicular cancer can be treated based on the type and staging of cancer. It also depends on several other factors, including overall health and personal preferences. There are several ways to manage and treat testicular cancer. The staging of testicular cancer is based on understanding the pattern of spread. One staging classification used is the TNM system:

• Stage I: Tumor (T) is limited to the testis.
• Stage II: Tumor has spread to the lymph nodes (N) in the back of the abdomen (retroperitoneum).
• Stage III: Metastasis (M) of the cancer has occurred, meaning it has spread to other parts of the body such as the lungs, liver, brain, and bone.

For testicular cancer, an S is also added to the TNM system. Serum tumor marker (S) indicates any elevation of serum tumor markers like AFP, beta-hCG, and LDH.

1. Surgery
   • Radical inguinal orchiectomy: This is the primary treatment option for testicular cancer at nearly all stages and types. The surgeon makes an incision in the groin region and removes the affected testicle. A prosthetic saline-filled testicle can be inserted into the scrotum if desired. In early stages, this surgery may be sufficient as the only treatment needed.
   • Retroperitoneal lymph node dissection: This surgery involves making an incision in the abdomen. The surgeon aims to avoid injuring nerves surrounding the lymph nodes, although some risk of nerve damage exists, which may lead to difficulties with ejaculation, but will not prevent erections. Follow-up appointments are typically scheduled monthly for the first few years, decreasing in frequency later. Blood tests and CT scans may be required to monitor for signs of cancer recurrence.
2. Radiation therapy

   Radiation therapy uses high-powered energy beams to effectively kill cancer cells. During an appointment, the patient lies flat on a table while a large machine moves around the body, targeting precise points. Radiation therapy is often recommended for patients with seminoma-type testicular cancer and may be suggested after surgery to remove a testicle. Side effects can include nausea, fatigue, and skin irritation in the abdominal and groin areas. It may also lead to a temporary decline in sperm count and affect fertility. Discuss potential side effects and sperm preservation options with your doctor before starting treatment.

3. Chemotherapy

   Chemotherapy uses strong medications to kill cancer cells that may have spread from the original tumor. Depending on the stage of testicular cancer, chemotherapy may be the only treatment option or may be recommended before or after lymph node surgery. Commonly used chemotherapeutic agents include:

   • Bleomycin
   • Cisplatin
   • Etoposide
   • Ifosfamide

   Serum tumor markers are monitored throughout treatment and typically normalize during or after. Cisplatin-based chemotherapy can cause side effects like myelosuppression, nausea, vomiting, and hair loss. Bleomycin may be associated with pulmonary fibrosis. Consult your doctor about managing side effects and preserving sperm before starting chemotherapy.

4. Bone marrow transplantation

   Bone marrow transplantation, or stem cell transplantation, is a state-of-the-art treatment modality. In this procedure, bone marrow is taken from the patient and treated with drugs to eliminate cancer cells, then frozen. The patient undergoes high-dose chemotherapy with or without radiation therapy to destroy remaining marrow. The previously removed marrow is thawed and injected into a vein to replace the destroyed marrow.

It generally takes about two weeks to two months to recover from an orchiectomy, which allows doctors to remove the affected testicle. It is important to follow the post-operative instructions given by your doctor during your recovery time.

• You will be advised to avoid lifting anything over ten pounds for the first few weeks after surgery.
• You will also be asked to refrain from engaging in any kind of sexual activity until you have fully recovered.
• Activities such as exercising, running, or playing sports should be avoided for nearly four weeks post-surgery.

You will be asked to maintain a schedule of follow-up appointments to minimize the risk of testicular cancer returning. There is a small risk that cancer may return or grow in the other testicle. Hence, it is vital that patients maintain follow-up appointments and learn how to perform self-testicular examinations. The duration of your follow-up care may vary based on your diagnosis and disease prognosis.

Untreated testicular cancer can lead to certain complications such as:

• Excessive female hormone: In some cases, testicular cancer can lead to the increased production of another hormone known as human chorionic gonadotropin (hCG), also referred to as the “pregnancy hormone.” The excessive production of hCG can result in the abnormal enlargement of breast tissue in men, a condition known as gynecomastia. Other types of testicular cancer may lead to gynecomastia due to increased levels of another female hormone, estrogen.
• Metastasis or spread of cancer: If testicular cancer is undiagnosed or left untreated for an extended period, it can spread from the original tumor to other parts of the body, resulting in complications. The site to which the original tumor spreads is known as a secondary or metastatic tumor. In cases of metastasis, patients may present with various symptoms based on the location of the metastatic tumor, including lower back pain, swollen lymph nodes, or swelling and pain in the lower extremities. The retroperitoneum is the most commonly involved site in metastatic disease. Most blood-borne metastasis occurs after lymph node involvement, with the lungs being the most common organ affected. If a secondary tumor is present in the lungs, it may cause shortness of breath, coughing up blood, or a chronic cough. Symptoms such as headaches or confusion can occur if a secondary tumor spreads to the brain.
• Late effects of chemotherapy: Patients treated with cisplatin-based chemotherapy have an increased risk of developing hypertension, hyperlipidemia, metabolic syndrome, and cardiovascular events. Additionally, patients who receive a high cumulative dose of etoposide may face a risk of developing other cancers, such as acute myeloid leukemia (AML), typically 2-3 years after therapy.

Testicular cancer requires orthodox medical treatment. However, some patients believe that a complementary approach through alternative therapies can assist in managing the side effects caused during treatment.

• Acupuncture
  Acupuncture has proven to be an effective alternative therapy for patients experiencing testicular pain. It involves the insertion of needles through the skin at specific points on the body. Acupuncture can also provide relief for patients suffering from epididymitis, which is the inflammation of the epididymis located at the back of the testicle.
• Aromatherapy
  Aromatherapy utilizes a blend of essential oils for massages that promote relaxation. Many patients find that alternative therapies like aromatherapy help them cope with cancer treatment and enhance their sense of relaxation.

Being diagnosed with testicular cancer can cause stress and anxiety in men. This medical condition directly affects the quality of life, and patients struggle with the concept of cancer itself. Some men also face a decreased sperm count or experience difficulty in ejaculating, leading to embarrassment. However, timely diagnosis and treatment can help you manage the signs and symptoms linked with testicular cancer.

Learn about testicular cancer

• Learning about testicular cancer can help you make informed decisions regarding your treatment options.
• Empower yourself with knowledge to alleviate the fear of the unknown.
• Write down questions to ask your doctor at your next appointment.
• Utilize reputable sources to read more about the condition and available treatment options.

Take care of yourself

• Preparing for treatment can seem daunting, so prioritize self-care.
• Eat a well-balanced diet rich in fruits and vegetables.
• Ensure you get plenty of rest each night.
• Practice meditation and eliminate sources of stress before treatment.
• Discuss strategies with your doctor to help your body prepare for treatment.

Join a support group

• Dealing with testicular cancer can be isolating, even with friends and family.
• Talking to others who have experienced similar challenges can be beneficial.
• Explore online support group forums that include cancer survivors.

Take the help of your loved ones

• Undergoing chemotherapy can be tough; seek assistance from those close to you.
• Ask for help with transportation to doctor’s appointments or treatment centers.
• Engaging with loved ones during treatment can help you cope with the fear of cancer.