However, it is the most common malignancy in men between 20 and 34. There is considerable geographic variation with the highest incidence being in North American White males. Factors such as cryptorchidism (undescended testis), or gonadal dysgenesis are known risk factors. Ten percent of patients with testicular cancer have a history of cryptorchidism. The usual presentation is a painless swelling in the scrotum though 10% of patients will report a history of pain. Heaviness and tenderness are not uncommon. Many patients report a traumatic event prior to diagnosis; however, this is more of a coincidence than cause. Back pain and/or abdominal swelling can be seen if there is marked lymph node involvement. There are essentially two types of testicular cancer – seminoma and non-seminoma. Both are seen in equal frequency. Seminomas generally have a better prognosis.
If a testicular mass is detected, an ultrasoundis obtained to determine if the mass is solid or cystic. If a solid mass is found, bloodwork is obtained. There are two tumor markers found in testicular cancer – alpha fetoprotein (AFP) and betahuman chorionic gonadotropin (B-HCG). Depending on the type of testicular cancer, one or both will be elevated. Some, but not all, seminomas produce B-HCG. AFP elevation is never seen in seminoma. Non-seminomatous tumors can produce AFP and/or BHCG. The bloodwork will help differentiate the type of tumor. If a solid mass is seen on ultrasound and/or the bloodwork is abnormal, surgery will be recommended. Prior to surgery, a chest x-ray and computed tomography (CT scan) of the abdomen are obtained for staging. The surgery involves removal of the entire testicle, also known as a radical inguinal orchiectomy. If a non-seminoma is diagnosed preoperatively, thelymph nodes in the abdomen may be dissected as well. The testicle is sent for pathological review at the time of surgery. Tumor markers will be obtained after surgery to help ensure all disease has been removed.
“Testicular cancer is rare. There are approximately 8800 cases per year with an incidence of 5.2 per 100,000 males.”
Most testicular cancers are Stage 1 (i.e. no evidence of spread to lymph nodes). For Stage 1 seminomas, radiation to the pelvis andlymph nodes in the mid-abdomen is recommendedin this country for most patients after orchiectomy (removal of the testicle). There are some studies questioning whether radiation is necessary, however, standard of care in the United States is postoperative radiation. Stage 1 non-seminomas can be cured with surgery alone. There is no role for radiation in the treatment of early stage non-seminoma.
Testicular cancer is a highly curable disease. Testicular self-exam as well as annual examination by a physicianis the key to detection, diagnosis, and cure. However awkward or embarrassing, this simple, life-saving evaluation should not be ignored or taken lightly. Prior to receiving treatment, fertility issues should be discussed with the urologist. Many patients may be subfertile or infertile because of the tumor. Surgery can also reduce fertility. If radiation is recommended, a sperm count should be obtained prior to treatment and sperm banking may be recommended as the radiation will also reduce fertility.