Testicular (testis) cancer is the most common cancer in males aged 15-40, and with modern treatments has an excellent prognosis, with cure rates over 95% if detected early. The most common reason for diagnosis is a lump within the testicle, usually firm and painless. Nearly all testicular cancers are tumours of ‘germ cells’, which normally give rise to sperm. Testicular cancers are divided into two main types: Seminoma and Non-seminoma. Seminomas generally occur in slightly older men, and are not as rapidly growing as non-seminomas. Overall around 75% of tumours are confined to the testicle at diagnosis (i.e. have not spread to lymph nodes or other organs).

Testicular Self-Examination

Because the most common early sign is a lump within the testicle, it is important for all men to perform regular testicular self-examination. If men are accustomed to the shape and feel of their testes they will easily detect any significant change such as a new lump. This can be performed in or after a bath/shower, and simply involves rolling the testicle gently between thumb and forefinger from top to bottom, feeling for any irregularity/firmness. This should be performed approximately every 6 months and any change reported to your local doctor for further assessment.

To further investigate a testicular lump, an ultrasound scan of the testicles is performed, and blood taken for ‘tumour markers’ – specific proteins made by some testicular cancers and released into the bloodstream.

Orchidectomy

Diagnosis of testicular cancer can only be confirmed following removal of the affected testicle and detailed examination under a microscope. Orchidectomy is the surgical removal of a testicle. This procedure is performed in hospital under general anaesthetic. A small incision is made into the groin, where the blood vessels leading to the testicle are first controlled to prevent cancer cells ‘spilling' into the rest of the body. For cosmetic reasons, insertion of a prosthetic testicle can be performed at the same time if requested.

Staging

As in all cancers, a series of tests is necessary to determine the extent, or ‘stage’ of the tumour. This will involve imaging studies such as a CT scan, and blood tests to measure certain proteins made by testicular cancer cells that can help monitor the success of treatment.

Staging describes whether the cancer : ·

Is confined to the testis only (Stage I) ·
Has spread to the lymph nodes within the abdomen (Stage II – see figure below) ·
Has spread to other organs (Stage III)

Even if testicular cancer has already spread, it is important to note that it is one of the few cancers that can still be treated with very high cure rates. Further treatment is given as chemotherapy, radiotherapy, surgery, or a combination.

Further treatment of testis cancer

The type of treatment required, if any, following removal of the testicle depends upon the type and stage of the testicular cancer.

Seminoma

STAGE I

No treatment – at least three quarters of patients are cured without further treatment, and for the 15-25% of patients who experience a recurrence of the cancer, this can be readily treated with radiotherapy or chemotherapy with around 98% success rates. If this approach is chosen, patients need to be closely monitored for early signs of recurrence, which involves regular CT scans, chest X-rays, and blood tests for a number of years.

Radiotherapy – involves daily doses of external beam radiotherapy delivered to the abdomen for 2-3 weeks. There is a low risk of side effects, (including the slightly increased risk of a second cancer developing more than 10 years after treatment) and this reduces the risk of recurrence to 1-2%.

Chemotherapy – recent trials report efficacy similar to radiotherapy for prevention of recurrence using short courses of chemotherapy and this option can be discussed further with an oncologist (cancer specialist)

STAGE II

Radiotherapy – if there is minimal enlargement of abdominal lymph nodes on CT scans then a course of external beam radiotherapy is curative in up to 90% of patients. For recurrence after radiotherapy, chemotherapy is indicated.

Chemotherapy – for more bulky lymph node enlargement on CT scanning, chemotherapy offers the best chance of cure as this treats cancer cells throughout the body, as opposed to radiotherapy which treats cancer cells only within the part of the body exposed to the radiation. Chemotherapy causes complete shrinkage of the lymph nodes (i.e. complete response) in over 90% of patients.

STAGE III

Chemotherapy – for cancers that have spread beyond the abdominal lymph nodes, chemotherapy is indicated for a systemic treatment, with excellent response rates

Non-seminoma

STAGE I

No treatment – Surveillance may be offered to patients with small stage I tumours depending on the appearance of the cancer under the microscope, however involves a commitment on the patients behalf to comply with rigorous CT scanning, chest X-rays, and blood tests over a number of years in order to detect any sign of cancer recurrence. Up to a quarter of patients will experience a recurrence of their cancer requiring further treatment and as these cancers can grow rapidly, best chances of successful treatment are with early detection.

Chemotherapy – To reduce the 25% risk of relapse to around 1%, a short course of chemotherapy is effective, and usually well tolerated by young and otherwise healthy patients.

Surgery – In certain centres, particularly in the United States, preventative removal of the abdominal lymph nodes is recommended to remove the microscopic cancer spread and prevent future recurrence. This is a major operation and because no cancer is found in around 75% of patients, is not routinely offered to patients with stage I non-seminoma in most Australian and European centres.

STAGE II and III

Chemotherapy - for cancers that have spread beyond the abdominal lymph nodes, chemotherapy is indicated for a systemic treatment. If there is still a residual mass on the CT scan, surgery to remove this may be required (in around 20-30%).

Effect of treatment on fertility

The impact on fertility depends upon the function of the other testicle and the exact treatment received. Overall it is worth considering storage of sperm if any treatment is required after orchidectomy. This gives the option of future in vitro fertilisation (IVF) in the event of sperm production being permanently affected during the course of treatment. Below is a summary of the impact of each treatment on fertility:

Orchidectomy – removal of the cancer should not reduce fertility if the other testicle is normal; in fact it may improve sperm production as testicular cancer may have a dampening effect on the other testicle. In patients with an abnormal or absent other testicle, then sperm storage may be worth considering prior to surgery. In these circumstances, it is also important to monitor the levels of testosterone (the male hormone produced by the testicles) post-operatively as this may need to be supplemented or replaced.

Radiotherapy – if the other testicle is exposed to radiation, this will permanently reduce the production of sperm. To minimize this risk the testicle is shielded during radiotherapy so that the chances of subsequent infertility are low.

Chemotherapy – as a side effect of chemotherapy, sperm production is reduced to zero, and this can take 1-2 years to recover. As there is a chance of permanently lowered sperm count it is advisable to store sperm for future use prior to commencing chemotherapy.

Abdominal surgery – the operation to remove lymph nodes within the abdomen, usually for residual tumour after receiving chemotherapy, can damage the nerves that allow ejaculation. For this reason, after surgery there is the risk of the ejaculated semen going backwards into the bladder (retrograde ejaculation) rather than out the end of the penis, or of failure to ejaculate at all (anejaculation). Again, it is advisable to store sperm for future use pre-operatively.

FOLLOW-UP

Whatever the stage of cancer or treatment received, close follow-up with scans and blood tests is required for at least 10 years after diagnosis. In addition, regular examination of the other testis should be regularly carried out although the risk of a cancer in the remaining testicle is only about 2%.

For a consultation with one of our urologists, please call AUA on 03 8506 3600.