Health Topics: Testis Cancer

Testis cancer is the most common cancer in young men between the ages of 17-39. Approximately 6,900 new cases will be diagnosed in 2000, and 300 men will die from this disease in 2000. However, testis cancer represents a success story in modern oncology. This is the result of effective diagnostic techniques, improved serum tumor markers (alpha-feto protein, beta-HCG), effective platinum-based chemotherapy for advanced disease (i.e. Lance Armstrong), and modification of surgical technique (nerve-sparing retroperitoneal lymphadenectomy for early stage and some moderate/advanced disease). The mortality of advanced disease was greater than 50% before 1970. That number has decreased to less than 10% since 1979.

Most testicular cancers are found by men themselves, by accident or when doing testicular self-examination (TSE). The testicles are smooth, oval-shaped, and rather firm. Men who examine themselves regularly become familiar with the way their testicles normally feel. Any changes in the way they feel from month to month should be reported to a doctor.

TSE should be performed after a warm bath or shower. The heat relaxes the scrotum, making it easier to find anything unusual. The procedure is simple and only takes a few minutes.

• Stand in front of a mirror.

• Look for any swelling on the skin of the scrotum.

• Examine each testicle with both hands.

• The index and middle fingers should be placed under the testicle while the thumbs are placed on the top.

• Gently roll the testicle between the thumbs and fingers. It is normal for one testicle to be slightly larger than the other.

• Find the epididymis (the soft, tube-like structure at the back of the testicle that collects and carries the sperm). Do not mistake the epididymis for an abnormal lump.

If you find a lump, contact your doctor right away. Most lumps are found on the sides of the testicles, but some appear on the front. Remember that testicular cancer is highly curable, especially when treated promptly.

TSE performed regularly is an important health habit, but it cannot substitute for a physician's examination. Your doctor should check your testicles when you have a physical exam. You also can ask your doctor to teach you how to do TSE.

Testicular cancer can cause a number of symptoms. Listed below are warning signs that men should watch for:

• a lump in either testicle

• any enlargement of a testicle

• a feeling of heaviness in the scrotum

• a dull ache in the lower abdomen or the groin

• a sudden collection of fluid in the scrotum

• pain or discomfort in a testicle or in the scrotum

• enlargement or tenderness of the breasts

• a lump in the neck or in the clavicle region

• gastrointestinal pain

• lumbar back pain

• bone pain

• central nervous system changes

If any of these symptoms lasts as long as 2 weeks, it is very important to see a doctor. Early diagnosis of testicular cancer is especially important because the sooner cancer is found and treated, the better a man's chance for complete recovery.

The diagnosis is made by removing the affected testicle through an incision in the groin, similar to a hernia operation, not through the scrotum. This is called an inguinal orchiectomy. Before the operation, a chest x-ray, blood for tumor markers, and a urine sample will be taken. The pathologist will examine the tissue under the microscope and determine what type of testicular cancer.

The most common types of testicular cancer are seminomas and nonseminoma.

• Seminomas make up about 40 percent of all cases.

• Nonseminomas are actually a group of cancers. They include choriocarcinoma, embryonal carcinoma, teratoma, and yolk sac tumors.

Each of these two major types of testicular grows and spreads differently--and they are treated differently.

Staging: Once the cancer has been diagnosed, it is important to find out the extent, or stage, of the disease (whether it has spread to other parts of the body). Staging procedures include a thorough physical exam, blood tests (tumor markers), x-rays and CT or CAT scans of the abdomen, chest, and sometimes the brain.

Surgery: Additional surgery to remove the lymph nodes deep in the abdomen may be recommended. In the past, this surgery removed the nerves that control the ability to ejaculate during sexual intercourse. Today, we use a nerve-sparing technique developed and perfected at Indiana University that preserves these nerves in over 90% of cases. Patients are able to ejaculate and in many cases father children.

A pathologist then examines the nodes to see whether they contain cancer cells. For patients with nonseminoma, removing the nodes can cure many patients and help stop the spread of their disease in others. If a large amount of tumor is found in the lymph nodes, adjuvant chemotherapy (the use of anticancer drugs following surgery) may be recommended. Seminoma patients do not need this surgery, if the disease is limited, because cancer cells in their lymph nodes can be destroyed with radiation therapy.

If the patient has a lot of cancer in the abdomen, chest, or brain, then chemotherapy is given first. The patient is restaged after 4-6 cycles, and if there is remaining disease, then surgery is performed to remove the tumor/lymph nodes that are remaining. In over 80% of cases, the tumor is destroyed by the chemotherapy and the surgery completes the job by removing the remaining tissue. In the other 20%, cancer cells remain in the tissue removed and these patients require additional chemotherapy (salvage) or a bone marrow transplant with high-dose chemotherapy.

Loyola has several faculty members who are experts in the surgical treatment of testicular cancer (such as Dr. Flanigan).

Radiation therapy: In radiation therapy (also called x-ray therapy, radiotherapy, cobalt treatment, or irradiation), high-energy rays are used to damage cancer cells and stop their growth. Like surgery, radiation therapy is a local treatment; it affects only the cells in the treated area. The patients usually receives radiation therapy as an outpatient.

Seminomas are highly sensitive to radiation. Following inguinal orchiectomy, men with seminomas generally have radiation therapy to their abdominal lymph nodes.

We work with a team of radiation oncologist in a multi-specialty setting to assure the patient receives the best care and follow up.

Chemotherapy: The use of drugs to treat cancer is called chemotherapy. Anticancer drugs are recommended when there are signs that the cancer has spread. The drugs that have been so successful in treating testicular cancer usually contain a drug called cis-platinum. The chemotherapy is given into the blood stream. Depending on the specific drugs and the patient's general condition, chemotherapy may be taken as an outpatient in the Cardinal Bernardin Cancer Center. Sometimes, however, the person must be hospitalized for a time so the effects of the treatment can be watched. Again, we work with a group of oncology physicians who specialize in the treatment of testis cancer requiring chemotherapy in order to give the patient the best care possible.

Testicular cancer is a very curable disease if it is diagnosed early. We have physicians with expertise in all treatment modalities of testicular cancer.

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