Testicular cancer develops in the testicles inside the scrotum, which is the bag of skin hanging behind the penis. Testicular cancer develops when cells in the testicles divide in an uncontrolled way and tend to spread to other parts of the body. Such testicular cells which divide in an uncontrolled way should be removed urgently.
Testicular cancer, a rare type of cancer, develops in only 3 out of every 100,000 men per year on average. Despite its low incidence rate, testicular cancer is the most common cancer in men between 20 and 34 years of age.
The curability rate of testicular cancer is quite high, even when it has spread beyond the testicle. You may receive one of the various treatments or a combination of them, depending on the type and stage of your testicular cancer.
What are the Symptoms of Testicular Cancer?
The most known symptom of testicular cancer is a painless lump or swelling in a part of the testicle. However, not every lump or swelling is necessarily a sign of testicular cancer.
Since cancer cells that have formed in the testicles may carry the risk of metastasis, you should definitely be treated by a specialist urologist in case of any symptoms.
The signs and symptoms of testicular cancer include:
- Lump or enlargement in both testicles (abnormal size of testicles)
- Feeling of heaviness in the scrotum (the bag of skin where the testicles are located)
- A dull pain in the abdomen or groin
- Sudden accumulation of fluid in the scrotum
- Testicular or scrotal pain
- Enlargement or tenderness of the breasts
- Back pain
What are the Causes of Testicular Cancer?
The causes of testicular cancer are not known exactly.
Healthy cells grow and divide regularly to ensure that your body functions normally. However, sometimes some cells develop abnormalities, which cause growth to get out of control. These cancerous cells continue to divide even when new cells are unnecessary. The accumulated cells form a tumor in the testis.
Almost all testicular cancers begin to develop in the germ cells. Germ cells produce immature sperm in the testicles.
Certain risk factors are known to be associated with testicular cancer.
What are the Risk Factors?
Risk factors that may cause the formation of cancer cells in the testicles include:
Undescended Testicle (Cryptorchidism)
The testicles develop in the abdomen during fetal development process and then normally descend into the scrotum before birth. Boys who have undescended testicles are at risk of cancer. Even if the testicles are surgically placed in the scrotum, the boys are still at a high risk of developing cancer.
Abnormal Development of the Testicles
Conditions that cause abnormal development of the testicles can raise the risk of testicular cancer.
People with a family member, who has a history of testicular cancer, are at an increased risk of developing cancer.
Cancer development in the testicles usually occurs in young men between 15 and 35 years of age. However, it can be seen in men of all ages.
White-skinned men are at a higher risk than black-skinned men.
STAGE 1: Testicular cancer is confined to the testis.
> Stage 1a: The cancer is confined to the testis and epididymis. There is no lymphovascular invasion.
> Stage 1b: The cancer has expanded beyond the testis and epididymis or there is a lymphovascular invasion.
> Stage 1s: The cancer has been removed from the testicle. Even if there is no metastasis in other tissues, blood values suggesting the presence of cancer (AFP, beta-HCG, LDH) are high.
STAGE 2: There is metastasis in the lymph nodes in the abdomen, and the blood values suggesting the presence of cancer (AFP<1000, beta-HCG<5000, LDH<1.5 kat) are not high.
> Stage 2a: Retroperitoneal lymph nodes (insignificant in number) are smaller than 2 cm in size.
> Stage 2b: Retroperitoneal lymph nodes (insignificant in number) are between 2 cm and 5 cm in size.
> Stage 2c: Retroperitoneal lymph nodes (insignificant in number) are greater than 2 cm in size.
STAGE 3: Metastases are observed in lymph nodes or organs distant from the testis. Or, the blood values suggesting the presence of cancer are quite high.
> Stage 3a: Testicular cancer metastases are observed in distant lymph nodes or lungs. The blood values suggesting the presence of testicular cancer are not too high.
> Stage 3b: The blood values suggesting the presence of testicular cancer are considerably high. (AFP:1000-10.000; beta-HCG:5000-50.000, LDH: 1.5-10 kat fazla)
> Evre 3c: Cancer has also spread to other organs besides the lung. Or, the blood values suggesting the presence of cancer are ultra-high. (AFP:>10.000; beta-HCG:>50.000, LDH: >10 times more)
Life Expectancy in Testicular Cancer
The success rate of testicular cancer treatments performed worldwide is higher than 90%. For this reason, testicular cancer allows for a very good life expectancy compared to other types of cancers.
To give a rough percentage, less than 5% of patients diagnosed with this disease die.
Types of Testicular Cancer?
The vast majority of the types of testicular cancer develop in the germ cells which produce sperm. Germ cell tumors are classified into two groups as seminomas and nonseminomas.
Cancer confined to the testis: Cancerous tissues in the testicle is removed through an incision made in the groin. If the size of the cancer in the testicle is 4 cm in size or if the pathology report indicates the presence of a “rete testis invasion”, an additional 1 cycle of chemotherapy is administered.
Testicular cancer that has metastasized to the lymph nodes in the abdomen: The testicular cancer is urgently removed. Abdominal radiation therapy is performed or 3 cycles of chemotherapy are administered.
Testicular cancer that has metastasized to the lung: The cancer in the testicle is urgently removed. 3 cycles of chemotherapy are administered.
Testicular cancer that has metastasized to organs other than the lung: The cancer in the testicle is urgently removed. 4 cycles of chemotherapy are administered.
Cancer confined to the testis: Cancerous tissues in the testicle is removed through an incision made in the groin. if the pathology report indicates the presence of a “vascular invasion", an additional 1 cycle of chemotherapy is administered.
Testicular cancer that has metastasized to the lymph nodes in the abdomen: Cancerous tissues in the testicle are removed through an incision made in the groin. 3 cycles of chemotherapy are administered.
Testicular cancer that has metastasized to the lung: Cancerous tissues are the testicle is removed through an incision made in the groin. If the cancer markers in the blood values are high, 3 cycles of chemotherapy are administered; and if they are too high, 4 cycles of chemotherapy are administered;
Testicular cancer that has metastasized to organs other than the lung: The testicular cancer is urgently removed through an incision made in the groin. 4 cycles of chemotherapy are administered.
Treatment of Testicular Cancer
In the first phase of the testicular cancer treatment process, the goal is to urgently save the patient from cancer cells. The cancerous testicle, i.e. the ovary, is surgically removed. Even if the patient has suspected testicular cancer, this diseased testicle should be removed from the body. This surgical procedure is called radical orchiectomy.
The cancerous testicle removed from the patient with testicular cancer is then taken under pathologic examination. Additional treatments to be performed vary depending on the type of testicular cancer, the extent of the cancer, as well as the patient's response to treatment.
After radical orchiectomy, the treatment procedure to be performed is determined based on the stages. If the disease has not metastasized, and if the cancer is confined to the lower abdomen and testicles, radiotherapy is performed. In this method, side effects include classical side effects of radiotherapy such as nausea, hair loss and fatigue.
If the testicular cancer is in its second stage, it can be treated by administering a short-term chemotherapy. In such a case, the side effects include classical side effects of chemotherapy such as hair loss, nausea, fatigue, weakness, lack of appetite and impotence.
In the third stage, where the cancer has metastasized to distant regions or even to the lungs, chemotherapy is administered again but the procedure becomes more difficult and more time-consuming. It side effects, on the other hand, include hair loss, lack of appetite, nausea, vomiting, and fatigue.
If the patient does not response to all these treatments, or if the cancer grows again despite the shrinking, Retro Peritoneal Lymph Node Dissection, abbreviated as RPLND, should be performed. This surgical procedure is very dangerous. Therefore, it should definitely be performed by a specialist physician. Although the disease is prevented to a considerable extent after surgery, it sometimes gives different results.
Recovery Process and Sex Life after Testicular Cancer Surgery
Bleeding is the riskiest factor after surgical treatment of cancers in the testicles. Compared to open surgery, robotic surgery does not cause postoperative bleeding in the treatment of testicular cancers.
After surgery, it may take time for the patient’s bowel movements to return to normal.
The patient may be unable to pass gas for a day or two after the surgery, but this is a short-time condition that will resolve spontaneously if there is no injury to the intestines.
Patients are usually discharged on the 3rd post-operative day.
Especially when performing surgery for left-sided testicular tumors, the lymph nodes may be found to be attached to a main nervous system called the sympathetic chain. When separating these lymph nodes from around the aorta, there is a risk of damage to these nerves.
The most important function of these nerves is related to orgasm sensation and ejaculation. Damage to these nerves cause problems such as ejaculatory dysfunction that we call anejaculation. Although the patient does not have an erectile dysfunction problems, ejaculation functions are lost.
With chemotherapy, it is possible to treat all testicular cancers, including those in advanced stages,.
Chemotherapy provides high success rates in the treatment of testicular cancer. Almost in all cases, early-stage cancers and most advanced-stage cancers are cured completely.
As in all types of cancers, chemotherapy is administered in testicular cancers for two purposes: Post-operative prevention, and the treatment of common stage disease.
Treatment of testicular cancer begins with surgery. After surgical removal of the cancerous testicle, the patient is prepared for chemotherapy.
If the patient’s postoperative values are at normal levels, adjuvant chemotherapy (preventive) is administered. The purpose of adjuvant (preventive) chemotherapy is to prevent the recurrence of the disease. Even if the cancer has been completely removed, recurrence of the disease is still possible. This is because the cancer cells in the body tend to grow.
Adjuvant chemotherapy administered for prevention is selected depending on the type of the cancer. If the cancer is seminoma type, the chemotherapy drug called carboplatin is given, but if it is non-seminoma type, the chemotherapy drug called BEP is given.
Adjuvant/preventive therapy for seminoma:
In the preventive treatment of seminoma and various testicular cancers, three methods can be used for the early stage.
- Administering one or two cycles of chemotherapy once every three weeks with the drug called carboplatin.
- Untreated control
Each of these three methods provides a success rate of close to 100%. The type of the treatment is determined by evaluating the side effects. With its less side effects and ease of administration, carboplatin is the first of the treatment modalities that can be chosen.
Adjuvant/protective treatment for non-seminoma
The method to use in the adjuvant/protective treatment of non-seminoma testicular tumors is the BEP regimen. One or two cycles of treatment can be performed.
For patients with regional or distant metastases (seminoma and non-seminoma)
If the blood values suggest the presence of cancer is high, and/or a mass is seen in the X-ray images, administration of therapeutic chemotherapy will be considered. The chemotherapy to be administered for this purpose is BEP chemotherapy for both seminoma and non-seminoma. It is usually given in three cycles.
BEP represents the initial letters of the chemotherapy drugs given:
How is the Treatment Performed?
BEP chemotherapy should be administered by an expert staff in the hospital. This is a treatment that should be performed in medical oncology clinics. Blood tests should be done in all chemotherapy periods. These include blood count, biochemical tests involving the kidney and liver functions, and most importantly, the tumor markers. The decrease in the level of tumor markers should be controlled throughout the chemotherapy period. If a decrease at an appropriate rate cannot be achieved, then the chemotherapy drugs should be evaluated and changed if necessary. However, this is a rare condition.
The physician, who follows up the patient with blood tests, evaluates the patient before chemotherapy. The heart, lung, and kidney functions, additional diseases, drugs used are all evaluated. If the test and examination results are normal, treatment is started.
After the determination of the doses of chemotherapy drugs by the physician, the patient is taken to the chemotherapy room.
The nurse inserts a flexible tube called a cannula into your arm or hand. Drugs are given through this tube.
Before each cycle of chemotherapy, preparative serum is given to all patients. This serum contains preparative drugs intended to prevent nausea, allergies, etc. Chemotherapy drugs are placed in serum and given in the order and at a speed determined by the physician. To maintain the normal functioning of the kidneys, it is recommended to consume plenty of fluids before the administration of chemotherapy.
Frequency of Treatment
Chemotherapy is administered at 21-day intervals. The way the treatment is administered is shown in the Chart. Bleomycin is given on days 1, 8, and 15. On days when Bleomycin alone is given (days 8 and 15), the treatment takes 30 minutes.
Etoposide and Cisplatin are given on days 1, 2, 3, 4, and 5. These days the treatment takes 5 hours. These all constitute a cycle of treatment. In other words, the patient received treatment for 7 days in a cycle.
Side Effects of Chemotherapy
Each patient gives a different response to chemotherapy. The side effects we will mention may not be necessarily observed in every patient who receives BEP chemotherapy. Almost all patients complete the treatment with quite few side effects. It is of importance for you to stay in close contact with your doctor in the management of side effects.
- Decreased resistance to infection
The Drugs in the BEP combination can negatively affect the production of white blood cells. This means the patient becomes vulnerable to infection. This effect can be observed 1 week after the administration of the drug. However, this effect gets minimized after 10-14 days. Before the next cycle of chemotherapy, white blood cells reach the normal levels.
- When the body temperature exceeds 38ºC, the patient suddenly begins to feel cold and shiver.
- Bleeding or bruises
The drugs in the BEP combination can cause a decrease in the amount of platelets, which provide blood coagulation when needed. It is recommended to visit the doctor for examination when there is bruising, bleeding and redness on the skin.
- Anemia (low number of red blood cells)
The drugs in the BEP combination may cause anemia. It causes the patient to feel tired and weak. If deemed necessary, blood transfusion can be done. The use of blood-doping drugs such as erythropoietin is not recommended.
- Sickness and vomiting
Supportive drugs are given to minimize vomiting and nausea suffered during the treatment period. Some anti-nausea medications may cause constipation.
- Hair Loss
Hair loss may develop 3.5 weeks after the first cycle of chemotherapy. The patient’s hair falls out completely. In addition to hair, eyebrows and eyelashes may fall out as well. These are temporary losses. After the completion of chemotherapy, hair, eyebrows and eyelashes begin to grow again.
- Development of sores in the mouth
Sores may develop in the patient’s mouth. This risk can be reduced by increasing the fluid consumption and cleaning the teeth with a soft toothbrush.
- Taste change
Patients may notice changes in their sense of taste. This is a temporary condition that resolves spontaneously at the end of the treatment period.
- Tingling in hands or feet
Tingling sensation may be felt due to the effect of the drug Cisplatin on nerve cells. This condition is called peripheral neuropathy. This side effect resolves gradually several months after treatment.
- Discoloration of the skin
Discoloration of your skin may rarely be observed in patients. The skin returns to normal after the treatment.
In case of diarrhea, drug therapy is administered. In case of severe diarrhea, the patient should inform the doctor. The patient should consume 2-3 liters of fluid a day to make up for the lost fluid.
- Problems in the lungs
Chemotherapy may cause problems in the patient's lungs. If the patient uses tobacco products, he/she is more likely to face such problems. Problems can be in the form of coughing and shortness of breath.
The median age for the diagnosis of testicular cancer is 33. Once chemotherapy treatment is administered, the ability to have children may be adversely affected. However, the sperm storage method makes it possible to have a baby after the treatment.
Masses which Persist Despite Chemotherapy
In 20% of patients, metastatic masses in the abdomen do not completely disappear as a result of chemotherapy administered for the treatment of testicular cancer. It should be investigated whether the cancer cells in these masses have been destroyed.
Tumor markers (AFP, beta HCG, LDH) and PET scan results are analyzed for masses in the abdomen, which cannot be eliminated. Masses found to be cancerous are surgically removed. This surgical procedure is called retroperitoneal lymph node dissection (RPLND).
Other Chemotherapy Options Besides BEP
Besides the BEP regimen, there are also some other chemotherapy regimens used in the treatment of testicular cancer. The main ones among them can be listed as VİP, VeİP, TİP, GemOx, and EP. These regimens are usually used in relapsing diseases. Their success rates in treatment are as high as that of the BEP regimen. It should be administered by medical centers, which have been specialized in the field.
Stem cell transplantation is also performed to treat advanced, recurrent testicular cancers. The treatment success rate in testicular cancer is higher than in other organ cancers.