October is a month dedicated to cancer globally. It has come and gone with a great deal of awareness created around the dreaded illness. Activities such as “cancer walks” and “shaveathons” usually held annually were held by various organisations as a “fun” way to impart information and to gather everyone affected by cancer. With over 100 types of Cancer ranging from Bone, Kidney, Leukemia, Prostate, Vaginal, Lung, Skin, Colon, bladder and more others, in this issue, Sister Thabisile Makhaye, Health Operations Manager for the Phelophepa trains zooms in to focus on Testicular Cancer.
What Is Testicular Cancer?
Many people may be asking themselves about what Testicular Cancer is and how it affects one’s life. This type of cancer is the most common malignancy in 15 to 45 years old males. The vast majority (95%) of testicular cancer develops from the germinal cells of the testes.
The incidence of testicular cancer shows marked variation among different countries, races and socio-economic groups. The disease is most common in Scandinavia, and rare in Africa. Carcinoma in situ (CIS) is believed to be the precursor of cancer. Men with undescended testicles have a 5 –10 times increased risk of developing testicular cancer, compared to the general population. Five percent of patients who have had testicular cancer develop a second cancer on the other side.
Testicular cancer typically presents with a painless lump in the testes. Left untreated, the tumour cells can spread via the lymphatic pathways to the retroperitoneal glands around the aorta at the level of the kidneys. It can also later spread via the blood stream to the lungs, liver, bone and the brain (metastasis). Most patients have the disease confined to the testes or the regional lymph glands at presentation.
The exact cause of testicular cancer is unknown. The clinical evidence suggests that congenital (born with), environmental and genetic factors play a role. Testicular cancer develops from the primitive germ cells of the testes. During development the germ cell may be affected by environmental factors, resulting in disturbed differentiation (cell development). Factors that may interfere with normal germ cell development include cryptorchidism (undescended testicle), genetic predisposition or chemical carcinogenesis.
Statistical analysis indicates that one third of patients with germ cell testicular tumours are genetically susceptible to the condition. The incidence of testicular cancer has increased fourfold over the last five decades. During the same period an apparent decrease in semen quality and an increase in genital abnormalities, such as hypospadia (a penile malformation) and undescended testicles, have been observed. The higher incidence of testicular cancer in men with testicular atrophy, undescended testes and infertility, suggests a common environmental factor as the most likely link between these genital abnormalities.
Testicular cancer can be completely asymptomatic in its early stage. Most testicular tumours start with a painless lump or swelling of the testis, noted by the patient or his sexual partner. 30-40% of patients complain of a dull ache or heaviness in the scrotum or lower abdomen. Acute pain is the presenting symptom in ±10% of patients. Approximately 10% of patients’ symptoms or signs are due to the spread of the tumour to organs outside of the testes. Spread to the lymph glands, cancer can present with a mass in the abdomen or the neck.
Testicular cancer develops in the primordial germ cell. The pre-malignant (non-invasive) stage of the disease is called carcinoma in situ (CIS). The tumour grows as a hard painless lump in the testicle. The testis has a thick capsule that acts as a natural barrier to tumour spread. Direct local spread beyond the capsule of the testis is rare.
Testicular cancer typically spreads via the lymphatic pathways in an organised step-wise manner. Due to its embryological development, the lymphatic drainage of the testes is to the lymph glands around the aorta and vena cava at the level of the kidneys. These para-aortic lymph glands are the first to be involved in the spread of testicular cancer. Most testicular cancers are fast growing, with doubling times ranging from 10 to 30 days. Patients left untreated, and those unfortunate enough to suffer treatment failure, demise rapidly, usually within 2-3 years.
Although there is no known cause for testicular cancer, definitive risk factors have been identified:
One would need to see a doctor if a lump or hardness is detected in the testicle itself or an unexplained enlargement of the testicle. It could also be an unexplained pain, ache or swelling within the scrotum. The diagnosis of testis cancer is based on a medical history, physical examination and some confirmatory special tests. It could also be based on a scrotum ultrasound, which is an excellent test to define the site and nature of scrotal masses. Almost all solid masses of the testes itself are cancerous and almost all scrotal masses not arising from the testes are benign.
Testicular cancer is one of the most treatable cancers. The vast majority of patients, including those with widespread metastatic disease, are cured by modern day chemotherapy and/or radiotherapy. The treatment regimes, however, are not without complications and despite the excellent overall results, a small group of poor prognosis patients do badly despite intensive therapy. A primary tumour is treated by radical inguinal orchidectomy. An incision is made in the groin and the spermatic cord carrying the testicular blood vessels is tied off. The testes and its coverings are removed. The testicle is not removed via the scrotum because this can lead to spread to the scrotal skin and the lymph glands of the groin.
The orchidectomy specimen is sent for histological analysis (biopsy) to determine the type of testicular tumour. Subsequent treatment will depend on the type and stage of disease. Most of the treatment options affect fertility. This needs to be discussed with the patient prior to commencing treatment. If appropriate, semen should be preserved for possible future assisted reproduction. The standard treatment is radiotherapy to the para-aortic lymph glands and to the pelvic glands on the side of the tumour. Seminomas are exquisitely sensitive to radiotherapy. The relapse rate is 3-5% and overall survival is 92 – 99%.
Surveillance is an alternative to initial adjuvant radiotherapy. This involves regular follow up with CT scans and Chest X Rays and only irradiating if and when nodes become apparent. The relapse rate on surveillance is 20%. Thus, 80% of patients are cured by orchidectomy alone and will receive necessary radiation under standard treatment regimes. The 20% who relapse do so mainly at the para-aortic node.
A third option in stage is a course of Carboplatin chemotherapy. Results with Carboplatin are good and it is a reasonable option for patients with moderate to high risk seminoma who do not want radiotherapy. The other option is chemotherapy with 4 cycles of Etoposide and Cisplatin. The overall survival is 85%. For patients with widespread disease beyond the lymph glands and lungs the survival is 57%.
It is not possible to prevent the development of testicular cancer. All men should examine their testicles regularly for swellings or lumps. It is debatable whether men with undescended testicles or previous testicular cancers should have biopsies of their testes to rule out Carcinoma (CIS). Carcinoma in situ is the precursor to testicular cancer and if detected it can be treated successfully with radiation. This destroys the CIS but preserves the hormonal function of the testes. As with all cancer earlier treatment leads to improved outcome. Testicular cancer is fast growing, and any man with a suspicious lump in his testes should not delay seeking professional help.
Advise: Check your testes
Men between the ages of 15 and 40 should become familiar with the usual level of lumpiness of their testicles. They should examine themselves about once a month, preferably after a warm shower or bath when the scrotum is relaxed. To examine, roll each testicle between the thumb and first two fingers of both hands. Normal testicles feel smooth and slightly spongy.