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What is testicular cancer?
The testes (located under the penis in the scrotum) are male sex glands. There role is to produce sperm and male hormones (called Testosterone). Testicular cancer is the development of cancer in one or both testes.

Cancer of the testis occurs most often in men between the ages of 20 and 39, and is the most common form of cancer in men between the ages of 15 and 34. 

How is testicular cancer detected? What are symptoms of testicular cancer?

Most testicular cancers are found by men themselves. Also, doctors generally examine the testicles during routine physical exams. Between regular checkups, if a man notices anything unusual about his testicles, he should talk with his doctor. Men should see a doctor if they notice any of the following symptoms:
  • a painless lump or swelling in a testis
  • pain or discomfort in a testis or in the scrotum
  • any enlargement of a testis or change in the way it feels
  • a feeling of heaviness in the scrotum
  • a dull ache in the lower abdomen, back, or groin
  • a sudden collection of fluid in the scrotum

    These symptoms can be caused by cancer or by other conditions. It is important to see a doctor to determine the cause of any of these symptoms.

How to perform a testicular self examination?
Monthly testicular self examinations (TSE) are the most effective way to detect a tumor early. Testicular examination is best done after a warm bath or shower when the skin of the scrotum is relaxed. You should feel for any change in size and check for any lumps in testis by rolling it between the fingers and thumbs of both the hands. While many lumps are non cancerous, a high percentage of testicular masses are cancerous. It is important to consult a specialist about any change in the testis.
What are the risk factors for testicular cancer?

  • Undescended testis (Cryptorchidism): During the early development (before birth), the testes develop inside the abdomen and subsequently descend into the scrotum. In some individuals, one or both of the testes do not move down into the scrotum and stays inside the abdomen. This is known as Cryptorchidism or Undescended testes. In such cases the testes is not palpable and the scrotal sac is empty on one or both the sides. The risk of testicular cancer is increased in males in whom the testis does not move down into the scrotum. This risk does not change even after surgery to reposition the testicle into the scrotum therefore a regular self examination is recommended. However, after repositioning the testes into scrotal sac, it becomes easier to examine and detect early testicular cancers.
  • History of testicular cancer: Men who have had testicular cancer are at increased risk of developing cancer in the other testis.
  • Family history of testicular cancer: The risk for testicular cancer is greater in men whose brother or father has had the disease.

How is testicular cancer diagnosed?

In case of suspicion of testicular cancer on examination or history, the doctor performs certain laboratory and imaging tests to confirm the diagnosis. These tests include:

  • Tumor Markers: Tumor markers are substances often found in higher-than normal amounts when cancer is present. The type of tumor marker ordered by doctor will vary depending upon the kind of suspected cancer. In case of testicular cancer, tumor markers such as alpha-fetoprotein (AFP), Beta-human chorionic gonadotropin (ßHCG), and lactate dehydrogenase (LDH) in the blood are ordered. Abnormal level of tumor markers may suggest the presence of a testicular tumor, even if the tumor is too small to be detected by physical exams or imaging tests.
  • Ultrasound Ultrasonography uses high-energy sound waves to produce images of the internal organs. It is generally not uncomfortable and usually no preparation is needed for this test. Ultrasound of the scrotum can show the presence and size of a mass in the testicle. It is also helpful in ruling out other conditions, such as swelling due to infection or a collection of fluid unrelated to cancer.
  • Biopsy (microscopic examination of testicular tissue by a pathologist) to determine whether cancer is present. In nearly all cases of suspected cancer, the entire affected testicle is removed through an incision in the groin. This procedure is called radical inguinal orchiectomy. In rare cases (for example, when a man has only one testicle), the surgeon performs an inguinal biopsy, removing a sample of tissue from the testicle through an incision in the groin and proceeding with orchiectomy only if the pathologist finds cancer cells.

    If testicular cancer is found, more tests are needed to find out if the cancer has spread from the testicle to other parts of the body (Staging). Determining the stage (extent) of the disease helps the doctor to plan appropriate treatment.

What are different types of Testicular cancer?

Based on the type of the cell in the tumor, testicular cancers are classified into two most common kind i.e seminomas or nonseminomas. Rarely, other types of cancer arise in the testes such as lymphoma, endocrine tumors etc.

The preferred treatment modality may vary with the type of testicular cancer.

Seminomas may be one of three types: classic, anaplastic, or spermatocytic. Types of nonseminomas include choriocarcinoma, embryonal carcinoma, teratoma, and yolk sac tumors. Testicular tumors may contain both seminoma and nonseminoma cells.

How is testicular cancer treated? What are the side effects of treatment?

Most men with testicular cancer can be cured with surgery, radiation therapy, and/or chemotherapy. Treatment is often provided by a team of specialists, which may include a surgeon, a medical oncologist, and a radiation oncologist.

Seminomas and nonseminomas grow and spread differently and are treated differently. Treatment also depends on the stage of the cancer, the patient's age and general health, and other factors. Treatment is more likely to be successful when testicular cancer is found early. In addition, in early stages, the treatment can often be less aggressive and may cause fewer side effects.

The side effects depend on the type of treatment and may be different for each person.

The three types of standard treatment are:

Surgery to remove the testicle through an incision in the groin is called a radical inguinal orchiectomy. Men may be concerned that losing a testicle will affect their ability to have sexual intercourse or make them sterile (unable to produce children). However, a man with one healthy testicle can still have a normal erection and produce sperm. Therefore, an operation to remove one testicle does not make a man impotent (unable to have an erection) and seldom interferes with fertility (the ability to produce children). For cosmetic purposes, men can have a prosthesis (an artificial testicle) placed in the scrotum at the time of their orchiectomy or at any time afterward.

More aggressive tumors (decided on the basis of pathologic examination of the testis) may require surgical removal of the lymphnodes in the abdomen (Retroperitoneal lymph node dissection). This type of surgery does not usually change a man's ability to have an erection or an orgasm, but it can cause problems with fertility if it interferes with ejaculation. Robot Assisted Retroperitoneal lymphnode dissection (Robotic RPLND) is an alternative to open surgery which gives equivalent results while minimizing the morbidity of the procedure.

Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells and shrink tumors. Seminoma tumors are responsive to radiation therefore external beam radiation (radiation from source outside the body), aimed at the lymph nodes in the abdomen are used to treat seminomas. It is usually given after the surgery. It is a local therapy, meaning that it affects cancer cells only in the treated areas. Radiation therapy affects normal as well as cancerous cells. The side effects of radiation therapy depend mainly on the treatment the radiation dose and the area exposed. Common side effects include fatigue, skin changes at the site where the treatment is given, loss of appetite, nausea, and diarrhea. Radiation therapy interferes with the sperm production, but many patients regain their fertility over a period of 1 to 2 years.

Because nonseminomas are less sensitive to radiation, men with this type of cancer usually do not undergo radiation therapy. Non seminomatous tumors are treated by surgery or chemotherapy.

Chemotherapy is the use of anticancer drugs to kill cancer cells. When chemotherapy is given to testicular cancer patients, it is usually given as adjuvant therapy (after surgery) to destroy cancerous cells that may remain in the body. Chemotherapy may also be the initial treatment if the cancer is advanced; that is, if it has spread outside the testicle at the time of the diagnosis. Most anticancer drugs are given by injection into a vein.

Chemotherapy is a systemic therapy (as opposed to local therapy), meaning drugs travel through the bloodstream and affect normal as well as cancerous cells throughout the body. The side effects depend largely on the specific drug used and their doses. Common side effects include nausea, hair loss, fatigue, diarrhea, vomiting, fever, chills, coughing/shortness of breath, mouth sores, or skin rash. Other side effects include dizziness, numbness, loss of reflexes, or difficulty hearing. Some anticancer drugs also interfere with sperm production. Although the reduction in sperm count is permanent for some patients, many others recover their fertility.

Some men with advanced or recurrent testicular cancer may undergo treatment with very high doses of chemotherapy. These high doses of chemotherapy kill cancer cells, but they also destroy the bone marrow (which makes and stores blood cells). Such treatment can be given only if patients can undergo a bone marrow transplant. In a transplant, bone marrow stem cells are removed from the patient before chemotherapy is administered. These cells are frozen temporarily and then thawed and returned to the patient through a needle (like a blood transfusion) after the high-dose chemotherapy has been administered.

Men with testicular cancer should discuss their concerns about sexual function and fertility with their doctor. It is important to know that men with testicular cancer often have fertility problems even before their cancer is treated. If a man has pre-existing fertility problems, or if he is to have treatment that might lead to infertility, he may want to ask the doctor about sperm banking (freezing sperm before treatment for use in the future). This procedure allows some men to have children even if the treatment causes loss of fertility.

Is follow-up treatment necessary? What does it involve?

Regular follow-up exams are extremely important for men who have been treated for testicular cancer. Like all cancers, testicular cancer can recur (come back). Men who have had testicular cancer should see their doctor regularly and should report any unusual symptoms right away. Follow-up varies for different types and stages of testicular cancer. Generally, patients are checked frequently by their doctor and have regular blood tests to measure tumor marker levels. They also have regular x-rays and computed tomography, also called CT scans. Men who have had testicular cancer have an increased likelihood of developing cancer in the remaining testicle. Patients treated with chemotherapy may have an increased risk of certain types of leukemia, as well as other types of cancer. Regular follow-up care ensures that changes in health are discussed and that problems are treated as soon as possible.
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