As with all cancers, testicular cancer evolves from a disruption in one or more genes in a cell’s DNA. Genes control all cell activities including division and growth. When cells die, a normal and common event, they are replaced by new cells as the body needs them.
However, when the genes that orchestrate this natural replacement process are disrupted by chemicals, illness or other unknown factors, control over cell division and growth is lost. The resultant uncontrolled growth of tissue becomes a tumor. The vast majority of testicular cancer arises in germ cells, the reproductive cells of the body. In women, these cells are the ova. In men, they are the sperm.
There are two primary types of testicular cancers:
Seminoma arises from young germ cells, grows slowly and stays relatively immobile. Between 30% and 40% of testicular cancers are seminoma.
Non-seminoma evolves from more mature germ cells. These tend to be more aggressive tumors. There are also testicular cancers that are a blend of both seminoma and non-seminoma.
A lot of publicity has been given to women and self-examination for breast cancer over the years, but self examination for men checking for testicular cancer has been scant. It works the same way. The testes are palpated (felt) for any suspicious lumps. In 90% of instances of cancer, they will note a small, pea-sized lump that may be uncomfortable but not necessarily painful.
One or both testicles may be enlarged. Some men report an awkward feeling of heaviness or generalized ache in the lower abdomen or scrotum. A few may note breast growth or tenderness in their breasts. This is because some testicular tumors may secrete high levels of human chorionic gonadotropin (HCG), which stimulates breast development.
In some men, the cancer may spread (metastasize) via the lymphatic system or bloodstream to other parts of the body. Symptoms depend on where the metastatic cells have spread and lodged. There may be central abdominal pain due to enlarged lymph nodes or liver involvement.
About 25% of those with metastatic testicular cancer may note:
- lower back pain
- shortness of breath
- chest pain
Most men will have no symptoms at all other than the lump in their testes. It is important to consult a doctor when any of these symptoms are noted because the earlier the cancer is detected, the more likely it will be cured.
When cancer is detected during the inguinal orchiectomy the affected testicle is removed. Surgery is sometimes used to remove non seminomatous tumors. Adjuvant (secondary) radiation treatments or chemotherapy is often applied after surgery to insure that any cancerous cells missed by surgery or that have gone undetected are destroyed.
Cancer cells are continually dividing and growing. This makes them more susceptible to radiation than normal cells. Radiation can be administered in a number of ways. External beam radiation focuses the rays like a tight flashlight beam directly at suspicious tissues that may be cancerous. Brachytherapy involves placing tiny radioactive seeds into tumors under the guidance of an imaging system. The seeds are placed so that the radiation field they create matches the shape of the tumor and minimizes risk to surrounding tissue.
Chemotherapeutic compounds are designed to destroy cancer cells with minimal effects on other cells. Chemotherapy is systemic. It is injected to circulate through the blood stream and destroy cells and tumors too small or too awkwardly located to be removed surgically. Some chemotherapy is targeted. It is placed into the spinal column, an organ or body cavity to destroy cancer in those regions, however it is not done for testicular cancer.
Stem Cell transplantation
Germ cell tumors are a clear success story in medical oncology, as most patients are cured with chemotherapy with or without radiation therapy. A subset of patients, however, have a poor prognosis. Those with rapidly recurring and/or refractory disease generally have short survival. Over a decade ago, initial data showed that high-dose chemotherapy and autologous bone marrow transplantation could potentially salvage a proportion of patients. As a result, autologous stem cell transplantation is now the treatment of choice for this poor-risk patient population.
More recently, however, it has been shown that tandem transplantation (two autologous transplantations performed sequentially) is preferable than one. The source of this data is primarily Indiana University, which has the largest referral base of germ cell tumors in the world. As a result, tandem transplantation for testicular cancer is now viewed to be the treatment of choice for this malignancy.
Again, the patient population who are transplant candidates are limited to patients with recurrent/refractory disease. Germ cell tumors are a clear success story in medical oncology, as most patients are cured with chemotherapy with or without radiation therapy. A subset of patients, however, have a poor prognosis. Those with rapidly recurring and/or refractory disease generally have short survival.