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Testicular Cancer: Your Questions Answered

Online Health Chat with Dr. Eric A. Klein

November 16, 2011

Introduction

Cleveland_Clinic_Host: Although testicular cancer is relatively rare in the general population of men, it is the most common cancer diagnosed in men between the ages of 15 to 34. It is a highly treatable cancer with more than 95 percent of all such cancers being labeled as cured following therapy. The cure rate is nearly 98 percent when the cancer is detected early.

There are two primary types of testicular cancers: seminoma and non-seminoma. Seminoma arises from young germ cells, grows slowly, and stays relatively immobile. Between 30 percent and 40 percent of testicular cancers are seminomas. 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.

Eric A. Klein, MD, is Chair of the Glickman Urological & Kidney Institute and a staff member in the Taussig Cancer Institute at Cleveland Clinic. His clinical interests are all aspects of urologic oncology, including cancers of the prostate, bladder, testis, and kidney, and all major reconstructive procedures, such as continent urinary diversion. Dr. Klein is listed in Best Doctors in America.

Dr. Klein received his medical degree from University of Pittsburgh School of Medicine in Pennsylvania. He completed his residency in urology at Cleveland Clinic and a fellowship in urology at Memorial Sloan Kettering Cancer Center in New York.

If you would like to make an appointment with Dr. Klein or any of the urologists in the Glickman Urological & Kidney Institute, please call 800.223.2273, ext.45600, or request an appointment online by visiting www.clevelandclinic.org/appointments.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Dr. Eric Klein. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


The Disease

nelsonr: I know you can get testicular cancer at any age, but what is the most common age group for diagnosis?

Dr__Eric_Klein: Men aged 15 to 35 are the most common.

carter398: Is it common to get cancer in both testes?

Dr__Eric_Klein: Not common. Only 1 percent to 2 percent of men with testis cancer get a second one on the other side.

KLV11: Is a lump in the testicle always cancer? Can it be something else?

Dr__Eric_Klein: Not always. There are lots of benign causes of lumps. A physician, usually aided by scrotal ultrasound, can usually tell the difference.

strickler: I know it depends on the person, but typically, how quickly does testicular cancer progress?

Dr__Eric_Klein: Actually, it depends entirely on the aggressiveness of the cancer. It’s variable, but most testis cancers do not spread rapidly.

carla: My brother had a right I/O a week ago and just found out yesterday that he has a Stage I seminoma. He sees an oncologist in about a week. What should we expect for him at this point?

Dr__Eric_Klein: If it’s truly Stage I, then observation with serial exams, blood work, chest X-rays, and CT scans is the standard management, and a VERY high likelihood (virtually 100 percent) of cure!


Risk Factors

Djunga: Are there any risk factors for testicular cancer? Are you more at risk if you have had a vasectomy?

Dr__Eric_Klein: Great question. The risk factors are a positive family history, history of an undescended testis, and age -- testis tumors are rare after age 35. Vasectomy does not increase the risk.

Cat: My son was born with an undescended testicle (cryptorchidism) and had surgery to correct it. Is he at a greater risk of testicular cancer?

Dr__Eric_Klein: He is at greater risk for testis cancer and should perform a monthly self-exam. (Described under “Prevention”)

soso: How much does family history increase one’s chance of getting testicular cancer?

Dr__Eric_Klein: It’s at least double the risk of the general population and higher if the relative with cancer is closer to you genetically (i.e., a brother versus an uncle).

jmn1535: Are there any lifestyle habits that seem to have a positive correlation with testicular cancer?

Dr__Eric_Klein: None that I know of.

jmn1535: Following up on the "lifestyle" question: no evidence that always carrying a cell phone in your front pocket or using a laptop computer a lot has any relation to testicular cancer?

Dr__Eric_Klein: I'd say there is no proven link.


Signs and Symptoms

sqaullie: What are the signs and symptoms of testicular cancer?

Dr__Eric_Klein: The usual presenting sign is a lump in the testis. Occasionally men present with fatigue, loss of appetite or other systemic symptoms, or enlarged lymph nodes in the neck. The latter symptoms usually mean Stage III cancer and treatment with chemotherapy, and most are still curable.

tomj: I am 19 and have a ‘lump’ on my left testicle. I’ve also noticed that it is now larger than the right one and it has begun to ache. Are these signs of cancer?

Dr__Eric_Klein: Possibly, although other conditions can also cause this. However, you are in the age group most at risk for cancer and should be seen by a physician soon to be sure. Even if it is cancer, it’s almost always curable. Please call 216.444.5591 to schedule an appointment with one of our specialists.

gordie: Pain in the testicle, weight loss and fatigue – are these signs of cancer?

Dr__Eric_Klein: Very possibly and you need to see a doctor soon to be sure. Call 1.800.223.2273, ext. 45600.


Diagnosis

Arias: How is this disease diagnosed and what causes it?

Dr__Eric_Klein: The cause of testis cancer is unknown. It’s usually self-diagnosed by the presence of a painless swelling or lump in the testis, although occasionally by enlarged lymph nodes or abdominal pain. Young men (ages 15 to 35) should perform a monthly self-exam. While the vast majority of testis cancers are curable, there is clear evidence that early diagnosis makes this easiest.

Clarke: I am 52 and recently found a lump in my scrotum. I am worried about testicular cancer. Should I go see my primary care physician or straight to a urologist? Is prognosis worse the older you are?

Dr__Eric_Klein: First, most lumps in the scrotum in men over 35 are not cancer. They can be fluid collections (called hydroceles), or cysts, or benign tumors. I think seeing a urologist is best. He or she is likely to order a scrotal ultrasound, which is the best way to sort out the diagnosis. In the rare testis cancer in men over 35, they usually behave less aggressively than in younger men.

going_fishing: Is it possible to miss testicular cancer on an ultrasound? If so, what is the most accurate test?

Dr__Eric_Klein: Yes, but it is very unusual to not see a lump larger than 5 to 10mm. Masses smaller than that are unlikely to be clinically important.

plank: In your opinion, is it recommended to get a second opinion in regards to a diagnosis of cancer and a suggested treatment plan? If so, and you get two differing opinions, how do you know which is the right one?

Dr__Eric_Klein: It is always a good idea to get another opinion. Testis cancer has very standard treatment protocols that are widely known, and differences of opinion on their management are unusual. More often, patients are presented with good alternative choices (for example, surveillance or node dissection for Stage I non-seminomas) that can lead to anxiety or confusion. Testis cancer is a relatively rare form of cancer (only about 8000 cases a year in the US, compared to 200,000 cases of prostate cancer), so going to a center of excellence that has a significant experience with the disease is important. Getting the treatment right the first time is the easiest and best way to be cured.


Treatment

Arias: How is testicular cancer treated? Is treatment determined by stage or age of the patient?

Dr__Eric_Klein: Treatment is determined by the stage (extent) of the cancer rather than the age of the patient. The initial treatment is removal of the testis, which may be followed by simple observation, radiation (for seminomas), surgery for removal of the lymph nodes in the abdomens (for non-seminomas), or chemotherapy for Stage II tumors. Surgery is also used to remove any residual nodes after chemo.

felipe: Is it always necessary to remove the lymph nodes for testicular cancer?

Dr__Eric_Klein: No, it is not. Most Stage I tumors can be cured by simply removing the testis. For Stage II seminomas, the nodes are usually treated by radiation rather than surgery; they are removed surgically for Stage II non-seminomas. Any remaining nodes after chemotherapy for Stage III tumors are usually removed surgically.

thejer: What is the typical surveillance for a man with Stage III seminoma cancer?

Dr__Eric_Klein: I assume you mean after chemotherapy, which is the usual way to treat Stage III testis cancers. Follow-up includes office visits for a physical exam, chest X-ray, tumor markers, and a CT scan of the chest, abdomen and pelvis on a periodic basis.

lond: I have been cancer-free for about a year now. What are your opinions on surveillance therapy and which do you recommend?

Dr__Eric_Klein: The main time for recurrence on surveillance for low-stage tumors is in the first two years. If you go that long cancer-free, then the risk of recurrence is very low (on the order of 1 percent). I usually recommend that patients be seen every other month for the second year of surveillance and yearly thereafter. The only way you can run into trouble is if you miss an appointment. Be diligent!

can_do: From what I have read and heard, having a couple of small masses is more rare than having one larger mass. What does this mean in terms of treatment and prognosis?

Dr__Eric_Klein: Not sure I have enough info here to answer. There can be multiple tumors within a testis or a single large lymph node or multiple smaller ones in the abdomen, but the prognosis is not linked to any of these. However, involvement by cancer in more than one visceral organ (i.e., lung or liver) is harder to cure.

bobe: What is the recovery period for removal of a testicle? The doctor said that I will go home the same day of surgery, but after that, how long should I expect to be out of work (realistically)?

Dr__Eric_Klein: I usually recommend reduced activity until all the pain is gone, typically 7 to 10 days.


Prevention

Sarah: My husband had testicular cancer in his teens. We have young sons. At what age should they start self-exams?

Dr__Eric_Klein: They should start at age 15. It is best done in the shower when the scrotal skin is lose and thin, once a month. Anything suspicious should be checked by a doctor.

Sully: Is there any way to prevent testicular cancer or is it just random?

Dr__Eric_Klein: NO known way to prevent it. Not sure it’s truly random, but we certainly do not know or understand all of the factors that predispose or cause this form of cancer.


Complications

cabana02: Does cutting through the outer layer of a testicle to get a tissue sample spread the cancer?

Dr__Eric_Klein: Usually not, although there is a small risk of spilling some tumor that could implant in the scrotum and require additional treatment.

jmn1535: If a 21-year-old has testicular cancer, is he at a greater risk than someone who has not of getting another form of cancer later in life?

Dr__Eric_Klein: There is evidence of a higher risk for a subsequent cancer, which may be related to inborn genetics and treatment-related effects. We have a late-effects clinic here that you might want to attend to discuss details with an expert. I recommend Dr. Tim Gilligan at 216.444.6833. He is an expert on this issue.

Comix12: Is testicular cancer at a young age linked to prostate cancer later in life?

Dr__Eric_Klein: No. Prostate cancer is not linked to testis cancer.

harley_man: Does testicular cancer always or usually spread if there is vascular or lymphatic invasion involved with the tumor?

Dr__Eric_Klein: No, although there is a higher risk of that occurring when these features are present in the tumor.

Dove1765: What are the chances of developing cancer in the remaining testicle following surgery?

Dr__Eric_Klein: About 1 percent to 2 percent. Testicular self-exam of the remaining testis is important to catch this early if it occurs.


Sex and Paternity

Wonderingat15: If I have testicular cancer, does this mean I will not be able to have kids?

Dr__Eric_Klein: No. Most testis cancer patients can have kids. Usually the opposite testis makes a normal amount of sperm. In cases where it does not, a variety of assisted reproductive techniques are available. If you're going to have chemotherapy or a retroperitoneal lymph node dissection, it’s a good idea to donate and store some sperm beforehand. Information on sperm banking is available at www.clevelandclinic.org/spermbanking.

playon: Is it more difficult to get someone pregnant if you only have one testicle?

Dr__Eric_Klein: Not if the remaining testis is making normal sperm, which most do, although fertility can be suppressed during the first year after diagnosis. A sperm count should be able to tell you the odds.

carter398: If both testes have to be removed, what does that mean for your sex life?

Dr__Eric_Klein: The main issue here is loss of testosterone, which is produced by the testes and is responsible for maintaining sex desire (libido). Fortunately, there are many forms of testosterone on the market that are available by prescription. The easiest one to use is a gel that is rubbed on the skin every day. It maintains normal testosterone levels in the blood, so sex drive can be maintained.

LPdog: I’ve just been diagnosed with testis cancer, and I’m pretty young (25). I’d like to have kids someday. Does your hospital offer sperm banking services?

Dr__Eric_Klein: We do indeed offer sperm banking, including a new service that allows the specimens to be collected at home and sent by mail (amazing, huh?). Be optimistic - most testis cancer patients are able to have children.


General Questions

raleigh1990: I've read that the incidence of testicular cancer is pretty low. Is there much research being done or is the condition just not prevalent enough to warrant attention?

Dr__Eric_Klein: Most research in testis cancer is directed at curing advanced stage disease. Both its rarity and high curability make it of not much interest otherwise.

Ynaky34: Where can I find good reliable information about testicular cancer?

Dr__Eric_Klein: We have a wonderful overview on testis cancer that can be downloaded at www.clevelandclinic.org/testicularguide.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Eric Klein is now over. Thank you again, Dr. Klein, for taking the time to answer our questions today about testicular cancer.

Dr__Eric_Klein: Thank you very much. Great questions!

Cleveland_Clinic_Host: If you are interested in additional information on testis cancer and treatment options, please download our guide at www.clevelandclinic.org/testicularguide.


More Information

If you would like to make an appointment with Dr. Klein or any of the urologists in the Glickman Urological & Kidney Institute, please call 800.223.2273, ext.45600, or request an appointment online by visiting www.clevelandclinic.org/appointments.

You may request a remote second opinion from Cleveland Clinic through the secure Cleveland Clinic MyConsult Web site. To request a remote second opinion, visit eclevelandclinic.org/myConsult.

If you need more information, click here to contact us or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272, ext. 43771, to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!

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This chat occurred on 11.16.2011

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