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Information
about testicles cancer
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Testicular
Cancer
Definition
Testicular cancer
is a disease in which cancer cells are discovered in one or both
testicles. The testicles, also known as testes or gonads, are
located in a pouch beneath the penis called the scrotum.
Description
The testicles
make up one portion of the male reproductive system. Normally, they
are each somewhat smaller than a golf ball in size and are contained
within the scrotum. The testicles are a man's primary source of male
hormones, particularly testosterone. They also produce sperm.
There are
several types of cells contained in the testicles, and any of these
may develop into one or more types of cancer. Over 90% of all
testicular cancers begin in cells called germ cells. There are two
main types of germ cell tumors in men: seminomas and nonseminomas.
Seminomas make up about 40% of all testicular germ cell tumours.
Nonseminomas make up a group of cancers, which include choriocarcinoma,
yolk sac tumors, embryonal carcinoma, and teratoma.
Although
testicular cancer accounts for less then 2% of all cancers in men,
it is the most commonly seen cancer in young men aged 15 to 35. It
is also one of the most curable.
The American
Cancer Society estimates that approximately 8,980 new cases of
testicular cancer will be diagnosed in American men in 2004. In
addition, about 360 men will die of the disease during that year.
Although the incidence of testicular cancer is rising, having
doubled since 1975, it is still rare. Scandinavian countries have
the highest rate in the world. Germany and New Zealand also have
high rates. The lowest incidences of testicular cancer are in Asia
and Africa.
Causes and
symptoms
The exact
causes of testicular cancer are unknown. However, there is research
showing that some men are more likely to acquire it than others. The
risk for testicular cancer is much higher for boys born with one or
both of their testicles located in the lower abdomen rather than in
the scrotum. This condition is called cryptorchidism or undescended
testicles. The lifetime risk of getting testicular cancer is four
times higher for boys with cryptorchidism than the risk in the
general population. This risk factor remains even if surgery is done
to place the testicle back into the scrotum.
Boys born with Down
syndrome are also at higher risk of developing testicular
cancer, although the reasons for this increased risk are not yet
fully understood as of 2004.
There are other
risk factors as well. Men who have had abnormal development of their
testicles are at increased risk, as are men with Klinefelter's
syndrome (a disorder of the sex chromosomes). A family history of
testicular cancer increases the possibility of getting the disease.
Men infected with the human immunodeficiency
virus (HIV), especially those with AIDS,
have a higher incidence, as do infertile men. Certain testicular
tumors appear more frequently among men who work in certain
occupations, like miners, oil workers, and utility workers. There is
no conclusive evidence that injuries to the testicles or
environmental exposure to various chemicals cause the disease.
Testicular
cancer usually shows no early symptoms. It is suspected when a mass
or lump is felt in the testes, although a testicular mass does not
always indicate cancer and is usually painless.
Symptoms:
- a lump in
either testicle (usually pea-sized, but may be as large as a
marble or an egg)
- any
enlargement or significant shrinking of a testicle
- a
sensation of heaviness in the scrotum
- a dull
ache in the groin or lower abdomen
- any
sudden collection of fluid in the scrotum
- tenderness
or enlargement of the breasts
- pain or
discomfort in a testicle or in the scrotum
Diagnosis
When a man
exhibits symptoms that suggest a possibility of testicular cancer,
several diagnostic steps will occur before a definitive diagnosis is
made.
History and
physical
The physician
takes a personal and family medical history and a complete physical
examination is performed. The doctor will examine the scrotum as
well as the abdomen and other areas to check for additional masses.
Imaging
studies
If a mass is
found, the physician will likely have an ultrasound performed.
Through the use of sound waves, ultrasounds can help visualize
internal organs and may be useful in telling the difference between
fluid-filled cysts and solid masses. If the tumor is solid, it is
most likely cancerous.
Computed
tomography as well as ultrasound may be used to diagnose malignant
germ cell tumors in undescended
testes.
Blood tests
Certain blood
tests can be helpful in diagnosing some testicular tumors. Tumor
markers are substances often found in higher-than-normal amounts
in cancer patients. Some testicular cancers secrete high levels of
certain proteins such as alpha-fetoprotein (AFP), human chorionic
gonadotropin (HCG), and enzymes like lactate dehydrogenase (LDH).
These markers may help find a tumor that is too small to be felt
during a physical examination. In addition, these tests are also
helpful in determining how much cancer is actually present, and in
evaluating the response to treatment to make sure the tumor has not
returned.
Surgery
If a suspicious
growth is found, a surgeon will need to remove the tumor and send it
to the laboratory for testing. A pathologist examines the testicular
tissue microscopically to determine whether cancer cells are
present. If cancer cells are found, the pathologist sends back a
report describing the type and extent of the cancer. In almost all
cases, the surgeon removes the entire affected testicle through an
incision in the groin, though not through the scrotum. This
procedure is called radical inguinal orchiectomy.
Once testicular
cancer is determined, further tests are necessary to find out if the
cancer has metastasized (spread) to other parts of the body, and to
ascertain the stage or extent of the disease. This information helps
the doctor plan appropriate treatment. These tests may include
computed tomography (CT scan), lymphangiography
(x rays of the lymph system), bone scans, and chest x rays.
Treatment
Staging
One method the
cancer treatment team uses to describe the scope of a patient's
cancer is the use of a staging system. Testicular cancer is
classified using the TNM system. However, in order to simplify and
summarize this information, the TNM description can be grouped
according to stages.
Stages of
testicular cancer:
- Stage I.
This stage refers to a cancer found only in the testicle, with
no spread to the lymph nodes or to distant organs.
- Stage II.
This indicates that the cancer has spread to the lymph nodes in
the abdomen, but not to lymph nodes in other parts of the body.
- Stage
III. In this stage, the cancer has spread beyond the lymph nodes
in the abdomen, and/or the cancer is in parts of the body far
away from the testicles, such as the lungs or the liver.
- Recurrent.
Recurrent disease indicates that the cancer has come back after
it has already been treated. Testicular cancer can come back in
the same testicle (if it was not surgically removed) or in some
other body part.
Treatment
The treatment
decisions for testicular cancer are dependent on the stage and cell
type of the disease, as
well as the
patient's age and overall health. The four kinds of treatment most
commonly used are surgery, radiation
therapy, chemotherapy, and bone marrow or stem
cell transplantation.
Surgery is
normally the first line of treatment for testicular cancer and
involves the removal of the affected testicle. This procedure is
known as a radical inguinal orchiectomy. Depending on the type and
stage of the cancer, some lymph nodes may also be removed at the
same time, or possibly in a second operation. This procedure is
called a retroperitoneal lymph node dissection, and can be a major
operation. Some patients will experience temporary complications
after surgery, including infections and bowel obstruction. If both
of the testicles are taken out, a man will have no ability to
produce sperm cells and will become infertile (unable to father a
child). Surgery removing the lymph nodes may cause some damage to
nearby nerves, which may interfere with the ability to ejaculate.
Men undergoing surgery for testicular cancer may wish to discuss
nerve-sparing surgery with their doctor, as well as sperm banking.
Radiation
therapy for testicular cancer is delivered from a machine and is
known as external beam radiation. One potential problem with this
type of radiation is that it can also destroy nearby healthy tissue
as well as cancer cells. Other potential side effects include
nausea, diarrhea and fatigue.
A special device can be used to protect the unaffected testicle to
preserve fertility.
Chemotherapy
refers to the use of drugs in treating cancer. Since the drugs enter
the bloodstream and circulate throughout the body, chemotherapy is
considered a systemic treatment. The drugs primarily used in the
treatment of testicular cancer are cisplatin, vinblastine,
bleomycin, cyclophosphamide, etoposide, and ifosfamide. These drugs
are given in various combinations, since the use of two or more
drugs is considered more effective than using only one drug.
Since
chemotherapy agents can affect normal as well as cancerous cells,
several side effects are possible. These side effects include:
- nausea
and vomiting
- changes
in appetite
- hair loss
(temporary)
- mouth
sores
- increased
risk of infections
- bleeding
or bruising
- fatigue
- diarrhea
or constipation
Several drugs
are available to assist in treating these side effects, most of
which will disappear after the treatment is completed. However, some
of the chemotherapy agents used during treatment of testicular
cancer may cause long-term side effects. These include hearing
loss, nerve damage, and possible kidney or lung damage. Another
potentially serious long-term complication is an increased risk of
leukemia. This is a rare side effect, however, as it occurs in less
than 1% of testicular cancer patients who receive chemotherapy.
Chemotherapy may also interfere with sperm production. This may be
permanent for some, but many will regain their fertility within a
few years.
Studies are
ongoing to determine whether high doses of chemotherapy combined
with stem-cell transplantation will prove effective in treating some
patients with advanced testicular cancer. In this treatment,
blood-forming cells called stem cells are taken from the patient
(either from the bone marrow or filtered out of the patient's
blood). These cells are kept frozen while high-dose chemotherapy is
administered. After receiving the chemotherapy, the patient is given
the stem cells through an infusion. This treatment enables the use
of extra large doses of chemotherapy that might increase the cure
rate for some testicular cancers.
Preferred
treatment plans by stage of disease
Stage I: Stage
I seminomas are normally treated with a radical inguinal orchiectomy
followed by radiation treatment aimed at the lymph nodes. More than
95% of Stage I seminomas are cured through this method. Another
approach is to perform surgery only. Patients are then followed
closely for several years with blood tests and imaging studies. If
the cancer spreads later on, radiation or chemotherapy can still be
used. Stage I non-seminomas are also highly curable with surgery,
followed by one of three options. These options include the
performance of a retroperitoneal lymph node dissection, two cycles
of chemotherapy, or careful observation for several years.
Stage II: Stage
II seminomas and non-seminomas are cured in 90% to 95% of the cases.
For the purposes of treatment, stage II testicular cancers are
classified as either bulky or nonbulky. Nonbulky seminomas (no lymph
nodes can be felt in the abdomen) are treated with an orchiectomy
followed by radiation to the lymph nodes. Men with bulky seminomas
have surgery, which may be followed by either radiation or a course
of chemotherapy. Nonbulky Stage II non-seminomas are treated with
surgery and lymph node removal, with possible chemotherapy. Men with
bulky disease have surgery followed by chemotherapy.
Stage III:
Stage III seminomas and non-seminomas are treated with surgery
followed by chemotherapy. This produces a cure in about 70% of the
cases. Those who are not cured may be eligible to participate in
clinical trials of other chemotherapy agents.
Recurrent:
Treatment of recurrent testicular cancer is dependent upon the
initial stage and the treatment given. This might include further
surgery and chemotherapy. Many men whose disease comes back after
chemotherapy are treated with high-dose chemotherapy followed by
bone marrow or stem cell transplantation.
As of 2004,
there is growing evidence that men treated with cisplatin for
testicular cancer are at increased risk of coronary
artery disease ten years or longer after treatment. In addition,
men who have had an orchiectomy followed by external beam radiation
therapy have a significantly increased risk of dying from heart
disease or a second cancer.
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