Testicular Cancer
Definition
Malignant tumour of the testis. The commonest types are teratoma, seminoma,
a mixture of teratoma and seminoma and lymphoma.
Incidence
Testicular cancer is the commonest solid tumour in young men and the incidence
is increasing. Teratoma is most common in young men aged 25-35, seminoma age
35-40 and lymphoma in the elderly.
Causes
Failure of the testes to normally descend into the scrotum is associated
with an increased risk of testicular cancer. This increased risk remains even
after the testes have been brought down into the scrotum by surgery. It has
also been suggested that increased exposure to environmental oestrogens is implicated
in the increasing incidence of testicular cancer but this is not proven. It
is important that all men in the age group at risk practice self-examination
of the testes. Advice on this is available in most general practices.
Symptoms & Signs
Testicular cancer usually presents as a lump on the testis. This is not
usually painful. Although most testicular lumps are not cancer, it is important
for anyone finding a lump to see their doctor immediately.
Complications
Testicular cancer can spread, usually to the lymph nodes in the abdomen
first and then to the lymph nodes in the chest and to the lungs.
Investigation
Blood tests for tumour markers will be done before any treatment takes place.
They will include alpha feto protein and beta HCG and may include placental
alkaline phosphatase and lactate dehydrogenase. An ultrasound scan of the testis
may be necessary to distinguish a tumour lump from a cyst. If cancer is suspected,
removal of the testicle is recommended and the exact type of cancer can be established.
Staging investigations will be performed to look for evidence of spread to the
lymph nodes or other organs; this includes a CT scan of the chest, abdomen and
pelvis. If the tumour markers were abnormal before the operation, they will
be repeated to see if they have returned to within normal limits.
Surgical Treatment
The initial treatment is to remove the cancer, which involves removing the
entire affected testis. Following this the patient will be referred to an oncologist
for further assessment and treatment as necessary. In cases when there has been
spread to the lymph nodes, additional surgical treatment may be required if
these lymph nodes in the chest or abdomen persist despite chemotherapy treatment.
Medical Treatment
The subsequent treatment of testicular cancer following surgery depends
on the type of cancer and on the extent of it. In the UK, there are several
Medical Research Council (MRC) randomised trials in testicular cancer looking
at improving the treatment by increasing cure rates further or reducing long-term
side-effects. Many patients are being offered treatment on one or more of these
trials.
Seminoma
In early stage seminoma (stage I) despite no evidence of spread, there is
a risk of approximately 15-25% that recurrence will occur in the para-aortic
lymph nodes of the abdomen. Therefore, the standard treatment is a short course
of preventative (adjuvant) radiotherapy to this region, which will reduce this
risk of relapse to approximately 3%.
In cases where there is spread to the para-aortic lymph nodes, the treatment
will be radiotherapy if the disease there is of low volume or chemotherapy if
the lymph nodes are larger. If there has been spread outside the para-aortic
lymph nodes such as to the lungs, chemotherapy will be the recommended option.
On the whole, the treatment for seminoma is very successful despite being spread
to the lymph nodes or lungs and the overall survival rate is over 95%.
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