Anatomy
The testis consists of predominantly seminiferous tubules, which produce sperm, and these drain to the epididymis. Its blood supply is from the spermatic artery and its venous drainage is to the pampiniform plexus of gonadal veins. Its lymphatic drainage is to the retroperitoneal lymph nodes.
Incidence
Testis cancer is most commonly seen in men between the ages of 15 to 35 years. Fortunately, testis cancer is an eminently curable disease, provided patients are compliant with treatment and follow up. Testis cancer is a perfect example of how the interplay of different treatment modalities have resulted in excellent outcomes.
Symptoms and Signs
Testicular cancer usually effects one testicle only, however, in a small percentage of patients testis cancer can occur in both testicles either at the same time or at some time in the future. Most patients who present with testicular cancer will have noticed a swelling in one testicle. The swelling is usually painless but in about 10% of patients, pain in the testicle is the initial presenting symptom. Rarely patients may present with symptoms related to the spread of the cancer to other areas of the body, such as, swollen lymph nodes in the neck, shortness of breath, or abdominal or low back pain. Cryptorchidism or undescended testicle is thought to be a risk factor fo the development of testis cancer.
Diagnosis
Any patient who suffers from persistent pain in the testicle or notices a lump in the body of the testicle should see their general practitioner for review. A scrotal ultrasound is a painless examination and the most reliable way of detecting testicular tumours. Testicular self examination on a monthly basis is a sensible recommendation allowing early detection of testicular abnormalities.
Two thirds of testicular tumours produce proteins that can be measured in the blood called tumour markers. Alpha feto protein (AFP) and beta human chorionic ganatoprophin (HCG) are the most common markers produced.
If testicular cancer is suspected, the testicle will need to be removed through a small incision in the groin. Provided the remaining testicle is normal this operation will have no impact on a patients libido or erectile function. Unfortunately infertility is not uncommon in patients suffering from testicular cancer. Patients should have sperm collected and frozen prior to treatment.Fortunately in the vast majority of patients, simply removing the testicle will result in cure of their disease. The majority of testicular tumours arise from germ cells within the testicle.
Pathology
There are essentially 2 different types of testicular cancers, seminoma and non seminoma. Within the non seminomatous group there are 4 sub types namely embryonal carcinoma, choriocarcinoma, yolk sack tumour and teratoma. Commonly testicular tumours will consist of multiple different germ cell types (eg: embryonal carcinoma, yolk sack tumour and teratoma, ie a mixed germ cell tumour).
The spread of testicular cancer is relatively predictable based upon the lymphatic drainage of the testicle. The most common sites of spread are to the lymph nodes within the abdomen, the lungs and the lymph nodes in the chest. Rarely testicular cancer can spread to the brain or bones.
Staging
The TNM classification system is used to stage testicular tumours. This system uses the microscopic examination of the testicular tumour, the size and number of abdominal lymph nodes involved with tumour and the presence of spread elsewhere to stage testicular cancer.
Once the diagnosis of testicular cancer is made, patients require measurement of their testicular tumour markers and CT scans of their chest, abdomen and pelvis to adequately stage their disease.
Staging is important as it dictates treatment options.
Treatment of testis cancer
As already indicated the vast majority of patients with testicular cancer are cured simply by removing the testicle, however diligent follow up is required in order to detect a recurrence of disease at the earliest possible time. Treatment options are dependent on both the type of testicular cancer (seminoma or non seminoma) and the stage of the disease. In patients with seminoma treatment options include surveillance radiotherapy and/or chemotherapy.
For patients with non seminomatous testicular cancer, treatment options include surveillance, surgical removal of the abdominal lymph nodes and/or chemotherapy. Surgical removal of the abdominal lymph nodes (RPLND – retroperitoneal lymph node dissection), often resulted in the inability to ejaculate because the post-ganglionic sympathetic nerves were damaged. Today, in experienced hands, these nerves can be preserved and ejaculation maintained in the majority of patients.
To ensure the best possible outcome, patients with testicular cancer need to be managed in centres that offer multi disciplinary treatment clinics and in units that treat large volumes of patients with the disease.
Copyright © 2005 Urology Sydney. All Rights Reserved.
ABN: 91 374 648 664
Level 1, St George Medical Centre
1 South Street
Kogarah NSW 2217
Ph: 9587 4888 Fax: 9587 4899
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