The usual presentation of a testicular tumour is a nodule or painless swelling of one testis. This is sometimes discovered by a sexual partner. About one-third of patients report a dull ache and in 10% the symptoms include sudden, severe testicular pain.
Other conditions may cause a lump or swelling nearby the testicle and can sometimes be confused with a testicular lump. The most common of these is an epididymal cyst. These benign cysts originate in the epididymis, a structure which lies just behind the body of the testicle. Within this structure sperm cells mature before entering the vas deferens, the tube that carries sperm cells to the prostate and then into the seminal fluid. The cause of epididymal cysts is unknown, but they are entirely benign.
Other benign causes of swelling within the scrotum:
|Hydrocoele||Painless collection of fluid around the testicle. May grow to a very large size|
|Epididymo-orchitis||Infection of the epididymis and testis. May be secondary to a UTI or STD|
|Varicocoele||Varicose veins in the spermatic cord. Occurs in 15% of men and may be associated with subfertility|
|Testicular Torsion||Painful, sudden twisting of the spermatic cord. In the early phases the testicle may swell.|
Whenever a lump is first noticed, it is very important that it is reported to your family doctor. Never assume that it is a benign epididymal cyst or just an infection.
Rarely, if the above symptoms are ignored and the swelling is in fact a cancer, it may be allowed to spread. In this circumstance the patient may experience symptoms related to cancer deposits in other parts of the body (such as lungs, lymph nodes etc). These symptoms include abdominal discomfort, shortness of breath and weight loss.
Remember: Never ignore a new testicular swelling.
Diagnosis and Staging
If a testicular cancer is suspected, a series of standard tests are performed in order to help establish 2 main things:
- The stage of the cancer (ie has it spread beyond the testis)
- The type of cancer (ie Seminoma vs Non-seminoma)
The tests include the following:
- Alfa-fetoprotein (Only abnormal in Non-Seminomas)
- Beta HCG (Can be abnormal in either type of cancer)
- Liver function tests
- Blood count and kidney function tests
- Ultrasound of the scrotum to confirm the diagnosis of a testicular tumour
- CAT Scan of the Chest, Abdomen and Pelvis to find and sign of cancer spread
Stages of Testicular Cancer
Accurate staging of testicular cancer is absolutely vital if successful treatment is to be administered.
|Carcinoma in situ||Cancer cells only in tubules where sperm cells develop|
|1||Cancer has broken through tubules but limited to the testis alone|
|2||Cancer has spread to lymph nodes in the abdomen|
|3||Cancer has spread to distant lymph nodes or other organs (eg. lungs)|
Ultimately, the only way to confirm the diagnosis of testicular cancer is to remove the testicle involved. A solid lesion within the testicle is always presumed to be a cancer. Needle biopsy of a solid testicular lesion is avoided. This is because biopsy may induce spread of cancer cells, possibly to areas in the body which become more difficult to clear of cancer.
The first step in the treatment of testicular cancer is to remove the affected testis. This operation is called a Radical Orchidectomy. The cancer is examined by a histopathologist to determine its type. The next steps in treatment depend on the type of cancer and the stage of the disease.
More detailed information about Radical Orchidectomy is available on this website.
This consists of regular monitoring by means of repeated CAT scans and blood tests aimed to look for any sign of cancer recurrence after the radical orchidectomy. Active surveillance is only suitable for patients with Stage 1 disease and is standard management for stage 1 Non-seminoma in most cancer centres throughout Australia. Overall, between 25-27% of patients with stage 1 Non-Seminoma will experience a relapse of cancer. This most commonly occurs within the first year after diagnosis. The risk of relapse is higher in some patients, especially when cancer cells have invaded blood vessels and lymphatic channels in the testis.
More recently, Stage 1 Seminomas have also been managed this way in selected patients, although Radiotherapy is still considered by many to be the gold standard management for these patients. One important difference between Seminomas and Non-Seminomas is that relapse may occur significantly later with Seminoma and therefore long-term vigilant surveillance beyond 5 years is important.
Immediate post-orchidectomy radiotherapy to the abdominal lymph node area and a portion of the pelvis has long been the standard treatment for patients with Stage 1 Seminoma, with 5 year survival rates of 95% or higher. However, all treatments, including radiotherapy carry risks of long-term side effects. Recent studies suggest that radiotherapy should be reserved for patients with larger and more aggressive tumours, rather than advised for all Stage 1 patients. Currently, only approximately 20% of stage 1 Seminoma patients are strongly advised to have immediate radiotherapy. The remainder are enrolled in vigilant active surveillance.
Patients with low-volume Stage 2 disease are also candidates for radiotherapy. Detailed information about the treatment and its side effects will be provided to you by the Radiation Oncology team.
Platinum based chemotherapy regimens for the treatment of testicular cancer has been one of the great triumphs of cancer medicine. Because of this, testicular cancer has one of the highest cure rates of any solid malignant tumour . Chemotherapy combinations using drugs such as Cisplatin, Bleomycin and Etoposide in various combinations are the gold standard treatment for patients with testicular cancer that has spread beyond the testis (Stage 2 and 3 disease). Clinical Trials are are underway to further improve the results of chemotherapy for advanced testicular cancer. Chemotherapy is also standard treatment in Stage 1 testicular cancer when tumour markers remain abnormal after removal of the cancerous testis.
More recently, single-dose chemotherapy has been used in some major centres in Europe for patients with stage 1 Seminoma. This is not yet standard treatment in Australia but may become more popular if long-term results from Europe are favourable.
Detailed information about the side effects of chemotherapy will be provided to you by your Medical Oncology team, together with follow up tests that will be required after treatment is completed.
Retroperitoneal Lymph Node Dissection
As outlined above, testicular cancer may spread to the lymph glands behind the abdomen, even as high as the level of the kidneys. Surgery to remove these glands is sometimes required to cure the disease. This operation is very involved and is only carried out in high-volume cancer centres, such as the Sydney Cancer Centre (Royal Prince Alfred Hospital). Almost all patients who undergo this operation have already completed chemotherapy but have persisting evidence of lymph node enlargement on the post-chemotherapy CAT Scans.