Testicular cancer

Types of testicular cancer

Different types of cancer can develop in the testicles depending on the cells causing the tumour. It is important to distinguish between seminomatous cancers and non-seminomatous. Seminomatous cancers are tumours derived from gonadal differentiated germ cells (reproducing cells). The generic term ‘non-seminomatous’ refers to all types of testicular cancer that develop from embryonic or extra-embryonic differentiating germ cells (i.e. cells that behave as if fertilisation had already taken place). This distinction is important because the two types of tumours are treated differently. For example, in the case of non-seminomatous cancer, radiotherapy will not be offered as this form of cancer does not respond to radiation.

Causes and risk factors

The exact causes of testicular cancer are still largely unknown. Testes not descended at birth (cryptorchidism) are a high risk factor. In cases of cryptorchidism, the migration of the testicle into the scrotum (the bursa) at foetal age is incomplete or occurs too late for various reasons. The testicle remains in the abdominal cavity or abdominal wall. It is not always fully functional. It seems that there is also a hereditary factor; indeed, testicular cancer sometimes occurs in several individuals within the same family. There are no known environmental factors that cause testicular cancer.

Symptoms of testicular cancer

At first, testicular cancer causes little or no symptoms. Early symptoms may include:

• swelling or an enlarged scrotum as well as hardening 
• nodules in the testicle. 

These symptoms are usually painless. Over time, a feeling of heaviness or a tightness in the testicle may appear. At an advanced stage of the illness, the following symptoms may occur:

• fatigue, 
• loss of appetite, 
• weight loss,
• back pain.

Diagnosis

Most of the time, testicular cancer is discovered by chance during palpation of the testicles. Any change in size or hardening of a testicle as well as the presence of nodules should be the subject of prompt medical consultation without being urgent. If testicular cancer is suspected, various tests such as an ultrasound examination, a blood test (notably tumour markers) or a tomography are performed.

Testicle check: Early detection through palpation

Regular palpation of the testicles can detect cancer at an early stage. It is by this regular (once a month) palpation of the testicles that abnormalities can be easily detected at an early stage. It is preferable to perform the palpation in a standing position under a hot shower to relax the skin of the scrotum and make it easier to grasp the testicles. The discovery of a lump, hardening or hard nodule in a testicle should prompt the patient to see a urologist quickly for further investigation. 

Regular (monthly) testicular palpation is recommended in men at risk (including a history of cryptorchidism, personal or family history of testicular cancer). It is often also suggested to young men aged between 14 and 45 who are not particularly at risk to detect this type of cancer at an early stage.

Treatment of testicular cancer

Treatment of testicular cancer depends on the type of tumour and the stage of the disease. In principle, we start by proposing the freezing of sperm cells to preserve fertility. Only then should the diseased testicle be surgically removed. Indeed, if there are no sperm cells in the sperm, the intervention should be performed in a hyperspecialised centre to search for sperm cells in the healthy tissue of the testicle(s) at the same time as the intervention (called oncoTESE). In some specific cases, a contralateral testis biopsy is suggested.

In the case of an unsuspicious lesion of less than 1 cm and with negative markers, ablative surgery with preservation of the rest of the affected testicle can be discussed and performed in a specialised centre. Very often, and even in the absence of remote involvement (lymphatic nodes or metastases), short-term chemotherapy is offered to control the risk of recurrence. Patients should attend regular monitoring visits to monitor the success of treatment.

If the tumour has reached an advanced stage, surgery will be followed by chemotherapy and also, depending on the type of cancer, radiation therapy. Testicular cancer responds very well to these types of treatment. This means that even later stages of the disease involving metastases can be cured in most cases.

Sometimes the level of sex hormone (testosterone) produced after removing a testicle is no longer sufficient. In such cases, medical testosterone must be administered to the patient.

Testicular cancer, sexual function and fertility

As the tumour usually affects only one testicle, the surgery has no impact on sexuality. The ability to procreate generally remains in most patients. This ability may be impaired by high-dose chemotherapy or radiotherapy in some cases. 

Therefore, consideration should be given to freezing semen prior to initiation of treatment, especially if there is a wish for children. After the removal of a testicle or after radiotherapy, the secretion of sex hormones (testosterone) is sometimes insufficient. In this case, the patient should receive testosterone supplements.

In very rare cases, surgery to remove residual metastases (called retroperitoneal dissection) may result in no ejaculation (dry orgasm). This risk is limited if the surgery is performed by an expert centre that is used to preserving the nerves involved.