Testicular cancer(TC) refers to cancer arising from the testes. They represent 1% of adult neoplasms and 5% of urological tumours, with 3 to 10 new cases per 100,000 males/year in Western societies. Testis tumours are most common between the ages of 15 and 55. The incidence rate rises rapidly after puberty, peaking at ages 25 to 35, and then slowly declines such that men aged 50 to 54 years have the same incidence as males aged 15 to 19 years.
RISK FACTORS:
There are five well-established risk factors for testis cancer:
- White race
- Cryptorchidism/ undescended testes
- Family history of testis cancer
- A personal history of testis cancer
- Germ cell neoplasia in situ (GCNIS)/intratubular germ cell neoplasia (ITGCN)
According to Dr Gutta Srinivas, Consultant Urologist & Transplant Surgeon, Clinical Director-Department of Urology, Yashoda Hospitals Hyderabad, infertile and sub-fertile men also have a higher incidence of testis cancer. Numerous studies have reported that recent increases in testis cancer incidence can be largely attributed to birth-cohort effects, which implies that diet and/or other environmental factors (pesticide, endocrine disruptive chemical exposure, dairy consumption, height/child growth) play a major role in carcinogenesis.
Men with cryptorchidism /undescended testis (absence of one or both testes in the scrotum) are 4 to 6 times more likely to be diagnosed with testis cancer in the affected gonad, but the relative risk falls to 2 to 3 if orchidopexy(surgery to fix testes into the scrotum) is performed before puberty. Opposite side descended testis is also at 1.74 times slightly increased risk of cancer. Undescended testes(UDT) are usually congenital but sometimes may be acquired(post hernia surgery) or can be confused with retractile testis.1-9% of full-term born and 1-45% of preterm babies can have UDT. 30% are bilateral and 70% are unilateral. 30% are not palpable(testes may be present intra abdominal,inguino scrotal or absent )and 70% are palpable. Spontaneous descent happens by the first month in most cases, the child can be kept under observation till 6 months, by which most testes will fall back into the scrotum. 1% who still have UDT at 6 months, it is better to undergo surgery between 6-12 months. After 12 months of age, there will be progressive deterioration of germ and Leydig cells, which may lead to a high risk of infertility and testicular cancers in future. When UDT is bilateral check for other congenital genital abnormalities.
Men with a first-degree relative with testis cancer have a substantially increased risk of testis cancer, and the median age at diagnosis in these men is 2 to 3 years younger than in the general population. The relative risk for testis cancer is 8 to 12 with an affected brother compared with 2 to 4 in those with an affected father.
Most GCTs(germ cell tumours) arise from a precursor lesion called GCNIS(germ cell neoplasia in situ) which is seen as a small calcification on ultrasound scan. GCNIS is present in adjacent testicular parenchyma in 80% to 90% of cases of invasive GCT and is associated with a 50% risk of GCT within 5 years and 70% within 7 years. Between 5% and 9% of patients with GCT have GCNIS within the unaffected contralateral testis.
SIGNS and SYMPTOMS:
The most common presentation of testis cancer is a painless testis mass. Acute testicular pain is less common and is caused by the rapid expansion of the testis resulting from intra-tumour haemorrhage or infarction caused by rapid tumour growth. Patients frequently report a history of testicular trauma, although incidental trauma is likely responsible for bringing the testis mass to the patient’s attention for the first time. The patient may have vague scrotal discomfort or heaviness.
Large retroperitoneal metastasis may cause a palpable mass, abdominal pain, flank pain resulting from ureteral obstruction, back pain because of involvement of the psoas muscle or nerve roots, lower extremity swelling resulting from compression of the inferior vena cava, or gastrointestinal (GI) symptoms. Pulmonary metastasis may present with difficulty in breathing, chest pain, cough, or hemoptysis. Metastasis to supraclavicular lymph nodes may be seen as a neck mass. Approximately 2% of men have gynecomastia(male breast), resulting from either elevated serum HCG levels, decreased androgen production, or increased estrogen levels (most commonly seen in men with Leydig cell tumours). Although approximately two-thirds of men with GCT have diminished fertility, it is an uncommon initial presentation.
TESTICULAR SELF EXAMINATION:
Various studies have shown that 60-88% of the male population had not heard of testicular cancer and most reported that they were not “ever taught about testicular self-examination,” and around 60% felt that a lump could be as benign as a carbuncle (boil) or something that could resolve spontaneously and was insignificant.
Before you start. Here are two things to keep in mind:
- Don’t worry if one testicle is bigger than the other or hangs lower. That’s normal.
- It’s easy to mistake the epididymis for an unusual mass. The epididymis is a coiled set of tubes that lines the back and top of each testicle. It’s the portion of the reproductive system where the sperm “mature” or learn to swim. It will feel softer and bumpier than the testicle it’s attached to.
Here’s how to perform a self-exam:
- Set aside five minutes while you’re in the shower. A warm shower will relax the scrotum and the muscles holding the testicles, making an exam easier.
- Starting with one side, gently roll the scrotum with your fingers to feel the surface of the testicle.
- Check for any lumps, bumps or unusual features. Contrary to what many assume, cancerous tumours typically aren’t painful.
- Make note of any changes in size over time. While the most common symptom of testicular cancer is a painless mass, some men experience swelling of the testicles and scrotum.
- Be aware of any dull soreness or heaviness.
- Switch sides and check the other testicle.
- Perform a self-exam once a month.
- Consult your urologist if you find any lump.
Remember, testicular cancer is more common in Western countries and the lowest incidences are found in Africa and Asia. At diagnosis, 1-2% are bilateral. Only about 13% are seen initially with distant metastatic disease.
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