If untreated, testicular tumours have a high potential to adversely impact lives, both in terms of longevity and quality. Dr A V S Suresh elucidates on the reasons why these tumours need to be widely discussed.
Though global statistics indicate that the lifetime risk of testicular tumours in men is approximately about 1 in 250, Indian statistics show a slightly lower incidence. The review suggests that it comprises of one per cent of all cancers in men. The disease is not as widely discussed as breast, lung or cervical cancers, though it deserves to be, because of the following reasons:
- Like breast cancer, it is one organ which can be easily felt and self-examined.
- It usually affects young men (ages 20-39) in the prime of their youth, which is the most productive age.
- Testicular cancer has the highest cure rate among all cancers (more than 90 per cent), and cure is possible even if detected late (there are documented cured cases in fair numbers even in stage IV, unlike breast or lung cancer) and for a given stage it has higher cure rates than any other screen detected malignancies.
- If untreated, it has a high potential to adversely impact lives, both in terms of longevity and quality.
Prominent symptoms include pain/swelling/ lumps in testicles/groin areas, though some uncommon and atypical symptoms are also known. If the disease spreads all over, it may show signs like cough, headache etc.
Other conditions that mimic testicular cancer
Not all lumps on the testicles are tumours, and not all tumours are malignant; there are many other conditions such as testicular microlithiasis, epididymal cysts, appendix testes (hydatid of Morgagni), and so on which may be painful but are non-cancerous. \
Like most other cancers, in many of the cases the cause is not known. Among the known causes, prominent risk factors include undescended testes (cryptorchidism), family history, mumps and inguinal hernia. These cases require more intense vigilance or are preferred for selective or high risk screening.
Although testicular cancer can be derived from any cell type found in the testicles, more than 95 per cent of testicular cancers are germ cell tumours, which are of two types; seminomas, or slow growing cancer and non-seminomas or fast growing cancer. Remaining five per cent are from other cells in the testes.
It is a model for multidisciplinary, management of cancer, with appropriate integration of surgery, chemotherapy and radiation therapy. However surgery is the mainstay and is mandatory in all the cases.
- Inguinal orchiectomy – While it may be possible in some cases to remove testicular cancer tumours from a testis while leaving the testis functional, this is almost never done, as the affected testicle usually contains pre-cancerous cells which spread throughout the entire testicle.removing the tumour alone without additional treatment greatly increases the risk that another cancer will form in that testicle. Since only one testis is typically required to maintain fertility, hormone production, and other male functions, the afflicted testis is almost always removed completely in a procedure called inguinal orchiectomy. (The testicle is almost never removed through the scrotum; an incision is made beneath the belt line in the inguinal area.) The common misbelief that surgical removal of a testicle will affect fertility is far from reality as most of these patients do have normal fertility and potency. Chemotherapy, used in advanced cases, on the other hand, can harm sperm count/quality, which is usually reversible. Sperm banking in such cases should be considered.
- Retroperitoneal Lymph Node Dissection (RPLND) leading to retrograde ejaculation, which has been modified and refined.
The abdomen is treated with radiation in some cases of seminoma to prevent nodal recurrences. Though rare with advanced radiation techniques, it may lead to many long term complications including second cancers in early stage seminomas, and can be replaced with more intense followup. It is proven that risk of recurrence is not very high, and even if it recurs, complete salvage is still possible.
It is the standard treatment for nonseminoma when the cancer has spread to other parts of the body (that is, stage 2B or3). The standard chemotherapy protocol is three or sometimes four rounds ofBleomycin, Etoposide and Cisplatin (BEP).
The unmet need Despite this aggressive approach,20-30 per cent of patients treated formetastatic disease die of the disease. This emphasises the need for well-conceived randomised trials to define newer therapies for this group of patients.
Complications of treatment and debated issues This issue is becoming more prominent as it is now recognised that there is risk of overtreatment, long term sequelae and morbidity. The ability to achieve equivalent results with more than one competing modality has also raised many controversies in the management of this cancer.