View source for Testicular cancer

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{{Infobox_Disease |
  Name           = Testicular cancer |
  Image          = |
  Caption        = |
  DiseasesDB     = 12966 |
  ICD10          = |
  ICD9           = |
  ICDO           = |
  OMIM           = 273300 |
  MedlinePlus    = |
  MeshName       = Testicular+Neoplasms |
  MeshNumber     = C04.588.322.762 |
}}
{{Search infobox}}
{{CMG}}

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==Overview==
'''Testicular cancer''' is [[cancer]] that develops in the [[testicle]]s, a part of the [[male]] reproductive system.

In the United States, about 8,000 to 9,000 diagnoses of testicular cancer are made each year.  Over his lifetime, a man's risk of testicular cancer is roughly 1 in 250 (four tenths of one percent, or 0.4%).  It is most common among males aged 15-40 years, particularly those in their mid-twenties. Testicular cancer has one of the highest cure rates of all cancers: in excess of 90%; essentially 100% if it is not [[malignant]]. Even for the relatively few cases in which malignant cancer has spread widely, chemotherapy offers a cure rate of at least 85% today. Not all lumps on the testicles are tumors, and not all tumors are malignant; there are many other conditions such as [[Epididymal cyst]]s, [[Hydatid of Morgagni]], and so on which may be painful but are non-cancerous.  It should be emphasized however that all unusual lumps or pain in the testicles should be checked by a doctor immediately. 

==Symptoms and early detection ==
Because testicular cancer is curable (stage I can have a success rate of >95%) when detected early, experts recommend regular monthly [[testicular self-examination]] after a hot shower or bath, when the [[scrotum]] is looser. Men should examine each testicle, feeling for pea-shaped lumps.
Symptoms may include one or more of the following:
* a lump in one testis or a hardening of one of the testicles 
* pain and tenderness in the testicles
* loss of sexual activity
* build-up of fluid in the [[scrotum]]
* a dull ache in the lower abdomen or groin
* an increase, or significant decrease, in the size of one testis
* blood in semen [http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=85&sectionId=20098]

Men should report any of these to a [[physician|doctor]] as soon as possible.

The nature of any palpated lump in the [[scrotum]] is evaluated by scrotal [[ultrasound]], which can determine exact location, size, and some characteristics of the lump, such as cystic vs solid, uniform vs heterogeneous, sharply circumscribed or poorly defined. The extent of the disease is evaluated by [[CT scan]]s, which are used to locate [[metastasis|metastases]].  Blood tests are also used to identify and measure [[tumor marker]]s that are specific to testicular cancer. The diagnosis is made by performing an orchiectomy, surgical excision of the entire [[testis]] along with attached structures [[epididymis]] and [[spermatic cord]]; the resected specimen is evaluated by a [[pathologist]]. A [[biopsy]] should not be performed, as it raises the risk of migrating cancer cells into the scrotum. The reason why inguinal orchiectomy is the preferred method is that the lymphatic system of the scrotum links to the lower extremities and that of the testicle links to the retroperitoneum.  A transscrotal biopsy or orchiectomy will potentially leave cancer cells in the scrotum and create two vectors for cancer spread, while in an inguinal orchiectomy only the retroperitoneal route exists.

==Differential diagnosis==
An incorrect diagnosis is made at the initial examination in up to 25% of patients with testicular tumors and may result in delay in treatment or a suboptimal surgical approach (scrotal incision) for exploration.

* [[Epididymitis]] or epididymoorchitis
* [[Hematocele]]
* [[Hydrocele]]
* [[Spermatocele]]
* Granulomatous orchitis
* [[Varicocele]]

==Prevalence and distribution==
Testicular cancer is most common among Caucasians and rare among African Americans. Testicular cancer is uncommon in Asia and Africa.  Worldwide incidence has doubled since the 1960s, with the highest rates of prevalence in Scandinavia, Germany, and New Zealand. 

Incidence among African Americans doubled from 1988 to 2001 with a bias towards [[germinoma|seminoma]]. The lack of significant increase in the incidence of early-stage testicular cancer during this timeframe suggests that the overall increase was not due to heightened awareness of the disease.

Although testicular cancer is most common among men aged 15-40 years, it has three peaks: infancy, ages 25-40 years, and age 60 years.

[[Germ cell tumor]]s of the testis are the most common cancer in young men between the ages of 15 and 35 years.

A major risk factor for the development of testis cancer is [[cryptorchidism]].

==Diagnosis==

The cardinal diagnostic finding in the patient with testis cancer is a mass in the substance of the testis. Unilateral enlargement of the testis with or without pain in the adolescent or young adult male should raise concern for testis cancer.

The differential diagnosis of [[testicular cancer]] requires examining the [[histology]] of tissue obtained from an [[orchiectomy]] specimen. Orchiectomy, rather than transcrotal biopsy, is preferred to reduce the risk of '''spill''' and thus the risk of [[metastasis]], in the event that the tumor is [[malignant]].  For orchiectomy, an inguinal surgical approach is preferred.

==Management==

Before 1970, the young man with recurrent testicular cancer was destined to have rapid progression and death from disseminated disease. Currently, although 7000 to 8000 new cases of testicular cancer occur in the United States yearly, only 400 men are expected to die of the disease.  Much of this improvement is due to advances in adjuvant therapy.

Due to the risk of subsequent metastasis, post-surgical adjuvant therapy may be offered to the patient following orchiectomy.  The type of adjuvant therapy depends largely on the [[histology]] of the tumor and the stage of progression at the time of surgery.  These two factors contribute to the risk of recurrence, including metastasis.  Adjuvant treatments may involve chemotherapy, radiotherapy or careful surveillance by frequent CT scans and blood tests by oncologists.

==Classification==

{{main|Germ cell tumor}}

Although testicular cancer can be derived from any cell type found in the testicles, more than 95% of testicular cancers are [[germ cell tumor]]s.  Most of the remaining 5% derive from [[Leydig cell]]s or [[Sertoli cell]]s.  Thus, the focus of diagnosis is on determining which germ cell tumor is present.  Correct diagnosis is necessary to ensure the most effective and least harmful treatment.  To some extent, this can be done via blood tests for [[tumor marker]]s, but differential diagnosis requires examination of the [[histology]] of a specimen by a [[pathologist]].

=== Staging ===

After removal, a testicular tumor is staged by a [[pathologist]] according to the [[TNM|TNM Classification of Malignant Tumors]] as published in the [[American Joint Committee on Cancer|AJCC]] Cancer Staging Manual.  Testicular cancer is categorized as being in one of three [[Cancer staging|stages]] ([[TNM|which have subclassifications]]).  The size of the tumor in the testis is irrelevant to staging. [http://www.cancerstaging.org/cstage/CSPart1Manual.pdf]  In broad terms, testicular cancer is staged as follows:
*Stage I: the cancer remains localized to the [[testis]]. 
*Stage II: the cancer involves the testis and [[metastasis]] to [[Retroperitoneum|retroperitoneal]] and/or [[Paraaortic lymph node]]s ([[lymph node]]s below the [[Urogenital diaphragm|diaphragm]]). 
*Stage III: the cancer involves the testis and [[metastasis]] beyond the [[Retroperitoneum|retroperitoneal]] and [[Paraaortic lymph node]]s.  Stage III is further subdivided into nonbulky stage III and bulky stage III. [http://tcrc.acor.org/staging.html]

===Histology===

After removal, a testicular tumor is classified by a [[pathologist]] according to its [[histology]].
 
==== Germ cell tumors of the testis, by frequency ====
{{main|Germ cell tumor}}
* 40% mixed (usually teratoma plus another)
* 35% [[seminoma]] ([[germinoma]] of the testis)
* 20% [[embryonal carcinoma]]
* 5% [[teratoma]] (pure)
* <1% [[choriocarcinoma]]
* [[Gonadoblastoma]]

Also:  Intratubular germ cell [[neoplasm]]s (the in-situ stage of germ cell tumors)

====Non-germ cell tumors of the testis====

* [[Sertoli-Leydig cell tumour|Sertoli-Leydig cell tumor]] (usually [[benign]])
* Gonadoblastomas [http://www.health.am/cr/testis-non-germ-cell-tumors/]

====Secondary tumors of the testis====
* [[Lymphoma]]
* Leukemic infiltration of the testis
* [[Metastasis|Metastatic]] tumors [http://www.health.am/cr/more/secondary-tumors-of-the-testis/]

==Treatment==
The three basic types of treatment are [[surgery]], [[radiation therapy]], and [[chemotherapy]].

Surgery is performed by [[urologist]]s; radiation therapy is administered by [[radiation oncologist]]s; and chemotherapy is the work of medical [[oncologist]]s.

===Surgery===
====Orchiectomy====

While it may be possible, in some cases, to remove testicular cancer tumors from a testis while leaving the testis functional, this is almost never done, as more than 95% of testicular tumors are [[malignant]].  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.)  Most notably, since removing the tumor alone does not eliminate the precancerous cells that exist in the testis, it is usually better in the long run to remove the entire testis to prevent another tumor.  A plausible exception could be in the case of the second testis later developing cancer as well.

====Retroperitoneal Lymph Node Dissection (RPLND)====

In the case of [[nonseminoma]]s that appear to be stage I, surgery may be done on the [[Retroperitoneum|retroperitoneal]]/[[Paraaortic lymph node|Paraaortic]] [[lymph node]]s (in a separate operation) to accurately determine whether the cancer is in stage I or stage II and to reduce the risk that [[malignant]] testicular cancer cells that may have [[Metastasis|metastasized]] to lymph nodes in the lower abdomen.  This surgery is called [[Retroperitoneal Lymph Node Dissection]] (RPLND).  However, this approach, while standard in many places, especially the United States, is falling out of favor due to costs and the high level of expertise required to perform the surgery.

Many patients are instead choosing surveillance, where no further surgery is performed unless tests indicate that the cancer has returned. This approach maintains a high cure rate because of the growing accuracy of surveillance techniques.

Lymph node surgery may also be performed after chemotherapy to remove masses left behind, particularly in the cases of advanced initial cancer or large [[nonseminoma]]s.

===Radiation therapy===
[[Radiation]] may be used to treat stage II seminoma cancers, or as [[adjuvant]] (preventative) therapy in the case of stage I seminomas, to minimize the likelihood that tiny, non-detectable tumors exist and will spread (in the inguinal and para-aortic [[lymph nodes]]).  Radiation is never used as a primary therapy for [[nonseminoma]] because a much higher dose is required and chemotherapy is far more effective in that setting.

===Chemotherapy===
As an [[adjuvant]] treatment, use of [[chemotherapy]] as an alternative to radiation therapy is increasing, because radiation therapy appears to have more significant long-term side effects (for example, internal scarring, increased risks of secondary malignancies, etc.).  Two doses of [[carboplatin]], typically delivered three weeks apart, is proving to be a successful [[adjuvant]] treatment, with recurrence rates in the same ranges as those of [[radiotherapy]].

Chemotherapy is the standard treatment, with or without radiation, when the cancer has spread to other parts of the body (that is, stage II or III).  The standard [[chemotherapy protocol]] is three to four rounds of [[Bleomycin]]-[[Etoposide]]-[[Cisplatin]] (BEP). This treatment was developed by Dr. [[Lawrence Einhorn]] at Indiana University. An alternative, equally effective treatment involves the use of four cycles of [[Etoposide]]-[[Cisplatin]] (EP).

While treatment success depends on the stage, the average survival rate after five years is around 95%, and stage I cancers cases (if monitored properly) have essentially a 100% survival rate (which is why prompt action, when testicular cancer is a possibility, is extremely important).

==Actions after treatment==
===Surveillance===
For stage I cancers that have not had any adjuvant (preventive) therapy, close monitoring for at least a year is important, and should include blood tests (in cases of [[nonseminoma]]s) and CT-scans (in all cases), to ascertain whether the cancer has [[Metastasis|metastasized]] (spread to other parts of the body).  For other stages, and for those cases in which radiation therapy or chemotherapy was administered, the extent of monitoring (tests) will vary on the basis of the circumstances, but normally should be done for five years (with decreasing intensity).

===Fertility===
A man with one remaining testis can lead a normal life, because the remaining testis takes up the burden of [[testosterone]] production and will generally have adequate fertility.[http://www.fda.gov/fdac/features/196_test.html] However, it is worth the (minor) expense of measuring hormone levels before removal of a testicle, and sperm banking may be appropriate for younger men who still plan to have children, since fertility may be lessened by removal of one testicle, and can be severely affected if extensive [[chemotherapy]] and/or [[radiotherapy]] is done.

Less than five percent of those who have testicular cancer will have it again in the remaining testis.  A man who [[castration|loses both testicles]] will normally have to take hormone supplements (in particular, [[testosterone]], which is created in the testicles), and will be infertile, but can lead an otherwise normal life.

==Famous survivors==
* Decorated cyclist Lance Armstrong
* In 1997, figure-skater Scott Hamilton
* Mike Lowell, Boston Red Sox third baseman was diagnosed during spring training of his rookie year.
* Christopher Arena, National Basketball Association and co-founder of ArenaTilton Golf
* Hockey player Phil Kessel of the Boston Bruins, diagnosed during his rookie season in 2006-07



==References==
*[http://www.emedicine.com/MED/topic863.htm eMedicine  Germ Cell Tumors]
*[http://www.fda.gov/fdac/features/196_test.html Testicular Cancer: Survival High with Early Treatment]
*[http://www.health.am/cr/testis-non-germ-cell-tumors/ Non-Germ Cell Tumors of the Testis] Tumors of the Testis 
*[http://www.health.am/cr/testis-germ-cell-tumors/ Germ Cell Tumors of the Testis]
*[http://content.nejm.org/cgi/content/full/356/8/842 Case 6-2007 — A 28-Year-Old Man with a Mass in the Testis], Kaufman D. S., Saksena M. A., Young R. H., Tabatabaei S., N Engl J Med 2007; 356:842-849, Feb 22, 2007. Case Records of the Massachusetts General Hospital.
* [http://content.nejm.org/cgi/content/full/337/4/242 Medical Progress: Testicular Germ-Cell Cancer], Bosl G. J., Motzer R. J., N Engl J Med 1997; 337:242-254, Jul 24, 1997. Review Article

== External links ==
*[http://www.bidmc.org/YourHealth/ConditionsAZ.aspx?ChunkID=11513 Beth Israel Deaconess Medical Center: Testicular cancer]
*[http://testicularcancer.org.uk/ UK testicular cancer support forums]
*[http://tcrc.acor.org/ Testicular Cancer Resource Center]
*[http://www.nlm.nih.gov/medlineplus/testicularcancer.html National Institute of Health information and links]
*[http://www.cancercouncil.com.au/html/patientsfamiliesfriends/typesofcancer/testicular/downloads/testicular.pdf Understanding Testicular Cancer] from [http://www.cancercouncil.com.au/editorial.asp?pageid=894 The Cancer Council Australia]
*[http://gallery.hd.org/_c/medicine/_more2006/_more01/scan-xray-X-Ray-testicular-testicle-scrotal-scrotum-for-cancer-or-other-lesions-or-abnormalities-all-clear-shrunk-tweaked-mono-1-ANON.jpg.html Images of scans for testicular cancer]
*[http://www.checkemlads.com/ checkemlads.com Testicular cancer support and awareness, run by survivors]
*[http://www.checkyourballs.co.uk/ checkyourballs] Support and Awareness site, created by a survivor.

{{Tumors}}
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[[Category:Disease state]]
[[Category:Andrology]]
[[Category:Types of cancer]]
[[Category:Oncology]]
[[Category:Mature chapter]]

[[da:Testikelkræft]]
[[de:Hodenkrebs]]
[[es:Cáncer de testículo]]
[[fr:Cancer du testicule]]
[[no:Testikkelkreft]]
[[pl:Nasieniak]]
[[pt:Câncer testicular]]
[[ro:Cancer la testicole]]
[[simple:Testicular cancer]]
[[fi:Kivessyöpä]]
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