Testicular cancer is a common cancer among young American men. This year, there are estimated to be nearly 5000 new cases. These cancers are usually diagnosed after a man feels a mass in his scrotum or has sensations of “heaviness” in his testis. A select group of men will have a tumor present elsewhere in their bodies (such as a neck mass or an abdominal mass) that is removed and then determined to be testicular cancer. Many men with testis cancer have a history of trauma to the scrotum or an undescended testes.
When a man discovers a testicular mass, he should see his doctor immediately. In addition to a testicular exam (feeling the testis), an ultrasound X-ray study of the testes may be performed. Several blood tests (called tumor markers or biomarkers), including an alpha-fetoprotein [AFP], a beta-hCG, and an LDH will be obtained. Surgery will then performed to remove the testis and make the diagnosis of cancer. This is called a radical orchiectomy and is required for any suspicious testicular lesion or mass.
Fortunately, most patients with testicular cancer will be cured of their disease. In addition, most will return to normal activities in an expeditious timeframe. Treatment for testicular cancer depends upon several factors, including the type of testis cancer and the extent of disease. First, surgery is performed to remove the testis (radical orchiectomy) and make the diagnosis of testis cancer. Once the testis is removed and the extent of disease is determined, treatments can consist of further surgery, radiotherapy, chemotherapy, a combination of these approaches, or close observation with blood tests and radiologic studies. Although most men maintain normal fertility, at some point in treatment the role of sperm-banking, to preserve the ability to father children after treatment for the testicular cancer is completed, may occur.
The diagnosis of testis cancer is made by removing the testis and examining its content under a microscope. This operation is called a radical orchiectomy. During this operation, the testis and its surrounding capsule and “cord” are removed. The incision is made in the lower abdomen, similar to hernia surgery. The testis is removed through the lower abdomen to prevent untoward spread of tumor cells. After the cancerous testis is removed, a chest X-ray and CT scan of the abdomen and pelvis to rule-out any metastatic spread will be performed.
Once the involved testes is removed, several management options become available. This depends upon a number of issues: (1) the type of testis cancer found in the testes, (2) whether the tumor markers where elevated and whether they normalize after the orchiectomy, and (3) whether the imaging studies show residual or metastatic cancer.
There are several subtypes of testis cancer. Most are germ cell neoplasms and consist of either a seminomaor a non-seminoma (or both). Several other types of rare tumors can be found in the testes but those are uncommon. The type of tumor will dictate in part the kind of treatment used after orchiectomy. Likewise, the presence or absence of biomarkers (alpha-fetoprotein [AFP], beta-hCG, and LDH) before and/or after orchiectomy may impact upon the type of treatment as this can indicate the presence of residual disease. Finally, the presence of absence of metastatic lesions on CT scans and/or chest X-rays will determine in part the type, if any, of additional treatment that may be necessary. These treatments can consist of further surgery, radiotherapy, chemotherapy, a combination of these approaches, or close observation with blood tests and radiologic studies. Because of the complexities in managing testis cancer, it is advised that a man with testis cancer see a urologist and/or medical oncologist at a high volume academic center to help understand the nuances and intricacies of the disease to help determine what to do.
The Procedure: Orchiectomy
This is almost always the first step in making the diagnosis of testis cancer. Prior to the orchiectomy, blood should be collected to monitor the following biomarkers: alpha-fetoprotein [AFP], beta-hCG, and LDH. The presence or absence of these tumor biomarkers before and/or after orchiectomy may indicate the type of testis cancer present and the presence of residual disease and may impact upon the type (if any) of treatment after the orchiectomy.
- This involves removal of the testes, the surrounding capsule, and the spermatic cord – the structure that connects the testes to the abdomen.
- The radical orchiectomy is performed through an incision in the lower part of the abdomen: the scrotum is left untouched. This is to prevent spread of testes cancer cells.
- After surgery, the patient is advised to be sedentary for several days and is given and ice pack and athletic supporter to help prevent untoward bleeding.
Once the diagnosis is made, additional treatments can consist of further surgery, radiotherapy, chemotherapy, a combination of these approaches, or close observation with blood tests and radiologic studies.
Some men with testis cancer can be followed after orchiectomy without undergoing additional therapy. If they should relapse, treatment is then initiated. Surveillance for testis cancer after orchiectomy follows a strict protocol with regular exams, X-ray studies, and blood tests and requires active participation for the patient as well as his physician. Before initiating this approach, intensive counseling with a physician is required.
RPLND (Retroperitoneal Lymph Node Dissection)
Some men with testis cancer clearly will benefit from additional surgery. This operation is called an RPLND, or retroperitoneal lymph node dissection.
- This involves removal of the lymph tissue from the retroperitoneum, the part of the abdomen behind the intestines. This operative field is very close to the kidneys, the ureters, the intestines, large blood vessels, and nerves that assist with sperm emission.
- Generally, the RPLND can be performed in an open manner, through an incision that involves just the abdomen or, on occasion, the abdomen and chest. The role of laparoscopic surgery for RPLND is very controversial and is not recommended by most testis cancer specialists.
- Surgery is performed in such a way as to preserve all normal bodily functions, including seminal emission. Sometimes, however, sperm-banking may be offered as a means of improving post-treatment reproduction.
- Sometimes, chemotherapy is needed after RPLND. This would be determined after the results of the RPLND are available.
Some men with testis cancer will require chemotherapy. This depends on the amount and location of disease. Blood tests and imaging studies are used to guide the need and application of chemotherapy.
Some men receive chemotherapy for the testis cancer and then need surgery. This is called a post-chemo RPLND.
- RPLNDs performed after chemotherapy are much more complicated and the rate of side effects is higher and the length of recovery is longer.
- These operations should be performed in an academic hospital by a urologic surgeon specially-trained and experienced in the technique.