Testicular cancer: What young men need to know

Testicular cancer is one of the most common cancers in young men in their 20s to 40s. Globally, there has been an increasing prevalence of testicular cancer.

Here are five things you should know about testicular cancer.

The testicles are responsible for the production of male hormones and sperm. Testicular cancer is a malignant condition of the testis, where cells begin to replicate out of control and develop the propensity to invade other organ systems, both around the testes and other parts of the body.

It can arise from various cell lines from within the testis. The commonest four are namely seminoma, yolk sac tumours, choriocarcinomas and teratomas.

Testicular cancer can occur in any age group, but the highest prevalence is between 20 and 40 years old. Thus, the impact of having such cancer goes beyond survival, as it also affects the patient’s future fertility, hormonal function, and self-esteem.

The most common way this cancer presents itself is by the presence of a slow-growing painless testicular lump, often found by chance during trivial accidents or a shower. Many patients might attribute this lump to an injury, leading to a delay in diagnosis and subsequent management.

Worryingly, over the past few decades, the local incidence of testicular cancer has steadily risen, from 92 (1998-2002) to 202 (2013-2017), according to the Singapore Cancer Registry.

Thankfully, the absolute number remains relatively low and, if diagnosed early, can be treated successfully in most cases. Most of these patients then go on to lead pretty normal adult lives.

Testicular cancer is diagnosed using a combination of a physical examination as well as an ultrasound scan. The physical examination would commonly reveal a hard testicular lump.

The ultrasound scan would often show a mass within the testis, with malignant ultrasound characteristics, such as increased blood flow to the lump and possible invasion into the surrounding tissues such as the spermatic cord or the scrotum.

If a mass is felt within the abdominal cavity during the physical examination, we would be worried about lymph nodal metastasis. A computer tomographic (CT) scan of the lung, abdomen and pelvis will confirm this. Blood tumour markers, including alpha-fetoprotein, B human chorionic gonadotropin and lactate dehydrogenase, may suggest what cellular type this tumour is arising from, as well as the tumour load on the body.

Similar to the monthly breast self-examination for females, there is a monthly testicular self-examination for males, especially those at risk of developing testicular cancer. There isn’t a specific “conducive” time to perform this check. Patients are encouraged to perform this quick examination in the privacy of the bathroom during a shower.

During this self-check, each testis is examined for unusual lumps and, if present, do seek medical attention. Patients who are unsure of how to perform this exam can approach their doctor for advice.

Those with:

a) Family history of testicular cancers. Paternal and fraternal history being the most relevant

b) Personal history of testicular cancer. Patients who had previous testicular cancer are at significantly higher risk of developing this condition again in the remaining testis

c) Prior history of undescended testis. Even if it was corrected early during childhood, there remains an elevated risk.

d) Younger males (<40 years old) with an issue of subfertility

e) Known HIV infection. Interestingly, HIV infection is associated with an increased risk for developing seminomas. However, the underlying reason isn’t clear at this moment

The primary treatment for testicular cancer is a radical inguinal orchidectomy. The whole diseased testis and its cord are removed through an inguinal incision. Care is taken not to breach the scrotum, as if that were to happen, there is a risk of tumour seeding into the scrotal skin.

A partial orchidectomy may be undertaken to preserve testicular function in rare scenarios where the patient only has one testis. However, this remains the significant minority of cases, as there is a significant risk of leaving viable cancer tissue behind in the remaining testis (necessitating a completion orchidectomy) as well as future recurrences.

Survival rates increase significantly when the disease is detected early and could also render the patient disease-free. Patients would only require regular surveillance scans and blood tumour markers. If the cancer is deemed high risk or has spread from the testis into the lymphatic system or beyond, chemotherapy would be required as a subsequent treatment to improve the patient’s survival and lower the risk of recurring disease.

In some cases, whereby residual/recalcitrant disease is present after chemotherapy, surgery may be offered to the patient to clear up these lymph nodes in the abdomen. However, the surgery, known as a retroperitoneal lymph node dissection, is a major undertaking. Some overseas institutions do offer radiotherapy to the retroperitoneal lymph nodes if the primary disease is a seminoma. In contrast, in Singapore, chemotherapy has shown to have a lower recurrence rate.

Before performing any treatment on a patient, sperm banking is advocated as surgery and chemotherapy can impact the patient’s fertility. Hence, patients would be referred to a sperm bank to store sperm for use in future artificial reproductive techniques if the condition permits.

Very rarely, when a patient comes into the hospital in crisis (e.g., severe back pain due to significant retroperitoneal metastasis or severe respiratory failure due to significant pulmonary metastasis), chemotherapy is commenced before the resection of the disease testis to treat the systemic disease. In these cases, sperm banking would not be feasible.

Support for patients goes beyond the medical aspects of this condition. It is important to review the patients in the post-operative period for wound care, follow-up tests to look for recurrences, and advocate regular testicular self-examination of the remaining testis.

Patients may suffer from subfertility. Often, patients starting a family are advised to try conceiving naturally. If the couple experiences difficulty conceiving, both should be evaluated for problems, which may contribute to the issue. One should not assume it is due to male factors alone.

Once we identify the underlying reason, we can map out a treatment plan targeting the issue. If the treatment plan fails, artificial reproductive techniques, such as intrauterine insemination, in vitro fertilisation, and intra-cytoplasmic sperm injection, can be explored to achieve a successful pregnancy.

Dr Chong Weiliang is an Associate Consultant at the Department of Urology, Tan Tock Seng Hospital.