Germ cell tumor

Alternative names
Cancer - testes; Testicular cancer; Seminoma

Definition
Testicular cancer is an abnormal, rapid, and invasive growth of cancerous (malignant) cells in the testicles (male sex glands adjacent to the penis).

Causes, incidence, and risk factors

Although the exact cause of testicular cancer has not been identified, several predisposing factors seem to increase risk. These include a past medical history of undescended testicle(s), abnormal testicular development, Klinefelter’s syndrome (a sex chromosome disorder that may be characterized by low levels of male hormones, sterility, breast enlargement, and small testes), or previous testicular cancer.

Other factors are under investigation as possible causes, such as exposure to certain chemicals and infection with the human immunodeficiency virus (HIV). A family history of testicular cancer may increase risk. There is no link between vasectomy (an operation to cause sterility) and elevated risk of testicular cancer.

Between 6,000 and 8,000 men will be diagnosed with testicular cancers each year. Although testicular cancer accounts for 1% of all cancers in men, it is the most common form of cancer in young men 15 to 40 years old. It may also occur in young boys, but only about 3% of all testicular cancer is found in this group.

White American men have about five times the risk of African-American men and more than twice the risk of Asian-American men. The risk for testicular cancer has doubled among white Americans in the past 40 years but has remained the same for African-Americans. The reasons for these differences are not known.

Testicular cancers may be classified as follows:

     
  • Seminomas account for about 30-40% of all testicular tumors. These are usually is found in men in their 30s and 40s. The condition is usually localized to the testes, although in about 25% of cases it has spread to lymph nodes.  
  • Non-seminomas account for 60% of all testicular tumors; subcategories of these tumors are listed below. Non-seminoma tumors often contain more than one of the following cell types:       o Embryonal carcinoma (about 20% of testicular cancers) occurs in 20-30 year olds and is highly malignant. It grows rapidly and spreads to the lung and liver.       o Yolk sac tumor (about 60% of all testicular cancers in young boys).       o Teratomata (about 7% of testicular cancers in adult men and 40% in young boys).       o Choriocarcinoma (rare).

Stromal cell tumors are a kind of tumor that is made of Leydig cells, Sertoli cells, and granulose cells. These tumors account for only 3-4% of all testicular tumors. However, these do make up nearly 20% of all childhood testicular tumors. These tumors may secrete a hormone - estradiol - that can cause one of the symptoms of testicular cancer, gynecomastia (excessive development of male breast tissue).

Symptoms

     
  • Enlargement of a testicle or a change in the way it feels  
  • Lump or swelling in either testicle  
  • Dull ache in the back or lower abdomen  
  • Gynecomastia (excessive development of male breast tissue), this can also occur normally in adolescent males, in whom it is not a symptom of testicular cancer  
  • Testicular discomfort/pain or a feeling of heaviness in the scrotum  
  • Occasionally, the initial symptoms are related to the spread of the cancer to other parts of the body, such as the lungs, abdomen, pelvis, or brain

Note: There may be no symptoms.

Signs and tests
A physical examination typically reveals a firm, non-tender testicular mass that does not “trans-illuminate” (light from a flashlight held to the scrotum does not pass through the mass).

Other tests include:

     
  • Scrotal ultrasound is used to confirm solid mass.  
  • Blood tests for tumor markers: alpha-fetoprotein (AFP), human chorionic gonadotrophin (beta HCG), and lactic dehydrogenase (LDH). Approximately 85% of non-seminomas will have elevations of either AFP or beta HCG. Seminomas will have elevations only in beta HCG or LDH. These tests can also be used to monitor the response to treatment.  
  • A chest X-ray is done to look for potential metastasis (spreading of cancer) to the lungs.  
  • An abdominal CT scan may be done to look for potential metastasis.

Tissue biopsy is usually by surgical removal of the testicle. After the testicle is removed, the tissue is examined.

Treatment
Treatment depends on the type of tumor, the stage of the tumor, and the extent of the disease. Most patients can be cured.

Once cancer is found, the first step is to determine the type of cancer cell. This determination is done by a microscopic exam. The cells can be seminoma or non-seminoma. If both types of seminoma and non-seminoma cells are found in a single tumor, the tumor is treated as a non-seminoma.

The next step is to determine how far it has spread to other parts of the body. This is called “staging.”

     
  • In Stage I, the cancer has not spread beyond the testicle.  
  • In Stage II, the cancer has spread to lymph nodes in the abdomen.  
  • In Stage III, the cancer has spread beyond the lymph nodes; it could be as far as the liver or lungs.

There are three types of treatment that can be used.

  1. Surgical treatment includes removing the testicle (orchiectomy) and removal of associated lymph nodes (lymphadenectomy). This is usually performed in the case of both seminoma and non-seminoma testicular cancers
  2. Radiation therapy using high-dose X-rays or other high-energy rays may be used after surgery for patients with seminomas to prevent the tumor from returning. The use of radiation therapy is usually limited to the treatment of seminomas.
  3. Chemotherapy - using drugs such as cisplatin, bleomycin, and etoposide to kill cancer cells - has greatly enhanced the survival rate of both seminomas and non-seminomatous testicular tumors.

The cure rate for Stage I seminoma tumor is over 95%. The treatment is usually surgery to remove the testis and radiation to the lymph nodes in the abdomen.

Stage II seminoma tumors are divided into bulky and non-bulky disease. Bulky disease is generally defined as tumors greater than 5 centimeters.

The treatment of Stage II seminomas includes surgery to remove the testis followed by either radiation to the lymph nodes in the case of non-bulky disease or chemotherapy with cisplatin for patients with bulky disease. The cure rate is between 85-95%.

Stage III seminoma tumors have a 90% cure rate. The treatment is surgery to remove the testis and multi-drug chemotherapy.

The cure rate for a Stage I nonseminoma tumor is over 95%. The treatment is removal of the testis and, possibly, removal of lymph nodes in the abdomen.

Stage II nonseminoma tumors have a cure rate of over 95%. The treatment is usually surgery to remove the testis and lymph nodes in the abdomen, possibly followed by chemotherapy.

Stage III nonseminoma has a 70% cure rate. The treatment will probably be chemotherapy and surgical removal of the testis.

If the cancer is a recurrence of a previous testicular cancer, the treatment usually consists of chemotherapy using combinations of different medications, such as ifosfamide, cisplatin, etoposide, or vinblastine, sometimes followed by an autologous bone marrow or peripheral stem-cell transplant.

Support Groups
Joining a support group where members share common experiences and problems can often help the stress of illness. Your local branch of the American Cancer Society may have a support group.

Lance Armstrong, a famous cyclist, is a survivor of testicular cancer. He has a web site that offers support and information. A Federal Government web site from the National Cancer Institute offers information and services for cancer patients and their families.

Expectations (prognosis)
The survival rate for men with early stage seminoma (the least aggressive type of testicular cancer) is greater than 95%. The disease-free survival rate for Stage I non-seminomatous cancer is nearly 95%; for Stage II seminomas it is 70-90%, depending on the size of the tumor when treatment is begun; for Stage II non-seminomas it is greater than 95%; and for Stage III for both is usually about 70% curable.

This response to treatment means that testicular cancer is one of the most treatable cancers.

Complications

Metastasis (spreading) to other parts of the body may occur with testicular cancer. The most common sites include the retroperitoneal area, the abdomen, the spine, and the lungs.

If both testicles are removed, the man becomes infertile (unable to have children) because no sperm cells will be produced. If surgery is done to remove lymph nodes, there can be damage to nerves that control ejaculation. This can also cause infertility as well as impotence. There is a newer type of surgery that has a better chance of preserving the nerves that maintain erection while still removing the lymph nodes.

Since testicular cancer affects men at the ages they may want to father children, nerve-sparing surgery and sperm banking (to save sperm and freeze it for use in artificial insemination) before any treatment should be discussed with the doctor.

Calling your health care provider
Call your health care provider if symptoms of testicular cancer occur.

Also call if you are a male over 15 years old who has not been taught testicular self-examination (TSE), or who has not had testicular screenings performed by your health care provider during routine physical examinations.

Prevention
There is no prevention for testicular cancer, but finding it early is important to successful treatment and survival. Young men should learn to perform testicular self-examination (TSE) shortly after puberty. A TSE performed on a monthly basis may play a major role in detecting tumors at earlier stages - before they spread.

Johns Hopkins patient information

Last revised: December 3, 2012
by Gevorg A. Poghosian, Ph.D.

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