Testicular cancer

Primary testicular tumours are the most common solid malignant tumour in men who are aged between 20 and 35 years in the UK. Testicular cancer is a rare condition. However, incidence has increased over the years—but the reasons for this are unknown. When a timely diagnosis is made, testicular cancer is highly treatable and is usually curable. Testicular cancers are sensitive to chemotherapy and even when metastatic they are curable. Testicular cancer is the most treatable form of urological cancer.

Most testicular tumours are malignant and the most common malignancy is in young men. Tumours occur in childhood and early adulthood when the affected testis has failed to descend, or has been late in descending into the scrotal sac (Waugh and Grant, 2018).

For many years, the cancer remains localised and eventually spreads to the lymph nodes (pelvic and abdomen) and the blood.

The testes are made up of a

Preventable cases of testicular cancer are unknown; it is not linked to any preventable risk factors. Testicular cancer risk is around 3-4 times higher in those with cryptorchidism (also known as undescended testicle, a condition where one or both testes fails to descend into the scrotum in the first year of life), meta-analyses have shown (Lip et al, 2013; Office for National Statistics, 2016). Undescended testicles are less common than descended testicles (Figure 3).

In unilateral cryptorchidism the risk of testicular cancer is 6.3 times higher in the undescended testicle and 1.7 times increased in the descended one, compared with the general population (Akre et al, 2009).

Testicular cancer risk is reported (Pettersson et al, 2007; Walsh et al,

The most common sign of testicular cancer is a lump or swelling in a testicle. However, other signs and symptoms may include:

• a swelling or a lump in a testicle; this is usually painless, but the swelling may suddenly increase in size and become painful
• a dull ache or pain, or a feeling of heaviness (a dragging sensation) in the scrotum
• most testicular cancers are not painful, but the first symptom a man may notice is a sharp pain in the testicle or scrotum.

If the cancer has spread to the lymph nodes or other parts of the body, some of the following symptoms may include:

• pain in the back or lower aspect of the abdomen, if the cancer has spread to abdominal lymph nodes (para aortic, retro peritoneal lymph glands, pelvic)
• a cough, breathlessness or difficulty swallowing, if the cancer has spread to lymph nodes in the chest area,

Diagnosis is made after a history is taken, a physical examination is performed and the various tests and investigations are made. A diagnosis can also be made after tests and other investigations have been carried out for another condition.

In England, 10% of testicular cancer cases are diagnosed after the patient presents as an emergency. Some 48% of emergency presentation cases are via the emergency department, with the other cases coming via an emergency GP referral, inpatient referral or outpatient referral (National Cancer Intelligence Network, 2015a; 2015b).

An ultrasound is usually the first investigation that is performed in order to make a diagnosis. Blood tests can help diagnose testicular tumours; most testicular cancers produce high levels of certain proteins (tumour markers) called, for example, alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG). When these tumour markers are present in the blood, this suggests that there is a testicular tumour.

Biopsy and

Once the investigations have been performed, it is possible to diagnose whether there is a cancer, if so, the type of cancer and whether or not the cancer has spread. The result (as well as the man's general health and level of fitness) will determine what type of treatment the man is offered. A multidisciplinary team approach is used and the man must be part of any decisions made about him and his health and wellbeing. Treatment options by cancer stage are outlined in Table 1.

References

Akre O, Pettersson A, Richiardi L. Risk of
contralateral testicular cancer among men with unilaterally undescended testis: a meta analysis. Int J Cancer. 2009; 124(3):687–9. https://doi.org/10.1002/ijc.23936

Bergholz R, Wenke K. Polyorchidism: a metaanalysis. J Urol. 2009; 182(5):2422-7. https://doi.org/10.1016/j.juro.2009.07.063. 

British Association of Urological Surgeons. Testicular self-examination. Frequently-asked questions (FAQs) from the British Association of
Urological Surgeons (BAUS). 2020. https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Testicular%20self%20examination.pdf (accessed 10 January 2023)

Cancer Research UK. Testicular cancer incidence statistics. 2023. https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/testicular-cancer#:~:text=1%20in%20215%20UK%20males,testicular%20cancer%20in%20their%20lifetime (accessed 10 January 2023)

Cancer Research UK. Finding it early. 2022a. https://www.cancerresearchuk.org/about-cancer/testicular-cancer/getting-diagnosed/finding-early (accessed 10 January 2023)

Cancer Research UK. Treatment decisions. 2022b. https://www.cancerresearchuk.org/about-cancer/testicular-cancer/treatment/treatment-decisions (accessed 10 January 2023)

Friman PC, Finney JW. Health education for testicular cancer. Health Educ Q. 1990;17(4):443–453

Hopcroft K. Routine testicular self-examination: it’s time to stop. BMJ. 2012; 344:e2120. https://doi.org/10.1136/bmj.e2120

Jack RH, Davies EA, Møller H. Testis and prostate cancer incidence in ethnic groups in south east England. Int J Androl. 2007;30(4):215–221

Lip SZ1, Murchison LE, Cullis PS, Govan L, Carachi R. A meta-analysis of the risk of boys with isolated cryptorchidism developing