Testicular Cancer

Testicles have 2 main functions:

1/  They make male hormones (androgens) such as testosterone.

2/  They make sperm, the male cells needed to fertilize a female egg cell to start a pregnancy.

Cancer that starts in the testicles is called testicular cancer. Testicles (also called the testes) are part of the male reproductive system. These 2 organs are each normally a little smaller than a golf ball in adult males and are contained within a sack of skin called the scrotum. The scrotum hangs beneath the base of the penis.

The testicles are made up of several types of cells, each of which can develop into one or more types of cancer. It is important to distinguish these types of cancers from one another because they differ in how they are treated and in their prognosis.

Cancer starts when cells in the body begin to grow out of control. Cells in nearly any part of the body can become cancer, and can spread to other areas of the body.

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Some factors that may increase a man’s risk of testicular cancer include:

- Undescended testicle (when an infant)

- Family history (having a father or brother who has had testicular cancer).

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There is no known link between testicular cancer and injury to the testicles, sporting strains, hot baths or wearing tight clothes.

Researchers are learning how certain changes in a cell’s DNA can cause the cell to become cancerous. DNA is the chemical in each of our cells that makes up our genes. Genes tell our cells how to function. They are packaged in chromosomes, which are long strands of DNA in each cell. Scientists are studying DNA and chromosome changes to learn more about which genes are affected and how this might lead to testicular cancer.

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Chemotherapy, radiotherapy and surgery are the three main treatments for testicular cancer.

Your recommended treatment plan will depend on:

• The type of testicular cancer you have – whether it's a seminoma or a non-seminoma

• The stage of your testicular cancer

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The first treatment option for all cases of testicular cancer, whatever the stage, is to surgically remove the affected testicle.  This procedure is called an Orchiectomy or Orchidectomy.

For stage 1 seminomas - after the testicle has been removed, a single dose of chemotherapy may be given to help prevent the cancer returning. A short course of radiotherapy is also sometimes recommended.

However, in many cases, the chance of recurrence is low and your doctors may recommend that you're very carefully monitored over the next few years. Further treatment is usually only needed for the small number of people who have a recurrence.

For stage 1 non-seminomas - close follow-up (called surveillance) may also be recommended, or a short course of chemotherapy using a combination of different medications.

For stage 2, 3 and 4 testicular cancers - 3 to 4 cycles of chemotherapy are given using a combination of different medications. Further surgery is sometimes needed after chemotherapy to remove any affected lymph nodes or deposits in the lungs or, rarely, in the liver.

Some people with stage 2 seminomas may be suitable for less intense treatment with radiotherapy, sometimes with the addition of a simpler form of chemotherapy.

In non-seminoma germ cell tumors, additional surgery may also be required after chemotherapy to remove tumors from other parts of the body, depending on the extent of the spread of the tumor.

Deciding what treatment is best for you can be difficult. Your cancer team will make recommendations, but the final decision will, and should, be yours.

Before discussing your treatment options with your specialist, you may find it useful to write a list of questions to ask them. For example, you may want to find out the advantages and disadvantages of particular treatments.  At times of diagnosis with any condition, a person’s thoughts can be confused, frustrated and stressed.  Dave Wells can support you through interpreting and understanding the information that doctors and specialists provide and assist you with exploring your reactions, thoughts and fears that maybe associated.  Whether it be a brief therapy intervention or ongoing support, Dave Wells can support you to communicate your needs and ask the right questions to assist in gaining control of your journey navigating through a diagnosis of Testicular cancer.

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Orchidectomy also known as Orchiectomy

An Orchidectomy is a surgical procedure to remove a testicle. If you have testicular cancer, the whole of the affected testicle will need to be removed because only removing the tumor may lead to the cancer spreading.

By removing the entire testicle, your chances of making a full recovery are greatly improved. Your sex life and ability to father children won't be affected.

About one in 50 people will get a second new testicular cancer in their remaining testicle. In such circumstances, it's sometimes possible to only remove the part of the testicle containing the tumor. You should ask your surgeon about this if you're in this position.

If testicular cancer is detected in its very early stages, an Orchidectomy may be the only treatment you require.

An Orchidectomy isn't carried out through the scrotum. It's done by making an incision in your groin through which the testicle is removed with all of the tubes and blood vessels attached to the testicle that pass through the groin into the abdomen. The operation is carried out under general anesthetic.

You can have an artificial (prosthetic) testicle inserted into your scrotum so that the appearance of your testicles isn't greatly affected. The artificial testicle is usually made of silicone (a soft type of plastic). It probably won't be exactly like your old testicle or the one you still have. It may be slightly different in size or texture.

After an Orchidectomy, it's often possible to be discharged quickly, although you may need to stay in hospital for a few days. If only one testicle is removed, there shouldn't be any lasting side effects.

If both testicles are removed (a bi-lateral Orchidectomy), you'll be infertile. However, removing both testicles at the same time is very rarely required, and only one in every 50 cases requires the other testicle to be removed at a later date (Based on NHS data).

You may be able to bank your sperm before having a bi-lateral Orchidectomy to allow you to father children if you decide to.

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Sperm banking

Most people are still fertile after having one testicle removed. However, some treatments for testicular cancer can cause infertility.

Some people with testicular cancer may have low sperm counts because of changes that occur in the testicles before the cancer develops.

For some treatments, such as chemotherapy, infertility may occur, but standard chemotherapies have a less than 50% chance of causing infertility if the remaining testicle is normal.

In people who need to have post-chemotherapy removal of lumps at the back of the abdomen, known as retroperitoneal lymph node dissection (RPLND) (see below), the ability to ejaculate (eject sperm from the penis) may be affected, even though the remaining testicle can still produce sperm.

Before your treatment begins, you may want to consider sperm banking. This is where a sample of your sperm is frozen so that it can be used at a later date to impregnate your partner during artificial insemination. Before sperm banking, you may be asked to have tests for HIV, hepatitis B and hepatitis C.

If you're having complex chemotherapy for stage 2 to 4 testicular cancer, you should always be offered sperm banking. Ask if you're concerned about your fertility.

Not all men are suitable for sperm banking. For the technique to work, the sperm has to be of a reasonably high quality. There may also be situations where it's considered too dangerous to delay treatment for sperm banking to take place.

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Testosterone Replacement Therapy

If you still have a remaining healthy testicle, it should make enough testosterone so you won't notice any difference.

If there are any problems with your remaining testicle, you may experience symptoms due to a lack of testosterone. These symptoms can be caused for other reasons but can include:

• Tiredness

• Weight gain

• Loss of libido (sex drive)

• Reduced beard growth

• Reduced ability to achieve or maintain an erection (erectile dysfunction)

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Having both testicles removed will definitely stop you producing testosterone and you'll develop the above symptoms.

Testosterone Replacement Therapy is where you're given testosterone in the form of an injection, skin patch or gel to rub into your skin. If you have injections, you'll usually need to have them every 2 to 3 months.

After having Testosterone Replacement Therapy, you'll be able to maintain an erection and your sex drive will improve.

Side effects associated with this type of treatment are uncommon, and any side effects that you do experience will usually be mild. They may include:

• Oily skin, which can sometimes trigger the onset of acne

• Breast enlargement and swelling

• A change in normal urinary patterns, such as needing to urinate more frequently or having problems passing urine (caused by an enlarged prostate gland that puts pressure on your bladder)

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Lymph Node and Lung Surgery

More advanced cases of testicular cancer may spread to your lymph nodes. Lymph nodes are part of your body's immune system, which helps protect against illness and infection.

Lymph node surgery is carried out under general anesthetic. The lymph nodes in your abdomen are the nodes most likely to need removing.

In some cases, the nerves near the lymph nodes can become damaged, which means that rather than ejaculating semen out of your penis during sex or masturbation, the semen instead travels back into your bladder. This is known as Retrograde Ejaculation.

If you have Retrograde Ejaculation, you'll still experience the sensation of having an orgasm during ejaculation, but you won't be able to father a child.

There are a number of ways of treating Retrograde Ejaculation, including the use of medicines that strengthen the muscles around the neck of the bladder to prevent the flow of semen into the bladder.

Men who want to have children can have sperm taken from their urine for use in artificial insemination or in-vitro fertilisation (IVF).

There are also a number of newer surgical techniques that carry a lower risk of retrograde ejaculation and infertility. These are described below.Some people with testicular cancer have deposits of cancer in their lungs and these may also need to be removed after chemotherapy if they haven't disappeared or reduced sufficiently in size. This type of surgery is also carried out under general anesthetic and doesn't usually significantly affect breathing in the long-term.

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Nerve-sparing Retroperitoneal Lymph Node Dissection

A newer type of lymph node surgery, called Nerve-sparing Retroperitoneal Lymph Node Dissection (RPLND), is increasingly being used because it carries a lower risk of causing retrograde ejaculation and infertility.

In nerve-sparing RPLND, the site of the operation is limited to a much smaller area. This means there's less chance of nerve damage occurring. The disadvantage is that the surgery is more technically demanding. Therefore, nerve-sparing RPLND is currently only available at specialist centers that employ surgeons with the required training.

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Laparoscopic Retroperitoneal Lymph Node Dissection

Laparoscopic Retroperitoneal Lymph Node Dissection (LRPLND) is a type of "keyhole" surgery that can be used to remove the lymph nodes. During LRPLND, the surgeon will make a number of small incisions in your abdomen.

An instrument called an endoscope is inserted into one of the incisions. An endoscope is a thin, long, flexible tube with a light and a camera at one end, enabling images of the inside of your body to be relayed to an external television monitor.

Small, surgical instruments are passed down the endoscope and can be used to remove the affected lymph nodes.

The advantage of LRPLND is that there's less post-operative pain and a quicker recovery time. Also, as with nerve-sparing RPLND, in LRPLND there's a smaller chance that nerve damage will lead to retrograde ejaculation.

However, as LRPLND is a new technique, there's little available evidence regarding the procedure's long-term safety and effectiveness. If you're considering LRPLND, you should understand there are still uncertainties about the safety and effectiveness of the procedure.

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Radiotherapy

Radiotherapy uses high-energy beams of radiation to help destroy cancer cells. Sometimes, seminomas may require radiotherapy after surgery to help prevent the cancer returning.

It may also be needed in advanced cases where someone is unable to tolerate the complex chemotherapies that are usually used to treat stage 2, 3 and 4 testicular cancer.

If testicular cancer has spread to your lymph nodes, you may require radiotherapy after a course of chemotherapy.

Side effects of radiotherapy can include:

• Reddening and soreness of the skin, which is similar to sunburn

• Nausea

• Diarrhea

• Fatigue

These side effects are usually only temporary and should improve when your treatment is completed.

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Chemotherapy

Chemotherapy uses powerful medicines to kill the malignant (cancerous) cells in your body or stop them multiplying.

You may require chemotherapy if you have advanced testicular cancer or it's spread within your body. It's also used to help prevent the cancer returning. Chemotherapy is commonly used to treat seminomas and non-seminoma tumors.

Chemotherapy medicines for testicular cancer are usually injected into a vein. In some cases, a special tube called a central line is used, which stays in a vein throughout your treatment so that you don't have to keep having blood tests or needles placed in a new vein.

Sometimes, chemotherapy medicines can attack your body's normal, healthy cells. This is why chemotherapy can have many different side effects. The most common include:

• Vomiting

• Hair loss

• Nausea

• Sore mouth and mouth ulcers

• Loss of appetite

• Fatigue

• Breathlessness and lung damage

• Infertility

• Ringing in your ears (tinnitus)

• Skin that bleeds or bruises easily

• Low blood counts

• Increased vulnerability to infection

• Numbness and tingling (pins and needles) in your hands and feet

• Kidney damage

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These side effects are usually only temporary and should improve after you've completed your treatment.

Side effects, such as infections that occur when you have a low blood count, can be life-threatening, and it's essential that you always call your cancer care team if you're worried between chemotherapy treatments.

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Bleomycin

One of the medicines commonly used, called bleomycin, can cause long-term lung damage and you should discuss this with your doctors if damage to your lungs would have specific issues for your career or lifestyle. However, the advice may still be that you should receive it for the best chance of a cure.

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Having children

You shouldn't father children while having chemotherapy and for a year after your treatment has finished. This is because chemotherapy medications can temporarily damage your sperm, increasing your risk of fathering a baby with serious birth defects. Therefore, you'll need to use a reliable method of contraception, such as a condom, during this time.

Condoms should also be used during the first 48 hours after having a course of chemotherapy. This is to protect your partner from any potentially harmful effects of the chemotherapy medication in your sperm.

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Follow-up

Even if your cancer has been completely cured, there's a risk it will return. The risk of your cancer returning will depend on what stage it was at when you were diagnosed and what treatment you've had since.

Most recurrences of non-seminoma testicular cancer occur within 2 years of surgery or completion of chemotherapy. In seminomas, recurrences still occur until 3 years. Recurrences after 3 years are rare, occurring in less than 5% of people.

Because of the risk of recurrence, you'll need regular tests to check if the cancer has returned. These include:

• A physical examination

• Blood tests to check for tumor markers

• A chest X-ray

• Computerised tomography (CT) scan

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Follow-up and testing is usually recommended depending on the extent of the cancer and the treatment offered. This is usually more frequent in the first year or two but follow-up appointments may last for up to 5 years. In certain cases, it may be necessary to continue follow-up appointments for 10 years or longer.

If the cancer returns following treatment for stage one testicular cancer, and it's diagnosed at an early stage, it will usually be possible to cure it using chemotherapy and possibly also radiotherapy. Some types of recurring testicular cancer have a cure rate of over 95%.

Recurrences that occur after previous combination chemotherapy can also be cured, but the chances of this will vary between individuals and you'll need to ask your doctors to discuss this with you.

Content adapted from https://www.nhs.uk