Awww, Nuts: Understanding Testicular Cancer

This article originally appeared in The Havok Journal on September 30, 2014.

Andrew D. Fisher is stationed at Fort Benning, GA, and is a Physician Assistant in the U.S. Army. He has no financial interest in any products mentioned, nor has any conflict of interest to disclose. These opinions are his own and are not endorsed by the U.S. Army or the Department of Defense.

How often do you touch yourself in the shower? I hope often, at least once a month. I ask this question often in the clinic. Every now and then, I get a strange look or two, especially when I am touching the patient’s testicles. I ask for a good reason. Testicular cancer is the most common cancer of men between the ages of 15-35. It is very treatable (95%) when caught early, but can be deadly. Some of the young men I see have no idea that testicular cancer is a risk; let alone how to check themselves for cancer.

Organizations like Susan G. Komen raise a tremendous amount of money and awareness for breast cancer, which is great and needed.  What about men? Why are we so behind the times? Where is our awareness? Are we too proud? There are several resources available (see bottom for links), but nothing close to what organizations like Susan G. Komen.

Over the last few years, Movember has begun to bring that needed awareness for men’s health including testicular cancer. Before that, Lance Armstrong was the unofficial spokesman for testicular cancer. Although his Livestrong campaign is about supporting cancer patients of any type, Lance did have testicular cancer and was treated successfully. There is still much to be done. More than 8,000 cases will be diagnosed this year, with about 400 deaths.

There are three types of testicular cancer:

1. Germ cell tumors

2. Stromal tumors

3. Secondary testicular tumors

Germ cell tumors are by far the most common (90%) of all testicular tumors. Germ cells make your sperm. The two subtypes of germ cell tumors: seminomas and non-seminomas. They can occur separately or at the same time, called mixed germ cell tumors. There is a further breakdown of subtypes that is beyond the scope of this article. Seminomas tend to grow much slower than non-seminomas, but both occur about the same frequency.

Stromal tumors also have two subtypes, Leydig cell tumors, and Sertoli cell tumors. Leydig cell tumors have a much higher incidence in adolescents and are usually benign. The name comes from their origin, Leydig cells, which make testosterone. Leydig cell tumors can cause an abnormal amount of testosterone and cause males to enter puberty early. It can also release estrogen and give the patient female characteristics. Although rare and usually benign, when Leydig tumors spread, they are difficult to treat. Sertoli cells support and nourish the Leydig cells. Sertoli cell tumors are usually benign and do not cause issues. On a rare occasion, it does spread, like Leydig cells, they are difficult to treat.

The final type of testicular cancer type is the secondary testicular tumor. As the name implies, the testicle is not the primary source of cancer. Common types of cancer that can cause this are lymphomas (usually >50 year old), leukemia (young children), and organ cancers (prostate, lung, kidney). It would be unlikely military men would have secondary testicular cancer.

The Testicular Self Exam (TSE) can be done a few ways, what is important is that you are conducting the exam monthly. The TSE is best done in the shower since the scrotum is more relaxed and it is easier to examine your testicles. Examine each testicle with both hands. Place the index and middle fingers under the testicle with the thumbs placed on top. Roll the testicle gently between the thumbs and fingers — you shouldn’t feel any pain when doing the exam. Don’t be alarmed if one testicle seems slightly larger than the other, that’s normal.

We all have our own unique anatomy, so you should know if there are masses and if they are increasing in size. While some patients will only have an abnormal testicular exam. Other signs and symptoms include discomfort or pain in the testicle, development of breast tissue, heaviness in the scrotum, pain in the lower abdomen, or general cancer symptoms (fever/weight loss/fatigue).

The differential diagnosis (other possibilities) for testicular cancer is small, given the relative size of the area. Varicoceles are varicose veins in your scrotum, very common in men (like a bag of worms). Hydroceles are benign masses of fluid; occasionally they are removed due to pain or size. Epididymal cysts and spermatoceles are only different by their size. Cysts greater than 2 cm are classified as spermatoceles. Cysts are occasionally removed secondary to pain.

Testing for testicular cancer is for the most part noninvasive and quick. If you notice something abnormal, you should immediately see your primary provider. Your provider will probably do a manual testicular exam because it may be something as benign as a varicocele. If your provider is also suspicious and rules out cancer, he or she will probably send you for an ultrasound.

An ultrasound of the testicles is only about 70% effective at finding tumors but is very good for distinguishing between hydroceles and testicular cancer. A blood test for tumor markers can be a good indicator of testicular cancer and should be the next testing completed. CT scans are on par with ultrasounds, but since there is a large amount of radiation unwarranted radiation exposure, CTs are not the primary imaging study. If you are diagnosed with testicular cancer, you will likely receive a CT scan that would identify any lymph node involvement and/or metastasis. The only definitive way to identify testicular cancer is through an orchiectomy (testicular removal).

When the orchiectomy is complete, the testicle is evaluated microscopically for any cancer and type. Based on the staging of the cancer, a patient might receive chemo and radiation therapy. Once treatment is complete and the patient is in remission, there will be periodic evaluation and blood testing for a period of time.

No man wants to make a trip to the doctor to get his genitals fondled. However, testicular cancer is real and it happens. There have been several cases in my own unit, the 75th Ranger Regiment. Due to early intervention, all the patients made a complete recovery and are still serving today. Take the time to learn the TSE, do it monthly, and make an appointment with your provider if you find something abnormal.

Below are some useful links if you want to learn more. And, as always, feel free to comment on our Facebook page.

http://www.livestrong.org

http://us.movember.com/mens-health/testicular-cancer

http://www.cancer.org/cancer/testicularcancer/index

http://tcrc.acor.org/tcexam.html

http://www.nlm.nih.gov/medlineplus/ency/imagepages/1113.htm

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