Testicular cancer

Testicular cancer occurs in the testicles (testes), which are located inside the scrotum, a loose bag of skin underneath the penis. The testicles produce male sex hormones and sperm for reproduction.
Compared with other types of cancer, testicular cancer is rare. Testicular cancer is highly treatable, even when cancer has spread beyond the testicle. Depending on the type and stage of testicular cancer, you may receive one of several treatments, or a combination.
Risk factors include an undescended testis, family history of the disease, and previous history of testicular cancer. The most common type is germ cell tumors which are divided into seminomas and nonseminomas. Other types include sex-cord stromal tumors and lymphomas. Diagnosis is typically based on a physical exam, ultrasound, and blood tests. Surgical removal of the testicle with examination under a microscope is then done to determine the type.

Symptoms
Symptoms of testicular cancer do not normally appear until a later stage. In most cases, the individual finds the cancer himself. Sometimes, it is discovered by doctors during a routine physical exam.
Anyone who notices anything unusual about their testicles should see a doctor, especially if they detect any of the following:
• a painless lump or swelling in a testicle
• pain in a testicle or scrotum
• discomfort in a testicle or scrotum
• a sensation of heaviness in the scrotum
• a dull ache in the lower back, groin, or abdomen
• a sudden accumulation of fluid in the scrotum
• unexplained tiredness or malaise.

Early signs
It is important to catch testicular cancer early to improve the chances for successful treatment.
The earliest signs that occur are a painless lump and swelling. The testicle may also seem to be larger than usual.
However, this type of cancer may not cause noticeable symptoms until a later stage. That is why self-examination is so important - it is often the only way to catch testicular cancer at an early stage.

Causes
Although scientists are not sure what the specific causes of testicular cancer are, there are some factors which may raise a man's risk of developing the disease. These risk factors include:
• Cryptorchidism (undescended testicle): If a testicle has not moved down when a male is born, there is a greater risk that he will develop testicular cancer later on.
• Congenital abnormalities: Males born with abnormalities of the penis, kidneys, or testicles.
• Inguinal hernia: Males born with a hernia in the groin.
• Having had testicular cancer: If a male has had testicular cancer, he is more likely to develop it in the other testicle, compared with a man who has never had testicular cancer.
• Family history: A male who has a close relative with testicular cancer is more likely to develop it himself compared with other men.
• Abnormal testicular development: Conditions, such as Klinefelter's syndrome, where the testicles do not develop normally, may increase a person's risk of testicular cancer.
• Mumps orchitis: This is an uncommon complication of mumps in which one or both testicles become inflamed.
• Ancestry: Testicular cancer is more common among Caucasian males, compared with men of African or Asian descent. The highest rates are found in Scandinavia, Germany, and New Zealand.
Having a vasectomy does not increase a man's risk of developing testicular cancer.

Risk factors
Factors that may increase your risk of testicular cancer include:
• An undescended testicle (cryptorchidism). The testes form in the abdominal area during fetal development and usually descend into the scrotum before birth. Men who have a testicle that never descended are at greater risk of testicular cancer than are men whose testicles descended normally. The risk remains elevated even if the testicle has been surgically relocated to the scrotum.
Still, the majority of men who develop testicular cancer don't have a history of undescended testicles.
• Abnormal testicle development. Conditions that cause testicles to develop abnormally, such as Klinefelter syndrome, may increase your risk of testicular cancer.
• Family history. If family members have had testicular cancer, you may have an increased risk.
• Age. Testicular cancer affects teens and younger men, particularly those between ages 15 and 35. However, it can occur at any age.
• Race. Testicular cancer is more common in white men than in black men.

Diagnosis
In some cases men discover testicular cancer themselves, either unintentionally or while doing a testicular self-examination to check for lumps. In other cases, your doctor may detect a lump during a routine physical exam.
To determine whether a lump is testicular cancer, your doctor may recommend:
• Ultrasound. A testicular ultrasound test uses sound waves to create an image of the scrotum and testicles. During an ultrasound you lie on your back with your legs spread. Your doctor then applies a clear gel to your scrotum. A hand-held probe is moved over your scrotum to make the ultrasound image.
An ultrasound test can help your doctor determine the nature of any testicular lumps, such as whether the lumps are solid or fluid-filled. An ultrasound also tells your doctor whether lumps are inside or outside of the testicle.
• Blood tests. Your doctor may order tests to determine the levels of tumor markers in your blood. Tumor markers are substances that occur normally in your blood, but the levels of these substances may be elevated in certain situations, including testicular cancer. A high level of a tumor marker in your blood doesn't mean you have cancer, but it may help your doctor in determining your diagnosis.
• Testicular biopsy A small sample of tissue is taken from the targeted area in the testicle and examined under a microscope to determine whether the lump is malignant (cancerous) or benign (non-cancerous).

Determining the type of cancer
Your extracted testicle will be analyzed to determine the type of testicular cancer. The type of testicular cancer you have determines your treatment and your prognosis. In general, there are two types of testicular cancer:
• Seminoma. Seminoma tumors occur in all age groups, but if an older man develops testicular cancer, it is more likely to be seminoma. Seminomas, in general, aren't as aggressive as nonseminomas.
• Nonseminoma. Nonseminoma tumors tend to develop earlier in life and grow and spread rapidly. Several different types of nonseminoma tumors exist, including choriocarcinoma, embryonal carcinoma, teratoma and yolk sac tumor.

Treatment
Around 95 percent of all men with testicular cancer make a full recovery after receiving treatment. The sooner a patient is diagnosed and treated, the better his prognosis is.
Treatment for testicular cancer may involve surgery, radiotherapy, chemotherapy, or a combination.
Surgery
Orchiectomy
Orchiectomy is usually the first line of treatment. The testicle is surgically removed to prevent the tumor from spreading. If the patient is diagnosed and treated in stage 1, surgery may be the only treatment needed.
An orchiectomy is a straightforward operation. The patient receives a general anesthetic. A small incision is made in the groin, and the testicle is removed through the incision. The patient remains in hospital for a few days.
If the man still has one testicle after the operation, his sex life and chances of reproducing should not be affected.
Fertility
If after the operation, the patient has no testicles, he will be infertile. He will not be able to produce sperm.
Males who wish to have children one day should consider banking their sperm before the operation - some sperm is kept in a sperm-bank before the testicle or testicles are removed.
Other testicular cancer therapies, including radiotherapy and chemotherapy, can also affect a cancer patient's long-term fertility.
Lymph node surgery
If the cancer has reached the lymph nodes, they will need to be surgically removed. This usually involves the lymph nodes in the abdomen and chest. Sometimes lymph node surgery can result in infertility.
Radiation therapy
Radiotherapy involves the use of beams of high-energy X-rays or particles (radiation) to destroy cancer cells. Radiotherapy works by damaging the DNA inside the tumor cells, destroying their ability to reproduce.
Patients with seminoma testicular cancer will typically require radiotherapy as well as surgery. The radiotherapy is used to prevent cancer recurrence. Patients whose cancer has spread to their lymph nodes will need radiation therapy. Radiation therapy may cause the following temporary side effects:
• tiredness
• rashes
• muscle stiffness
• joint stiffness
• loss of appetite
• nausea
Chemotherapy
Chemotherapy is the use of chemicals (medication) to destroy cancer cells. Cytotoxic medication prevents cancer cells from dividing and growing.
Chemotherapy is usually given to patients with advanced testicular cancer - cancer that has spread to other parts of the body. Treatment is administered either orally (tablets by mouth) or injection. As chemotherapy attacks healthy cells as well as cancerous ones, the patient may experience the following temporary side effects:
• nausea
• vomiting
• hair loss
• mouth sores
• tiredness
• malaise
Most people immediately link chemotherapy with uncomfortable side effects. However, side-effect management has improved considerably over the last 20 years.

Self-exam
The best time to check yourself is when the scrotal skin is relaxed; usually after a warm shower or bath.
• Gently hold the scrotum in the palms of both hands. Stand in front of the mirror and look for any swelling on the skin of the scrotum.
• Feel the size and weight of the testicles first.
• With fingers and thumbs press around and be receptive to any lumps or unusual swellings. Some men have one testicle that hangs lower than the other. Some people have one testicle which is bigger than the other. This is normal.
• Each check, try to detect any significant increase in the size or weight of the testicles.
• Feel each testicle individually. Place the index and middle fingers under the testicle while your thumbs are on the top. Gently roll the testicle between the thumbs and the fingers - it should be smooth, oval-shaped, and somewhat firm. There should be no lumps or swellings. The top and back of each testicle should have a tube-like section where sperm is stored, known as the epididymis, which may be slightly tender. It is normal for it to feel tender.

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