Testicular Cancer and Fertility Preservation Options

Testicular cancer is one of the most common malignancies found in young men aged between 15 and 35 years of age. So, as a part of awareness, the Testicular Cancer Society has recognised April as the Testicular Cancer Awareness Month. However, as healthcare providers, we believe that awareness programmes should continue throughout the year to help raise caution amongst patients, the cancer survivors and their loved ones.

WHAT IS TESTICULAR CANCER?

As the name suggests, testicular cancer occurs in the testes (testicles), and the testes are located inside the scrotum.The scrotum is a loose bag of skin found underneath the penis. The testes are responsible for the release of male sex hormone and sperm production. The occurrence of testicular cancer though rare but are the most common type of cancer that affects young males aged between 15 and 35 years. However, the sigh of relief is that this type of cancer is very much treatable, even when cancer has spread beyond the testicles. Depending on nature and the stage at which the testicular cancer is, a patient might receive a specific treatment or a combination of treatments.

WHAT ARE THE SIGNS AND SYMPTOMS OF TESTICULAR CANCER?

It is to be noted that testicular cancer usually affects only one testicle, and the symptoms that a man typically notice are:

  • A lump in either of the testis
  • A dull ache in the abdomen or groin
  • A feeling of heaviness in the scrotum
  • Collection of fluid in the scrotum suddenly
  • Pain or discomfort in the testicle or the scrotum
  • Enlargement or tenderness of the breasts
  • Back pain

It is better to see a doctor if one detects pain, swelling or lump in the testicles or groin area, and primarily if any one of these signs and symptoms last longer than two weeks.

WHAT ARE THE CAUSES OF TESTICULAR CANCER?

Most of the times, the exact cause of testicular cancer is not known. Research says that specific alterations in the testicular cell’s DNA can cause that cell to become cancerous. Healthy cells grow and divide systematically, to keep the normal body functioning. However, at times, some cells develop abnormalities, causing the growth to get out of control — these are the cancer cells, and they continue to divide even when new cells aren’t needed. These cells start accumulating and form a mass in the testicle. Mostly all testicular cancers begin in the germ cells. The germ cells are the cells in the testicles that produce immature sperm. However, what causes germ cells to become abnormal and develop into cancer isn’t known.

WHAT ARE THE RISK FACTORS THAT MAY INCREASE THE CHANCES OF TESTICULAR CANCER?

The risk factors that may increase the chances of a man developing testicular cancer are:

  • Age It has been seen that testicular cancer affects males in the age group of 15 – 35 years. However, it can occur at any age also.
  • Ethnicity Testicular cancer is found to be more common in white men than in black men.
  • Family history If family members have had testicular cancer, then a man may have an increased risk of having testicular cancer.
  • Cryptorchidism (An undescended testicle)The testes usually form in the abdominal area during foetal development and then descends into the scrotum just before birth. Some men have testicles that never descended, and hence they are at higher risk of having testicular cancer than men whose testicles descended usually. The risk stays even if the testicle has been relocated to the scrotum through a surgery. Many men still develop testicular cancer who do not have a history of undescended testicles.
  • Abnormal testicle development Some conditions may cause testicles to develop abnormally, such as in Klinefelter syndrome, and this may increase the risk of testicular cancer.

HOW IS TESTICULAR CANCER DIAGNOSED?

Men usually discover testicular cancer themselves, either accidentally or while doing a self-examination to check the testicles for any presence of lumps. Alternatively, a doctor might detect a lump during a routine physical examination. The doctor might recommend the following tests to determine whether the lump found in the testicles are cancerous or not:

  • Ultrasound – Through ultrasound, the doctor might determine the nature of any testicular lumps – if found, whether the lumps are solid or fluid-filled. With the help of ultrasound, the doctor might also tell you whether the lumps are inside or outside the testicle.
  • Blood tests – The doctor may order tests to see the levels of tumour markers in your blood. Getting an elevated tumour marker may be a possibility that a man has testicular cancer, but it is always not so. However, it may help the doctor to give you an exact diagnosis.
  • Surgery to remove a testicle – If while running tests, it is found that the lump in the testis may be cancerous, then surgery is done to remove the testicle. The removed testicle is then analysed to see if the lump is cancerous or not, and if cancerous then what type of cancer it is.

WHAT ARE THE TYPES OF TESTICULAR CANCER FOUND IN MEN?

There are two types of testicular cancer

  • Seminoma – This type can occur in all ages and aren’t so aggressive and hence can be treated with radiation therapy.
  • Non-seminoma – This type of cancer usually occurs in the earlier stages of life and is known to spread very rapidly. Depending on the origin of cancer there are different types of Non-seminoma cancer like choriocarcinoma (uterus cancer), embryonal carcinoma (germ cell tumour), teratoma (tumours made up of tissues) and yolk sac tumour (rare, malignant tumour of cells that line the yolk sac of the embryo.). So, an effective way to stop these types of cancer is with chemotherapy, as they are not found to be very sensitive to radiation.

WHAT ARE TREATMENT OPTIONS FOR TESTICULAR CANCER?

Once the doctor confirms the diagnosis of testicular cancer, the next step usually is to see what stage the cancer is in. Depending on the extent of how much cancer has spread, has it affected your overall health, the treatment options will vary accordingly.

The stages of testicular cancer are symbolised by Roman numerals that can range from 0 to III, with the lowest stage indicating that the cancer is limited only around the testicle area. When it advances to stage three (stage III), the cancer is recognised as advanced, and there might be a possibility that it has spread to other parts of the body, like the lungs.

  • Surgery of testicles – Surgery to remove the testicle, which is known as radical inguinal orchiectomy is the primary treatment for mostly all the stages and types of testicular cancer. The surgery to remove the testicle involves the surgeon to make an incision in the groin area and then extract the entire testicle through the opening. In cases of early-stage testicular cancer, the only treatment needed might be the surgical removal of the testis.
  • Surgery to remove lymph node – Surgery is also done to remove the nearby lymph nodes which are called retroperitoneal lymph node dissection and is performed through an incision which is made in the abdomen. The surgeon should be careful and avoid damaging the nerves surrounding the lymph nodes, but in some cases, this is unavoidable. The nerves if damaged, can cause difficulty with ejaculation but won’t prevent an erection.
  • Radiation – Radiation therapy uses high-powered energy rays to kill cancer cells. This therapy is useful in seminoma type of testicular cancer. It might also be recommended after you have surgery to remove the testicle. Side effects may include nausea, fatigue, irritation and skin redness around the abdominal and groin area. For the time being, it can also reduce the sperm count and, in a way, impact a man’s fertility. So, it is best to talk to the doctor about the options available for fertility preservation before undergoing radiation therapy.
  • Chemotherapy – This treatment involves using drugs to kill cancer cells. The treatment might be recommended to a patient before or after a lymph node removal surgery. Side effects of chemotherapy generally depend on the drug that was used. So, it is always advisable to ask the doctor beforehand the pros and cons of the treatment. Common side effects can include fatigue, nausea, hair loss and increased susceptibility to infection. These side effects can be countered by medications and treatments. However, it can also lead to infertility in some men, and for some, this damage is permanent. Hence it is very important to talk to doctors about fertility preservation before starting chemotherapy.

WHAT ARE THE FERTILITY OPTIONS FOR MEN BATTLING TESTICULAR CANCER?

The testis is extremely sensitive to radiation and chemotherapy. Either of the treatment can kill the dividing cells in the testes and affect sperm production resulting in damage to sperm cells. It will lead to oligospermia (low sperm count) or azoospermia (nil sperm count) in the patients. So, if you are a young male with plans to conceive biologically in the future, our suggestion to you would be to opt for options like fertility preservation before undergoing any cancer treatment.

The fertility preservation options for men battling testicular cancer are:

  • Sperm freezing – If you visit a fertility clinic, the treating doctor can give options of freezing the sperm before going through any radiation or chemotherapy treatment. The sperm can be frozen as long as you want, and when needed, you can opt to conceive through IVF with your frozen sperm.
  • Testicular tissue cryopreservation (TESE) – This treatment is suggested for boys who are affected with testicular cancer and have reached puberty and men who have azoospermia. The process involves testicular biopsy that is extracting tissues from the testicle and extracting sperm from that tissue. If there are sperm detected, they will be frozen until the patient opts for IVF. This procedure can also be tried in cases where the patient has not opted for sperm cryo-banking before the treatment.
  • Radiation shielding – During radiation treatment, there are special shields available which are placed over both the testicles to reduce the damage to the cells in the area during radiation. It can help to a certain extent and protect the sperm cells against radiation and chemotherapy.

CONCLUSION

Cancer is on the rise all around the world, and different types of cancers keep affecting men. However, testicular cancer is very much treatable with a curable rate of 99% during stage I treatment when cancer is only contained within the testicle area, 96% for stage II cancer when it has spread to the lymph nodes. So, to preserve one’s fertility and before starting treatment as a part of spreading awareness on Testicular Cancer, the fertility preservation options should be well discussed and well explained with patients who have been diagnosed with testicular cancer.

 

References

https://www.fertstert.org/article/S0015-0282(97)81465-3/abstract
https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2605.1987.tb00205.x
https://www.sciencedirect.com/science/article/pii/S0022534717539968