Testicular Cancer Basics

MD Anderson Cancer Center
Date: 07-15-13

[ Music ]

Lisa Garvin: Welcome to Cancer Newsline, a podcast series from the University of Texas MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment, and prevention, providing the latest information on reducing your family's cancer risk. I'm your host, Lisa Garvin, and today our guest is Dr. Lance Pagliaro. He is a professor of genitourinary medical oncology here at MD Anderson and our subject today is testicular cancer. Now Dr. Pagliaro, testicular cancer is kind of disease of the younger male is it not?

Dr. Lance Pagliaro: Well, in a way that's true. It's the most common malignant cancer in young men who for whom cancers in general are uncommon. But actually any male of any age from infancy to very old age can get testicular cancer.

Lisa Garvin: Okay, because I had always thought that by the time you reach 30, your risk would kind of decrease after that.

Dr. Lance Pagliaro:  It does decrease until about [pause] early 50's and then it increases again. There's a, as we say, a second peak of incidents later in life.

Lisa Garvin: So about how many men in the U.S. get testicular cancer every year?

Dr. Lance Pagliaro:  It's estimated about 8,500 new cases per year in the United States.

Lisa Garvin: And in that same year how many people might lose their lives to testicular cancer?

Dr. Lance Pagliaro: Oh 300 or 400. The statistics worldwide are more than 95 percent of men with testicular cancer are cured.

Lisa Garvin: And typically this is because, testicular cancer it seems to me would be very easy to [pause] find or diagnosis even amongst the patient himself. I mean the symptoms are fairly obvious aren't they?

Dr. Lance Pagliaro: Not always. A testicular tumor of [pause] a size larger than a walnut, say, will be noticeable to the patient. But the exceptions are that patients don't always seek medical attention for symptoms that they are having and these are not always painful and may simply be enlargement or discomfort that is more of a pressure or heaviness, but not necessarily pain, and remember, depending on the age and the cultural background they may be simply embarrassed or reluctant to talk about it. But there are cases of testicular cancer where the, as well call the primary tumor, the tumor in the testicle, is actually quite small where even a doctor can't feel it, and yet it spreads and causes illness in other parts of the body. So we do have patients, and they are a small percentage, but there are patients who come to medical attention initially with shortness of breath or coughing blood or back pain, other kind of symptoms. But about one-half of testicular cancer, new cases, are diagnosed with what we call stage I, in other words, only the tumor in the testicle that can be detected at that time.

Lisa Garvin: And typically, the diagnosis and the treatment are the same. I mean, don't they remove the suspicious testicle just for diagnosis?

Dr. Lance Pagliaro:  Yes. But when the new case of testicular cancer is first diagnosed, whether it has spread or not, assuming there is a primary tumor in the testicle, the first step in treatment is to remove the testicle. And that's done without a biopsy. There's several reasons for that, but the removal of the testicle, in a sense, is the biopsy and that's where you get the tissue to confirm what it is. And then if that patient requires additional treatment, for example, if the cancer has spread, then that would occur after that first surgery.

Lisa Garvin: Now I know that, that men and their genitalia are very tight. I mean, how do men react when they find out that they're getting one of their testicles removed even though cancer isn't confirmed yet?

Dr. Lance Pagliaro:  Well it's always a shock. I don't know that I can say whether the cancer diagnosis or losing a testicle is the bigger, is the bigger [pause] shock to the patient, but fortunately, most men have two testicles and in terms of testicular function, whether you're talking about the masculinizing affects of testosterone or the ability to father children, that is really unaffected by the loss of one testicle, because one healthy testicle can perform all of those functions.

Lisa Garvin: And do you, you rarely see the disease in both testicles, is that correct?

Dr. Lance Pagliaro: Well we do see it. And we see it at a much greater frequency than you would expect by chance alone. A man who has had testicular cancer has a lifelong risk of a second cancer in the other testicle. That is about a 2 or 3 percent risk, much higher than the average population. And it's enough of a risk that we do see it. I have several patients in my clinic that have had testicular cancer twice at different points in their life.

Lisa Garvin: Now at what point do we bring up preserving sperm for those who want to have children, is this when they lose their first testicle or when should this be brought up I guess?

Dr. Lance Pagliaro: Well, [pause] what I recommend to patients is to consider sperm banking or the freezing of sperm for use in assisted reproduction at any time that we're completing chemotherapy treatment, or certainly if they've already lost one testicle and are losing the remaining testicle, that's another incidence where you'd want to preserve sperm. But that first surgery, what we call the orchiectomy, removal of the cancerous tumor, that doesn't require sperm banking, again, because one testicle is still there and usually it's not [pause] really practical or convenient to be donating sperm at that point in time.

Lisa Garvin: Does testicular cancer metastasize easily? I mean I think of Lance Armstrong and also a patient we had here at MD Anderson that we used for marketing who had, I mean, the cancer was just, it was primary in the testicle, but it just metastasized to many areas of their body, I mean, does that happen very often?

Dr. Lance Pagliaro:  Well, it does happen often. About one-half of cancers, of testicular cancers, appear to be confined to the testicle at the time that they're diagnosed. The other half have already shown signs of spread. Of those that are clinical stage I, a diagnosis, some 20 or 30 percent will later have recurrence or spread, so actually more than half are destined to spread at some point in time, but when you look at the individual case, their behavior varies tremendously. There are, and to some extent we can identify this with different cell types, but there are types of testicular cancer that may grow to a very large size and not spread. And there are others that can spread all over the body even before they're large enough to detect. So that is something that is all over the map.

Lisa Garvin: Are there typical areas of metastasis for testicular cancer?

Dr. Lance Pagliaro: Yes. There's a very characteristic pattern of metastasis. There are basically two ways that it can spread, one is through the lymph system following the lymphatics or the channels that, that [pause] connect lymph nodes throughout the body. And the other is through the bloodstream where cancer cells actually gain access to the circulation and are pumped by the heart all over the body. Usually the first step in that spread of testicular cancer from the testicle is through the lymphatic that leads from the testicle all the way up to the lymph nodes near the kidney in the abdomen on that same side of the body. So from the left testicle to what we call the left para-aortic lymph nodes, or from the right testicle, to what we call the interaortocaval lymph nodes. From there, if it's not treated, the lymph nodes get larger it will show up in more of the lymph nodes, in the abdomen, and then eventually spreading to lymph nodes further away, for example, in the chest or the neck. Spread through the bloodstream, typically it happens, typically occurs later, although it can occur at the same time and, again, depending on the type of testicular cancer, there are some types that even preferentially spread through the bloodstream and can do that with minimal or no evidence of spread through the lymph system. So they're really separate events. Most commonly we see it in the lymph system, but not spreading through the bloodstream. I could also add, spread through the bloodstream can lead to tumor deposits in the lungs, liver, brain, bones, obviously anywhere the blood can go the tumor can go. Most commonly lungs.

Lisa Garvin: Now when does the prognosis start to become, because the prognosis overall for testicular cancer is pretty good, as you said, when does the prognosis start to take a turn for the worse in patients, like at what stage or at what point of metastasis does it become a poor prognosis?

Dr. Lance Pagliaro:  Well, there are a couple of ways to answer that question. [Pause] First of all, there are two, and I mentioned a couple of times different cell types, all of the testicular germ cell tumors, which are what we're talking about, can be divided into two groups. Those that are pure seminoma and those that are non-seminoma, and that can also include mixed tumors that have a portion of seminoma, but seminoma and non-seminoma. So seminoma, virtually all of those patients are cured. There is no poor prognosis, seminoma, so if we're going to talk about poor prognosis, we can kind of set that aside. With the non-seminoma, you can look at different phrases in treatment. Those that are previously untreated, those that have recurrence after treatment who are getting a second-line treatment, and those that are in the third-line or what you might call treatment-resistant type cancer. So in the second line, the chance of cure and the outlook for survival are not as good as a newly diagnosed patient, but it's still about 50/50 overall. Beyond that, tumors that come back a third time, there's a high mortality rate. Now if we look at the newly diagnosed cancers in terms of the extent or severity of disease, there is a subgroup that we call poor-prognosis germ cell tumor, that even prior to their orchiectomy, prior to anything, we know these patients have a higher risk of mortality, and their cure rate from the time of diagnosis is about 50/50. And we refer to that in the staging system, we refer to that as stage IIIC, that's the worst, there is no stage IV testicular cancer. And for stage IIIC, there has been some research. We've done some research here at MD Anderson recently, a randomized clinical trial, looking at a novel therapy for these patients, and certainly in the second line, after the first chemotherapy has failed, there are other more aggressive forms of treatment, such as high-dose chemotherapy and stem cell transplant or bone marrow transplant.

Lisa Garvin: But now testicular cancer is, is it a sporadic disease or is there some sort of genetic or some sort of genetic basis to it?

Dr. Lance Pagliaro: It's really both. [Pause] Most patients with testicular cancer have no obvious cause or risk factor. The most common risk factors that we identify are a relative with testicular cancer, a family history, we see that 2 or 3 percent of the time, or having had an undescended testicle as a child?

Lisa Garvin: Cryptorchidism I guess they call it.

Dr. Lance Pagliaro: Cryptorchidism is what we call it. So, you know, some of your listeners may be aware of that history, you know, in their own childhood. Any man whose had cryptorchidism in childhood has an increased risk of testicular cancer throughout their life, but again, that only accounts for about 3 percent of patients that we see. So the majority are really sporadic. There's no obvious reason why that person got testicular cancer, except that, and you mentioned genetics. It's much more common among Caucasian Americans than African Americans, and if you look at other racial groups, the incidents of testicular cancers varies. There's a particularly high incident of testicular cancer in Northern Europe or Scandinavia. So there is something in presumably the genetic makeup that makes some populations more at risk for testicular cancer than others. But going back to one of the first comments that we made, any man, at any age, from any racial background, regardless of lifestyle, could potentially have testicular cancer. And we talked a little bit before we came on the air about testicular self-exams and really what it boils down to is just men being aware of their bodies and noting any changes and bringing them to their physician.

Lisa Garvin: Right. Any pain or symptom relating to the testicles should be brought to a doctor's attention right away, you know, testicular cancer is curable and relatively easy to detect with, for example, ultrasound, which is painless, a quick procedure. And there are other conditions that can affect the testicles like testicular torsion that one would certainly want to know about.

Lisa Garvin: Are there any like final messages for men out there that just, you know, to be aware or whatever?

Dr. Lance Pagliaro: Not to be afraid to talk to your doctor about testicular cancer because more than 95 percent of cases are cured and if it's detected earlier and treated promptly, than the amount of treatment required and the burden of therapy will be less.

Lisa Garvin: Great. Thank you very much. If you have questions about anything you've heard today on Cancer Newsline, contact Ask MD Anderson at 1-877-MDA-6789 [Background Music] or online at mdanderson.org/ask. Thank you for listening to this episode of Cancer Newsline. Tune in for the next podcast in our series.

[ Music ]