Testes Cancer Update

Testes Cancer Update & How to Do a Self-Exam or Partner Exam

April is Testicular Cancer Awareness month.

Note Well: If you think you might have a lump, bump, or irregularity in or on your testes, please see a urologist. You will never be chided for getting a potential problem checked out and it is truly better to be safe and cautious. The good news is that most testes lumps, bumps, and growths are benign and not problematic.

Although rare with less than 10,000 cases annually in the USA, testes cancer is the most common solid cancer in young men aged 15-40, with its greatest incidence in the late 20s, striking men at the peak of life. Because it occurs in young men, you tend to hear about it in professional athletes including baseball player Scott Shoenweis; Olympian skater Scott Hamilton; Olympian swimmer Eric Shanteau; cyclist Lance Armstrong; golfer Billy Mayfair, etc.

Testes cancer is more prevalent in Caucasian men than African American or Asian men and it occurs more commonly in men with undescended testes and Klinefelter’s syndrome. The good news is that it is a highly curable cancer, especially when picked up in its earliest stages, and it is also potentially curable even at advanced stages. It typically causes a lump, irregularity, asymmetry, enlargement, heaviness, or a dull ache of the testicle. It most often does not cause pain, so the absence of pain should not dissuade you from getting evaluated if you are concerned about something that does not feel right. It can also present with a sudden fluid collection around the testes, breast enlargement and/or tenderness, back pain and rarely shortness of breath, coughing up blood or a lump in the neck.

When a patient presents with a testes abnormality, the first step is a careful physical examination, usually followed by an ultrasound of the scrotum. The ultrasound will confirm if the mass is solid or cystic (fluid-filled) and determine its precise location and size. If there is a suspicion for a malignancy, blood tests—known as tumor markers—consisting of alpha-feto protein (AFP), human chorionic gonadotropin (B-HCG) and lactate dehydrogenase (LDH) are routinely obtained. Under the circumstance of a testes abnormality suspicious for a possible cancer, an outpatient surgical procedure removes the testicle along with its blood and lymphatic supply (spermatic cord) via an incision in the groin. At the time of surgery, some men will elect to have a testicular prosthesis implanted, whereas others are not concerned about an empty scrotal sac on one side.

The testicles have two functions: the manufacture of sperm (germ cell function) and the manufacture of testosterone (Leydig cell function). Most testes cancers (95% or so) are of germ cell origin. Germ cell cancers consist either of seminomas or non-seminomas. Non-seminomas include embryonal cell cancers, choriocarcinomas, yolk sac tumors and teratomas. Many testes cancers are mixed germ cell tumors consisting of several of the sub-types. 5% of testes cancers are stromal cell origin, including Leydig and Sertoli cell tumors.

Depending on the final pathology report and staging studies to determine if there is any spread of the cancer to remote areas of the body– repeat tumor markers after testes removal and computerized tomogram (CT) of the abdomen and pelvis and a chest x-ray–further management options may include careful surveillance, surgical removal of abdominal lymph nodes, chemotherapy or radiation therapy.

Stage I is confined to the testes; stage II involves the regional lymph nodes (abdominal lymph nodes); stage III is distant spread. When chemotherapy is the treatment of choice, the go-to cocktail of medications is often a combination of bleomycin, etoposide and cisplatinum (BEP). Under certain circumstances, sampling of the abdominal lymph nodes is necessary (retroperitoneal lymph node dissection) and depending on the specific pathology, at other times, radiation therapy is necessary. In addition to the urologist, a medical oncologist and radiation oncologist often are involved with the treatment process.

How to Do a Testes Self-Exam or Partner Exam

Only 5% or so of men with testes cancer are diagnosed by a physician based on an abnormality found on physical exam, whereas 95% are brought to a physician’s attention because of an abnormality noted by a patient or his partner, so it really makes a lot of sense to learn how to do a good quality examination. This simple exam can be lifesaving.

Note: Shockingly, the United States Preventive Services Task Force (USPSTF) recommends against testes self-exam. Balderdash, what a bunch of ivory tower feckless idiots! Of note, there are no urologists on this force. What their advice has often prevented is the early detection of many cancers, including prostate cancer. Sadly, their recommendations are heeded by many primary care physicians, who generally do not teach men how to do a testes self-exam.

My video of The Horse’s Ass Award to the USPSTF for disservice regarding prostate cancer.

Because sperm production requires that testes are kept cooler than core temperature, nature has conveniently designed men with testicles dangling from their mid-sections. There are no organs in the body—save female breasts—that are more external and easily accessible to examination. One of the great advantages of having one’s gonads located in such an accessible locale—conveniently “gift wrapped” in the scrotal satchel—is that it makes them so easy to examine. This is as opposed to the ovaries, which are internal and not amenable to ready inspection. This explains why early testes cancer diagnosis is a cinch as opposed to ovarian cancer, which most often presents at a more advanced stage.

If your (maybe stoic) man is not willing to do self-exams, at a moment of intimacy do a “stealth” exam under the guise of affection. This just might be lifesaving.  Numerous times in my career as a urologist I have treated patients with testes cancer diagnosed because of their partners recognizing an abnormality.

The goal of an exam is to pick up a testes mass in an early and treatable stage when it is a localized issue that has not spread to the lymph nodes or lungs, which are common sites of metastasis.

The testicles can be examined anywhere, but a warm shower or bath is an ideal setting as the warm water tends to relax the thin scrotal sac and allow the testes to descend to a position that is most accessible. Soapy skin will eliminate friction and allow the examining fingers to easily roll over the testicles.

The exam is best performed with the thumb in front and the remaining fingers behind the testicles. The four fingers immobilize and support the testicle and the thumb does the important work in examining the front, sides, top and bottom of the testicle; then the four fingers immobilize the front while the thumb examines the back surface of the testes. The motion is a gentle rolling one, feeling the size, shape, and contour and checking for the presence of lumps and bumps.

Compare the two testes in terms of size, shape and consistency. Generally, the testicles feel firm, similar to the consistency of hard-boiled eggs, although this can vary between individuals and even in an individual. Lumps can vary in size from a kernel of rice to a large mass many times the size of the normal testes. The epididymis is a comet-shaped structure located above and behind the testes that is responsible for sperm storage and maturation. It has a head, a body and tail, and it is worthwhile running your fingers over this structure as well.

This exam should be done regularly—perhaps every couple of weeks or so—such that you get to know your (or your partner’s) anatomy to the extent that you will be attuned to a subtle change. Once you get in the habit of doing this on a regular basis, it will become second nature.