Tumors and testicular cancer: what are the causes and symptoms? + Prevention

Testicular tumours and testicular cancer are rare cancers, but the incidence of this type of cancer is increasing. It has increased up to fivefold in the last three decades.

The disease progresses rapidly. At the time of diagnosis, metastases may already be present in nearby lymph nodes. In worse cases, metastases may also be present in distant organs such as the lungs, liver or brain.

Risk factors for testicular cancer include cryptorchidism (undescended testicles), which should be treated in childhood.

Prevention of the disease is important, especially educating young men about proper and regular self-examination of the testicles.

The testicles are the male sex glands in which sex cells (sperm) and male sex hormones (androgens) are produced. It is a paired organ located at the base of the scrotum.

The testicles are suspended from the spermatic cords. The left is always positioned lower than the right.

The testicle is shaped like an egg. The average size is 4.5 cm in length and 3 cm in width. One testicle weighs approximately 30 grams.

Testicular tumours are rare and account for only 2 % of all cancers in men. They mainly affect young men, most often between the ages of 20 and 44, but can also occur in a 15-year-old boy.

The incidence of this type of cancer is increasing.

However, thanks to modern cancer treatments such as radiotherapy or modern combinations of chemotherapy, the death rate from this disease is falling.

The most important thing is early diagnosis of the disease. Tumours metastasize relatively early to nearby inguinal and abdominal lymph nodes or to distant organs such as the lungs or brain.

Histopathologically, germ cell tumours are the most common tumours of the testis. Germ cell tumours arise from multipotent stem cells that further develop into mature differentiated cells such as germ cells.

For treatment purposes, these tumours are divided into seminoma and other germinative tumours, i.e. non-seminomatous tumours. This is due to the difference in the effectiveness of radiation as a treatment method.

Seminomas are characterised by high radiosensitivity. In contrast, irradiation is not very effective in non-seminomatous tumours.

The most rare are medullary cord tumours, Leydig and Sertoli cell tumours and others. Leydig cells produce testosterone. Sertoli cells are essential for spermatogenesis, i.e. sperm production and nutrition of maturing sperm.

The cause of these tumours is still unknown.

Only some risk factors that may promote the development of testicular tumours are known.

These tumours arise at a very young age. Some risk factors may therefore already be present in the intrauterine period, i.e. during pregnancy.

The most serious influencing factor is a disorder of the pregnant mother's sex hormones.

Another significant risk factor for testicular cancer, but after the boy is born, is testicular non-descent (i.e. retentio testis or cryptorchidism).

Cryptorchidism (retentio testis) is the name given to a testicle that does not descend into the scrotum. It is a relatively common developmental defect affecting boys. With testicular retention, one side (or even both sides) of the scrotum is actually empty.

Approximately 5% of premature newborns are affected by cryptorchidism. After the first year of life, this number drops to just 1%.

This is because by the 6th month, the testicles spontaneously descend in almost all babies. After this period, testicular retention is very rare, but if it occurs, it should be cured by 18 months.

Treatment of cryptorchidism is twofold. If the testis can be palpated, an orchidopexy is performed via the groin. If the testis is not palpable, a diagnostic laparoscopy is necessary to "localize" the testis.

Depending on the type of testicular location, surgical treatment is then proceeded with.

Other risk factors for testicular cancer include:

• genetic influences, family history of cancer
• inguinal hernia
• overcoming orchitis, i.e. inflammation of the testicles, e.g. mumps
• trauma to the genital area
• history of testicular cancer in the testicular region or on the secondary testicle

A malignant testicular tumour rarely causes pain. Because the testicle is covered only by the skin of the scrotum, the tumour may soon be palpable to the touch.

Regular self-examination of the testicles is therefore a very important step in preventing late stages of this malignant disease and its metastasis to surrounding organs.

The first sign of a tumour is a palpable, firm to the touch and enlarging content in the scrotum. It may have a bumpy or smooth surface. A firm nodule in the scrotum is not painful.

A malignant tumour of the testicle rarely causes pain. If pain does occur, it is usually localised in the lower abdomen. It may be caused by pulling on a heavier testicle.

If the tumour causes pain in the scrotum, in most cases the pain is dull. Rarely, sharp and sharp pain may occur, for example, due to bleeding into the tumour.

Another symptom of a tumour of the male sex gland is loss of libido (i.e. loss of desire for sexual intercourse) and infertility.

A particular symptom of testicular cancer may also be gynecomastia, an enlargement of the male breast glands. This symptom may occur even before the testicular tumour itself is detected.

Testicular tumors metastasize early. Therefore, it is common for symptoms of metastasis to be among the first signs of the disease. The first metastases appear in nearby lymph nodes. Enlarged and hardened nodes may be palpable in the groin.

Nonspecific pain may be caused by metastatic nodes in the abdomen, kidneys and sacrum.

The first metastases to distant organs spread haematogenously (i.e. by blood), most commonly to the lungs.

Symptoms caused by metastases in the lungs include:

• cough
• difficulty breathing
• intolerance to physical exertion
• excessive fatigue
• unexplained rapid weight loss

In addition to the lungs, bones, brain, liver, kidneys, adrenal glands, muscles, spleen, prostate, heart and even the eye can be affected by metastases.

The basis of the diagnosis is the examination of the scrotum by palpation.

It is performed by gentle palpation with the fingers of both hands in both lying and standing patients. Both sides of the scrotum are examined, i.e. both testicles separately.

In the scrotum, the testicles are located anteriorly. The epididymis, which is softer to the touch, is located behind the testicles. The glands can be gently pushed apart with the thumb and examined individually.

Ultrasound (USG) of the scrotum is a reliable and accessible imaging test. The advantage is the easy accessibility of the scrotum and the position of the testicles close to the surface, just under the skin. In addition, ultrasound does not burden the sensitive glands with radioactive radiation.

Testicular tumours are easy to see. Seminoma are hypoechoic (darker than the surrounding tissue) compared to healthy tissue, well and sharply demarcated from the surrounding area.

Non-seminomatous tumours may be hypoechoic but also hyperechogenic. This indicates a teratoma component of the tumour (teratoma - a tumour made of cells from other tissues, e.g. teeth, hair, nails).

In the diagnosis of lung metastases, the gold standard is the conventional chest X-ray, which shows well the metastasis of a seminoma. The most sensitive examination for non-seminoma metastases is the CT scan of the lung, which reveals even small metastases.

In addition to the lungs, bone metastases or metastatic lymph nodes enlarged over 15 mm are also visible on CT.

MRI of the brain is the best imaging method to detect brain metastases and MRI of the orbit can be beneficial if the eye is affected.

Testicular cancer affects young men. Although it is a rare disease, it can have a rapid course and early progression to advanced stages.

It is not uncommon for metastases to already be present in nearby lymph nodes at the time of diagnosis. In worse cases, metastases may also be present in distant organs such as the lungs, liver or brain.

Thanks to modern treatment options such as radiation or effective chemotherapy, this cancer has a relatively good prognosis if diagnosed early.

If the disease is diagnosed in the last stage IV (i.e. distant metastases) and salvage chemotherapy is started, up to ¼ of patients have a chance of cure and remission.

If the disease returns, up to 30% of men are successfully cured.

Prevention

Testicular cancer is a disease of young age. It affects healthy men in their productive years and significantly interferes with a young man's full life.

The first step in the prevention of this disease is to take care of the correct anatomical position of the testicles already in pre-pubertal age and not to wait for the descent of the testicles until puberty.

If the testicle does not descend even by puberty, it is necessary to undergo orchiectomy.

The second, equally important step is to instruct young men in the proper and regular self-examination of the testicles.

Education is also important on the part of outpatient paediatricians, who should perform testicular examinations regularly and on all male patients over 15 years of age.

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