Swedish and Norwegian Testicular Cancer Group
About testicular cancer
Testicular cancer (TC) is the most common cancer in Norwegian and Swedish adolescents and men between the age of 15 and 49 years. Approximately 600 new cases of testicular cancer are diagnosed each year in Norway and Sweden. The incidence of TC varies greatly geographically and Norway has, alongside with Denmark, the highest incidence of testicular cancer in the world. Approximately 1% of Norwegian males are expected to be diagnosed with testicular cancer by the age of 75. The incidence in Sweden is about half that of Norway´s.
Prior to modern chemotherapy treatment TC was a highly deadly disease and as recent as in the 1960s it was the most frequent single cause of death in young males in Scandinavia. However, with increasing knowledge of the disease and specifically with the introduction of the chemotherapeutic drug cisplatin in the late 1970s the cure rate has greatly improved, and today more than 95 % of all patients diagnosed with testicular cancer are cured.
Today´s TC patients have a nearly normal life expectancy despite their cancer diagnosis and therefore the focus of further development within TC treatment lies on minimizing long term effects of the disease with maintained high cure rates. We know that both intense chemotherapy as well as radiotherapy and surgery is associated with long term consequences such as a risk of reduced fertility and a mildly increased risk of cardiovascular disease and of getting a second cancer later in life.
In 95% of cases, tumors of the testes originate from the germ cell. A small proportion develops from stromal cells such as the Sertoli cell or the Leydig cell.
Testicular germ-cell cancers are usually divided into seminomas or non-seminomas. Seminomas are defined by a pure seminoma histopathology and a normal level of alpha-fetoprotein (AFP). All other germ-cell cancers are defined as non-seminomas. This includes choriocarcinomas, embryonal carcinomas, yolk sac tumors, teratomas and mixed tumors. AFP is a so called tumor marker and is thus only elevated in non-seminomas. A second tumor marker is β-HCG which can be elevated in both seminomas and non-seminomas. We use the tumor markers for diagnostics, for treatment evaluation and also to detect possible disease relapses.
Seminomas are slightly more common than non-seminomas, and typically occur a little later in life. Both seminomas and non-seminomas have excellent prognosis, non- seminomas have a higher tendency to metastasize and will therefore more often require more intense treatment, both chemotherapy and surgery.
The most common symptom of TC is a palpable testicular tumor, sometimes together with scrotal pain. Initial management of the disease includes an ultrasound of the testicles indicating a testicular tumor, followed by an orchiectomy, i.e. surgical removal of the tumor-bearing testicle. Often a biopsy (a tissue sample) of the other testicle is taken to rule out signs of pre-cancer, cancer in situ, of the healthy testicle. A CT scan of the chest and abdomen and blood testing, including tumor markers is also done in order to stage the disease. All patients should be offered to save sperm in a sperm bank, ideally before the surgery is done, otherwise prior to further treatment, such as chemotherapy.
Further management will depend on the histopathological diagnosis, i.e. seminoma vs non- seminoma and whether the disease has spread or is localized to the testis only. A CT scan will reveal disseminated disease, typically to the lymph nodes in the abdomen (retroperitoneum) and/or to the lungs, and less often to other organs including the liver, the bone and the brain. Sometimes tumor markers remain elevated despite a normal CT scan, and if so the disease is considered to be disseminated.
In case of stage I disease, disease limited to the removed testicle only, we sometimes recommend so called adjuvant chemotherapy treatment. Such treatment aims at reducing the risk of a disease recurrence, and typically consists of one cycle of chemotherapy.
Even if the CT scan shows metastatic disease or if the tumor markers remain elevated the prognosis remains very good. Typically treatment will include at least 3 cycles of chemotherapy. Sometimes, typically in case of non-seminomas, further surgery after chemotherapy is needed. In rare cases the disease is even more advanced and if so more intense chemotherapy, more extensive surgery and sometimes radiotherapy might be warranted.
When treatment is finished we always have regular check-ups, including blood sampling, body imaging and doctor´s visits for up to 5-10 years post treatment. The check-ups are needed primarily to detect a possible relapse as early as possible, but also to follow-up on potential side effects of the treatment given.