Testicular Cancer Treatment Information

TESTICULAR CANCER TREATMENT INFORMATION

What Do the Testicles Do?

The testicles are the paired organs of male fertility (“gonads”) suspended in the loose scrotal sac. The testicles provide the hormonal signals for maleness, and begin to generate sperm (“spermatozoa”) after puberty. A hormone is a chemical substance produced in one area of the body that has its effects in a different area-- thus it is a “chemical messenger”. Specifically, the testicles produce “androgens” which are male hormones. The best known androgen is testosterone. Male hormones are even produced in the womb (by other glandular tissue); they signal the “Y” sex chromosome to activate and develop the penis and testicles. Androgens circulate in the bloodstream to all of the other tissues of the body, to tell them about the male sex. Thus, in the growing male the breasts stay small, the voice deepens, facial hair becomes coarse, the upper torso enlarges, and the red blood cell count is higher.

The testicles are best known for producing sperm, the male seed (“gamete”) which they do from puberty through old age. Although the amount of sperm decreases as a man ages, males can produce an unlimited number of sperm over their lifetimes. This is in contrast to females, who’s number of eggs (“ova” or female “gametes”) are predetermined by the time of birth. Each sperm contains one-half of the total genetic information needed to produce a new human being; the other necessary one-half of the genetic information is found in the female egg (“ovum”). The formation of gametes utilizes a unique form of division found only in the testicles and ovaries, called “meiosis.” This process uses “reduction divisions” to halve the parent genetic material. After all, if each parent gave their full amount of genetic material, we would have twice as much as necessary to build a new human. Meiosis contrasts with the much more common process of “mitosis”, which keeps the same amount of genetic material in every cell produced. The other non-gamete body (“somatic”) cells and all cancer cells divide by mitosis. When a viable sperm and egg meet, the process of fertilization occurs resulting in a “zygote.” The zygote cells divide into increasingly specialized (“differentiated”) cells to form the embryo, then fetus, infant, and ultimately viable adult human. Interestingly, each sperm or egg produced can have a unique content of genetic material, since the process of “halving” the parent’s genetic code is random (the genes are “re-assorted” differently into each sperm or egg cell). This explains why siblings have different genetic makeup (“genotype”) and appearance (“phenotype”). Only identical twins, resulting from one zygote splitting (“mitosing”) into two exactly identical zygotes, have the precise same genotype.

The paired testicles are each one and one-half to two inches in length in the adult male, and inch in breadth, and an inch in depth. The left testicle is usually slightly larger, they weigh about one and one-half onces apiece. The testicles are also called “testes” for short, they are contained within the scrotum which protects them and keeps them at the proper temperature. The “cremasteric” muscle controls how closely the testes are held to the body are from which they dangle, called the “perineum”. The perineum is the area between the anus and the base of the penis. Sperm are best produced at a temperature slightly below the normal body temperature of 98.6 degrees F. (38C.). When sensing cold, the testicles are drawn up toward the body and held snug by the cremasteric muscle; which relaxes as the testicles warm up. Immature sperm are produced within the testes by cells called “spermatogonia,” these line the “seminiferous tubules” where sperm start. The newly minted sperm travel through a network called the “rete testes,” and then in the “efferent ducts” exiting each testicle. During this journey, which can take several weeks, the young sperm are maturing. They are then delivered into the “vas deferense” which is a twisted tube taking them out of the scrotum, and eventually sending them to the part of the “urethra” housed within the “prostate gland.” The urethra carries both urine from the bladder and sperm from the testes out through the penis, but not at the same time (owing to control valves). Within the “prostatic portion” of the urethra, sperm are mixed with “prostatic fluid” produced by the “seminal vesicals” atop the prostate gland. This mixing with the high-sugar (fructose) fluid from the prostate gives the sperm their yellowish color and energy when they are “ejaculated” out of the tip of the penis. This energy is crucial to “capacitate” the sperm and enable them to swim up into the woman’s cervix to fertilize an egg resting on her uterine lining. It takes about 70 days to produce new, capacitated sperm ready to fertilize an egg. Spermatogenesis is a complex and elegant process; normally 60 million sperm are found in each ejaculate.

Male hormones are made by different cells within the testes, the “Sertoli-Leydig” cells. These cells also provide support for the inner structures of the seminiferous tubules. When a male child is forming in the womb, and to a small degree afterward, androgens like testosterone are synthesized by the “adrenal glands” atop each kidney. In adult males, about 95% of their androgens are made by the testes and 5% by these adrenal glands. If the testicles are removed (“castration”) prior to a boy reaching puberty, he will be a “eunich”. Besides for being unable to father children (“infertile”), a eunich will have more body fat, a higher pitched voice, larger breasts, and less facial hair. However, when castration occurs after puberty, most of these “secondary sexual characteristics” of maleness will stay intact-- although he will be infertile, he won’t become a eunich. Recall that some young boys used to be castrated in earlier cultures to either guard the King’s harem or keep their pre-pubescent singing voices.

The testicles are formed in a pre-born baby boy’s abdomen. They “migrate” down through a special canal (“inguinal canal”) into the scrotum shortly before or after birth. If they fail to “descend”, and remain in the abdomen or trapped in the canal, they stay too warm and will wither over time. This is called “cryptorchidism”. Nowadays, young boys with undescended testicles will have them surgically brought down into their proper home in the scrotum. Normally the inguinal canal seals up after the testicles descend. An “inguinal hernia” is when the canal fails to close and tissue from the abdomen (such as intestine) improperly gets caught in it (“incarcerated”). Hernias can be fixed with no danger to the normal testicle(s).

The blood supply to the testes is via the “gonadal arteries” which come from the body’s main artery, the aorta. These gonadal arteries form smaller arteries which nourish the spermatic cord, and ultimately the substance of the testicles. Other smaller arteries from the pelvic circulation “collateralize” with the gonadal arteries to provide more bloodflow. The scrotal sac gets blood from the deep pelvic arteries (“pudic artery”), not from the gonadal. However, all of the arteries suppying the area can be traced back to the aorta. Blood returning to the heart from the testes drains back to the main low body vein, the “vena cava.” The pattern of circulation is important in tracing the spread of infections or cancers from the testicles.

The lymphatic drainage means the way that the tissue fluid which bathes the cells manages to return to the bloodstream. The lymph fluid is the liquid portion of the blood which migrates through the delicate walls of the smallest blood vessels (“capillaries”) and bathes individual body cells with food and oxygen. It drains into special one-way channels called “lymph channels”, and ultimately to pea-sized glands called “lymph nodes”. These nodes help purify the lymph fluid, filtering out infectious agents and cancer cells. Lymph nodes are normally filled with White Blood Cells and are a crucial part of the “immune system”. Other immune system cells are found within the testicle tissue itself. When foreign cells become trapped in lymph nodes, they react and swell. This is called “lymphadenopathy”, and is said to exist when lymph nodes become larger than about 1 cm. (1/2 inch) across. There are groups of local and regional lymph nodes to which body fluids drain. If this system gets clogged up, involved limbs or the scrotum may swell (“edema”). Ultimately the purified lymph fluid is collected from groups of lymph nodes and sent back to the heart, to rejoin the circulating blood. The drainage of the testes is along the “aortic lymph nodes”-- these are called the “para-aortic chain”. The lymphatic drainage of the scrotal tissues is into the “inguinal nodes” in each groin. Again, the lymph system can act as either a barrier or a conduit of spread for infections, cancer, or both.

The nerve supply to the testes is from the “sympathetic chain” along the thoracic spine, this is joined by filaments from the “parasympathetic pelvic chain” which accompany the artery of the Vas Deferens (Ref. Gray's Anatomy). Both these sympathtetic and parasympathetic inputs are necessary for erection and ejaculation, respectively. The nerves to the scrotal sac are from the large internal pudic nerve. It is important to know that surgeries which cut the above nerves can cause impotence.

What is Testicular Cancer?

As alluded to above, there are several different types of cells within the testicles, and each has a designated function and “life cycle”. If a cancer starts in the testes, the particular type will depend upon the normal cell counterpart it arose from. Since there are different types of cells within the testicles, there are different types of cancers which may arise from them, as will be discussed. Firstly, we must understand that all cell division in the testicles is under tight control of the “genes” within each cell. Testicular cancer, like all cancers, starts in just one cell. When the genes within a particular cell become damaged, that cell may start dividing out of control, and form a clump called a “tumor”. A tumor merely means a swelling, which may be caused by infection, inflammation or anything-- it is not necessarily a cancer. When a tumor grows only within its local area (although it may become very large) it is called “benign”, and is not cancer. However, when a tumor’s cells have the capacity to spread to other areas of the body, it is called “malignant”, and it is cancer. When a cancer spreads, it is called “metastasis”. At first, the spread is just individual cells too small to be seen, that is called “micrometastasis” or “seeding”. Eventually, those “seeds” may get trapped in distant body areas (e.g. lungs, liver, lymph nodes, bone, brain) and grow into large tumors there. Thus, all tumors that can develop a metastasis are malignant, and all those that cannot are benign. As a cancer grows in its local area, its chances for spread increase. It is the quality of spread for malignant tumors that makes uncontrolled cancer so dangerous.

How Common is Testicular Cancer?

There are about 6000 new cases of testicular cancer each year in the U.S.A., which causes perhaps 400 deaths. Dramatic improvement in survival rates in the past three decades have greatly reduced the numer of men dying of it. In fact, survival has increased from just 10% five decades ago to over 90% today for most subtypes. About 3 in 100,000 men per year develop testicular cancer, and it is the most common cancer in young men between the ages of 15 and 35 years old. Overall, an average man has a 0.1% lifetime risk for testicular cancer, and this risk has actually doubled over the past 50 years. Still, however, testicular cancer represents less than 1% of all new cancers each year. About 3% of patients have “bilateral” disease, that is in both testicles. These cancers may occur at the same time (“simultaneously”) or at successive times (“metachronously”). White males get testicular cancer 6 times as commonly as African-American or Asian males. While young men predominantly get “germ cell tumors” derived from sperm, men over age 60 tend to get a completely different type of cancer, called lymphoma, arising from immune cells. In young boys, acute leukemia (ALL) tends to go to the testicles and swell them, but the treatment for this follows that of the primary disease. Only a cancer which actually starts in the testicles is called “primary testicular cancer”. A cancer spreading to them from some other area (this is rare) is NOT considered testicular cancer, but is named according to the originating area. Again, the risk of testicular cancer has been steadily rising over the past 5 decades; some possible reasons are outlined below.

The testicles control male development in the youth, and generate sperm after puberty. Furthermore, they continue to produce testosterone, the essential male hormone, throughout life. Testicular cancer is most common in early adulthood, and usually first gets noticed as a lump in the scrotum. In fact, men are advised to check their testicles monthly for any new lumps or bumps, and show them promptly to a doctor if discovered.

It is critical to get proper diagnosis and treatment for a testicular cancer problem. This can literally make the difference between life and death. While great advances have been made in treating most testicular cancers, and the success rate is high, some varieties are highly aggressive and quickly fatal without expert management and follow-up. Understanding your options will give you the peace-of- mind knowing that you have done everything possible for a successful outcome for yourself or a loved one.

CancerAnswers's material explains, in plain English, the definition, types, frequency, evaluations, historical and latest effective treatments for testicular cancer. We describe surgery, radiation, and chemotherapy along with their results and side-effects. We tell you everything you need to know to help make the right choices today for a testicular cancer problem.

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