Testicular Cancer in Children
Testicular tumors are thankfully rare in children, are highly treatable and usually curable. But would you know how to recognize this condition? The following information should help you spot this tumor long before it becomes a life-threatening issue.
What happens under normal conditions?
The testicles (also called the testes; a single testicle is also called a testis) are part of the male reproductive system. These two golf ball–sized organs are usually contained within a sac of skin called the scrotum, which hangs beneath the penis. However, up to three percent of all full-term male children may be born with undescended testicles (cryptorchidism).
The testicles manufacture the male hormones. With the most abundant hormone being testosterone which maintains the sex drive or libido in men and stimulates the development of male characteristics. The testicles also produce sperm, the male reproductive cell, which travel through a rich network of tube-like structures to the epididymis. Sperm cells are then carried from the testicles by the vas deferens to the seminal vesicles where they are mixed with fluid produced by the prostate gland. During ejaculation, sperm cells, seminal vesicle fluid and prostate fluid enter the urethra, the tube in the center of the penis through which both urine and seminal fluid exit the body.
What is testicular cancer?
Cancer of the testicle (also called the testis), a rare kind of cancer in men, is a disease in which malignant cells are found in the tissues of one or both testicles.
What is the incidence rate?
There are two peak ages for testicular tumors. Germ cell tumors may occur in early boyhood or in adolescence. Prior to puberty, boys rarely develop tumors of the testicles. The likelihood of a boy developing a testicular tumor is approximately 1 in 100,000. In infants and boys, testicular tumors account for approximately 1 to 2 percent of all tumors. On the other hand, testicular cancer is the most common malignancy occurring in men from the ages of 15 to 35.
What are the risk factors?
Prior to puberty, few risk factors have been identified. One risk factor in early boyhood is the presence of an intersex disorder. This complex group of children with ambiguous genitalia and other sexual abnormalities may have an abnormal testicle that puts them at risk for tumors known as gonadoblastomas and dysgerminomas.
In older boys, a previous history of undescended testis (usually detected and treated in boyhood) is associated with a higher risk of developing a testicular cancer. For this reason, it is recommended that boys with history of undescended testicles perform a testicular exam monthly.
Testicular cancer affects younger men, particularly those between the ages of 15 and 35. It is also more common in white men than in black men.
What are the symptoms?
A painless lump in the testicles is the most common symptom of a testicular tumor. Other symptoms may include a feeling of heaviness in the scrotum, a dull ache in the groin and pain or discomfort in the testicle or scrotum. An urologist should immediately be consulted especially if symptoms persist for more than two weeks. The examining urologist must rule out other disorders affecting the testis such as epididymitis, testicular torsion, inguinal hernia or hydrocele. In 10 percent of all cases, testicular tumors may be associated with hydroceles, an abnormal fluid collection within the scrotum.
How are testicular tumors diagnosed?
Careful physical examination may reveal a firm lump within the testicles. A sonogram of the scrotum should be obtained to distinguish between tumors involving the testicles and those affecting surrounding structures. However, if there is suspicion of an abnormality, even a normal physical exam or sonogram does not rule out that a tumor exists. The only sure way to confirm that the swelling is cancer is for a surgeon to examine the testicle during an operation. During the surgery the surgeon can usually see whether the lump is a cancer or not. Sometime a small piece of tissue is removed and immediately examined under a microscope by a pathologist (this is known as a biopsy). If the biopsy shows that the lump is a cancer then the testicle will be removed (this operation is known as orchiectomy). More extensive evaluation with CT scan or magnetic resonance imaging (MRI) is not recommended until after surgery and when the actual diagnosis of the tumor is complete.
Specific blood tests to identify tumor markers are often obtained when there is suspicion of a testicular tumor. Elevated blood levels of the markers alpha-fetoprotein (AFP), and less commonly beta-human chorionic gonadotropin (HCG), heighten clinical suspicion of the presence of specific malignant testicular tumors. Your urologist may use pre-operative levels of these tumor markers as a standard by which to compare treatment results following surgery.
What are the stages of testicular cancer?
- Stage 1: Cancer is found only in the testicle (testis).
- Stage 2: Cancer has spread to the lymph nodes in the abdomen
- Stage 3: Cancer has spread beyond the lymph nodes in the abdomen. There may be cancer in parts of the body far away from the testicles, such as the lungs and liver.
What are the different types of testicular tumors?
The most common tumors of the testicles in prepubescent males are yolk sac tumors and teratomas. Together, these two tumor types make up approximately 80 percent of all testicular tumors seen in young boys.
Yolk sac tumor: This tumor is the most common form of testicular cancer in infants and young boys and it resembles the yolk sac of an early human embryo. When they occur in young children, these tumors are usually treated successfully. However, when they develop in adults they are more dangerous.
Teratoma: Under the microscope, these germ cell tumors resemble each of the three layers of a developing embryo. They are indeed the most common benign tumors of the testicles. Most children show symptoms by 14 months of age.
Gonadal stromal tumors (sertoli cell tumor, leydig cell tumor and juvenile granulosa cell tumor): Together, these rare tumors make up 8 percent of all documented testicular tumors on the Prepubertal Testis Tumor Registry. Older children have a slightly higher chance of developing metastatic disease and should undergo careful and thorough examination including a CT scan and chest X-ray.
Gonadoblastoma and Dysgerminoma: These are rare tumors occurring most commonly in children with intersex disorders. The tumor develops in those children with testicles that have failed to develop normally. Gonadoblastomas are benign tumors but they can progress to the malignant dysgerminoma in 50 percent of cases. Most cases show symptoms after puberty.
What are some treatment options?
A surgical procedure known as an inguinal exploration with total orchiectomy (surgical removal of the testis) or, in some select cases, testis-sparing surgery is recommended for any child with a testicular tumor. This procedure, usually performed on an outpatient basis, is useful as a diagnostic and potentially curative procedure. An inguinal cut (on the skin crease just above the child's pubic bone) is made through which the testicle is guided out of the scrotum and exposed.
If the surgeon suspects the tumor is benign based on the intra-operative appearance, normal tumor markers and ultra sonography, then testicle-sparing surgery may be considered for young boys. The surgically removed tumor tissue is sent for rapid pathological analysis known as a frozen section. If there is suspicion of malignancy based on a frozen section, elevated tumor markers, extensive tumor on ultra sonography or a testis tumor in a post-pubertal child, then a total orchiectomy is necessary.
Further treatment including a retroperitoneal lymph node dissection, radiation therapy or chemotherapy is sometimes required. Recommendations as to the role of these treatments are contingent on the final pathological analysis of the tumor and on the evidence of spread of the tumor based on radiological studies that may be required depending on the tumor cell type
What can I expect after treatment?
A pathologist will carefully examine the removed tumor following surgery.
Frequently asked questions:
What will become of my son's remaining testicle after removal of the affected one?
The remaining testicle will not be adversely affected by surgery to remove a diseased testis. It may increase in size as a compensatory response. However, your son should be cautioned to report the presence of abnormalities noted on the routine monthly self-examination to his pediatrician or to his urologist.
Will my son still be able to have children in the future?
Long-term data on patients that have undergone a childhood orchiectomy for a testicular tumor is unclear at this time. It is generally agreed, however, that normal sperm production occurs in the remaining testis following puberty. Furthermore, the advent of revolutionary assisted reproductive techniques makes paternity a real possibility even for the most subfertile men today.
What will my son look like after the procedure? Will he be noticeably different from other boys?
Usually boys do not appear noticeably different following an orchiectomy because the scrotum is not incised and the remaining testis grows in size. If a child is uncomfortable with the cosmetic result, a prosthesis may be easily placed into the scrotum. This is most commonly done after puberty.
How long will it take for my son to recover physically after the inguinal orchiectomy?
The procedure is performed on an outpatient basis and most children return home on the same day following surgery. He should avoid contact sports for at least two weeks, but should be able to return to school within one week.
What type of follow-up is required after orchiectomy for the malignant yolk sac tumor?
Patients that undergo an orchiectomy for a yolk sac tumor without evidence of metastatic disease and a normal post-operative AFP level must be closely followed for at least two years. Various follow-up protocols exist. A sample protocol would consist of a physical exam with chest X-ray with serum AFP level every six weeks and a CT scan of the abdomen and pelvis every three months for two years.
What are the chances that the cancer will develop in the other testicle?
The Society of Pediatric Urology Prepubertal Tumor Registry registered 307 patients with testicular tumors. No new tumors in the remaining normal testis have been reported thus far. A 2 to 3 percent incidence rate of a bilateral tumor occurring simultaneously or successively is reported in the adult testis tumor experience.
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Reviewed January 2011
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