Treatment

Chemotherapy, radiotherapy and surgery are the threemain treatments for testicular cancer.

Your recommended treatment plan will depend on:

• the Testicular cancer whether it's aseminoma or a non-seminoma
• the stageof your testicular cancer

The first treatment option for all cases of testicular cancer, whatever the stage, is to surgically remove the affected testicle (an orchidectomy).

For stage one seminomas, after the testicle has been removed, a single dose of chemotherapy may be given to help prevent the cancer returning. A short course of radiotherapy is also sometimes recommended.

However, in many cases, the chance of recurrence is low and your doctors may recommend that you're very carefully monitored over the next few years. Further treatment is usually only needed for the small number of people who have a recurrence.

Forstage one non-seminomas, close follow-up (called surveillance) may also be recommended, or a short course of chemotherapy using a combination of different medications.

For stage two, three and four testicular cancers, three to four cycles of chemotherapy are given using a combination of different medications. Further surgery is sometimes needed after chemotherapy to remove any affected lymph nodes or deposits in the lungs or, rarely, in the liver.

Some people with stage two seminomas may be suitable for less intense treatment with radiotherapy, sometimes with the addition of a simpler form ofchemotherapy.

In non-seminoma germ cell tumours, additional surgery may also be required after chemotherapy to remove tumours from other parts of the body, depending on the extent of the spread of the tumour.

Deciding what treatment is best for you can be difficult. Your cancer team will make recommendations, but the final decision will be yours.

Before discussing your treatment options with yourspecialist,you may find it useful to write a list of questions to ask them. For example, you may want to find out the advantages and disadvantages of particular treatments.

Orchidectomy

An orchidectomy is a surgical procedure to remove a testicle. If you have testicular cancer, the whole of the affected testicle will need to be removed because only removing the tumour may lead to the cancer spreading.

By removing the entire testicle, your chances of making a full recovery are greatly improved.Your sex life andability to father children won't be affected.

Aboutone in 50 people will get a second new testicular cancer in their remaining testicle. In such circumstances, it'ssometimes possible to only remove the part of the testicle containing the tumour. You should ask your surgeon about this if you're in this position.

If testicular cancer is detected in its very early stages, an orchidectomy may be the only treatment you require.

An orchidectomy isn't carried out through the scrotum. It's done by making an incision in your groin through which the testicle isremoved with all of the tubes and blood vessels attached to the testicle that pass through the groin into the abdomen. The operation is carried out under general anaesthetic .

You can have an artificial (prosthetic) testicle inserted into your scrotum so that the appearance of your testicles isn't greatly affected. The artificial testicle is usually made of silicone (a soft type of plastic).It probably won't be exactly like your old testicle or the one you still have. It may be slightly different in size or texture.

Afteran orchidectomy, it's often possible to be discharged quickly, although you may need to stay in hospital for a few days. If only one testicle is removed, there shouldn't be any lasting side effects.

If both testicles are removed (a bi-lateral orchidectomy), you'll be infertile. However, removing both testicles at the same time is very rarely required, and only one in every 50 cases require the other testicle to be removed at a later date.

You may be able to bank your sperm before having a bi-lateral orchidectomy to allow you to father children if you decide to.

Sperm banking

Most people are still fertile after having one testicle removed. However, some treatments for testicular cancer can cause infertility .

Some people with testicular cancer may have low sperm counts because of changes that occur in the testicles before the cancer develops.

For some treatments, such as chemotherapy, infertility may occur, but standard chemotherapies have a less than 50% chance of causing infertility if the remaining testicle is normal.

In people who need to have post-chemotherapy removal of lumps at the back of the abdomen, known as retroperitoneal lymph node dissection (RPLND) (see below), the ability to ejaculate (eject sperm from the penis) may be affected, even though the remaining testicle can still produce sperm.

Before your treatment begins, you may want to consider sperm banking. This is where a sample of your sperm is frozen so that it can be used at a later date to impregnate your partner during artificial insemination . Before sperm banking, you may be asked to have tests for HIV , hepatitis B and hepatitis C .

If you're having complex chemotherapy for stage two to fourtesticular cancer, you should always be offered sperm banking. Ask if you're concerned about your fertility.

Not all men are suitable for sperm banking. For the technique to work, the sperm has to be of a reasonably high quality. There may also be situations where it's considered too dangerous to delay treatment for sperm banking to take place.

MostNHS cancer treatment centres offer a free sperm banking service. However, it's up to each area of the country to decide whether they store sperm for free of whether you have to pay.

Cancer Research UK has more information about sperm banking , including the cost of sperm storage.

Testosterone replacement therapy

If you still have a remaining testicle, in most cases (90%)your body will make enough testosterone so you won't notice any difference.

If there are any problems with your remaining testicle, you may experience symptoms due to a lack of testosterone. These symptoms can be caused for other reasons but can include:

• tiredness
• weight gain
• loss of libido (sex drive)
• reduced beard growth
• reduced ability to achieve or maintain an erection ( erectile dysfunction )

Having both testicles removed will definitely stop you producing testosterone and you'll develop the above symptoms.

Testosterone replacement therapy is where you're given testosterone in the form of an injection, skin patch or gel to rub into your skin. If you have injections, you'll usually need to have them every two to three months.

After having testosterone replacement therapy, you'll be able to maintain an erection and your sex drive will improve.

Side effects associated with this type of treatment are uncommon, and any side effects that you do experience will usually be mild. They may include:

• oily skin, which can sometimes trigger the onset of acne
• breast enlargement and swelling
• a change innormal urinary patterns, such as needing to urinate more frequently or having problems passing urine (caused by an enlarged prostate gland that puts pressure on your bladder)

There are also concerns that testosterone replacement may increase the risk of prostate cancer and you should discuss this with your doctor.

However, the risks from having testosterone replacement are usually much lower than the benefits of receiving it.

Lymph node and lung surgery

More advanced cases of testicular cancer may spread to your lymph nodes. Lymph nodes are part of your body's immune system, which helps protect against illness and infection.

Lymph node surgery is carried out under general anaesthetic. The lymph nodes in your abdomen are the nodes most likely to need removing.

In some cases, the nerves near the lymph nodes can become damaged, which means that rather than ejaculating semen out of your penis during sex or masturbation, the semen instead travels back into your bladder. This is known as retrograde ejaculation .

If you have retrograde ejaculation, you'll still experience the sensation of having an orgasm during ejaculation, but you won't be able to father a child.

There are a number of ways of treating retrograde ejaculation, including the use of medicines that strengthen the muscles around the neck of the bladder to prevent the flow of semen into the bladder.

Men who want to have children can have sperm taken from their urine for use in artificial insemination or in-vitro fertilisation (IVF) .

There are also a number ofnewer surgical techniques that carry a lower risk of retrograde ejaculation and infertility. These are described below.

Some people with testicular cancer have deposits of cancer in their lungs and these may also need to be removed after chemotherapy if they haven't disappeared or reduced sufficiently in size. This type of surgery is also carried out under general anaesthetic and doesn't usually significantly affect breathing in the long-term

Nerve-sparing retroperitoneal lymph node dissection

A newer type of lymph node surgery, called nerve sparing retroperitoneal lymph node dissection (RPLND), is increasingly being used because it carries a lower risk of causing retrograde ejaculation and infertility.

In nerve-sparing RPLND, the site of the operation is limited to a much smaller area. This means there's less chance of nerve damage occurring. The disadvantage is that the surgery is more technically demanding. Therefore, nerve-sparing RPLND is currently only available at specialist centres that employ surgeons with the required training.

Laparoscopic retroperitoneal lymph node dissection

Laparoscopic retroperitoneal lymph node dissection (LRPLND) is a type of "keyhole" surgery that can be used to remove the lymph nodes. During LRPLND, the surgeon will make a number of small incisions in your abdomen.

An instrument called an endoscope is inserted into one of the incisions. An endoscope is a thin, long, flexible tube with a light and a camera at one end, enabling images of the inside of your body to be relayed to an external television monitor.

Small, surgical instruments are passed down the endoscope and can be used to remove the affected lymph nodes.

The advantage of LRPLND is that there's less post-operative pain and a quicker recovery time. Also, as with nerve-sparing RPLND, in LRPLND there's a smaller chance that nerve damage will lead to retrograde ejaculation.

However, as LRPLND is a new technique, there's little available evidence regarding the procedure's long-term safety and effectiveness. If you're consideringLRPLND, you should understand there are still uncertainties about the safety and effectiveness ofthe procedure.

Radiotherapy

Radiotherapy uses high-energy beams of radiation to help destroy cancer cells. Sometimes, seminomas may require radiotherapy after surgery to help prevent the cancer returning.

It may also be needed in advanced cases where someone is unable to tolerate the complex chemotherapies that are usually used to treat stage two, three and four testicular cancer.

If testicular cancer has spread to your lymph nodes, you may require radiotherapy after a course of chemotherapy.

Side effects of radiotherapy can include:

• reddening and soreness of the skin, which is similar to sunburn
• nausea
• diarrhoea
• fatigue

These side effects are usually only temporary and should improve when your treatment is completed.

Chemotherapy

Chemotherapy uses powerful medicines to kill the malignant (cancerous) cells in your body or stop them multiplying.

You may require chemotherapy ifyou have advanced testicular cancer or it's spread within your body. It's also used to help prevent the cancer returning. Chemotherapy is commonly used to treat seminomas and non-seminoma tumours.

Chemotherapy medicines for testicular cancer are usually injected into a vein. In some cases, a special tube called a central line is used, which stays in a vein throughout your treatment so that you don't have to keep having blood tests or needles placed in a new vein.

Sometimes, chemotherapy medicines can attack your body's normal, healthy cells. This is why chemotherapy can have many different side effects. The most commoninclude:

• vomiting
• hair loss
• nausea
• sore mouth and mouth ulcers
• loss of appetite
• fatigue
• breathlessness and lung damage
• infertility
• ringing in your ears ( tinnitus )
• skin that bleeds or bruises easily
• low blood counts
• increased vulnerability to infection
• numbness and tingling ( pins and needles ) in your hands and feet
• kidney damage

These side effects are usually only temporary and should improve after you've completed your treatment.

Side effects, such as infections that occur when you have a low blood count, can be life-threatening, and it's essential that you always call your cancer care team if you're worried between chemotherapy treatments.

Bleomycin

One of the medicines commonly used, called bleomycin, can cause long-term lung damage and you should discuss this with your doctors if damage to your lungs would have specific issues for your career or lifestyle. However, the advice may still be that you should receive it for the best chance of a cure.

Having children

You shouldn't father children while having chemotherapy and for a year after your treatment has finished. This is because chemotherapy medications can temporarily damage your sperm, increasing your risk of fathering a baby with serious birth defects. Therefore, you'll need to use a reliable method of contraception , such as a condom , during this time.

Condoms should also be used during the first 48 hours after having a course of chemotherapy. This is to protect your partner from any potentially harmful effects of the chemotherapy medication in your sperm.

In seminomas, recurrences still occur until three years. Recurrences after three years are rare, occurring in less than 5% of people.

Because of the risk of recurrance, you'll need regular tests to check if the cancer has returned. These include:

• a physical examination
• blood tests to check for tumour markers
• a chest X-ray
• computerised tomography (CT) scan

Follow-up and testing is usually recommended dependingon the extent of the cancer and the treatment offered. This is usually more frequent in the first year or two but follow-up appointments may last for up to five years. In certain cases, it may be necessary to continue follow-up appointments for 10 years or longer.

If the cancer returns following treatment for stage one testicular cancer, and it's diagnosed at an early stage, it will usually be possible to cure it using chemotherapy and possibly also radiotherapy. Some types of recurring testicular cancer have a cure rate of over 95%.

Recurrences that occur after previous combination chemotherapy can also be cured, but the chances of this will vary between individuals and you'll need to ask your doctors to discuss this with you.

Cancer Research UK has more information about follow-up for testicular cancer .

Chemotherapy

Chemotherapy is a treatment of an illness or disease with a chemical substance,such asin the treatment of cancer.

Hormone replacement therapy

Hormone replacement therapy or HRT involves giving hormones to women when the menopause starts, to replace those the body no longer produces.

Lymph nodes

Lymph nodes are small oval tissues that remove unwanted bacteria and particles from the body. They are part of the immune system.

Radiotherapy

Radiation therapy uses X-rays to treat disease, especially cancer.

Testicle

Testicles are the two oval-shaped reproductive organsthat make up part of the male genitals. They produce sperm and sex hormones.

Testosterone

Testosterone is a male sex hormone, which is involved in making sperm and sexual characteristics such as the voice getting deeper. Testosterone is also found in small amounts in women.