**2. Epidemiology**

TC incidence is increasing worldwide, but the reasons for this increase are not fully documented [18]. There were a total of 36,747 cases of TC in the Scandinavian countries from 1960 to 2014 [19]. 9.4 affected individuals per 100,000 males in Denmark had the highest incidence of TC for decades, but while the incidence rate stabilized in Denmark, the rate is now highest, 9.9 affected individuals per 100,000 males in Norway [20, 21]. In the United States, TC is more common in white individuals (6.9 affected individuals per 100,000 males) than in African Americans (1.2 affected individuals per 100,000 males) [18]. TC took first place with 24.8 percent of men in the 15-24 age group in Turkey [22]. An analysis from the International Agency for Research on Cancer indicates age-standardized rates of TC varied from less than 1/100,000 person 14-35 years in Africa and Asia [23]. Worldwide, there are approximately 72,000 cases and 9000 deaths per year attributable to TC [24]. TC death in the United States accounts for approximately 4% of the annual incidence [25]. There is a significant global variability in mortality rates that are largely inverse in incidence rates. TC mortality is highest in low-income countries compared with higher-income countries [20]. Also, in spite of the highest incidences of this disease in Europe, North America and New Zealand account for only one-fifth of mortalities caused by TC [26]. About 50% of patients worldwide with TC are diagnosed with seminoma and the median ages at diagnosis 37 years [27].

### **2.1 Risk factors**

The majority of TC (98%) had germ cell tumors; therefore, the terms testicular germ cell tumor and TC are often used interchangeably [28]. While most cancers occur in adulthood, the incidence of TC does not increase with age. The peak ages of occurrence are 25–29 years for non-seminomas and 35**–**39 years for seminomas [29]. The risk factors for TC are not well understood, but the risk factors most consistently associated with cryptorchidism, contralateral testicular tumor, a family history of TC, male factor ınfertility, and testicular microlithiasis [30–32].

Cryptorchidism, also referred to as maldescended testis, is the failure of descent of one or both of the testes into the scrotum and is a common clinical diagnosis in newborn boys and one of the strongest risk factors for infertility and testicular cancer [33–35]. Approximately 10% of all cases of testicular tumors occur in boys with a history of cryptorchidism [36]. In a study of patients with bilateral germ cell tumor, while 9.5% had cryptorchidism history, cryptorchidism was found in 2.2% of patients with unilateral tumors [37]. In addition, in a cohort study, cryptorchidism repair prior to puberty was associated with a doubling in risk of testicular cancer; postponement of the repair after the age of 12 showed that the risk increased fivefold [38].

TC is associated with a family history link as well [33–35]. Men, who have a firstdegree relative with testicular cancer, have a reasonably increased risk [39]. Patients

**117**

**Table 1.**

*\**

*Testicular Cancer and the Importance of Early Diagnosis DOI: http://dx.doi.org/10.5772/intechopen.89241*

developing a TC [42].

masses [52].

TC [15].

**Infertility**

Intratesticular mass

*Information from Ref. [15].*

Painless swelling and redness

*Signs and symptoms of testicular cancer.*

disruptors), and hormones [45–50].

**3. Diagnosing testicular cancer**

**Discomfort Metastases\***

Acute pain in the testicle or scrotum Gynecomastia Scrotal heaviness Lumbar back pain Mass effect Neck mass

*About 5% of patients with testicular cancer have symptoms of metastases.*

Dull ache in the scrotum or abdomen Gastrointestinal symptoms

with a history of personal testicular cancer have a 12-fold higher risk of developing TC than the general population [40]. Family cancer studies have shown that sons whose fathers have TC have four times the risk of testicular cancer and brothers of patients with TC have eight times the risk of having testicular cancer [41]. Family history of this relationship is white men are more likely than black men to develop TC [15]. In a study with a large population, contralateral testicular cancer explained that a man younger than age of 30 with testicular seminoma has a 3.1% risk of

TC has increased in the last 30 years, while in Western countries there has been a decrease in semen quality and fertility [41]. Men with infertility have an increased risk of TC, with an incidence ratio of 1.6–2.8 [43]. The cohort study, based on more than 22,000 men undergoing evaluation for infertility, examined an association between infertility and the development of testicular cancer [44]. Other risk factors in TC are vasectomy, scrotal trauma, inguinal hernia, diet, smoking, the gene, environment (such as heavy metals exposure and endocrine

TC is often seen as a painless mass in the testis, but in many patients there is a widespread pain, swelling, or stiffness in the scrotum [51]. Testicular masses appear more often on the right side [8]. Acute testicular pain is less widespread and is reasoned by swift expansion of the testis owing to intratumor hemorrhage or infarction caused by swift tumor growth [39]. Men often notice a history of testicular trauma, though accidental trauma is probably liable for leading the testicular mass to the men' s attention, firstly. Men may complain of unclear scrotal pain or heaviness [39]. Testicular masses can be urgently evaluated by physical exam and bilateral testicular ultrasound [6]. Physical examination may be determinative but is sometimes vague in differentiating a malignancy from nonmalignant testicular

The physician should carefully examine the testes, noting their notional size and density and palpating for any testicular masses [39]. Any doubtful symptoms should give rise to adjuvant studies [53]. **Table 1** shows the signs and symptoms of

Firmness of the testicle Respiratory symptoms (e.g., cough, hemoptysis, dyspnea)

*Testicular Cancer and the Importance of Early Diagnosis DOI: http://dx.doi.org/10.5772/intechopen.89241*

*Male Reproductive Health*

**2. Epidemiology**

**2.1 Risk factors**

not shown that they improve outcomes [17].

considerations for adolescent and young adult populations.

examination or because of symptoms [15]. As with breast cancer, early detection of TC is best done through self-examination [16]. Although routine screening and monthly self-examination in young men have been recommended, studies have

This chapter explains the epidemiology, etiology, stages, treatment of TC, and importance of early diagnosis for TC as well as TSE, as far as possible, with special

TC incidence is increasing worldwide, but the reasons for this increase are not fully documented [18]. There were a total of 36,747 cases of TC in the Scandinavian countries from 1960 to 2014 [19]. 9.4 affected individuals per 100,000 males in Denmark had the highest incidence of TC for decades, but while the incidence rate stabilized in Denmark, the rate is now highest, 9.9 affected individuals per 100,000 males in Norway [20, 21]. In the United States, TC is more common in white individuals (6.9 affected individuals per 100,000 males) than in African Americans (1.2 affected individuals per 100,000 males) [18]. TC took first place with 24.8 percent of men in the 15-24 age group in Turkey [22]. An analysis from the International Agency for Research on Cancer indicates age-standardized rates of TC varied from less than 1/100,000 person 14-35 years in Africa and Asia [23]. Worldwide, there are approximately 72,000 cases and 9000 deaths per year attributable to TC [24]. TC death in the United States accounts for approximately 4% of the annual incidence [25]. There is a significant global variability in mortality rates that are largely inverse in incidence rates. TC mortality is highest in low-income countries compared with higher-income countries [20]. Also, in spite of the highest incidences of this disease in Europe, North America and New Zealand account for only one-fifth of mortalities caused by TC [26]. About 50% of patients worldwide with TC are diagnosed with seminoma and the median ages at diagnosis 37 years [27].

The majority of TC (98%) had germ cell tumors; therefore, the terms testicular germ cell tumor and TC are often used interchangeably [28]. While most cancers occur in adulthood, the incidence of TC does not increase with age. The peak ages of occurrence are 25–29 years for non-seminomas and 35**–**39 years for seminomas [29]. The risk factors for TC are not well understood, but the risk factors most consistently associated with cryptorchidism, contralateral testicular tumor, a family

Cryptorchidism, also referred to as maldescended testis, is the failure of descent

TC is associated with a family history link as well [33–35]. Men, who have a firstdegree relative with testicular cancer, have a reasonably increased risk [39]. Patients

history of TC, male factor ınfertility, and testicular microlithiasis [30–32].

of one or both of the testes into the scrotum and is a common clinical diagnosis in newborn boys and one of the strongest risk factors for infertility and testicular cancer [33–35]. Approximately 10% of all cases of testicular tumors occur in boys with a history of cryptorchidism [36]. In a study of patients with bilateral germ cell tumor, while 9.5% had cryptorchidism history, cryptorchidism was found in 2.2% of patients with unilateral tumors [37]. In addition, in a cohort study, cryptorchidism repair prior to puberty was associated with a doubling in risk of testicular cancer; postponement of the repair after the age of 12 showed that the

**116**

risk increased fivefold [38].

with a history of personal testicular cancer have a 12-fold higher risk of developing TC than the general population [40]. Family cancer studies have shown that sons whose fathers have TC have four times the risk of testicular cancer and brothers of patients with TC have eight times the risk of having testicular cancer [41]. Family history of this relationship is white men are more likely than black men to develop TC [15]. In a study with a large population, contralateral testicular cancer explained that a man younger than age of 30 with testicular seminoma has a 3.1% risk of developing a TC [42].

TC has increased in the last 30 years, while in Western countries there has been a decrease in semen quality and fertility [41]. Men with infertility have an increased risk of TC, with an incidence ratio of 1.6–2.8 [43]. The cohort study, based on more than 22,000 men undergoing evaluation for infertility, examined an association between infertility and the development of testicular cancer [44]. Other risk factors in TC are vasectomy, scrotal trauma, inguinal hernia, diet, smoking, the gene, environment (such as heavy metals exposure and endocrine disruptors), and hormones [45–50].

### **3. Diagnosing testicular cancer**

TC is often seen as a painless mass in the testis, but in many patients there is a widespread pain, swelling, or stiffness in the scrotum [51]. Testicular masses appear more often on the right side [8]. Acute testicular pain is less widespread and is reasoned by swift expansion of the testis owing to intratumor hemorrhage or infarction caused by swift tumor growth [39]. Men often notice a history of testicular trauma, though accidental trauma is probably liable for leading the testicular mass to the men' s attention, firstly. Men may complain of unclear scrotal pain or heaviness [39]. Testicular masses can be urgently evaluated by physical exam and bilateral testicular ultrasound [6]. Physical examination may be determinative but is sometimes vague in differentiating a malignancy from nonmalignant testicular masses [52].

The physician should carefully examine the testes, noting their notional size and density and palpating for any testicular masses [39]. Any doubtful symptoms should give rise to adjuvant studies [53]. **Table 1** shows the signs and symptoms of TC [15].


### **Table 1.**

*Signs and symptoms of testicular cancer.*

In men showing with testicular mass, unexplained scrotal pain or signs, ultrasonography should be regarded an appendage of the physical examination due to being broadly existing, cheap, and noninvasive [54]. After Physical examination, for revealing a mass in the testicle and the first radiological evaluation was Ultrasonography [55]. First of all intratesticular mass or the extratesticular location is examined. The intratesticular masses tend to be malignant, and the extratesticular masses tend to be benign. The nature of the detected masses (solid or cystic) is determined by Ultrasonografi (US). Solid masses suggest more malignancy, whereas cystic masses are often benign, such as rete testis ectasia, simple cyst, and tunica albuginea cyst [55].

Tumor markers are also an important part of the diagnostic workup. Betahuman chorionic gonadotropin (Bhcg), alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH) levels are checked for the diagnosis of testicular tumors [56]. At the same time, these marker levels should be acquired after orchiectomy and to monitor chemotherapy treatment [39]. At the beginning of cancer, levels of these markers tend to be in the normal level. LDH levels are often elevated metastatic testicular cancer [15].

A biopsy can damage the testicles and spread the cancer into scrotum, so biopsy is not recommended [57]. But if suspected of having testicular tumor, one should undergo a radical inguinal orchiectomy for pathologic evaluation [39].
