Like many athletes, swimmer Nathan Adrian was disappointed about the cancellation of the 2020 Tokyo Olympics last summer. He was hoping to make it onto his fourth U.S. Olympic swim team. However, for this five-time gold medalist, the COVID-19 pandemic delay may have worked in his favor.
As a professional athlete, Adrian is hyper aware of his body. In December 2018, he noticed an unusual swelling and hardness in his left testicle. When it did not resolve after a week, he knew he should be seen by a doctor.
He was diagnosed with testicular cancer, underwent surgery to remove his left testicle, and 1 month later underwent a second surgery to remove some lymph nodes. The back-to-back surgeries delayed his ability to get back into a pool to resume training.
For over a month post-op, he was instructed not to lift anything more than 15 pounds. In addition, surgeons had placed five incisions in his abdominal wall, which forced him to readjust his training techniques so as not to favor the abdominal muscles on his right side.
In July 2019, he anchored the U.S. 4×100 meter freestyle relay team to a world record and victory at the 2019 World Championships in South Korea.
During the pandemic, Adrian had to improvise his training. He and former University of California All-American swimmer Will Copeland bought a recreation pool, the Ann Curtis School of Swimming in San Rafael, California.
Although the pool is only 3½ feet deep and 25 yards long (compared with a 10-feet deep, 55-yard long Olympic pool), Adrian appreciated having somewhere to train: “It doesn’t translate perfectly, but it’s water,” he told the Mercury News. He also recreated a slide board, known as a lateral trainer, by doing exercises wearing socks on the hardwood floors of his home.
He has been regularly tested with MRIs and blood work, and so far, there are no signs of recurrence.
In a Today interview last week profiling potential Tokyo Olympians, he told Hoda Kotb: “I feel good. The extra year helped to smooth out some kinks that popped up from the surgeries.”
Adrian has used his Olympic status to raise awareness about testicular cancer and to advocate for early screening. In November 2019, he partnered with the “Movember” campaign by being featured in a video, “No Less of a Man.”
In it, he notes: “There is this huge stigma around testicular cancer. Men have this direct correlation equivocating their masculinity to having two testicles — i.e., ‘grow a pair.’ Well, I don’t have a pair anymore. I only have one. I think the way to break that down is to do exactly what we’re doing right now and talk about it. I don’t feel like any less of a man because I have one testicle.”
Testicular Cancer
Testicular cancer is a highly treatable, potentially curable, cancer that most often develops in young and middle-aged men.
Most testicular cancers are germ cell tumors, which for treatment planning, are broadly divided into seminomas and nonseminomas, with each having different prognostic and treatment algorithms.
The NCI’s Statistics, Epidemiology, and End Results program estimates that there will be 9,470 new cases of testicular cancer and 440 deaths from the disease in the United States in 2021. For patients with seminoma (all stages combined), the cure rate exceeds 90%. For patients with low-stage seminoma or nonseminoma, the cure rate approaches 100%.
Risk Factors
Risk factors for testicular cancer include the following:
- An undescended testis (cryptorchidism)
- A family history of testis cancer (particularly in a father or brother)
- A personal history of testis cancer
Surgical correction of an undescended testis (orchiopexy) before puberty may lower the risk of testicular cancer.
Histopathology
The five histopathological subtypes of testicular germ cell tumors are:
- Seminomas
- Embryonal carcinomas
- Teratomas
- Yolk sac tumors
- Choriocarcinomas
Testicular tumors that are 100% seminoma are considered seminomas. All other testicular tumors, including those with a mix of seminoma and nonseminoma components, are considered and should be managed as nonseminomas.
Most nonseminomas consist of a mixture of the different germ-cell tumor subtypes. Tumors that appear to have a seminoma histology but are accompanied by an elevated serum level of alpha-fetoprotein (AFP) should be treated as nonseminomas because seminomas do not produce AFP.
Prognosis and Staging
AFP, beta-human chorionic gonadotropin, and lactase dehydrogenase all play an important role as serum tumor markers in the staging and monitoring of germ cell tumors and should be measured prior to removing the involved testicle.
For patients with nonseminomas, the degree of tumor-marker elevation after the cancerous testicular has been removed is one of the most significant predictors of prognosis. Serum tumor markers are also very useful for monitoring all stages of nonseminomas and for monitoring metastatic seminomas because elevated marker levels are often the earliest sign of relapse.
Staging and Risk Stratification
The prognosis of testicular germ cell tumors is determined by the following factors:
- Histology (seminoma vs nonseminoma)
- The extent to which the tumor has spread (testis only vs retroperitoneal lymph node involvement vs pulmonary or distant nodal metastasis vs nonpulmonary visceral metastasis)
- For nonseminomas, the degree to which serum tumor markers are elevated
For men with disseminated seminomas, the main adverse prognostic variable is the presence of metastases to organs other than the lungs (e.g., bone, liver, or brain). For men with disseminated nonseminomas, the following variables are independently associated with poor prognosis:
- Metastases to organs other than the lungs
- Highly elevated serum tumor markers
- Tumor that originated in the mediastinum rather than the testis
Nonetheless, even patients with widespread metastases at presentation, including those with brain metastases, may have curable disease and should be treated with this intent.
Treatment and Survivorship
Seminomatous types of testicular cancer are more sensitive to radiation therapy and chemotherapy and less prone to distant metastases.
Nonseminomas may have teratomatous elements, which tend to be resistant to chemotherapy and often require surgery for cure. By definition, pure seminomas do not contain elements of teratoma.
Therefore, surgery plays a larger role in the management of nonseminomas than in seminomas. Radical inguinal orchiectomy with initial high ligation of the spermatic cord is the procedure of choice in diagnosing and treating a malignant testicular mass. For many patients, this is followed by scheduled chest x-rays and abdominal and pelvic CT scans for surveillance.
Patients with advanced disease, as well as those who are uncomfortable with surveillance only and wish to minimize the risk of relapse, may receive radiation therapy or chemotherapy — typically with a cisplatin-based regimen.
Patients who have been cured of testicular cancer have an approximately 2% cumulative risk of developing a cancer in the opposite testicle during the 15 years after initial diagnosis. Within this range, men with nonseminomatous primary tumors appear to have a lower risk of subsequent contralateral testis tumors than men with seminomas.
Because the majority of testicular cancer patients who receive adjuvant chemotherapy or radiation therapy are curable, it is necessary to be aware of possible long-term effects of the various treatment modalities:
- Fertility: Many patients have oligospermia or sperm abnormalities before therapy, but semen analysis results generally become more normal after treatment. It is well documented that most men can father children after treatment, often without the use of cryopreserved semen. Radiation therapy, used to treat pure seminomatous testicular cancers, can cause fertility problems because of radiation scatter to the remaining testicle during radiation therapy to the retroperitoneal lymph nodes
- Secondary leukemias: Several reports of elevated risk of secondary acute leukemia, primarily nonlymphocytic, have appeared; an increased risk of leukemia has been associated with platinum-based chemotherapy and radiation therapy
- Renal function: Minor decreases in creatinine clearance occur (about 15%, on average) during platinum-based therapy, but these appear to remain stable in the long term and without significant deterioration
- Hearing: Bilateral hearing deficits occur with cisplatin-based chemotherapy, but the deficits generally occur at sound frequencies of 4-8 kHz, which is outside the range of conversational tones; therefore, hearing aids are rarely required if the patient has received standard doses of cisplatin
- Lung function: A study of pulmonary function tests in 1,049 long-term survivors of testis cancer found a cisplatin dose-dependent increase in the incidence of restrictive lung disease. Patients who received no chemotherapy had an incidence of restrictive lung disease of less than 8%, compared with about 18% for those who received more than 850 mg of cisplatin. However, only 9.5% of those with pulmonary function testing indicative of restrictive lung disease reported dyspnea
- Cardiovascular disease: Men with testis cancer who have been treated with radiation therapy and/or chemotherapy have been reported to be at a slightly increased risk of cardiovascular events
Michele R. Berman, MD, and Mark S. Boguski, MD, PhD, are a wife-and-husband team of physicians who have trained and taught at some of the top medical schools in the country, including Harvard, Johns Hopkins, and Washington University in St. Louis. Their mission is both journalistic and educational: to report on common diseases affecting uncommon people and summarize the evidence-based medicine behind the headlines.