What is Testicular Cancer?
Testicular cancer is a disease in which malignant (cancer) cells form in the tissues of one or both testicles.
The testicles are 2 egg-shaped glands located inside the scrotum (a sac of loose skin that lies directly below the penis). The testicles are held within the scrotum by the spermatic cord, which also contains the vas deferens and vessels and nerves of the testicles.
The testicles are the male sex glands and produce testosterone and sperm. Germ cells within the testicles produce immature sperm that travel through a network of tubules (tiny tubes) and larger tubes into the epididymis (a long coiled tube next to the testicles) where the sperm mature and are stored.
Almost all testicular cancers start in the germ cells. The two main types of testicular germ cell tumors are seminomas and nonseminomas. These 2 types grow and spread differently and are treated differently. Nonseminomas tend to grow and spread more quickly than seminomas. Seminomas are more sensitive to radiation. A testicular tumor that contains both seminoma and nonseminoma cells is treated as a nonseminoma.
Risk Factors for Testicular Cancer
Testicular cancer is the most common cancer in men 20 to 35 years old. Health history can affect the risk of developing testicular cancer. Having a risk factor does not mean that you will get cancer; not having risk factors doesn’t mean that you will not get cancer. People who think they may be at risk should discuss this with their doctor. Risk factors for testicular cancer include:
- Having had an undescended testicle.
- Having had abnormal development of the testicles.
- Having a personal history of testicular cancer.
- Having a family history of testicular cancer (especially in a father or brother).
- Being of Caucasian descent.
Symptoms of Testicular Cancer
Possible signs of testicular cancer include swelling or discomfort in the scrotum. These and other symptoms may be caused by testicular cancer. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:
- A painless lump or swelling in either testicle.
- A change in how the testicle feels.
- A dull ache in the lower abdomen or the groin.
- A sudden build-up of fluid in the scrotum.
- Pain or discomfort in a testicle or in the scrotum.
Detecting Testicular Cancer
Tests that examine the testicles and blood are used to detect (find) and diagnose testicular cancer. The following tests and procedures may be used:
Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. The testicles will be examined to check for lumps, swelling, or pain. A history of the patient’s health habits and past illnesses and treatments will also be taken.
Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.
Serum tumor marker test: A procedure in which a sample of blood is examined to measure the amounts of certain substances released into the blood by organs, tissues, or tumor cells in the body. Certain substances are linked to specific types of cancer when found in increased levels in the blood. These are called tumor markers. The following 3 tumor markers are used to detect testicular cancer:
- Alpha-fetoprotein (AFP).
- Beta-human chorionic gonadotropin (β-hCG).
- Lactate dehydrogenase (LDH).
Tumor marker levels are measured before radical inguinal orchiectomy and biopsy, to help diagnose testicular cancer.
Radical inguinal orchiectomy and biopsy: A procedure to remove the entire testicle through an incision in the groin. A tissue sample from the testicle is then viewed under a microscope to check for cancer cells. (The surgeon does not cut through the scrotum into the testicle to remove a sample of tissue for biopsy, because if cancer is present, this procedure could cause it to spread into the scrotum and lymph nodes. It’s important to choose a surgeon who has experience with this kind of surgery.) If cancer is found, the cell type (seminoma or nonseminoma) is determined in order to help plan treatment.
Factors Affecting Prognosis & Treatment Options
The prognosis (chance of recovery) and treatment options depend on the following:
- Stage of the cancer (whether it is in or near the testicle or has spread to other places in the body, and blood levels of AFP, β-hCG, and LDH).
- Type of cancer.
- Size of the tumor.
- Number and size of retroperitoneal lymph nodes.
Testicular cancer can usually be cured.
Treatment for testicular cancer can cause infertility. Certain treatments for testicular cancer can cause infertility that may be permanent. Patients who may wish to have children should consider sperm banking before having treatment. Sperm banking is the process of freezing sperm and storing it for later use.
Testicular Cancer Staging
After testicular cancer has been diagnosed, tests are done to find out if cancer cells have spread within the testicles or to other parts of the body.
The process used to find out if cancer has spread within the testicles or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:
Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
Abdominal lymph node dissection: A surgical procedure in which lymph nodes in the abdomen are removed and a sample of tissue is checked under a microscope for signs of cancer. This procedure is also called lymphadenectomy. For patients with nonseminoma, removing the lymph nodes may help stop the spread of disease. Cancer cells in the lymph nodes of seminoma patients can be treated with radiation therapy.
Radical inguinal orchiectomy and biopsy: A procedure to remove the entire testicle through an incision in the groin. A tissue sample from the testicle is then viewed under a microscope to check for cancer cells.
Serum tumor marker test: The following 3 tumor markers are used in staging testicular cancer:
- Alpha-fetoprotein (AFP)
- Beta-human chorionic gonadotropin (β-hCG).
- Lactate dehydrogenase (LDH).
Tumor marker levels are measured again, after radical inguinal orchiectomy and biopsy, in order to determine the stage of the cancer. This helps to show if all of the cancer has been removed or if more treatment is needed. Tumor marker levels are also measured during follow-up as a way of checking if the cancer has come back.
The three ways that cancer spreads in the body are:
- Through tissue. Cancer invades the surrounding normal tissue.
- Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
- Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.
When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.
Stages of Testicular Cancer
The following stages are used for testicular cancer:
Stage 0 (Carcinoma in Situ)
In stage 0, abnormal cells are found in the tiny tubules where the sperm cells begin to develop. These abnormal cells may become cancer and spread into nearby normal tissue. All tumor marker levels are normal. Stage 0 is also called carcinoma in situ and is very uncommon.
In stage I, cancer has formed. Stage I is divided into stage IA, stage IB, and stage IS and is determined after a radical inguinal orchiectomy is done.
In stage IA, cancer is in the testicle and epididymis and may have spread to the inner layer of the membrane surrounding the testicle. All tumor marker levels are normal.
In stage IB, cancer is in the testicle and the epididymis and has spread to the blood vessels or lymph vessels in the testicle; or has spread to the outer layer of the membrane surrounding the testicle; or is in the spermatic cord or the scrotum and may be in the blood vessels or lymph vessels of the testicle. All tumor marker levels are normal.
In stage IS, cancer is found anywhere within the testicle, spermatic cord, or the scrotum and either: all tumor marker levels are slightly above normal; or one or more tumor marker levels are moderately above normal or high.
Stage II is divided into stage IIA, stage IIB, and stage IIC and is determined after a radical inguinal orchiectomy is done.
In stage IIA, cancer: is anywhere within the testicle, spermatic cord, or scrotum; and has spread to up to 5 lymph nodes in the abdomen, none larger than 2 centimeters. All tumor marker levels are normal or slightly above normal.
In stage IIB, cancer is anywhere within the testicle, spermatic cord, or scrotum; and either: has spread to up to 5 lymph nodes in the abdomen; at least one of the lymph nodes is larger than 2 centimeters, but none are larger than 5 centimeters; or has spread to more than 5 lymph nodes; the lymph nodes are not larger than 5 centimeters. All tumor marker levels are normal or slightly above normal.
In stage IIC, cancer: is anywhere within the testicle, spermatic cord, or scrotum; and has spread to a lymph node in the abdomen that is larger than 5 centimeters. All tumor marker levels are normal or slightly above normal.
Stage III is divided into stage IIIA, stage IIIB, and stage IIIC and is determined after a radical inguinal orchiectomy is done.
In stage IIIA, cancer: is anywhere within the testicle, spermatic cord, or scrotum; and may have spread to one or more lymph nodes in the abdomen; and has spread to distant lymph nodes or to the lungs. Tumor marker levels may range from normal to slightly above normal.
In stage IIIB, cancer: is anywhere within the testicle, spermatic cord, or scrotum; and may have spread to one or more lymph nodes in the abdomen, to distant lymph nodes, or to the lungs. The level of one or more tumor markers is moderately above normal.
In stage IIIC, cancer: is anywhere within the testicle, spermatic cord, or scrotum; and may have spread to one or more lymph nodes in the abdomen, to distant lymph nodes, or to the lungs. The level of one or more tumor markers is high.
Cancer is anywhere within the testicle, spermatic cord, or scrotum; and may have spread to one or more lymph nodes in the abdomen; and has not spread to distant lymph nodes or the lung but has spread to other parts of the body. Tumor marker levels may range from normal to high.
Recurrent Testicular Cancer
Recurrent testicular cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back many years after the initial cancer, in the other testicle or in other parts of the body.
Treatment Option Overview
There are different types of treatment for patients with testicular cancer.
Different types of treatments are available for patients with testicular cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.
Testicular tumors are divided into 3 groups, based on how well the tumors are expected to respond to treatment.
- For nonseminoma, all of the following must be true: The tumor is found only in the testicle or in the retroperitoneum (area outside or behind the abdominal wall); and The tumor has not spread to organs other than the lungs; and The levels of all the tumor markers are slightly above normal.
- For seminoma, all of the following must be true: The tumor has not spread to organs other than the lungs; and The level of alpha-fetoprotein (AFP) is normal. Beta-human chorionic gonadotropin (β-hCG) and lactate dehydrogenase (LDH) may be at any level.
- For nonseminoma, all of the following must be true: The tumor is found in one testicle only or in the retroperitoneum (area outside or behind the abdominal wall); and The tumor has not spread to organs other than the lungs; and The level of any one of the tumor markers is more than slightly above normal.
- For seminoma, all of the following must be true: The tumor has spread to organs other than the lungs; and The level of AFP is normal. β-hCG and LDH may be at any level.
- For nonseminoma, at least one of the following must be true: The tumor is in the center of the chest between the lungs; or The tumor has spread to organs other than the lungs; or The level of any one of the tumor markers is high.
- There is no poor prognosis grouping for seminoma testicular tumors.
Treating Testicular Cancer
There are five types of standard treatment used to treat testicular cancer:
Surgery to remove the testicle (radical inguinal orchiectomy) and some of the lymph nodes may be done at diagnosis and staging. (See the General Information and Stages sections of this summary.) Tumors that have spread to other places in the body may be partly or entirely removed by surgery.
Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy or radiation therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will recur, is called adjuvant therapy.
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.
Advances in chemotherapy account for the overall cure rate of testicular cancer being greater than 90%. Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.
Watchful waiting is closely monitoring a patient’s condition without giving any treatment until symptoms appear or change. This is also called observation.
High-dose chemotherapy with stem cell transplant
High-dose chemotherapy with stem cell transplant is a method of giving high doses of chemotherapy and replacing blood -forming cells destroyed by the cancer treatment. Stem cells (immature blood cells) are removed from the blood or bone marrow of the patient or a donor and are frozen and stored. After the chemotherapy is completed, the stored stem cells are thawed and given back to the patient through an infusion. These re-infused stem cells grow into (and restore) the body’s blood cells.
New types of treatment are being tested in clinical trials. Patients may want to think about taking part in a clinical trial. For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.
Many of today’s standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.
Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward. Patients can enter clinical trials before, during, or after starting their cancer treatment.
Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.
Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from NCI’s listing of clinical trials.
Follow-up tests may be needed.
Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.
Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.
Men who have had testicular cancer have an increased risk of developing cancer in the other testicle. A patient is advised to regularly check the other testicle and report any unusual symptoms to a doctor right away.
Long-term clinical exams are very important. The patient will probably have check-ups frequently during the first year after surgery and less often after that.