Testicular Cancer

What is testicular cancer?

Testicular cancer can start in one or both testicles. It is most often found in young men. This type of cancer can be treated and very often cured.

The testicles

The testicles (or testes) are part of the male reproductive system. In adult men, each one is normally a little smaller than a golf ball. They are held in a sac of skin called the scrotum. The scrotum hangs beneath the base of the penis.

The testicles make the male hormones testosterone. They also make sperm. Sperm cells are carried from the testicles through small tubes (the vas deferens) to the seminal vesicles. Fluid from the vesicles and from the prostate gland is added. During ejaculation (orgasm), this fluid, now called semen, travels through a tube (the urethra) in the center of the penis and out of the body. See the picture below.

 

The testicles are made up of several kinds of cells and each may develop into one or more types of cancer. It is important to know which kind of cell the cancer started from because these types of cancer are treated differently. They also differ in the chance of survival for the patient (prognosis).

Main types of testicular tumors

  • Germ cell tumors are the most common type of testicular tumors. Germ cell tumors start in the cells that make sperm.
  • Stromal tumors start in the cells that make hormones and the cells that support the cells that make sperm.
  • Secondary testicular tumors are from cancer that has spread to the testicles from other parts of the body.

Each of the 3 types is explained in more detail below.

Germ cell tumors

More than 9 out of 10 of cancers of the testicles start in the germ cells. As used here, the term “germ” means seed. These are the cells that make sperm.

The 2 main types of germ cell tumors are seminomas and nonseminomas.

Seminomas start from germ cells of the testicle that make sperm. Within this group there are also subtypes. Seminomas usually happen in men when they are between 25 and 45.

Nonseminomas tend to develop earlier in life than seminomas. They are often found in men between their late teens and early 30s. There are 4 main subtypes. Most tumors are mixed, having at least 2 different subtypes. But all nonseminoma germ cell cancers are treated the same way, so the exact type is not that important.

Carcinoma in situ: Testicular germ cell cancers may begin as a non-invasive form of the disease called carcinoma in situ (CIS). Carcinoma in situ may not always go on to become invasive cancer, but if it does, it can take about 5 years.

It is hard to find CIS because it often causes no symptoms and may not form a lump that you or the doctor can feel. Some cases are found by chance in men who have a testicular biopsy for some other reason, such as infertility.

Experts don’t agree about the best treatment for CIS. Since CIS doesn’t always become an invasive cancer, many doctors in this country feel that observation (watching and waiting) is the best course of action.

Stromal tumors

Tumors can also grow in the cells that make hormones and in the supportive tissues (the stroma) of the testicles. Stromal cell tumors are often benign (not cancer). They usually do not spread beyond the testicle and can be cured by taking them out. But a few stromal cell tumors spread to other parts of the body (metastasize). Metastatic stromal cell tumors have a poor outlook because they do not respond well to chemotherapy or radiation treatment. The 2 main types of stromal tumors are Leydig cell tumors and Sertoli cell tumors.

Secondary testicular tumors

Secondary testicular tumors start in another organ and then spread to the testicle. Lymphoma is the most common cancer that does this. In boys with acute leukemia, the leukemia cells can sometimes form a tumor in the testicle.

Cancers of the prostate, lung, skin, kidney, and other organs can also spread to the testicles. The outlook for these cancers is usually poor. That’s because very often these cancers have spread widely to other organs, too. Treatment depends on the exact type of cancer.

 

What are the risk factors for testicular cancer?

While we do not know the exact cause of most cases of testicular cancer, we do know some of the risk factors linked to testicular cancer.

A risk factor is something that affects a person’s chance of getting a disease. Different cancers have different risk factors. Some risk factors, such as smoking, can be controlled. Others, like a person’s age or race, can’t be changed. But having a risk factor, or even several, does not mean that a person will get the disease. And not having any risk factors doesn’t mean you won’t get the disease.

Scientists have found a few risk factors that make a man more likely to get testicular cancer. Even if a man has one or more risk factors for this disease, there’s no way to know for sure what part those factors played in causing the cancer. Also, most men with testicular cancer do not have any of the known risk factors. Research in this area is going on.

Risk factors for testicular cancer

Undescended testicle: One of the main risk factors for testicular cancer is a problem called cryptorchidism, or undescended testicle(s). Before birth, the testicles normally develop in the belly of the fetus and then move down (descend) into the scrotum before birth. But in about 3% of boys, the testicles do not move into the scrotum. Sometimes the testicle stays inside the belly. In other cases, the testicle starts to come down, but gets stuck in the groin.

Men who have had cryptorchidism are several times more likely to get testicular cancer than those who did not have the problem. The risk is higher for men with a testicle in the belly as opposed to one that has moved down at least part way. Among men with a history of this problem, most cancers start in the testicle that has not moved down. But about 1 out of 4 occurs in the normal testicle. Because of this, some doctors think that cryptorchidism is not the direct cause of testicular cancer. They believe that some other problem causes both the cancer risk and the cryptorchidism.

Most testicles will descend on their own in the child’s first year. Sometimes surgery (called orchiopexy) is needed to bring the testicle down into the scrotum. Surgery done when a child is younger may be more likely to reduce the risk of testicular cancer than surgery done when the child is older, but the best time to do this surgery is not clear.

Family history: A family history of testicular cancer increases the risk. If a man has the disease, there is a higher risk that his brothers or sons may also get it. But very few cases of testicular cancer are actually found in families.

HIV infection: There is some evidence that men infected with HIV (human immunodeficiency virus) have an increased risk of testicular cancer. This may be especially true for men who have AIDS. No other infections have been shown to increase testicular cancer risk.

CIS (carcinoma in situ): CIS is described in “What is testicular cancer?” It isn’t clear how often CIS in the testicles becomes cancer. It is sometimes found when a man is tested for infertility. It may also be found when a man has a testicle removed because of cryptorchidism. Radiation or surgery (to remove the testicle) is used to treat CIS. Since we don’t know how often CIS becomes true (invasive) cancer, it isn’t clear that treating CIS is a good idea. Some experts think that it may be better to wait and see if the disease gets worse or becomes a true cancer. This could allow many men with CIS to avoid the risks and side effects of treatment.

Cancer of the other testicle: Men who have been cured of cancer in one testicle have an increased risk (about a 3% to 4% chance) of getting cancer in the other testicle.

Age: About half of testicular cancers occur in men between the ages of 20 and 34. But this cancer can affect males of any age, including infants and older men

Race and ethnicity: White American men are about 5 times more likely to get testicular cancer than are African-American men. Whites have more than 3 times the risk of Asian-American and American Indian men. The risk for Hispanics falls between that of Asians and non-Hispanic whites. The reason for these differences is not known.

Body size: Some studies have that the risk of testicular cancer is somewhat higher in tall men but other studies have not shown a link.

 

How is testicular cancer found?

Most testicular cancers can be found at an early stage. In some men, early testicular cancers cause symptoms that prompt them to call their doctor. Most of the time a lump on the testicle is the first sign. But some testicular cancers don’t cause symptoms until they have reached an advanced stage.

Sometimes testicular cancer is found during testing for other problems. For instance, fertility tests sometimes find testicular cancer.

Most doctors agree that an exam of a man’s testicles should be part of his general physical exam. The American Cancer Society (ACS) recommends a testicular exam as part of a routine cancer-related check-up.

Regular self-exams of the testicles have not been studied enough to show that the practice lowers the death rate from this cancer. Because of this, the ACS does not does not have a recommendation about regular testicular self-exams for all men. But some doctors think otherwise, and may advise their patients to do self-exams every month. If you have certain risk factors that increase your chance of getting testicular cancer, you should talk about it with your doctor.

Signs and symptoms of testicular cancer

In most cases of testicular cancer, the man has a lump on a testicle or notices that the testicle is swollen or larger. Most of the time there is no pain. Men with testicular cancer may also notice a feeling of heaviness or aching in the lower belly or scrotum.

In rare cases, men with germ cell cancer notice their breasts are sore or have gotten bigger. This happens because some germ cell tumors give off high levels of a hormone called human chorionic gonadotropin (HCG), which causes the breasts to grow. Blood tests can measure HCG levels. These tests are important in finding, staging, and follow-up of some testicular cancers.

Some stromal tumors can make hormones. If the tumor makes male hormones (androgens), it can cause the growth of facial and body hair at a very early age in boys. The extra androgens are not likely to cause any symptoms in men. Some stromal tumors make female hormones (estrogens) and not male hormones. The female hormones can cause a man to grow breasts and/or lose his sex drive.

Signs of advanced testicular cancer

Even when the cancer has spread to other organs, few men have any symptoms. Lower back pain is a symptom of later-stage testicular cancer. Signs that the cancer has spread to the lungs can include:

  • Shortness of breath
  • Chest pain
  • Cough
  • Spitting up blood

A number of problems other than cancer, such as an injury to the testicle, infection, or inflammation, can cause symptoms like those of testicular cancer. If you have any of the signs or symptoms above, see a doctor right away. Remember, the sooner cancer is found the sooner you can start treatment. And the earlier you get treatment, the better it is likely to work. For more details, see our document Do I Have Testicular Cancer?

Medical history and physical exam

If you have signs or symptoms that suggest testicular cancer, your doctor will want to take a complete medical history to check for risk factors and symptoms. Then the doctor will do a physical exam. During the exam, the doctor will feel the testicles for any swelling, tenderness, or lumps. The doctor will also feel your belly for swollen lymph nodes which could be a sign that the cancer has spread.

Ultrasound

This test uses sound waves to make pictures of internal organs. The computer shows the picture on a screen. An ultrasound can help doctors tell whether a lump (or mass) is solid or filled with fluid. If the lump is solid, then it is more likely to be cancer.

This is a very easy test to have done, and it uses no x-rays. You just lie on a table while a flat wand is moved over the skin of the scrotum. Usually, your skin is coated with gel first.

Blood tests

Certain blood tests can help diagnose testicular cancer. Many cancers make proteins (called tumor markers) that can be found in the blood. The levels of these tumor markers might be used to tell the doctor how much cancer is present, how well treatment is working, and whether the cancer has come back.

Surgery to diagnose testicular cancer

If the doctor sees a solid tumor on ultrasound, it is likely to be cancer, so surgery will most likely be done to remove it as soon as possible. Whenever they can, surgeons try to remove the entire tumor, the testicle, and the spermatic cord. The spermatic cord carries sperm, blood, and lymph. It can act as a pathway for cancer cells to spread. For this reason, the cord is tied off early in the operation. Doctors usually do this operation through a cut (incision) in the groin. This is the same operation that is done for cancer in the testicle.

All of the tissue removed will be sent to the lab. A doctor with special training (called a pathologist) will look at it under a microscope. If cancer cells are present, the pathologist sends back a report describing the type and extent cancer.

In rare cases, the doctor may take a tissue sample (biopsy) before removing the testicle. This is done when doctors are not sure if the tumor is cancer. In surgery the doctor makes a cut in the groin, takes the testicle out of the scrotum, and looks at it without cutting the spermatic cord. If an area of concern is seen, part of that area is removed and sent to be looked at by the pathologist right away. If it is cancer, the doctor removes the testicle and spermatic cord. If the tissue is not cancer, the testicle can often be returned to the scrotum.

If testicular cancer is found, doctors use imaging tests to see how advanced it is.

Imaging tests

Chest x-ray: This is a plain x-ray of your chest to see whether the cancer has spread to your lungs or to lymph nodes around the chest. If the x-ray is normal, you probably don’t have cancer in your lungs. But most doctors feel a CT scan can better show whether the cancer has spread to the chest.

CT scan (computed tomography): A CT scan is helpful in finding out whether the cancer has spread to your lungs, liver, or other organs. The scan uses x-rays to make detailed pictures of your body. Instead of taking just one picture, a CT scanner takes many as it rotates around you. A computer then combines these into a picture of a slice of your body.

Before the scan, you may be asked to drink a liquid that contains a dye to help outline tissue in your body. Or the dye may be put into a vein. The dye may make you feel warm and flushed. A few people are allergic and get hives. Rarely, there can be more serious problems, like trouble breathing and low blood pressure. Be sure to tell the doctor if you have ever had a problem with a dye used for x-rays or if you are allergic to shellfish. Medicine can be given to prevent and treat these reactions.

CT scans take longer than regular x-rays. You need to lie still on a table. The part of your body being checked is placed inside the scanner. The test is painless, but you may find it hard to hold still for minutes at a time.

CT scans are sometimes used to guide a biopsy needle mass that might be cancer. You stay on the CT scanning table while the doctor moves needle through the skin toward the. .A thin needle (or a larger needle) removes a sample of tissue to be looked at under a microscope. This is not used to biopsy a testicular lump, but may be used to check for cancer spread.

MRI (magnetic resonance imaging): MRI scans use radio waves and strong magnets instead of x-rays to take pictures. MRI pictures show a lot of detail. They are very helpful when looking at the brain and spinal cord.

MRI scans can be a little more uncomfortable than CT scans because they take longer, often up to an hour. Also, you must lie still inside a tube, which can upset some people. The machine makes a thumping noise as the magnet switches on and off. Some places have earplugs or headphones with music to block this out. Special, more open MRI machines can help with this if needed. You may also get a dye like you would for a CT scan, but this is done less often.

PET scan (positron emission tomography): For a PET scan, a type of radioactive sugar is put into a vein. The sugar collects in cancer tissue, and a scanner can spot these areas. This test is useful for finding cancer that has spread beyond the testicles. It is also helpful in telling whether swollen lymph nodes contain scar tissue or cancer. Often the PET scan is combined with a CT scan. This helps the doctor decide whether changes on the CT are cancer or something else. PET scans are often more useful for seminoma than for the non-seminoma type of testicular cancer, and so are less often used in patients with non-seminoma.

 

How is testicular cancer treated?

This information represents the views of the doctors and nurses serving on the American Cancer Society’s Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.

The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.

Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don’t hesitate to ask him or her questions about your treatment options.

In recent years, much progress has been made in treating testicular cancer. Surgery has been improved, and doctors know more about the best way to use chemo and radiation to treat different types of testicular cancer.

Making treatment decisions

After the cancer is found and staged, your doctor will talk to you about treatment choices. You should take time and think about all of the options. In choosing a treatment plan, things to take into account include the type and stage of the cancer as well as your overall physical health. When time permits, getting a second opinion is often a good idea. This can give you more information and help you feel good about the choice you make. Some insurance companies even require a second opinion before they will agree to pay for treatments.

Where you are treated is important. There is no substitute for experience; you will have the best chance for a good outcome if you go to a hospital that treats many testicular cancer patients.

The 3 main methods of treatment for testicular cancer are surgery, radiation therapy, and chemotherapy.

 

What are some questions I can ask my doctor about testicular cancer?

As you cope with cancer, we encourage you to have honest, open talks with your doctor. Feel free to ask any question that’s on your mind, no matter how small it might seem. Here are some questions you might want to ask. Be sure to add your own questions as you think of them. Nurses, social workers, and other members of the treatment team may also be able to answer many of your questions.

  • Would you please write down the exact type of testicular cancer I have?
  • Has my cancer spread beyond the testicle?
  • What is the stage of my cancer? What does the staging mean in my case?
  • Are there other tests that need to be done before we can decide on treatment?
  • How much experience do you have treating this type of cancer?
  • What treatment choices do I have?
  • How many lymph node surgeries have you done?
  • What treatment do you suggest and why?
  • What is the goal of this treatment?
  • How long will treatment last? What will it involve? Where will it be done?
  • What are the risks or side effects that I should expect?
  • How long will it take me to recover from treatment?
  • When can I go back to work or other activities after treatment?
  • How soon after treatment can I have sex?
  • What are the chances I will become infertile? Should I bank sperm?
  • What are the chances of the cancer coming back after treatment?
  • What would we do if that happens?
  • Does one type of treatment reduce the risk of the cancer coming back more than another?
  • What should I do to be ready for treatment?
  • Based on what you’ve learned about my cancer, how long do you think I’ll survive?
  • Would a second opinion be helpful to me?

 

Moving on after treatment for testicular cancer

For most men with testicular cancer, treatment removes or destroys the cancer. While it can feel good to be done with treatment, it can also be stressful. You may find that you now worry about the cancer coming back. This is a very common concern among those who have had cancer. (When cancer comes back, it is called a recurrence.)

It may take a while before your recovery begins to feel real and your fears are somewhat relieved. You can learn more about what to look for and how to learn to live with the chance of cancer coming back in Living With Uncertainty: The Fear of Cancer Recurrence.

For a few people, the cancer may never go away completely. These people may get regular treatments with chemo, radiation, or other treatments to try to help keep the cancer in check. Learning to live with cancer that does not go away can be hard and very stressful. Our document, When Cancer Doesn’t Go Away, talks more about this.

Follow-up care

When treatment ends, your doctors will still want to watch you closely. There is still a good chance for cure even if the tumor comes back, so finding it early is important.

Your doctor will explain what tests you need and how often they should be done. You will need blood tests to measure levels of certain protein markers to see if the cancer has come back. You will also need x-rays, CT scans, and other tests to see whether the cancer has come back, has spread, or whether there is a new tumor. After a few years these visits and tests will not have to be done as often.

Most of the time, if the cancer comes back, it does so in the first 5 years. Still, there is always an outside chance the cancer can come back later. Also, there is about a 3% chance that men who have had cancer in one testicle will develop a cancer in the other. Usually this is a new cancer and is not spread (metastasis) from the first tumor. Should your cancer come back, the American Cancer Society document called When Your Cancer Comes Back: Cancer Recurrence can help you learn how to cope with this phase of your treatment. You can get a copy by calling 1-800-227-2345.

Most men get cancer in only one testicle. The other testicle usually can make enough testosterone (the male hormone) to keep the man healthy. If the other testicle needs to be removed because a new cancer develops, that man will need to take some form of testosterone the rest of his life. Most often this is in the form of a gel or patch that is applied to the skin or a monthly shot (given in a doctor’s office). If you need to take testosterone, talk to your doctor about what form is best for you.

Testicular cancer or its treatment can make a man infertile. Before treatment starts, men who wish to father children may want to think about storing sperm in a sperm bank for later use. But the disease can cause low sperm counts, which may make it hard to get a good sample. In some cases, if one testicle is left, fertility returns (for a short time or for good) after the cancer has been treated.

Even when sperm counts in semen are very low, men have options for fathering children. One of these options is in vitro fertilization. An egg cell that has been removed from your partner’s ovary is fertilized by your sperm cells in a lab and then returned to her uterus. Be sure to discuss any fertility concerns with your doctor before your treatment begins.

Almost any cancer treatment has side effects. Some may last for a few weeks to several months, but others can be permanent. Be sure to tell your cancer care team about any symptoms or side effects that bother you so they can help you manage them. It is also important to keep health insurance. While you hope your cancer won’t come back, it could happen. If it does, you don’t want to have to worry about paying for treatment.

Should your cancer come back, our document called When Your Cancer Comes Back: Cancer Recurrence can give you information on how to manage and cope with this phase of your treatment.

Seeing a new doctor

At some point after your cancer is found and treated, you may find yourself in the office of a new doctor. It is important that you be able to give your new doctor the exact details of your diagnosis and treatment. Make sure you have this information handy and always keep copies for yourself:

  • A copy of your pathology report from any biopsy or surgery
  • If you had surgery, a copy of your operative report
  • If you were in the hospital, a copy of the discharge summary that the doctor wrote when you were sent home from the hospital
  • If you had radiation treatment, a copy of the treatment summary
  • If you had chemo or targeted therapies, a list of your drugs, drug doses, and when you took them
  • Copies of your CT scans (or other imaging tests) – these can often be placed on a DVD

The doctor may want copies of this information for his records, but always keep copies for yourself.

 

What`s new in testicular cancer research and treatment?

Research into testicular cancer is going on right now around the country. Each year, scientists find out more about what causes the disease, how to prevent it, and how to improve treatment.

Researchers have found inherited changes in several genes that seem to increase a man’s risk of getting testicular cancer. These findings may help doctors figure out which men are at higher risk, but they need to be studied much more. And certain other changes in the genes have been linked to resistance to chemo and predict poor outcomes. These findings may help doctors choose the best treatment for each man.

Clinical trials have improved doctors’ approaches to treating these cancers. Studies are expected to answer other questions, too. For example, studies have found ways to predict which men may not need lymph node surgery or radiation therapy. Studies have also found other factors that suggest certain men may need stronger treatment.

A large amount of work is being done to try to limit long-term problems of treatment while still curing patients. Doctors want to be able to better predict whose cancer is more likely to come back and then base the amount of treatment on this. Thus men would get the exact amount of treatment they need. One study reported good results of this approach in men with testicular cancer that had spread to other parts of the body.

New drugs and new drug combinations are being tested for people with cancer that comes back. Stem cell transplant is being studied as a way to help those who need high doses of chemo. Chemo treatments are also getting better. Doctors are looking at different doses and combinations of drugs that reduce side effects but still work well to kill the cancer. Doctors are also studying new ways to help men be able to father children after treatment.

 

By American Cancer Society