Overview of Testicular Cancer

Symptoms, signs, diagnosis and evaluation of Testicular Cancer.

Overview of Testicular Cancers

Medically reviewed by Dr. C.H. Weaver M.D. Medical Editor (08/2018)

Testicular cancers are relatively rare but highly curable, and occur predominantly in young and middle aged males. Testicular cancers were among the first types of cancers to be cured by radiation and/or chemotherapy, and treatment has been refined over the last several decades. Currently, the majority of all patients are curable regardless of the extent of cancer and cure rates approach 100% for earlier stage cancers. Thus, all treatment of testicular cancer is delivered with the intent to cure. However, it is important to know the extent of cancer and the specific type of testicular cancer in order to administer the best therapy.[1],[2]

The testicles are located inside the scrotum (a sac of loose skin that lies directly under the penis). The testicles are similar to the ovaries in women. Sperm and male hormones are made in the testicles. Testicular cancer—also called germ cell cancer—occurs in the tissues of one or both testicles. Similar cancers called “non-gonadal germ cell cancers” can also occur outside the testicle; non-gonadal germ cell cancers are not discussed in this section.

Testicular cancer is the most common cancer in men 15 to 35 years old. Men who have an undescended testicle (a testicle that has never moved down into the scrotum) are at higher risk of developing testicular cancer than men whose testicles have moved normally down into the scrotum. This is true even if surgery has been performed early in life to place the testicle in the appropriate place in the scrotum.[1]

Symptoms & Signs of Testicular Cancer

  • A painless lump or swelling in either testicle.
  • A change in how the testicle feels.
  • A dull ache in the groin or lower abdomen
  • Pain or discomfort in a testicle or in the scrotum.

Cause

Testicular cancer begins when healthy cells acquire a genetic change (mutation) that causes them to turn into abnormal cells. Most Testicular cancers develop sporadically, which means for no known reason.

Risk factors

A risk factor is anything that increases a person’s chance of developing cancer. Risk factors can influence the development of cancer but most do not directly cause cancer. Many individuals with risk factors will never develop cancer and others with no known risk factors will. Some cancers however are more likely to develop in individuals with certain risk factors that increase an individual’s chance of developing cancer. The following factors may raise a person’s risk for developing Testicular cancer.[1],[2],[3],[4]

  • Having had an “undescended testicle”
  • Having had abnormal development of the testicles.
  • Having a previous history of testicular cancer.
  • Having a family history of testicular cancer (especially in a father or brother).
  • Being white.

Diagnosis & Tests for Testicular Cancer

Doctors use many tests to find, or diagnose, cancer. They also do tests to learn if cancer has spread to another part of the body from where it started. A biopsy is the only certain way to confirm a diagnosis of cancer. When performing a biopsy, the doctor takes a sample of tissue for testing in a laboratory.

When a testicular lump is found, the doctor will perform an ultrasound examination, which uses sound waves to make a picture of the inside of the testes.

When cancer is suspected, the entire testicle is surgically removed (orchiectomy) through an incision in the groin. The surgically removed tissue is then examined under a microscope to determine whether cancer cells are present. Removal of a small piece of tissue (biopsy) is usually not done because this is thought to cause spread of the cancer. When the cancer is small and localized to the testicle, removal of the testicle may be all of the treatment that is necessary to cure the cancer. The surgically removed testicle is examined under the microscope to determine the type of cancer. In some patients the cancer consists of only one cell type. But for many patients, the cancer under the microscope consists of a mixture of cell types.

Tumor or Cancer Markers

An important aspect of the evaluation of testicular cancer is the use of blood or serum tests to detect cancer markers. Cancer markers are abnormal substances in the blood associated with the presence of cancer somewhere in the body. Common cancer markers that are present in the blood of patients with testicular cancer include:

  • Alpha-fetoprotein (AFP)
  • Beta human chorionic gonadotropin (BHCG)
  • Lactate dehydrogenase (LDH).

These cancer markers should be measured before surgical orchiectomy and may detect cancers that are too small to be detected with a CT scan. In males under age 15, about 90% of testicular germ cell cancers are yolk sac tumors that make AFP, which is an excellent indicator of response to therapy and disease status.[1],[2]

Type of treatment and outcomes depend on the type (seminoma vs non-seminoma) and stage of the cancer. In order to learn more about the most recent information available concerning the treatment of testicular cancer, click on the appropriate stage.

Staging

The extent of disease, or “stage” is determined after surgical removal of the testicle. Cancer’s stage is a key factor in determining the best treatment. In addition to tumor markers the following tests may be performed to determine the stage of a testicular cancer.

Ultrasound (sonography): Ultrasound uses high frequency sound waves and their echoes to create an image. The ultrasound machine transmits sound pulses into the body using a probe. The sound waves travel through the body until they hit a boundary between tissues. At the boundary, some of the sound waves get reflected back to the probe, while some travel on further until they reach another boundary and get reflected. The reflected waves are detected by the probe and relayed to the machine, which calculates the relative distances and creates a two-dimensional image.

Imaging tests: Tests such as X-rays, CT scans, magnetic resonance imaging (MRI) and positron emission tomography (PET) are used to help determine the stage and whether the cancer has spread.

Computed Tomography (CT) Scan: A CT scan is a technique for imaging body tissues and organs, during which X-ray transmissions are converted to detailed images, using a computer to synthesize X-ray data. A CT scan is conducted with a large machine positioned outside the body that can rotate to capture detailed images of the organs and tissues inside the body.

Magnetic Resonance Imaging (MRI): MRI uses a magnetic field rather than X-rays, and can often distinguish more accurately between healthy and diseased tissue than a CT. An MRI gives a better picture of cancer located near bone than does CT, does not use radiation, and provides pictures from various angles that enable doctors to construct a three-dimensional image of the cancer.

Positron emission tomography (PET): Positron emission tomography scanning is an advanced technique for imaging body tissues and organs. One characteristic of living tissue is the metabolism of sugar. Prior to a PET scan, a substance containing a type of sugar attached to a radioactive isotope (a molecule that emits radiation) is injected into the patient’s vein. The cancer cells “take up” the sugar and attached isotope, which emits positively charged, low energy radiation (positrons) that create the production of gamma rays that can be detected by the PET machine to produce a picture. If no gamma rays are detected in the scanned area, it is unlikely that the mass in question contains living cancer cells.

Retroperitoneal Lymph Node Dissection (RPLND)

Lymph nodes are small, bean-shaped structures that are an essential component of the immune system. They are found throughout the body and are interconnected with lymph channels. Testicular cancer tends to spread through lymph channels that drain into lymph nodes in the groin area, into channels near the large blood vessel (the aorta) carrying blood from the heart, and into lymph nodes between the abdomen and back called retroperitoneal lymph nodes.

Direct surgical evaluation of the retroperitoneal lymph nodes is an important aspect of treatment planning in some adults with non-seminoma stage I or II testicular cancer. This is because some patients will appear to have no evidence of cancer in the retroperitoneal lymph nodes on CT scan and will appear to have a stage I cancer. They may actually have lymph nodes involved with cancer that were not detectable by the CT scan and may actually have stage II cancer. Some patients who appear to have cancer on CT scan will not have lymph nodes involved and actually have a stage I cancer. In general, stage IIA patients undergo RPLND to confirm the staging. As many as 40% of clinical stage IIA patients will be restaged as having pathological stage I disease following RPLND.[3] RPLND can thus prevent a significant number of clinical stage IIA patients from receiving unnecessary chemotherapy.

RPLND for diagnosis and prevention of relapse is a relatively major operation requiring skill to sample and remove all the nodes. The major complication is damage or removal of the connections of the sympathetic nervous system, which are located next to the lymph nodes. This can lead to disruption of ejaculation of sperm, thereby leading to infertility. Surgeons have devised techniques to spare the sympathetic nervous system connections while still removing most lymph nodes; this preserves normal ejaculation in approximately 90% of patients.[4] Newer treatment strategies involving the adjuvant (post-surgery) administration of chemotherapy have decreased the number of patients requiring lymph node dissection.

Stages of Testicular Cancer

Stage I Seminoma: Stage I testicular cancer is limited to the testes. Pathologic Stage I cancer refers to patients who have a lymph node dissection that is free of cancer. Clinical Stage I cancer is used to classify patients who do not undergo a lymph node dissection.

Stage II Seminoma: Stage II testicular cancer involves the testes and the retroperitoneal lymph nodes. Retroperitoneal lymph node involvement is further characterized by the number and size of involved lymph nodes.

Stage III Seminoma: Stage III testicular cancer has spread beyond the retroperitoneal lymph nodes. Stage III seminoma is subdivided into “non-bulky” Stage III and “bulky” Stage III based on the amount of cancer present at diagnosis.

Recurrent and/or Refractory Seminoma: Cancer has returned or progressed after primary treatment and may be resistant to chemotherapy.

Non-Seminoma Testicular Cancer

Stage I Nonseminoma: Stage I testicular cancer is limited to the testes. Pathologic Stage I cancer refers to patients who have a lymph node dissection that is free of cancer. Clinical Stage I cancer is used to classify patients who do not undergo a lymph node dissection. A retroperitoneal lymph node dissection detects cancer spread in 15–30% of patients whose diagnostic tests indicated no spread prior to surgery.

Stage II Nonseminoma: Stage II testicular cancer involves the testes and the retroperitoneal lymph nodes. Retroperitoneal lymph node involvement is further characterized by the number and size of involved lymph nodes.

Stage III Nonseminoma: Stage III testicular cancer has spread beyond the retroperitoneal lymph nodes. Stage III testicular cancer is subdivided into “non-bulky” Stage III and “bulky” Stage III based on the amount of tumor present at diagnosis.

Recurrent and/or Refractory Nonseminoma: Cancer has returned after primary treatment and may be resistant to chemotherapy.

References

[1] American Cancer Society: Cancer Facts and Figures 2017. Atlanta, Ga: American Cancer Society, 2017.

[2] Ries LAG, Melbert D, Krapcho M, et al.: SEER Cancer Statistics Review, 1975-2005. Bethesda, Md: National Cancer Institute, 2007

[3] Holzik MF, Rapley EA, Hoekstra HJ, et al.: Genetic predisposition to testicular germ-cell tumours. Lancet Oncol 5 (6): 363-71, 2004.

[4] Pettersson A, Richiardi L, Nordenskjold A, et al.: Age at surgery for undescended testis and risk of testicular cancer. N Engl J Med 356 (18): 1835-41, 2007.

[3] Stephenson AJ, Bosl GJ, Motzer RJ, et al.: Retroperitoneal lymph node dissection for nonseminomatous germ cell testicular cancer: impact of patient selection factors on outcome. J Clin Oncol 23 (12): 2781-8, 2005.

[4] Jewett MAS, Groll RJ. Nerve-sparing retroperitoneal lymphadenectomy. Urologic Clinics of North America. 2007;34:149-158.

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