Testicular Cancer Symptoms, Tests, Types & Staging

Testicular cancer facts*

*Testicular cancer facts medical author: Charles P. Davis, MD, PhD

Testicular cancer is a disease when testicular cells become abnormal (malignant) in one or both testicles. It is the most common cancer in 20- to 35-year-old men and has two main types, seminomas and nonseminomas.
The exact cause of testicular cancer is not known but risk factors include undescended testicle(s), congenital abnormalities (for example, kidney, penile abnormalities), and history of testicular cancer (for example, family history or personal history of testicular cancer in one testicle) and being white.
Testicular cancer is often first detected by the patient discovering a lump or swelling in a testicle; other symptoms include testicular pain or discomfort; testicular enlargement; aches in the abdomen, back, or groin; or a fluid collection in the scrotum.
Testicular cancer is diagnosed by the patient's history and physical, ultrasound, and blood tests that measure testicular tumor markers. Biopsy of testicular tissue may be done.
Testicular cancer can be cured by surgery, radiation therapy and/or chemotherapy; side effects include infertility and treatments may affect sexual function. Other side effects are due to radiation and chemotherapy.
Staging helps determine cancer spread in the body. Chest X-rays, CT, MRI, and PET scans, plus serum tumor markers and abdominal lymph node dissection, may help determine the stage of testicular cancer.
Testicular cancer has four stages, ranging from 0 to III. (Stage III is the most advanced cancer stage.) Some stages have sub-stages (for example, stages IA and IB) based on where the testicular cancer has spread.
Recurrent testicular cancer is cancer that has come back after treatment.
Treatments vary with the type and stage of the testicular cancer. Five types of standard treatments are used: surgery, radiation, chemotherapy, surveillance, and high-dose chemotherapy with stem cell transplant.
Clinical trials (clinical research) may be another treatment choice for some patients.
Treatment options for testicular cancers according to stage are outlined for all four stages.
Follow-up treatment is necessary because testicular cancer may recur. Follow-up treatment may involve regular blood tests and possibly CT scans.
Treatment options for recurrent testicular cancer may include combination chemotherapy, high-dose chemotherapy and stem cell implant, surgery, and/or clinical trials.
Prognosis depends on the cancer stage, type, size, and number plus size of retroperitoneal lymph nodes.
Testicular cancer treatment can cause infertility. Patients may consider sperm banking (freezing sperm and storing it) if they want children after their testicular cancer treatment.

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.

Testicular cancer is the most common cancer in men 20 to 35 years old.

Testicular Cancer Symptoms & Signs

The first and early sign of testicular cancer is most commonly a little
("pea-sized") lump on the testis (painless testicular lump). There may be no
real pain, at most just a dull ache in the lower abdomen or groin, perhaps a
sensation of dragging and heaviness. The signs and symptoms of cancer of the
testicle may include…

a lump in or on a testicle (testicular lump) is the most common sign;

any enlargement or
swelling of a testicle and/or scrotum;

shrinking of a testicle;

a feeling of heaviness in the scrotum (scrotal heaviness);

a dull
ache in the lower abdomen (lower abdominal pain) or in the groin (groin ache)…

Health history can affect the risk of testicular cancer.

Anything that increases the chance of getting a disease is called a risk factor. 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. Talk with your doctor if you think you may be at risk. 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 white.

Male Illustration - Testicular Cancer Male Illustration – Testicular Cancer

Signs and symptoms of testicular cancer include swelling or discomfort in the scrotum.

These and other signs and symptoms may be caused by testicular cancer or by other conditions. Check with your doctor if you have any of the following:

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

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 tumor markers are used to detect testicular cancer:
- Alpha-fetoprotein (AFP).
- Beta-human chorionic gonadotropin (β-hCG).
Tumor marker levels are measured before inguinal orchiectomy and biopsy, to help diagnose testicular cancer.
Inguinal orchiectomy: 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.

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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.
PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
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.
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 in staging testicular cancer:
- Alpha-fetoprotein (AFP)
- Beta-human chorionic gonadotropin (β-hCG).
- Lactate dehydrogenase (LDH).

Tumor marker levels are measured again, after 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.

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

Tissue. The cancer spreads from where it began by growing into nearby areas.
Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

Cancer may spread from where it began to other parts of the body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.

Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if testicular cancer spreads to the lung, the cancer cells in the lung are actually testicular cancer cells. The disease is metastatic testicular cancer, not lung cancer.

QUESTION

Cancer is the result of the uncontrolled growth of abnormal cells anywhere in the body.
See Answer

The following stages are used for testicular cancer:

Stage 0 (Testicular Intraepithelial Neoplasia)

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 testicular intraepithelial neoplasia and testicular intratubular germ cell neoplasia.

Stage I

In stage I, cancer has formed. Stage I is divided into stage IA, stage IB, and stage IS and is determined after an 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

Stage II is divided into stage IIA, stage IIB, and stage IIC and is determined after an 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

Stage III is divided into stage IIIA, stage IIIB, and stage IIIC and is determined after an 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.

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What is 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.

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.

Good Prognosis

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.

Intermediate Prognosis

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.

Poor Prognosis

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.

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Five types of standard treatment are used:

Surgery

Surgery to remove the testicle (inguinal orchiectomy) and some of the lymph nodes may be done at diagnosis and staging. 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 come back, is called adjuvant therapy.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. 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. External radiation therapy is used to treat testicular cancer.

Chemotherapy

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.

Surveillance

Surveillance is closely following a patient's condition without giving any treatment unless there are changes in test results. It is used to find early signs that the cancer has recurred (come back). In surveillance, patients are given certain exams and tests on a regular schedule.

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 reinfused stem cells grow into (and restore) the body's blood cells.

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.

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.

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.

Treatment Options by Stage

Stage 0 (Testicular Intraepithelial Neoplasia)

Treatment of stage 0 may include the following:

Radiation therapy.
Surveillance.
Surgery to remove the testicle.

Talk with your doctor about clinical trials that may be right for you.

Stage I Testicular Cancer

Treatment of stage I testicular cancer depends on whether the cancer is a seminoma or a nonseminoma.

Treatment of seminoma may include the following:

Surgery to remove the testicle, followed by surveillance.
For patients who want active treatment rather than surveillance, treatment may include:
- Surgery to remove the testicle, followed by chemotherapy.

Treatment of nonseminoma may include the following:

Surgery to remove the testicle, with long-term follow-up.
Surgery to remove the testicle and lymph nodes in the abdomen, with long-term follow-up.
Surgery followed by chemotherapy for patients at high risk of recurrence, with long-term follow-up.

Talk with your doctor about clinical trials that may be right for you.

Stage II Testicular Cancer

Treatment of stage II testicular cancer depends on whether the cancer is a seminoma or a nonseminoma.

Treatment of seminoma may include the following:

When the tumor is 5 centimeters or smaller:
- Surgery to remove the testicle, followed by radiation therapy to lymph nodes in the abdomen and pelvis.
- Combination chemotherapy.
- Surgery to remove the testicle and lymph nodes in the abdomen.
When the tumor is larger than 5 centimeters:
- Surgery to remove the testicle, followed by combination chemotherapy or radiation therapy to lymph nodes in the abdomen and pelvis, with long-term follow-up.

Treatment of nonseminoma may include the following:

Surgery to remove the testicle and lymph nodes, with long-term follow-up.
Surgery to remove the testicle and lymph nodes, followed by combination chemotherapy and long-term follow-up.
Surgery to remove the testicle, followed by combination chemotherapy and a second surgery if cancer remains, with long-term follow-up.
Combination chemotherapy before surgery to remove the testicle, for cancer that has spread and is thought to be life-threatening.

Talk with your doctor about clinical trials that may be right for you.

Stage III Testicular Cancer

Treatment of stage III testicular cancer depends on whether the cancer is a seminoma or a nonseminoma.

Treatment of seminoma may include the following:

Surgery to remove the testicle, followed by combination chemotherapy. If there are tumors remaining after chemotherapy, treatment may be one of the following:
- Surveillance with no treatment unless tumors grow.
- Surveillance for tumors smaller than 3 centimeters and surgery to remove tumors larger than 3 centimeters.
- A PET scan two months after chemotherapy and surgery to remove tumors that show up with cancer on the scan.
A clinical trial of chemotherapy.

Treatment of nonseminoma may include the following:

Surgery to remove the testicle, followed by combination chemotherapy.
Combination chemotherapy followed by surgery to remove the testicle and all remaining tumors. Additional chemotherapy may be given if the tumor tissue removed contains cancer cells that are growing or if follow-up tests show that cancer is progressing.
Combination chemotherapy before surgery to remove the testicle, for cancer that has spread and is thought to be life-threatening.
A clinical trial of chemotherapy.

Talk with your doctor about clinical trials that may be right for you.

Treatment Options for Recurrent Testicular Cancer

Treatment of recurrent testicular cancer may include the following:

Combination chemotherapy.
High-dose chemotherapy and stem cell transplant.
Surgery to remove cancer that has either:
- come back more than 2 years after complete remission; or
- come back in only one place and does not respond to chemotherapy.
A clinical trial of a new therapy.

Talk with your doctor about clinical trials that may be right for you.

Certain factors affect prognosis (chance of recovery) and 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 in patients who receive adjuvant chemotherapy or radiation therapy after their primary treatment.

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.

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