Testicular Cancer

Testicular cancer occurs in the testicles (testes), which are located inside the scrotum, a loose bag of skin underneath the penis. The testicles produce male sex hormones and sperm for reproduction.

Compared with other types of cancer, testicular cancer is rare – fewer than 20,000 US cases per year. But testicular cancer is the most common cancer in American males between the ages of 15 and 35.

Testicular cancer is highly treatable, even when cancer has spread beyond the testicle. Depending on the type and stage of testicular cancer, you may receive one of several treatments, or a combination.

With early diagnosis, testicular cancer can be cured. With treatment, the risk of death from this cancer is small.

Signs and symptoms:

• A painless lump or enlargement in either testicle (most common sign)
• A feeling of heaviness in the scrotum
• A dull ache in the abdomen or groin
• A sudden collection of fluid in the scrotum
• Pain or discomfort in a testicle, the scrotum or groin
• Enlargement or tenderness of the breasts
• Back pain
• Loss of sex drive
• Cancer usually affects only one testicle.

Causes

• It's not clear what causes testicular cancer in most cases.
• Doctors know that testicular cancer occurs when healthy cells in a testicle become altered. Healthy cells grow and divide in an orderly way to keep your body functioning normally. But sometimes some cells develop abnormalities, causing this growth to get out of control — these cancer cells continue dividing even when new cells aren't needed. The accumulating cells form a mass in the testicle.
• Nearly all testicular cancers begin in the germ cells — the cells in the testicles that produce immature sperm. What causes germ cells to become abnormal and develop into cancer isn't known.

Risk factors

• Factors that may increase the risk of testicular cancer include:
  • An undescended testicle (cryptorchidism). The testes form in the abdominal area during fetal development and usually descend into the scrotum before birth. Men who have a testicle that never descended are at greater risk of testicular cancer than are men whose testicles descended normally. The risk remains elevated even if the testicle has been surgically relocated to the scrotum.
    • Still, the majority of men who develop testicular cancer don't have a history of undescended testicles.
  • Abnormal testicle development. Conditions that cause testicles to develop abnormally, such as Klinefelter syndrome, may increase your risk of testicular cancer.
  • Family history. If father or brother have had testicular cancer, you may have an increased risk.
  • Age. Testicular cancer affects teens and younger men, particularly those between ages 15 and 35. However, it can occur at any age.
  • Race. Testicular cancer is more common in white men than in black men.
  • Abnormal cells in the testicle called germ cell neoplasia in situ (GCNIS), most often found during an infertility test
  • History of HIV positivity
  • Body size – tall slender males are at higher risk

Prevention

• There's no way to prevent testicular cancer.
• Some doctors recommend regular testicle self-examinations to identify testicular cancer at its earliest stage. But not all doctors agree. Discuss testicular self-examination with your doctor if you're unsure about whether it's right for you.

Diagnosis

• Testicular Self-Exam - The best time to do a testicular self-exam is after a warm bath or shower, while standing, when the scrotum is relaxed. It only takes a few minutes.
• Medical Exam
  • Health record and physical exam: Your urologist will talk with you about your health. They will examine the scrotum, belly (abdomen), lymph nodes, and other parts to look for signs of cancer. They will look for lumps, firmness or signs of swelling. Tell them if you have a history of undescended testes.
  • Testicular ultrasound: This imaging test is used to see inside the scrotum and to check a suspicious lump. Other scans or x-rays may be done if your doctor would like to see inside your chest or abdomen. This is done to see if cancer has spread to lymph nodes, the lungs or liver. MRIs are rarely used, but needed in some cases to check the brain and spinal cord.
  • Blood test: A blood test is taken to check tumor markers. These are proteins and hormones made by some testicular cancers. AFP, ACG and LDH tumor markers rise with some cancers but many testicular cancers will not produce tumor markers. In other words, just because tumor markers are normal does not mean that you are free of cancer. It’s of great value to ask your doctor about your tumor maker levels and learn what’s normal vs. not normal.
    • Serum Tumor Marker Test: Tumor markers (AFP, HCG, and LDH) should be measured before any treatment, such as surgery. If cancer is found, tumor marker tests will be repeated after treatment to track how well you’re doing over time. Some medicines and marijuana can create false positive levels of HCG. Tell your doctor about your medicine and/or marijuana use.
      • Pure seminomas can raise HCG levels but never AFP levels.
      • Non-seminomas often raise AFP and/or HCG levels.
      • Over the counter urinary pregnancy tests do check for HCG levels in the urine but are not reliable tests for testicular cancer.

Testicular Cancer Stages

With testicular cancer, cells are looked at after surgery is done to remove the cancerous tissue.”

• Stage 0: This is also called “Germ Cell Neoplasia In Situ (GCNIS)”. This is not really cancer, but a warning that cancer could grow. GCNIS may be found in the seminal tubules and nowhere else.
• Stage I (IA, IB, IS): Cancer is found only in the testicle. It has not spread to nearby lymph nodes.
• Stage II (IIA, IIB, IIC): Cancer has spread to one or more lymph nodes in the abdomen (belly). It has not spread to other parts of the body.
• Stage III (IIIA, IIIB, IIIC): Cancer has spread beyond the lymph nodes in the abdomen. Cancer may be found far from the testicles, like in distant lymph nodes or the lungs. Tumor marker levels are high.

Treatment

Often, a team of doctors (urologist, oncologist, radiation oncologist) will work together to find the best treatment plan for each patient. Choices will be based on the exact diagnosis and health of the patient.

• Treatment options include:
  • Surveillance - a way to look for changes with normal check-ups. These include a physical exam, tumor marker tests, and imaging tests. Imaging tests start with an ultrasound of the scrotum. They can also involve chest x-rays or CT scans. No matter what treatment, most men should be checked for signs of low-testosterone as well.
  • Surgery - the main treatment for testicular cancer. Most often, an orchiectomy is done to remove the entire testis. Depending on the diagnosis, other options may be offered. Changes in fertility should be discussed first.
  • Radiation - used to kill cancer cells on the testis or in nearby lymph nodes. It is used for seminoma-cell cancers, because some forms of non-seminoma are resistant to radiation. It may be an option if testicular cancer (either type) has spread to distant organs like the brain. There are a few radiation therapy types used.
  • Chemotherapy - used to kill cancer cells on the testis or in nearby lymph nodes. It is used for seminoma-cell cancers, because some forms of non-seminoma are resistant to radiation. It may be an option if testicular cancer (either type) has spread to distant organs like the brain. There are a few radiation therapy types used.
• Before any treatment starts, men should talk with their urologist about if they want to have a child. Infertility and changes in male hormones are common after certain treatments. Sperm banking may be useful before treatment, mostly if you hope to have children in the future.
• Men can also ask about a testicular prosthesis (fake body part) before surgery. This is a way to make the testicles look more “normal” after a testis is removed.

Treatment for Children

• Testicular tumors in children are rare. If it’s found early, treatment is often successful. If it’s found after it has spread, it’s harder to treat. As with men, this cancer often begins as a painless lump. The most common type in boys are yolk sac tumors and teratomas. The cancer cell-types found are:
  • Yolk Sac Tumors. When these tumors grow in adults, they are more unsafe.
  • Teratomas. These germ cells grow in hard to predict ways and do not respond to chemotherapy. They can be treated with surgery.
  • Gonadal Stromal Tumors. These are more likely to spread and require a chest x-ray if found.
  • Gonadoblastoma and Dysgerminoma are rare. They happen in children with testicles that did not grow normally before birth.
  • Gonadoblastomas are benign. They can become cancer in 50% of cases.
• After treatment, children are checked for at least two years to make sure all is well. Physical exams, tumor marker tests and chest x-rays are common follow-up tests. Most often boys do not look different if a testicle is removed. The scrotum is not cut and the other testicle keeps growing. If a boy does not like the result, a prosthesis is an option. This is most often done after puberty.
• Most boys who’ve been treated for testicular cancer will be healthy, and can have children when they grow up.

Sex Life and Fertility

• The removal of one testicle should not change your sexual energy or fertility (chances of having a child). Most men can have a normal erection after surgery. Still, men diagnosed with testicular cancer have a higher risk of infertility and low testosterone than the others. You may also have a brief decrease in sperm growth. If lymph nodes were removed, it may be harder to ejaculate.
• If you have problems, there are drugs that can help with ejaculation. If you are worried, talk with your doctor. You can also keep in mind using a bank sperm before treatment.
• As you heal, your body will find balance. Over time, the healthy testicle and lymph nodes will make enough testosterone to help you return to normal. Your doctor may check hormone levels on an annual basis as part of your check-up

What is the cure rate for testicular tumors?

• The good news is that surgery plus chemotherapy or radiation (alone or combined) can cure almost 100% of low stage or early disease tumors. These treatments also cure at least 85% of more advanced tumors.

What are the chances that the cancer will grow in the other testicle?

• For patients diagnosed as boys, it’s very rare for a new tumor to form after treatment. In adults there is a 2 to 3% chance of a tumor growing in the opposite side. Most often, no new tumor will grow after treatment. Self-exams are very helpful for piece-of-mind.

References & additional reading

• Mayo Clinic - Testicular cáncer
• Urology A-Z - What is Testicular Cancer?
• MedlinePlus - Testicular Cancer
• Flushing Hospital Medical Center – April is Testicular Cancer Awareness Month. Andrew Rubin. 22 Apr 2021
• The Urethra Clinic – What is Testicular Cancer; Symptoms, Diagnosis & Treatment
• Bismarck Cancer Center – Can Testicular Cancer be Found Early? By Bismarck Cancer. 1 Apr 2020