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. But testicular cancer is the most common cancer in American males between the ages of 15 and 34. The cause of testicular cancer is unknown.

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. Regular testicular self-examinations can help identify growths early, when the chance for successful treatment of testicular cancer is highest.

Signs and symptoms

Testicular cancer can result in a number of signs and symptoms. These may include:

A lump or enlargement in either testicle
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 or the scrotum
Enlargement or tenderness of the breasts
Unexplained fatigue or a general feeling of not being well
Cancer usually affects only one testicle.

Causes

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

Researchers don't know what causes testicular cancer. Risk factors may 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 other men are. The risk remains, 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's syndrome, may increase your risk of testicular cancer.

Family history. If other family members have had testicular cancer, you may have an increased risk.

Age. Testicular cancer affects teens and younger men, particularly those between ages 15 and 34. However, it can occur at any age.

Race. Testicular cancer is more common in white men than in black men. The reason for racial differences in the incidence of testicular cancer is unknown.

When to seek medical advice.

See your doctor if you detect any pain, swelling or lumps in your testicles or groin area, especially if these signs and symptoms last longer than two weeks. Make an appointment with your doctor even if a lump in your testicle isn't painful. Only a small percentage of testicular cancers are painful from the outset.

Screening and diagnosis

Most men discover testicular cancer themselves, either unintentionally or while doing a testicular self-examination to check for lumps. In other cases, your doctor may detect a lump during a routine physical exam.

To determine whether a lump is testicular cancer, your doctor may recommend:

Ultrasound. A testicular ultrasound test uses sound waves to create a picture of the scrotum. During an ultrasound you lie on your back with your legs spread. Your doctor then applies a clear gel to your scrotum. A hand-held probe is moved over your scrotum to make the ultrasound image.

An ultrasound test can help your doctor determine the nature of any testicular lumps, such as if the lumps are solid or fluid filled. Ultrasound also tells your doctor whether lumps are inside or outside of the testicle. Your doctor uses this information to determine whether a lump is likely to be testicular cancer.

Blood tests. Your doctor may order tests to determine the levels of tumor markers in your blood. Tumor markers are substances that occur normally in your blood, but the levels of these substances may be elevated in certain situations, including testicular cancer. A high level of a tumor marker in your blood doesn't mean you have cancer, but it may help your doctor in determining your diagnosis.

Surgery to remove a testicle (radical inguinal orchiectomy). If your doctor determines the lump on your testicle may be cancerous, he or she may recommend surgery to remove the testicle. Your testicle will be analyzed in a laboratory to determine if the lump is cancerous and, if so, what type of cancer.

In general, a biopsy or removal of the lump alone isn't used when testicular cancer is suspected. However, a biopsy may be an option in certain situations, for instance, if you have only one testicle.
Determining the type of cancer

Your doctor will have your extracted testicle analyzed to determine the type of the testicular cancer. The type of testicular cancer you have determines your treatment and your prognosis. In general, there are two types of testicular cancer:

Seminoma. Seminomas occur in all age groups, but if an older man develops testicular cancer it is more likely to be seminoma. Seminomas, in general, aren't as aggressive as nonseminomas, and are particularly sensitive to radiation therapy.

Nonseminoma. Nonseminoma tumors tend to develop earlier in life and grow and spread rapidly. Several different types of nonseminomatous tumors exist, including choriocarcinoma, embryonal carcinoma, teratoma and yolk sac tumor. Nonseminomatous tumors are sensitive to radiation therapy, but not as sensitive as seminomas. Chemotherapy is often very effective for nonseminomas, even if the cancer has spread.

Sometimes both types of cancer are present in a tumor. In that case, the cancer is treated as though it is nonseminoma.

Staging the cancer

Once your doctor confirms your diagnosis, the next step is to determine the extent (stage) of the cancer. To determine whether cancer has spread outside of your testicle, you may undergo:

Computerized tomography (CT). CT scans take a series of X-ray images of your abdomen. Your doctor uses CT scans to look for signs of cancer in your abdominal lymph nodes.

X-ray. An X-ray of your chest may determine whether cancer has spread to your lungs.

Blood tests. Blood tests to look for elevated tumor markers can help your doctor understand whether cancer likely remains in your body after your testicle is removed.

After these tests, your doctor assigns your testicular cancer a stage. The stage helps determine what treatments are best for you. The stages of testicular cancer are:

Stage I. Cancer is limited to the testis.
Stage II. Cancer has spread to the lymph nodes in the abdomen.
Stage III. Cancer has spread to other parts of the body. Testicular cancer most commonly spreads to the lungs, liver, bones and brain.

Complications

Testicular cancer treatment can cause infertility. Whether you'll experience infertility after cancer treatment depends on the extent of your cancer and what treatments you undergo. Many men with testicular cancer have decreased sperm production even before cancer treatment begins. Treatments that can cause infertility include:

Surgery. Surgery to remove one testicle (orchiectomy) won't cause infertility, and it won't affect your ability to have an erection. If your surgery involves removal of lymph nodes (retroperitoneal lymph node dissection) you may experience difficulty ejaculating if nerves are severed during surgery. Lymph node dissection won't affect your ability to get an erection. Surgery using a nerve-sparing technique reduces the chance that you'll have trouble ejaculating after treatment. Ask your surgeon whether this procedure may be appropriate for you.

Surgery to remove both testicles will leave you infertile. Also, your body will no longer be able to make testosterone, so your doctor will recommend testosterone replacement treatments.

Radiation therapy. Radiation therapy can interfere with sperm production, causing infertility. For some men, sperm production may be limited for a year or two, eventually returning as the treated area heals. For other men, infertility may be permanent after radiation therapy.

Chemotherapy. Certain chemotherapy drugs can cause infertility, while others won't. Ask your doctor about your particular chemotherapy drugs. In some cases, sperm production may come back with time. In other cases, infertility is permanent after chemotherapy.

Consider storing sperm in a sperm bank before you begin treatment — even if you've yet to consider having children or you think you won't want more children. In most cases, storing sperm now for later use is more successful than trying to restore fertility later if you decide you'd like to start a family. Sperm can be frozen (cryopreserved) for years in case you experience infertility after cancer treatment.

Treatment

The options you have for treating your testicular cancer depend on several factors, including the type and stage of your cancer, your overall health and your own preferences. Treatment options may include:

Surgery
Surgery to remove your testicle (radical inguinal orchiectomy) is the primary treatment for nearly all stages and types of testicular cancer. To remove your testicle, your surgeon makes an incision in your groin and extracts the entire testicle through the opening. A prosthetic, saline-filled testicle can be inserted if you choose. You'll receive anesthesia during surgery. All surgical procedures carry a risk of pain, bleeding and infection.

You may also have surgery to remove the lymph nodes in your groin (retroperitoneal lymph node dissection). Sometimes this is done at the same time as surgery to remove your testicle. In other cases it can be done later. Your lymph nodes are removed through a large incision in your abdomen. Your surgeon takes care to avoid severing nerves surrounding the lymph nodes, but in some cases severing the nerves may be unavoidable. Severed nerves can cause difficulty ejaculating, but won't prevent you from having an erection. A newer technique called nerve-sparing surgery may be an option.

In cases of early-stage testicular cancer, surgery may be the only treatment needed. Your doctor will give you a recommended schedule for follow-up appointments. At these appointments — typically every few months for the first few years and then less frequently after that — you'll undergo blood tests, CT scans and other procedures to check for signs that your cancer has returned. If you have a more advanced testicular cancer or if you're unable to adhere closely to the recommended follow-up schedule, your doctor may recommend other treatments after surgery.

Radiation therapy
Radiation therapy may be a treatment option if you have the seminoma type of testicular cancer. Radiation therapy uses high-powered energy beams, such as X-rays, to kill cancer cells. During radiation therapy, you're positioned on a table and a large machine moves around you, aiming the energy beams at precise points on your body. Side effects may include fatigue, as well as skin redness and irritation in your abdominal and groin areas. You may experience infertility as a result of radiation therapy. However, as the treated area heals you may regain your fertility.

Chemotherapy
Chemotherapy treatment uses drugs to kill cancer cells. Chemotherapy drugs travel throughout your body to kill cancer cells that may have migrated from the original tumor. Your doctor might recommend chemotherapy after surgery. Chemotherapy may be used before or after lymph node removal. Side effects of chemotherapy depend on the drugs being used. Ask your doctor what to expect. Common side effects include fatigue, nausea, hair loss, infertility and an increased risk of infection.

Treatment for advanced or recurrent testicular cancer
If your cancer hasn't responded to other treatments or if your cancer has returned, you and your doctor may consider other treatments. You may consider enrolling in a clinical trial. These research studies give you a chance to try experimental treatments and procedures that are being developed for future use. Clinical trials aren't guaranteed to bring a cure, and side effects of new medications may not be known. Ask your doctor about clinical trials that are open to people with testicular cancer, as well as the possible risks and benefits of experimental treatments.

One treatment being studied for use in advanced testicular cancer is stem cell transplant. Before a stem cell transplant, you're given drugs that coax your body's bone marrow stem cells out of your bones and into your bloodstream. Then the stem cells are filtered from your blood and frozen for later use. You then undergo high doses of chemotherapy to kill any cancer cells in your body, which may also kill bone marrow cells. Your stored stem cells are thawed and put back into your body to replenish your bone marrow cells.

Prevention

There's no sure way to prevent testicular cancer. However, regularly self-examination may improve your chances of finding a tumor at its earliest stage. Beginning in your midteenage years, and continuing throughout your life, examine your testicles at least once a month.

A good time to examine your testicles is after a warm bath or shower. The heat from the water relaxes your scrotum, making it easier for you to find anything unusual.

To do this examination, follow these steps:

Stand in front of a mirror. Look for any swelling on the skin of the scrotum.

Examine each testicle with both hands. Place the index and middle fingers under the testicle while placing your thumbs on the top.

Gently roll the testicle between the thumbs and the fingers. Remember that the testicles are usually smooth, oval shaped and somewhat firm. It's normal for one testicle to be slightly larger than the other. Also, the cord leading upward from the top of the testicle (epididymis) is a normal part of the scrotum. By regularly performing this exam, you will become more familiar with your testicles and aware of any changes that might be of concern.

If you find a lump, call your doctor as soon as possible. Testicular cancer is highly treatable, especially when identified early.

Your doctor should also examine your testicles whenever you have a physical. If you have an undescended testicle, be sure to tell your doctor, who may refer you to a urologist for treatment or a more specialized exam.

Coping skills

Each man comes to terms with his testicular cancer and deals with the ensuing emotions in his own way. You may feel scared and unsure of your future after your diagnosis. While feelings of anxiety may never go away, you can create a plan to help you manage your emotions. Try to:

Learn all you can about testicular cancer. The more you know about your cancer and your treatment options, the more confident you'll feel as you make decisions about your treatment. Write down any questions that come to mind and ask them at your next doctor's appointment. Ask your doctor or other members of your health care team to recommend reputable sources of further information. Good places to start include the National Cancer Institute and the American Cancer Society. Each has a Web site and a telephone support line you can call for more information.

Take care of your body. Make healthy choices in your everyday life to help your body as you begin cancer treatment. Eat a healthy diet with a variety of fruits and vegetables. Get plenty of rest so that you wake each morning feeling refreshed. Eliminate unnecessary stress from your daily life so that you can concentrate on getting well. With your doctor's approval, find time for gentle exercise a few times each week. If you smoke, quit. Talk to your doctor about medications and other strategies to help you stop smoking.

Connect with other cancer survivors. Find other testicular cancer survivors in your community or online. Contact the American Cancer Society for a listing of support groups in your area.

Stay connected with your loved ones. Your family and friends are just as afraid for your health as you are. They want to help, so don't turn down their offers to assist with transportation to appointments or with errands. Close friends and family will listen when you need someone to talk to or provide a distraction when you're feeling blue.

Adapted from: Mayo Foundation for Medical Education and Research