Testicular cancer accounts for only 1 percent of all cancers in men. About 7,500 men in the United States are diagnosed with testicular cancer each year.

Testicular cancer occurs most often in men between the ages of 15 and 39, and is the most common form of cancer in men between the ages of 20 and 34.

It is more common in Caucasian men than in African-American men. The testicular cancer rate has more than doubled among white men in the past 40 years, but has not changed for black men. The reason for these differences is not known.

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, which 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 matures and are stored.

What is testicular cancer?

Testicular cancer is a disease in which cells become malignant (cancerous) in one or both testicles.

Almost all testicular cancers start in the germ cells. The two main types of testicular germ cell tumors are seminomas (which make up about 30 percent of all testicular cancers), 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.

Nonseminomas are a group of cancers that include choriocarcinoma, embryonal carcinoma, teratoma, and yolk sac tumors.

RISK FACTORS

The causes of testicular cancer are not known. However, studies show that several factors increase a man's chance of developing this disease.

• Undescended testicle (cryptorchidism): Normally, the testicles descend into the scrotum before birth. A man's risk for testicular cancer is increased if a testicle did not move down into the scrotum. This is true even if surgery is done to move the testicle into the scrotum.
• Abnormal testicular development: Men whose testicles did not develop normally are at increased risk.
• Klinefelter’s syndrome: Men with Klinefelter's syndrome (a sex chromosome disorder that may be characterized by low levels of male hormones, sterility, breast enlargement, and small testes) are at greater risk of developing testicular cancer.
• History of testicular cancer: Men who have had testicular cancer are at increased risk of developing cancer in the other testicle.
  Family history of testicular cancer: The risk for testicular cancer is greater in men whose brother or father has had the disease.

SYMPTOMS

Men themselves find most testicular cancers. Also, doctors generally examine the testicles during routine physical exams. Between regular checkups, if a man notices anything unusual about his testicles, he should talk with his doctor. Men should see a doctor if they notice any of the following symptoms:

• A painless lump or swelling in a testicle.
• Any enlargement of a testicle or change in the way it feels
• A feeling of heaviness in the scrotum
• A dull ache in the lower abdomen, back, or the groin (the area where the thigh meets the abdomen)
• A sudden collection of fluid in the scrotum
• Pain or discomfort in a testicle or in the scrotum
• These symptoms can be caused by cancer or by other conditions. It is important to see a doctor to determine the cause of any symptoms.
  

TESTS AND DIAGNOSIS

To help find the cause of symptoms, the doctor evaluates a man's general health. The doctor also performs a physical exam and may order laboratory and diagnostic tests. If a tumor is suspected, the doctor will probably suggest a biopsy, which involves surgery to remove the testicle (orchiectomy) so that samples of tissue can be examined under a microscope.

• Blood tests measure the levels of tumor markers. Tumor markers are substances often found in higher-than-normal amounts when cancer is present. Tumor markers such as alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and lactase dehydrogenase (LDH) may indicate the presence of a tumor, even if it is too small to be detected by physical exams or imaging tests.
• Ultrasound is a diagnostic test in which high-frequency sound waves are bounced off tissues and internal organs. Their echoes produce a picture called a sonogram. Ultrasound of the scrotum can show the presence and size of a mass in the testicle. It is also helpful in ruling out other conditions, such as swelling due to infection.
• Biopsy is microscopic examination of testicular tissue by a pathologist. It is the only sure way to know whether cancer is present. In nearly all cases of suspected cancer, the entire affected testicle is removed through an incision in the groin. This procedure is called radical inguinal orchiectomy. In rare cases (for example, when a man has only one testicle), the surgeon performs an inguinal biopsy, removing a sample of tissue from the testicle through an incision in the groin and proceeding with orchiectomy only if the pathologist finds cancer cells. (The surgeon does not cut through the scrotum to remove tissue. If the problem is cancer, this procedure could cause the disease to spread.)

If testicular cancer is found, more tests are needed to find out if the cancer has spread from the testicle to other parts of the body. Determining the stage (extent) of the disease helps the doctor to plan appropriate treatment.

Certain factors affect prognosis (chance of recovery) and treatment options:

• 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, ß-hCG, and LDH)
• Type of cancer
• Size of the tumor
• Number and size of retroperitineal lymph nodes

STAGING

Staging is the process used to find out if cancer has spread within the testicles or to other parts of the body. 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. A computer linked to an x-ray machine makes the pictures. A dye may be injected into a vein or swallowed to help make the organs or tissues show up more clearly. This procedure is also called computed tomography (CT), computerized tomography (CT), or computerized axial tomography (CAT) scans
• Lymphangiography: A procedure used to x-ray the lymph system. A dye is injected into the lymph vessels in the feet. The dye travels upward through the lymph nodes and lymph vessels and x-rays are taken to see if there are any blockages. This test helps find out whether cancer has spread to the lymph nodes
• Abdominal lymph node dissection: A procedure to examine lymph nodes in the abdomen. Lymph nodes are removed and a patholigist checks them under a microscope for cancer cells. 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.
• Radical inguinal orchiectomy and biopsy: 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.
• 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 or 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 (ß-hCG)
  • Lactate dehydrogenase (LDH)

Tumor marker levels are measured again after radical 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.

The following stages are used for testicular cancer:

• Stage 0 - In stage 0, abnormal cells are found only in the tiny tubules where the sperm cells begin to develop. The cells do not invade normal tissues. This is sometimes called a "precancerous condition." Stage 0 cancer is also called carcinoma in situ. All tumor marker levels are normal
• Stage I - Stage I is divided into Stage IA, Stage IB, and Stage IS, and is determined after a radical inguinal orchiectomy is done
  • 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.
  • Stage IB: The cancer is in the testicle and the epididymis and has spread to the blood 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 or lymph vessels of the testicle. All tumor marker levels are normal.
  • 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 a radical inguinal orchiectomy is done
  • Stage IIA: The 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 (about 3/4 of an inch). All tumor marker levels are normal or slightly above normal.
  • Stage IIB: The 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 (about 3/4 of an inch), but none are larger than 5 centimeters (about 2 inches); or has spread to more than 5 lymph nodes; the lymph nodes are not larger than 5 centimeters (about 2 inches). All tumor markers levels are normal or slightly above normal.
  • Stage IIC: The 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 (about 2 inches). 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 a radical inguinal orchiectomy is done
  • Stage IIIA: The 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. The level of one or more tumor markers may range from normal to slightly above normal.
  • Stage IIIB: The cancer is anywhere within the testicle, spermatic cord, or scrotum; and may have spread to one or more nearby or distant lymph nodes or to the lungs. The level of one or more tumor markers may range from normal to high.
  • Stage IIIC: The cancer is anywhere within the testicle, spermatic cord, or scrotum; and may have spread to one or more nearby or distant lymph nodes or to the lungs or anywhere else in the body. The level of one or more tumor markers may range from normal to very high.

Testicular tumors are divided into 3 prognosis 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 (ß-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. ß-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.

TREATMENTS

Although the incidence of testicular cancer has risen somewhat in recent years, more and more men with this disease are successfully treated. When testicular cancer is found early, the treatment can often be less aggressive and may cause fewer side effects. Treatment is also more successful when testicular cancer is found early.

Most men with testicular cancer can be cured with surgery, radiation therapy, and/or chemotherapy. The side effects depend on the type of treatment and may be different for each person.

Although seminomas and nonseminomas grow and spread in similar ways, each type may need different treatment. (If the tumor contains both seminoma and nonseminoma cells, it is treated as a nonseminoma.)

Treatment also depends on the stage of the cancer, the patient's age and general health, and other factors. A team of specialists, which may include a surgeon, a medical oncologist, and a radiation oncologist, often provides treatment.

Surgery to remove the testicle through an incision in the groin is called a radical inguinal orchiectomy. Men may be concerned that losing a testicle will affect their ability to have sexual intercourse or make them sterile (unable to produce children). However, a man with one remaining healthy testicle can still have a normal erection and produce sperm. Therefore, an operation to remove one testicle does not make a man impotent (unable to have an erection) and seldom interferes with fertility (the ability to produce children). Men can also have an artificial testicle, called a prothesis, placed in the scrotum. The implant has the weight and feel of a normal testicle.

Some of the lymph nodes located deep in the abdomen may also be removed (lymph node dissection). This type of surgery does not change a man's ability to have an erection or an orgasm, but it can cause sterility because it interferes with ejaculation. Patients may wish to talk with the doctor about the possibility of removing the lymph nodes using a special nerve-sparing surgical technique that may preserve the ability to ejaculate normally.

Radiation therapy, also called radiotherapy, uses high-energy rays to kill cancer cells and shrink tumors. Radiation therapy is a local therapy; it affects cancer cells only in the treated areas. Radiation therapy for testicular cancer comes from a machine outside the body (external beam radiation) and is usually aimed at lymph nodes in the abdomen. Seminomas are highly sensitive to radiation. Nonseminomas are less sensitive to radiation, so men with this type of cancer usually do not undergo radiation. Radiation therapy may be given after orchiectomy.

Radiation therapy affects normal as well as cancerous cells. The side effects of radiation therapy depend mainly on the treatment dose. Common side effects include fatigue, skin changes at the site where the treatment is given, loss of appetite, nausea, and diarrhea. Radiation therapy interferes with sperm production, but most patients regain their fertility over a period of 1 to 2 years.

Chemotherapy is the use of anticancer drugs to kill cancer cells throughout the body. Chemotherapy is given to destroy cancerous cells that may remain in the body after surgery. The use of anticancer drugs following surgery is known as adjuvant therapy. Chemotherapy may also be the initial treatment if the cancer is advanced; that is, if it has spread outside the testicle. Most anticancer drugs are given by injection into a vein (IV).

Chemotherapy is a systemic therapy, meaning that drugs travel through the bloodstream and affect normal as well as cancerous cells all over the body. The side effects depend largely on the specific drugs and the dose. Common side effects may include nausea, loss of hair, fatigue, diarrhea, vomiting, fever, chills, coughing/shortness of breath, mouth sores, or skin rash. Other common side effects are dizziness, numbness, loss of reflexes, or difficulty hearing. Some anticancer drugs interfere with sperm production. Although the reduction in sperm count is permanent for some patients, many others recover their fertility.

Some men with advanced or recurrent testicular cancer may have a bone marrow transplant, which allows for high doses of chemotherapy. These high doses of chemotherapy destroy the bone marrow, which makes and stores blood cells. In a transplant, however, bone marrow or peripheral stem cells are removed from the patient before chemotherapy. The cells are frozen. The patient is given high doses of chemotherapy. The cells are then thawed and returned to the patient through a needle.

Men with testicular cancer should discuss their concerns about sexual function and fertility with the doctor. If a man is to have treatment that might lead to infertility, he may want to ask the doctor about sperm banking (freezing sperm before treatment for use in the future). This procedure can allow some men to produce children after loss of fertility.

This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Cancer.gov Web site.

Lifelong follow-up exams are very important for men who have had testicular cancer.

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.

Lifelong clinical exams are very important. The patient will probably have checkups once per month during the first year after surgery, every other month during the next year, and less often after that.