Testicular Cancer - Cancer Institute Overview
Taussig Cancer Institute's GU Medical Oncology Program has ongoing multidisciplinary clinics with colleagues from the Glickman Urologic and Kidney Institute and the GU section of the Department of Radiation Oncology. Urologic oncologists, pediatric urologists, cancer doctors, medical and radiation oncologists, radiologists, and genitourinary pathologists at the Clinic collaborate to provide services for more than 1,000 adrenal, renal (kidney), bladder, prostate and testicular cancer and Wilms’ tumor patients annually. More than 350 surgical procedures for urologic cancer are performed by our doctors each year.
What are the testicles?
The testicles are part of the male reproductive system and they are responsible for the production of sperm and testosterone. Testosterone is the primary male sex hormone and is responsible for many aspects of sexual function in men, including the desire for sexual activity.
It is also responsible for the increased body hair and muscle mass that characterizes the appearance of men (as compared to women). Men have two testicles, one on the right and one on the left, and they are located in the scrotum, the sac of tissue below the penis.
Each testicle is connected to the rest of the body by a cord referred to as the spermatic cord. The spermatic cord contains an artery and vein that bring blood to and from the testicles. It also contains lymph vessels that drain lymph from the testicle and a tube called the vas deferens that carries sperm from the testis toward the penis.
What is testicular cancer?
Testicular cancer is a disease in which a tumor - an abnormal and uncontrolled growth of cells - is found in the testicle. Several different kinds of cancer can grow in the testicles but the most common type by far is a group of cancers referred to as germ cell tumors.
Germ cell tumors include the following cancers: embryonal carcinoma, choriocarcinoma, seminoma, teratoma and yolk sac tumors. (Yolk sac tumors are sometimes referred to as endodermal sinus tumors.) Most germ cell tumors consist of a mixture of two or more of these cancers but some consist of only one type, usually seminoma. Tumors that contain more than one of these types of cancer are called mixed germ cell tumors.
For treatment purposes, cancer doctors divide germ cell tumors in men into two major categories: pure seminomas (tumors that consist entirely of seminoma) and tumors that contain other types of germ cell tumor either with or without elements of seminoma. Tumors that consist, at least in part, of embryonal carcinoma, choriocarcinoma, teratoma, and/or yolk sac tumor are referred to as nonseminomas even though they sometimes contain some seminoma.
In order for a tumor to be called a seminoma, it must be pure seminoma without other types of germ-cell cancer present. While seminomas and nonseminomas share an excellent prognosis, there are important treatment differences.
Other, very rare types of testicular cancer include leukemia, lymphoma, carcinoma of the rete testis, and sex-cord stromal tumors (including leydig-cell tumors and sertoli-cell tumors). Carcinoma of the of the epidymis is not technically testicular cancer but can present with similar symptoms of a painless or painful lump or mass in the scrotum. This discussion is about testicular germ cell tumors and not about the other, much rarer, forms of testicular cancer.
What causes testicular cancer?
Cancer doctors do not know what causes testicular cancer but several risk factors have been identified. A risk factor is a trait or behavior that increases a person's chance of developing a disease or predisposes a person to a certain condition.
There are no occupational exposures or personal behaviors that have been proven to increase the risk of testicular cancer. Risk factors for testicular cancer include:
- An undescended testicle (referred to as cryptorchidism). Some boys are born with only one testicle in the scrotum. This usually means that the other testicle is still in the abdomen or pelvis and has not completed its normal journey down to the scrotum. Such boys have an increased risk of developing testicular cancer both in the undescended testicle and in the other, descended testicle. However, it appears that the increased cancer risk associated with an undescended testicle can be almost entirely eliminated if the testis is surgically removed or brought down into the scrotum before puberty.
- Family member with testicular cancer. Men who have a brother or father with testis cancer also face an increased risk of developing the disease.
- A prior diagnosis of testicular cancer. Men who have had testis cancer in one testicle have an increased risk of developing a new testicular cancer in the other testicle.
What are the symptoms of testicular cancer?
Symptoms of testicular cancer include:
- Enlargement of the testicle or scrotum.
- Pain in the testicle.
- Growth of breast tissue in men (referred to as gynecomastia).
- Back pain (although there are many other more common causes of back pain)
Testicular cancer is usually diagnosed after a man (or his sexual partner) notices that one of his testicles is growing larger, has developed a lump, has become harder, has become painful or is otherwise abnormal. If this is discovered, you should see a cancer doctor immediately for further diagnosis.
Because most testis cancers grow quickly and are easy for a man to detect himself, some experts recommend that men examine their own testicles once a month. However, because self-examination has never been proven to save lives, there is no widespread agreement on whether or not self-examination should be recommended.
If a man does notice an abnormality in either or both of his testicles, he should see a doctor as soon as possible (certainly within days) for evaluation.
When evaluating a man suspected of having testicular cancer, a doctor will perform an examination and order tests to help determine whether a cancer is present. Tests may include:
- Physical examination - The first step in evaluating a man suspected of having testicular cancer is to examine the scrotum and testicles. This examination is performed using the fingers and the family doctor evaluates the size and consistency of the testicles and feels for any lumps, tenderness or other abnormalities.
- Ultrasound - This is a test that uses high-frequency sound waves that are transmitted through body tissues. The sound waves bounce off the tissue and return to the ultrasound probe and these returning sound waves (referred to as echoes) vary according to the type of tissue that the sound waves strike. The echoes are recorded and translated into video or photographic images that are displayed on a monitor. Ultrasound machines can detect even very small tumors in the testicles.
- Blood tests - The blood is tested for abnormal levels of three proteins that are sometimes produced by testicular cancer: alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG or beta-HCG), and lactate dehydrogenase (LDH). These blood tests are not usually ordered unless the physical examination or ultrasound detects an abnormality. AFP, HCG and LDH are referred to as serum tumor markers in this setting because they are blood tests that are used to detect tumors. AFP and HCG are also elevated during normal pregnancies and LDH can be elevated by many difference conditions besides cancer.
- Computed tomography (CT or CAT) scan - This is a special x-ray that uses a computer to create a series of images, or pictures, of the inside of the body. CT scans are not usually ordered unless an abnormality is detected on the testicular ultrasound or the blood tests.
The actual diagnosis of testicular cancer is made by surgically removing the testicle through an incision in the groin and then examining extremely thin slices of tissue from the testicle under a microscope. If cancer is seen under the microscope, then the man is diagnosed with testicular cancer.
Unlike other cancers, it is highly unusual to perform a biopsy of the testicle in someone suspected of having testicular cancer. Performing a biopsy can complicate the treatment of a cancer if one is detected and therefore men should NOT have a biopsy of the testicle except under certain very unusual circumstances (It is worth noting that in some parts of the world, after a cancerous testicle is removed, biopsies are taken of the other testicle to see whether any additional cancer can be found, but this is rarely done in the United States.).
Instead, when a cancer is suspected, the standard medical procedure is to surgically remove the testicle through an incision in the groin. It is important to remove the testicle through the groin rather than cutting through the scrotum. It is also important to perform the blood tests described above (AFP, HCG, LDH) before the testicle is removed.
If a testicular cancer is found, the doctor needs to know the stage of the cancer. In other words, he or she needs to know how far the cancer has spread and how much it has grown. Thus, more tests are performed to determine whether cancer cells have spread to other parts of the body.
This is called staging. Staging tests include blood tests (AFP, HCG, LDH, as discussed above), CT scans of the abdomen and pelvis, and either a CT scan or x-ray of the chest. Additional tests may be ordered depending on the patient's symptoms and test results.
There are three main stages of testicular cancer:
- Stage I - There is no evidence of cancer except for the tumor in the testicle. In other words, there is no evidence that the cancer has spread.
- Stage II - There is evidence that the cancer has spread to the lymph nodes in the back of the abdomen or the pelvis. (The back of the abdomen is referred to as the retroperitoneum)
- Stage III - There is evidence that the cancer has spread to distant locations, such as the lungs, liver, bones, brain or to lymph nodes other than those in the pelvis and back of the abdomen (When testis cancers spread to other lymph nodes, they usually spread to lymph nodes in the chest or neck).
If the blood tests discussed above for serum tumor markers (AFP, HCG, LDH) are persistently abnormal after the cancerous testicle is removed, this usually means that the cancer has spread to distant areas (stage III) even if no cancer can be found on CT scans and other studies.
How is testicular cancer treated?
The treatment for testicular germ cell tumors depends on the type of cancer and the stage of the cancer. The most important distinction regarding the type of cancer is between seminomas and nonseminomas.
Treatments for testicular cancer include:
Although observation is not a treatment, it an important part of the management of testicular cancer. Men with stage I testicular cancer who undergo surgical removal of the cancerous testicle and who have normal blood tests (AFP, HCG, LDH) after the testicle is removed, have a 20% (seminomas) to 30% (nonseminomas) chance of suffering a relapse of their cancer.
This means that 70% to 80% of men are cured simply with surgery to remove the disease testicle. One option for these men is to observe them carefully with physical examinations, CT scans and blood tests and only to administer chemotherapy or other treatment if the cancer comes back.
Surgery is performed on essentially all men with testis cancer because the disease is almost always diagnosed by surgically removing the cancerous testicle and examining the tissue under a microscope. Additional surgery is sometimes performed to remove lymph nodes from the back of the abdomen (this operation is referred to as a retroperitoneal lymph node dissection) or to remove tumors from other locations after they have been treated by chemotherapy.
Surgery following chemotherapy is sometimes needed because some germ cell tumors are composed of a mixture of tissue, some of which is killed by chemotherapy while other parts can only be eliminated by removing them surgically. As a result, a combined approach of chemotherapy plus surgery is often necessary.
Retroperitoneal lymph node dissections are major operations but because most testis cancer patients are young (in their twenties or thirties), the surgery is almost always completed without any major complications. Surgery in men who have had prior chemotherapy is more risky, however, than in men who have had no treatment prior to surgery.
The role of surgery following the removal of the testicle varies by stage and type.
Chemotherapy uses drugs to kill cancer cells. Chemotherapy for testicular cancer is administered to the body directly into the bloodstream through a small, soft tube (called an intravenous line or catheter) inserted into a vein. Chemotherapy is called a systemic treatment because the drug enters the bloodstream, travels through the body, and can kill cancer cells wherever they may be.
Radiation therapy uses high-energy x-rays to kill cancer cells and shrink tumors. Radiation is generated by a machine outside the body and then directed through the skin into the body. The radiation can pass through the body just like radiation from an x-ray does when an x-ray is taken of the lungs or bones.
Radiation therapy is not used very often for testis cancer but does play a role in the treatment of stage I and stage II pure seminoma. In addition, radiation is sometimes administered to the brain in those rare cases when testicular cancer has spread to that organ.
The different types of treatment apply to the different stages and types of testicular cancer as follows:
- Stage I Nonseminomas: Observation, OR Surgery (Retroperitoneal lymph node dissection), OR Chemotherapy
- Stage I: Seminomas: Observation, OR Radiation therapy, OR Chemotherapy
- Stage II Nonseminomas: Surgery (Retroperitoneal lymph node dissection), which is sometimes followed by chemotherapy, OR Chemotherapy which is sometimes followed by surgery
- Stage II Seminomas: Chemotherapy, OR Radiation therapy
- Stage III Seminomas and Nonseminomas: Chemotherapy sometimes followed by surgery.
A clinical trial is a research program conducted with patients to evaluate a new medical treatment plan, drug or device. There are not as many clinical trials for testicular cancer as for most other types of cancer because of the great success medicine has had in curing testicular cancer. Clinical trials of new treatments for testicular cancer are ongoing for men with advanced, high-risk disease and for those whose disease does not respond to established therapies.
What is the prognosis for people with testicular cancer?
The prognosis for most people with testicular cancer is outstanding. For every one hundred men diagnosed with testicular cancer, about 95 are cured. However, the prognosis gets worse as the cancer spreads.
Men with stage I disease thus have a much better prognosis than men with stage III disease, and men with very advanced stage III disease only have about a 50 percent chance of being cured. Nonetheless, one remarkable fact about testicular cancer is that almost all patients have a very real chance of being cured no matter how widely their cancer has spread. In contrast, most other cancers (such as lung cancer) are incurable one they have spread around the body.
Can testicular duct cancer be prevented?
Testicular cancer cannot generally be prevented. The only way doctors know of to prevent testis cancer is to provide treatment for men who have undescended testicles. This treatment involves either removing the testicle from the body altogether or else lowering the undescended testicle so that it is in the scrotum.