Testicles are the sex glands in men and are responsible for producing hormones and sperm. The testicles are situated in the scrotum, an area below the penis. Several types of cells are present in testicles. These include germ cells, macrophages, Sertoli cells, Leydig cells, peritubular hyoid cells, and epithelial cells. The uncontrolled division of one or more of these cells results in tumor formation, and the condition is known as testicular cancer.
Testicular tumors generally occur in males between the ages of 15 and 45. Some forms of testicular cancer are rapidly progressive. Cryptorchidism (undescended testis) significantly increases the risk of testicular tumors.
Testicular cancer is the most common abnormal tissue growth (neoplasm) in men between 15 and 40 years old. It represents 5% of the urological tumors and 1% of the neoplasms in adults. Western countries have higher incidences of testicular tumors than Asian and African countries. Although there is an increase in the incidence of testicular carcinoma, the mortality due to the disease has been almost similar for over three decades.
Following are the different testicular cancer types:
It is the most common testicular tumor. Over 90% of testicular tumors originate in the germ cells. Germ cells are the cells present in the testicles that develop into sperm. It is one of the most highly treatable testicular cancer types. Germ cell tumor classification is done through microscopy and imaging (ultrasound and magnetic resonance imaging). Testicular germ cell tumors are further classified into the following types:
This is one of the slow-growing testicular cancer types, and it usually affects people in their 40s and 50s. The three types of seminomas include spermatocytic, classical, and seminoma with syncytiocytotrophoblastic cells.
Non-seminomas progress at a relatively faster rate than seminomas. Patients mostly affected by non-seminomas are in their late 20s and 30s. There are various types of non-seminomas:
These grow quickly and metastasize to other body parts. Patients with embryonal carcinoma may have elevated levels of human chorionic gonadotropin and alpha-fetoprotein.
It is the most common form of cancer of the testicles in children and infants. It looks like the yolk sac of an early embryo. These tumors can be treated successfully in children.
These are usually present along with other non-seminomas as pure teratomas are rare and do not have the potential to increase human chorionic gonadotropin and alpha-fetoprotein. The three types of teratomas are mature, immature, and teratomas with somatic malignancy.
It is a rare and rapidly progressing testicular cancer. It may spread to bones, lungs, and the brain. Pure choriocarcinoma is rare and is present with other types of non-seminomas.
These tumors originate from Sertoli cells. These cells support the normal growth of sperm.
Leydig cells, present in testicles, produce testosterone. Tumors developed from Leydig cells are known as Leydig cell tumors.
This procedure for staging is also known as tumor-node-metastasis staging. During staging, the clinicians determine the size of the tumor, its invasion of the nearby node, and if the tumor has spread to other body organs, such as the bones, lungs, liver, or brain. The classification of the tumor is from pTX to pT4. Node classification is from cNX to cN3 for clinical node, from pNX to pN3 for pathological node, and M0 to M1b for metastasis.
Following are the testicular cancer stages:
Stage 1 testicular cancer is localized. The serum tumor marker levels are not done or are unavailable.
The tumor is limited to the testis and may have invaded the rete testis. However, it has not spread to hilar soft tissue, epididymis, or blood vessels.
The cancer has not spread to the lymph nodes but spreads to the epididymis, tunica vaginalis, hilar soft tissue, and the lymphatic and blood vessels within the testicle. Patients have normal serum markers.
Cancer has not spread to the lymph nodes. Stage 1S testicular cancer patients have elevated serum markers even after removing the affected testes.
The tumor has spread to nearby lymph nodes but not distant lymph nodes.
The tumor has spread to the lymph nodes of the retroperitoneum. The serum tumor marker levels are slightly high or normal.
The tumor has invaded the retroperitoneal lymph nodes. The lymph node mass is between 2 and 5 cm.
The cancer affects at least one lymph node larger than 5 cm. Patients have slightly high or normal serum tumor markers.
Cancer invades distant lymph nodes and/or organs in the late stage of testicular cancer.
The cancer has spread to lymph nodes and/or organs, such as the lungs. The serum tumor markers are slightly elevated or normal.
Cancer has spread to lymph nodes and/or lungs, and at least one tumor marker is substantially high.
In stage 3, the tumor marker levels are extremely high, and the cancer has spread to other organs in the body.
Testicular cancer may affect any male. However, some people are at increased risk of developing this condition. These include people between the ages of 15 and 45. The testicular cancer risk is also high among whites who have a family history of testicular cancer or suffer from cryptorchidism (undescended testicles). People with other medical conditions, such as HIV infection and carcinoma in situ in the testicles, are more likely to get testicular cancer. Further, people with testicular cancer in one testicle are at higher risk of developing it in another testicle.
Patients usually ask about what are the symptoms of testicular cancer. The common symptoms of testicular cancer are:
In most cases, swelling of the testicles and/or the presence of lumps are early-stage testicular cancer symptoms. Some patients with testicular cancer may also experience aching or heaviness in the scrotal area or a dull ache in the groin or the lower belly.
In the early stages, testicular cancer patients may not experience any pain. However, in some cases, pain, which is caused by swelling, may become one of the testicular cancer symptoms. Approximately one-third of the patients experience dull pain, while acute pain is reported in almost 10% of the patients.
Due to an increase in the size of the testicle due to swelling or the development of lumps, patients with testicular cancer may experience a feeling or sensation of fullness and heaviness in the scrotal region.
An increase or reduction in the size of testicles may also be one of the testicular cancer symptoms. The size may be increased due to swelling or the growth of a lump and can be reduced due to testicular atrophy. Testicular atrophy has a negative effect on the reproductive health of patients.
Pain and discomfort in the lower back or the groin are usually late-stage testicular cancer symptoms. It is because the cancer spreads to the lymph nodes present in the back of the abdomen.
A sudden fluid accumulation in the scrotum may also be a sign of testicular cancer.
In some patients, there is a significant increase in the levels of the human chorionic gonadotropin (HCG) hormone, which may stimulate breast development. It results in the growth of breasts. Some patients with Leydig cell tumors may have an increase in estrogen levels, resulting in low sexual desire and breast development.
Following are the symptoms of various types of testicular cancer:
Symptoms of seminomas include scrotal discomfort, fluid accumulation, testicular swelling or lump, dull pain, a feeling of fullness or heaviness, breast tenderness, and lower back pain.
The symptoms of non-seminomas include testicular mass (generally painless), pain and discomfort in the scrotum, swelling or lump in the testicles, heaviness or fullness in the scrotum, and nausea and vomiting (advanced stages). Patients may also have infertility due to poor sperm quality and a low sperm count.
Due to the hormonally active characteristics of Leydig cell tumors, patients with this condition experience breast tenderness, gynecomastia, precocious puberty, hypogonadism, infertility, or erectile dysfunction.
Patients with Sertoli cell tumors may have scrotal mass (usually painless), hormonal imbalance, and gynecomastia.
The possible testicular cancer causes are:
Testicular cancer mostly develops in people between 15 and 45 years old. Further, seminomas generally affect people in their 40s and 50s, and non-seminomas usually develop in patients in their late 20s and 30s.
An undescended testicle is one of the causes of testicular cancer. The patients may also be at increased risk even when the testicles are moved to the scrotum through a surgery known as orchiopexy.
A positive family history could also be one of the possible testicular cancer causes. Having close male relatives with testicular cancer can increase one’s testicular cancer risk. However, most men with testicular cancer do not have a family history of this disease. An inherited condition, Klinefelter's syndrome, may also cause testicular cancer.
HIV infection may also become one of the possible testicular cancer causes, especially seminomas. It may possibly be due to AIDS-related atrophy of testicles and impaired immune surveillance of tumors.
Male infertility may also be the cause of testicular cancer in some patients. It has been reported that males with infertility have a 1.9-fold increased risk of testicular cancer.
The use of cannabis may also cause testicular cancer, particularly aggressive cancer. Patients who use marijuana at least weekly or have started using it at the beginning of adolescence may also develop testicular cancer.
Intersex variations may also be the reason for testicular cancer. Patients with partial androgen insensitivity syndrome may also develop testicular cancer.
Patients should consult with oncologists in cases of pain or discomfort in the scrotum, fluid accumulation, breast tenderness, a feeling of fullness in the groin, lower back pain, and nausea and vomiting.
There are multiple tests available for the diagnosis of testicular cancer. These tests help in diagnosis, staging, and treatment planning, too. Some of the common tests for testicular cancer diagnosis are:
The patients undergo a detailed medical history assessment and physical examination to find the cause of the symptoms. A physical examination includes evaluating the scrotum for any sign of swelling or the presence of a lump. The belly and the surrounding lymph nodes are also examined to rule out the spread of cancer. It is important to inquire about the family history of the patients, as certain conditions, such as Klinefelter's syndrome, increase the risk of testicular cancer. The doctors may also ask about the family history of cancers, including testicular cancer, as it is one of the risk factors for this cancer type. If the doctor suspects the presence of testicular cancer, the patients are advised to undergo further testicular cancer tests.
It has been reported that ultrasound combined with physical examination has almost 100% sensitivity for testicular cancer diagnosis. Testicular cancer in ultrasound is viewed as solid and vascularized intratesticular lesions. It is also important to note that different types of testicular cancers have subtle differences in morphological characteristics when seen on ultrasound images. Normal testicles look even and smooth on ultrasound. Any shadow generally indicates the presence of cancer. Ultrasound differentiates between the intra- and extra-testicular lesions and is often performed before orchiectomy. However, it is not recommended for staging testicular cancer in patients with advanced disease (metastatic cancer).
Several proteins are produced by testicular cancer cells. The doctor may advise the patients to undergo blood tests to determine the level of these proteins. This test is known as the tumor marker test, which looks for the presence and levels of alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (HCG), and lactate dehydrogenase in the blood. Blood tests are not recommended for the confirmatory diagnosis of testicular cancer, as elevated levels of these substances may also be due to other conditions. It has been reported that pure seminomas occasionally increase HCG levels, but AFP levels are never elevated. However, non-seminomas generally raise the levels of AFP and/or HCG.
A biopsy is a test that involves obtaining a tissue sample from the abnormal site and examining it under the microscope for the presence of cancer. A biopsy is usually the confirmatory diagnostic test for various types of cancer. However, it is rarely performed to detect testicular cancer due to the risk of spreading it. The combination of physical examination, ultrasound, and tumor marker tests provides a fair idea about the presence of testicular cancer, and the oncologist may recommend the patients undergo orchiectomy (surgical removal of affected testicles) as soon as possible. A study found that trans-scrotal biopsy has a significantly higher risk of local recurrence than orchiectomy.
Computed tomography plays an important role in various aspects of testicular cancer. It assists in the accurate staging of testicular cancer. It is also the preferred imaging technique for monitoring the response of testicular cancer therapy and the recurrence of testicular cancer. A CT scan also allows the surgeons to plan the removal of the residual masses and detect the extent of tumor spread after recurrence. The oncologists may also perform CTs of the pelvis, abdomen, and chest. A CT of the brain is usually not required (unless the patient has a neurological presentation), as the spread of testicular cancer to the brain is not very common.
A chest x-ray is performed in patients with testicular cancer who are suspected of cancer in the lungs. Chest X-rays assist oncologists in the staging of testicular cancer. A study comparing chest radiography and chest CT found a preference for chest radiography in patients with seminoma and non-seminomatous germ cell tumors.
Although a CT scan provides high-quality, detailed images of the retroperitoneum, high radiation doses are required, and because of the relatively younger age of the patients developing testicular cancer, MRI is usually a modality of choice for evaluating the retroperitoneal lymph node. However, several barriers, such as a relatively longer scanning time, a shortage of radiologists who are experts in interpreting retroperitoneal MRI, and a higher cost, prevent MRI from becoming the preferred modality for detecting testicular cancer. However, as MRI provides high-quality images of the spinal cord and brain, it is recommended if the oncologist believes that testicular cancer has metastasized to the brain.
Radical inguinal orchiectomy is a procedure that involves the surgical removal of one or both testicles by making an incision in the pubic area. It serves two important functions. First, it removes the abnormal testicle and lowers the risk of cancer metastasis. Second, it helps obtain tissue for histopathological diagnosis. The examination provides detailed information about the presence, type, and extent of cancer.
If the patient diagnosed with testicular cancer has bone-related symptoms, such as bone pain, the oncologists may recommend a bone scan. Bone scintigraphy is implemented for the early detection of testicular cancer metastasis. It has been reported that conventional radiography has lower sensitivity than nuclear techniques for detecting cancer metastasis.
Upon arriving at a conclusive diagnosis of testicular cancer, it is further staged before devising a personalized treatment plan. While creating a treatment plan, specialists consider a myriad of factors, such as the type of testicular cancer, its stage, its size, the patient’s age and overall health status, and the patient’s preferences. Some of the testicular cancer treatments include:
Surgery is the primary treatment option for all types of testicular cancers. The surgery removes one or both the testicles and/or the affected lymph nodes. The types of testicular surgeries are:
Radical inguinal orchiectomy is a testicular cancer medical procedure that involves the surgical removal of one (unilateral orchiectomy) or both the testicles (bilateral orchiectomy). During this procedure, an opening is made in the pubic area through an incision, and the testicle is removed from the scrotum. The surgeon removes the complete tumor along with the spermatic cord. The spermatic cord contains blood vessels and lymph vessels. These vessels are tied before surgery to minimize the risk of spreading cancer.
Not all patients with testicular cancer have to undergo lymph node dissection. The oncosurgeons may remove the lymph nodes at the back of the abdomen surrounding the large blood vessels during orchiectomy or a separate surgery, depending upon the stage and type of cancer. The lymph node is removed through open surgery or laparoscopic surgery. During open surgery, the surgeon creates a large cut on the abdomen and removes the lymph nodes. In laparoscopic surgery, the surgeon makes a few small incisions and removes the lymph nodes through small instruments guided by a laparoscope.
It is a testicular cancer treatment approach that uses medicines to kill the cancer cells. This testicular cancer therapy involves administering powerful drugs, also known as chemotherapy drugs, orally or intravenously. Chemotherapy drugs interfere with the vital processes in the cell cycle of cancerous cells and kill them. Chemotherapy may be used in combination with radiation therapy or surgery.
Adjuvant chemotherapy for testicular cancer is done after the surgery to kill the cancer cells that are not removed by the surgery. Adjuvant chemotherapy aims to reduce the risk of cancer recurrence.
Primary testicular cancer chemotherapy is the administration of testicular cancer medications before localized treatment, such as radiation therapy or surgery. It is done to shrink the tumor so that it can be easily destroyed by radiation or easily removed through surgery.
During radiation therapy as a testicular cancer treatment, the cancer cells are killed through high-energy radiation, such as X-rays or gamma rays. As a part of a treatment strategy for testicular cancer, radiation therapy is used in cases where the disease has metastasized to the lymph nodes. Seminoma-type testicular cancer is highly sensitive to radiation therapy. It may be used in combination with surgery or radiation therapy.
Immunotherapy involves delivering drugs that interfere with the immune system-evading process of cancer cells. These drugs make the cancer cells more vulnerable to the immune system. The immune system identifies the cancer cells and kills them. As immunotherapy targets the procedure specific to cancer cells, this therapy has fewer side effects than chemotherapy.
HCG Cancer Center has all the required facilities for diagnosis, management, and post-surgical care for patients with testicular cancer. The center has advanced imaging testing facilities, including MRI, CT, ultrasound, and PET scans. Further, various treatment options, including surgery, chemotherapy, radiation therapy, and immunotherapy, are available at the center. The center also delivers the services of extensively experienced medical oncologists and oncology surgeons.
We do not know the exact cause of testicular cancer; however, we do know that certain factors can increase one’s risk of testicular cancer. The following are some of the most common testicular cancer risk factors:
White men are at 4 to 5 times more risk of developing testicular cancer than Asian American and black men. It has been further reported that the risk of developing testicular cancer is higher for people living in Europe and the United States compared to those living in Asia and Africa.
People between the ages of 15 and 45 are at a higher risk of developing testicular cancer. The average age at which men are diagnosed with testicular cancer is 33. Although any type of testicular cancer may develop at any age, men between 25 and 45 are at increased risk for seminoma. In contrast, younger men in their early 20s are at increased risk of developing non-seminomas.
Boys with a medical history of undescended testicles are at higher risk for testicular cancer. It is a significant risk factor for testicular cancer. It has been reported that the undescended testicles do not directly cause testicular cancer; rather, the undescended testis may have certain abnormalities that make the person more likely to develop testicular cancer.
Family history and the medical history of the person also impact the risk of developing testicular cancer. People with immediate family members, such as a father and brother, suffering from testicular cancer are more likely to have testicular cancer than those without any family history of testicular cancer. People with underlying medical conditions, such as Klinefelter's syndrome and the presence or history of testicular cancer in one testicle, have a higher risk for testicular cancer. Some types of testicular cancers, such as testicular germ cell cancers, may initiate in the form of carcinoma in situ. People with carcinoma in situ are at increased risk for testicular cancer; however, the condition does not always progress to testicular cancer.
Any abnormalities in the urethra or penis may also increase the risk of testicular cancer. Hypospadias is a condition in which the opening of the urethra is not present at the penile tip. The presence of hypospadias increases the risk of testicular cancer.
Several studies have reported that people with HIV have a higher risk of developing testicular cancer than men with no medical history of HIV. A study found an increased risk of developing seminoma in patients with HIV. An HIV diagnosis is not directly related to testicular cancer. It is possibly due to an impaired immune response and HIV-induced atrophy of the testicles.
Several studies have reported no association between testicular injury and testicular cancer. However, if the testicular trauma is so severe that it has led to testicular atrophy, it may increase the risk of testicular cancer.
Few studies have reported a higher risk for testicular germ cell tumors among white men with lower maternal testosterone levels. The maternal estrogen levels are higher in the first pregnancy compared to the subsequent pregnancy. This fact explains why a firstborn male child is at increased risk for developing testicular cancer compared to subsequent male children.
Various people ask about how to prevent testicular cancer. Although there is no method to prevent testicular cancer, certain measures lower the risk of developing testicular cancer:
Self-examining the testicles is one of the easiest ways to detect any abnormality in the testis, such as a lump or swelling, which is usually the initial sign of testicular cancer. It is advised to conduct a self-examination of the testicles monthly to become familiar with the shape and size of the testicles. Doctors may advise the patients about how to do a self-exam for testicular cancer.
A healthy lifestyle is vital for preventing various cancers, including testicular cancer. Testicular cancer may be prevented by regular exercise, a healthy weight, and a healthy diet. Quitting smoking and limiting alcohol consumption may also lower the risk of testicular cancer.
Like with other cancers, early detection of testicular cancer results in the complete removal of the cancer, lowering the risk of recurrence and enhancing overall quality of life. The patients, during self-examination, may feel the changes in the size of the testicles. The warning signs for testicular cancer are the presence of lumps or swelling, the feeling of discomfort or pain in the scrotum, experiencing heaviness or fullness, or a change in the size of the testis.
Regular check-ups are important to catch testicular cancer in its early stages, especially in people with a high risk of testicular cancer, such as people with undescended testicles, family history and medical history of testicular cancer, and the presence of HIV and urethral abnormalities.
It is important to spread awareness about testicular cancer. It will help detect the disease at early stages and identify people with high cancer risk. A study reported that most people in the study lacked knowledge about the symptoms of testicular cancer and did not give any importance to testicular cancer. Awareness of testicular cancer is, thus, important.
Cancer that occurs in the testicles is known as testicular cancer. Different types of testicular cancers are germ cell tumors, Sertoli cell tumors, and Leydig cell tumors. Germ cell testicular cancer is the most common type of testicular cancer. The other cells rarely affected by cancer are Sertoli cells and Leydig cells. Stage 3 is the most advanced stage of testicular carcinoma.
