• A rare disease in which cells in one or both testicles become malignant
   • Symptoms include an unusual lump or growth, pain or discomfort, and an unusual fluid buildup
   • Treatments include removal of the testicle, chemotherapy, radiation therapy, and surveillance
   • Involves urologic oncology program, medical oncology, radiology & biomedical imaging

Testicular cancer is a disease in which cells in the male testes—the sperm-producing glands inside the scrotum—become malignant. It is a relatively rare disease with only 8,000 new cases diagnosed in the U.S. annually. It is, however, the most common cancer among 15- to 34-year-old men in the United States.

   ● About 9,910 new cases of testicular cancer diagnosed
   ● About 460 deaths from testicular cancer

Overview

Men who have been diagnosed with testicular cancer may have pressing questions about their futures: Will I be healthy again? Will I be able to have a normal sex life? Will I be able to have children? The answer to each of these questions is most often yes.

Testicular cancer is highly treatable and in the majority of cases, it can be cured. It is also a rare disease and makes up only around 1% of cancers in men in the U.S. Though it is not a common form of cancer, it is still important for men to be aware of its signs and symptoms. When testicular cancer is detected at an early stage, before it has a chance to spread to other parts of the body, treatment is easier and the prognosis is generally excellent.

"Usually, it's not pain that causes someone to notice they have testicular cancer," says Preston Sprenkle, MD, a Yale Medicine urologist and expert in urologic cancers. "Very often it's a new lump on the testicle, so one thing we encourage is self-examination on a regular basis."

What is testicular cancer?

Testicular cancer occurs when cells in one or both testicles grow in an abnormal and uncontrolled manner. As the cells grow uncontrollably, they often form tumors. In some cases, these tumors are benign, meaning they do not spread to other parts of the body.

But more frequently, testicular tumors are malignant, or cancerous. The cells that comprise them can spread to nearby lymph nodes or to other tissues and organs in the body. Testicular cancer occurs when cells in one or both testicles become malignant. In most cases testicular cancer is diagnosed when the cancer is localized, meaning it has not spread beyond the affected testicle.

The testicles are made up of many types of cells, and cancer can occur in any of them. Doctors classify testicular cancer according to the type of cell that becomes cancerous.

• Germ cell tumors (GCTs). Germ cells are responsible for producing sperm. When malignant tumors form from these cells, they are called germ cell tumors. About 95% of testicular cancers are GCTs. There are two broad categories of GCTs, seminomas and non-seminomas (also known as non-seminomatous germ cell tumors, or NSGCTs).
• Non-germ cell tumors (gonadal or sex-cord stromal tumors). Approximately 5% of testicular cancers arise from cells other than germ cells. These cancers form from Leydig cells, Sertoli cells, and granulosa cells.

What are the risk factors for testicular cancer?

Several factors are associated with increased risk for testicular cancer. These include:

• Undescended testicle (cryptorchidism). Normally, the testicles descend from the abdomen into the scrotum before birth. Males born with an undescended testicle are at increased risk of developing testicular cancer.
• Family history of testicular cancer. Men who have a relative (especially a brother or father) with testicular cancer are at increased risk of developing testicular cancer themselves.
• Personal history of testicular cancer. Men who have a prior history of testicular cancer are at increased risk of testicular cancer in the previously uninvolved testicle as well as other types of cancer including rectal, pancreatic, bladder, kidney, and thyroid cancers, and acute myeloid leukemia.
• Intratubular germ cell neoplasia (ITGCN). A condition in which abnormal germ cells are present in the seminiferous tubules of the testicles.
• Age. Testicular most commonly affects men between 20 and 34 years of age.
• Certain genetic conditions. People with some genetic conditions including Down syndrome and testicular dysgenesis syndrome are at increased risk of testicular cancer.

What are the symptoms of testicular cancer?

Men may start to worry about cancer when they notice an unusual lump or growth in one or both of their testicles. This may be a sign of testicular cancer, but there are a few other symptoms and signs including:

• A firm lump or mass on or swelling of a testicle (which may or may not cause pain)
• Dull ache or feeling of heaviness in the lower abdomen or groin
• Pain or discomfort in the scrotum
• Build-up of fluid in the scrotum
• Enlarged breasts (gynecomastia). Some types of testicular tumors secrete hormones that promote breast development.

How is testicular cancer diagnosed?

During your appointment, your doctor will ask about symptoms and whether you have any risk factors for testicular cancer. He or she will also examine both testicles to check for masses, irregularities in shape, and/or swelling. Because testicular cancer may cause breast enlargement, the doctor may also examine your breasts. He or she may also check for swelling of lymph nodes along your collarbone and elsewhere.

Your doctor will also order a testicular ultrasound, a test that uses soundwaves to produce an image of the internal structure of the testicle. Bloodwork is usually necessary to measure the levels of certain proteins (known as tumor markers) produced by testicular tumors.

At this point, if your doctor suspects you have testicular cancer, he or she will likely recommend surgery to remove the affected testicle. A pathologist will examine tissue in the removed testicle for the presence of cancer cells. If cancer cells are detected, your doctor will order some additional tests to find out whether the cancer has spread to other parts of your body. These may include a chest X-ray, a computed tomography (CT) scan, a magnetic resonance imaging (MRI) study, or other imaging studies.

How is testicular cancer staged?

After making a diagnosis of testicular cancer, the doctor’s next step is to stage the disease. He or she will evaluate bloodwork and imaging studies and assign the cancer to a category—or stage—depending on the extent to which the cancer has spread. This helps the doctor determine the prognosis and best treatment plan for each patient.

• Stage I. Cancer is limited to one testicle.
• Stage II. Cancer has spread to nearby lymph nodes in the abdomen or pelvis.
• Stage III. Cancer has spread to more distant lymph nodes and/or to other tissues in the body.

How is testicular cancer treated?

There are a number of options for treating testicular cancer. The choice of treatment depends on the type and stage of testicular cancer.

• Radical inguinal orchiectomy. In this procedure, which is the initial treatment for the vast majority of testicular cancers, a surgeon removes the affected testicle through an incision in the groin. This lessens the risk of the cancer spreading to other parts of the body. A prosthetic testicle can be implanted to restore the natural appearance of the scrotum. Men who have one testicle removed are able to have a normal sex life and may have children.
  

• Chemotherapy. Drugs that destroy cancer cells, prevent them from spreading, or impair their growth are collectively known as chemotherapy. These medications are often used following orchiectomy to destroy any cancer cells that remain in the body. Some cancers are best treated with high-dose chemotherapy. While this destroys cancer cells, it unfortunately also damages healthy cells known as hematopoietic stem cells, which normally develop into blood cells that perform critical tasks such as transporting oxygen, helping to fight infection, and forming blood clots. Because of this, patients who receive high doses of chemotherapy may also be given a stem cell transplant (also called a bone marrow transplant) to replace stem cells that were damaged or destroyed during treatment.

• Radiation therapy. This treatment focuses high-energy beams of radiation (such as X-rays) on cancer cells that have spread beyond the testicle or testicles. The radiation destroys and damages cancer cells, impairing their ability to spread.
  

• Lymph node removal. When testicular cancer spreads beyond the testicle, it often first reaches the retroperitoneal lymph nodes in the abdomen. In these cases, a surgeon may remove the lymph nodes.
  

• Surveillance. Nearly all men who have testicular cancer undergo orchiectomy. If the cancer is at an early stage and localized to only the affected testicle, a doctor may opt to monitor the patient over a period of years after removal of the testicle rather than prescribe chemotherapy or radiation therapy. By keeping a close eye on the patient, the doctor can catch recurrent cancer at an early stage, when it’s most treatable. Surveillance requires that patients undergo periodic exams, bloodwork, and imaging tests.

Because certain treatments for testicular cancer can cause infertility, patients who may wish to have children should talk to their doctor about freezing and storing sperm for later use.

What is the outlook for men who have testicular cancer?

Testicular cancer is one of the most curable types of cancer. It has a five-year survival rate of 95%, and even when the cancer has spread beyond the testicle, it can often be cured.

Men who have had testicular cancer are at risk for a recurrence of cancer, either in the previously unaffected testicle or elsewhere in the body. Because of this, even after successful treatment, men should have periodic medical exams that include bloodwork and imaging studies.

What stands out about Yale Medicine's approach to testicular cancer?

Our physicians provide compassionate care while offering the most advanced diagnostic, medical and surgical treatments available. The most common treatment—surgical removal of the affected testicle—typically has no impact on sexual performance or the ability to have children, says Dr. Sprenkle.

Yale Medicine Urology is committed to offering our patients with early- and late-stage testicular cancer the most advanced diagnostic technologies and treatment strategies available. We take this journey with our patients as they move toward recovery.

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Source: Yale Medicine, Testicular Cancer, https://www.yalemedicine.org/conditions/testicular-cancer, February 4, 2022

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