Brief overview
- Symptoms: Palpable, painless induration in the scrotum; enlarged testis (with a feeling of heaviness); enlarged, painful breasts; advanced symptoms include cough and chest pain in pulmonary metastases
- Prognosis: Generally very treatable; successful cure possible in most cases; one of the highest cancer survival rates; recurrences are rare; fertility and libido usually maintained
- Diagnosis: Medical history; palpation of the testicles and chest; ultrasound; blood test, magnetic resonance imaging, computer tomography; possible exposure of the testicle.
- Treatment: Removal of the affected testicle; then, depending on the stage of the tumor and the type of testicular cancer, monitoring, chemotherapy or radiation therapy; possible removal of affected lymph nodes.
- Prevention: Regular self-scanning of the testicles; preventive examination for risk groups
What is testicular cancer?
Testicular cancer is a malignant tumor of the testicular tissue. Usually only one testicle is affected. The most common forms of testicular cancer are so-called seminomas, followed by non-seminomas.
Overall, testicular cancer is a rare cancer. It accounts for an average of 1.6 percent of all new cancer cases. There are only about ten cases per 100,000 men.
What are the symptoms?
Testicular cancer can be recognized by some typical symptoms:
Palpable induration
In about 95 percent of all cases, testicular cancer affects only one of the two testicles. In the remaining five percent of patients, cancer cells develop in both testicles.
Increase in size and feeling of heaviness
Due to the increase in size, the affected testicle feels heavy. This feeling of heaviness is accompanied by a pulling sensation in some affected individuals, which sometimes radiates to the groin.
Pain
In some patients, pain around the testicle is another testicular cancer symptom. Bleeding within the cancerous tissue causes a twinge or squeeze in some cases. However, pain is rarely the first sign of testicular cancer.
In advanced testicular cancer, the lymph nodes in the back of the abdomen enlarge. This may cause back pain.
Breast growth
The β-HCG is also considered a significant tumor marker. This is a blood value that is typical for some testicular cancers. It helps to diagnose testicular cancer and assess the course of the disease.
The enlarged breasts may hurt in some cases.
Symptoms due to spread (metastases)
For example, lung metastases often cause coughing (sometimes with bloody sputum) and shortness of breath. Chest pain is then also a common symptom. Testicular cancer metastases in the bones cause bone pain. Liver metastases are manifested by nausea, loss of appetite and unwanted weight loss in a short time, among other symptoms. If cancer cells spread to the brain, neurological deficits may be added to the common signs of testicular cancer.
As a rule, testicular cancer can be treated well and usually also cured. Five years after a testicular cancer diagnosis, about 96 percent of patients are still alive (5-year survival rate) – the rate hardly changes even after ten years (95 percent). Testicular cancer is thus one of the cancers with the highest probability of survival.
This good prognosis is mainly due to the fact that testicular carcinoma is detected at an early stage in most patients. The chances of successful treatment are then high. However, if the cancer has already spread further at the time of diagnosis, this worsens the chances of cure. However, the prognosis in individual cases is also influenced by this, for example,
- how well the patient responds to the therapy,
- where metastases have already formed in the body (for lymph node and lung metastases, the prognosis is usually more favorable than for metastases in the liver, bones or head),
- how long it takes for the cancer to progress again after the last chemotherapy (the longer, the more favorable),
- what the tumor marker readings are.
Keyword fertility
Many patients fear becoming infertile or no longer experiencing sexual desire as a result of testicular cancer treatment. In most cases, however, those affected can be reassured: The majority of patients have only unilateral testicular cancer. In this case, only the diseased testicle needs to be removed. The remaining testicle is usually sufficient to maintain sexuality and fertility.
Even more important are the issues of fertility and sexual retention mostly for the (few) patients who suffer from bilateral testicular cancer or who have already lost a testicle due to a previous disease. During surgery, the doctor then tries to remove only malignantly altered tumor tissue and to preserve as much testicular tissue as possible.
In principle, doctors recommend that all testicular cancer patients have their fertility examined before starting treatment. The best way to do this is to have a sample of the ejaculate analyzed in the laboratory for the number, shape and “swimming ability” of the sperm (spermiogram). Alternatively, the blood level FSH (follicle-stimulating hormone) can be measured: If it is elevated, this may indicate reduced sperm production.
It is advisable for patients to ask their own health insurance company in advance whether it will cover the costs. Sometimes insurance companies make an exception.
The testosterone missing after testicular cancer surgery can be replaced by injections, tablets, gel preparations or patches.
Relapse
The likelihood of testicular cancer recurrence depends particularly on the tumor stage at initial diagnosis and the type of initial treatment. For example, if early stage testicular cancer is only monitored after surgery (surveillance strategy), the risk of recurrence is higher than if chemotherapy is given after surgery.
On the other hand, it has more severe side effects. Among other things, the bone marrow and thus the hematopoiesis are damaged much more severely during high-dose therapy. For this reason, those treating the patients usually transfer hematopoietic stem cells (stem cell transplantation).
Overall, recurrence of testicular cancer is rare. Between 50 and 70 percent of patients respond favorably to the high-dose chemotherapy then administered.
Causes and risk factors
Testicular cancer (testicular carcinoma) in adult men arises in more than 90 percent of cases from the germ cells in the testis. They are called germ cell tumors (germinal tumors). Non-germinal tumors make up the small remainder. They arise from supporting and connective tissue of the testis.
Seminoma arises from degenerated stem cells of spermatozoa (spermatogonia). It is the most common form of malignant germ cell tumor in the testis. The average age of patients is around 40 years.
The term non-seminoma includes all other germinal testicular cancers that arise from other tissue types. They include:
- Yolk sac tumor
- Chorionic carcinoma
- Embryonal carcinoma
- Teratoma or the malignant form teratocarcinoma
The precursor of seminomas and non-seminomas is called testicular intraepithelial neoplasia (TIN) (intraepithelial = located within the covering tissue, neoplasia = new formation). The neoplasms arise from embryonic germ cells before birth. They lie dormant in the testis and may later develop into testicular cancer.
Non-terminal tumors occur mainly in children. They are very rare in adult men (most likely in older age).
Why does testicular cancer develop?
The exact cause of testicular cancer is not yet known. However, researchers have identified some risk factors for its development in the past.
Previous testicular cancer
Undescended testicle
Undescended testicles increase the likelihood of developing testicular cancer. This risk still exists even if the undescended testicle is surgically removed: For example, the risk of testicular cancer is 2.75 to 8 times higher for surgically removed undescended testicles than for normal testicular apposition.
Malposition of the urethral orifice
If the orifice of the urethra is below the glans (i.e. on the underside of the penis), physicians speak of hypospadias. Studies suggest that this abnormality increases the risk of testicular cancer.
Hypospadias and undescended testicles appear to have a similar genetic cause. Therefore, they often occur together. However, they also occur separately.
Genetic factors
In addition, testicular cancer has been found to be much more common in fair-skinned European-descended men than in African-descended men.
Estrogen excess during pregnancy
A slight estrogen surplus is observed, for example, in pregnant women who are expecting their first child or twins, or who are older than 30. In some cases, taking medications with estrogens also causes hormone levels to rise in pregnant women. However, nowadays pregnant women are rarely treated with hormones.
Infertility
The causes of infertility are different. Sometimes it is the result of testicular inflammation (orchitis) caused by the mumps virus. Deviations (anomalies) in the genetic material also cause men to become infertile, for example Klinefelter syndrome.
External influences
Diagnosis and examination
Men are well advised to regularly examine and palpate their testicles themselves, especially between the ages of 20 and 40. If you notice a change inside the scrotum, it is best to consult a urologist quickly. This specialist in urinary and genital organs will then clarify the suspicion of testicular cancer by means of a number of examinations.
You can read more about how the testicles are palpated in our article Palpating the testicles.
Doctor-patient consultation
- Have you noticed a hardening in the scrotum?
- Do you experience a feeling of heaviness in said area or even pain?
- Have you noticed any other changes in yourself, such as an increase in breast size?
During the consultation, the doctor will also clarify possible risk factors: Have you had a testicular tumor in the past? Have you had an undescended testicle? Has anyone in your family had testicular cancer?
Testicle palpation
Every man is well advised to regularly palpate his testicles himself. In this way, he can detect suspicious changes at an early stage and then consult a doctor. If it is indeed testicular cancer, early diagnosis improves the chances of recovery.
Palpation of the breast
Ultrasound
The physician performs the ultrasound examination for the clarification of testicular cancer with a high-resolution transducer. Irregular areas that appear darker than the surrounding tissue are typical. Smaller and non-palpable testicular cancer foci can also be detected by ultrasound. The examination is performed on both testicles to rule out bilateral involvement.
Blood test
One such tumor marker in testicular cancer is alpha-fetoprotein (AFP). This protein is produced during pregnancy in the yolk sac of an unborn child. In adults, it is produced only in very small amounts by liver and intestinal cells. If a man has an elevated AFP level, this indicates testicular cancer – and especially certain forms of non-seminoma (yolk sac tumor and embryonal carcinoma). In seminoma, on the other hand, the AFP level is normal.
Lactate dehydrogenase (LDH) is an enzyme that occurs in many body cells. It is only suitable as a supplementary tumor marker in testicular cancer (in addition to AFP and β-HCG).
The blood level of placental alkaline phosphatase (PLAP) is particularly elevated in seminoma. However, since the value is also elevated in almost all smokers, PLAP is only of very limited use as a tumor marker in testicular cancer.
CT and MRI
An alternative to CT is magnetic resonance imaging (MRI): this also provides detailed cross-sectional images of the inside of the body, but with the help of magnetic fields (and not X-rays). The patient is therefore not exposed to radiation. MRI is performed, for example, if the patient is allergic to the contrast agent used in CT.
Exposure of the testicle
Treatment
In principle, the following treatment measures are available for testicular cancer therapy:
- Surgery
- Surveillance strategy: “wait and see”.
- Radiotherapy (irradiation)
- Chemotherapy
The treating physician suggests an individualized treatment plan to a testicular cancer patient.
The first step in testicular cancer treatment is usually surgery. Further treatment steps depend on the stage of the disease and the type of tumor (seminoma or non-seminoma – by far the most common forms of testicular cancer).
Surgery
At the patient’s request, the physician will take a granule-sized tissue sample from the other testicle during the procedure and immediately examine it under the microscope. This is advisable because in about five percent of patients pathologically altered cells are also found in the second testicle. In this case, this testicle can be removed at the same time.
Tumor stages
The doctor examines the removed testicular cancer tissue for fine tissue. Together with other examinations (such as computer tomography), the stage of the disease can be determined. Doctors roughly distinguish between the following tumor stages:
- Stage I: Malignant tumor only in the testicle, no metastases
- Stage III: distant metastases also present (for example in the lungs); depending on severity, further subdivision (IIIA, IIIB, IIIC)
Seminoma
However, to improve the prognosis, it is also possible to treat early-stage seminoma with chemotherapy or radiotherapy after surgery. If the seminoma is already more advanced at the time of testicle removal, patients will in all cases receive either chemotherapy or radiation therapy after surgery. Which form of therapy is the best option in each individual case depends, among other things, on the exact tumor stage.
Read more about seminoma treatment and other important info about this most common form of testicular cancer in the article Seminoma.
Non-seminoma
Non-seminomas are the second most common type of testicular cancer after seminomas. Again, the treatment steps after testicle removal depend on the tumor stage:
Testicular cancer stage I
According to the definition, stage I testicular cancer is limited to the testis and has not yet spread to lymph nodes or other parts of the body. Despite modern imaging techniques such as computer tomography, however, this cannot be said with 100 percent certainty. Sometimes cancer metastases are so small that they are not detected by imaging. Two factors may indicate such invisible (occult) metastases:
- After tumor removal, the respective tumor markers in the blood do not drop or even rise.
In such cases, there is therefore an increased risk that the testicular cancer has already spread after all. To be on the safe side, doctors then recommend not a monitoring strategy after testicle removal, but chemotherapy (one cycle): patients are administered three chemotherapeutic agents over several days: cisplatin, etoposide and bleomycin (collectively called PEB for short).
Testicular cancer stages IIA and IIB
In these two stages of testicular cancer, lymph nodes are already affected and thus enlarged. Then there are two options for further treatment after testicular removal:
- Either the affected lymph nodes are removed surgically, possibly followed by chemotherapy (if individual cancer cells remain in the body).
Testicular cancer stages IIC and III
In these advanced non-seminoma stages, patients are treated with three to four cycles of chemotherapy after testicular removal. If affected lymph nodes are still present after this, they are removed (lymphadenectomy).
Side effects of testicular cancer therapy
Possible side effects therefore include anemia, bleeding, hair loss, nausea and vomiting, loss of appetite, inflammation of the mucous membranes, hearing disorders, and insensitivity in the hands and feet. Cytostatic drugs also attack the immune system. Patients are therefore more susceptible to pathogens during treatment.
In the case of (suspected) lymph node involvement in the posterior abdomen, doctors often treat this region with radiation therapy. The most common side effect is mild nausea. It occurs a few hours after radiation and can be alleviated with medication. Other possible side effects are temporary diarrhea and skin irritation in the radiation area (such as redness, itching).
Prevention
You can find out exactly how best to proceed with self-examination of the testicle in the article Palpating the testicle.
Since the exact causes of testicular cancer are otherwise unknown, no concrete prevention is possible beyond a healthy lifestyle.
Anyone who belongs to the risk groups, for example, with a known family history of testicular cancer, undescended testicles or a malposition of the urethral orifice, would be well advised to have the appropriate preventive examinations carried out by their doctor.
