TESTICULAR
CANCER OVERVIEWTesticular cancer occurs when cancer cells develop in one or
both of the testicles. Testicles are the male reproductive glands located
within the scrotum. The scrotum is a sack of loose skin that contains the
testicles and hangs directly below the penis.
Testicular
cancer is the most common cancer arising in young males. Fortunately, it has
become one of the most curable of all cancers. More than 95 percent of all
males diagnosed with testicular cancer survive their disease.
More
detailed information about testicular cancer, written for health care
providers, is available by subscription.
TYPES
OF TESTICULAR CANCERApproximately 95 percent of testicular cancers develop from a
type of cell in the testicle called a germ cell. Thus, they are called
testicular germ cell tumors.
Seminoma versus nonseminomatous germ cell tumor — There are two major types of testicular germ cell tumors:
●Seminomas and
●Nonseminomatous germ cell tumors (NSGCTs)
Approximately
one-third of all testicular germ cell tumors are seminomas; the remainder are
NSGCTs. Both seminoma and NSGCT typically affect males between the ages of 15
and 35 years old, although seminomas occur in a slightly older group of males.
Other types of testicular cancer — In about 5 percent of cases, cancer can arise from testicular
tissue other than the germ cells. Testicular "sex cord stromal
tumors," including Leydig cell tumors, Sertoli cell tumors, and granulosa
cell tumors, fall into this category.
TESTICULAR
CANCER SYMPTOMSMost of the time, the first symptom of testicular cancer is pain
or swelling in the scrotum. While a painless testicular lump is typically
indicative of testicular cancer, this finding is only present in about 10
percent of cases. Some people also feel a dull ache or heavy sensation in the
low belly, or around the anus or scrotum.
TESTICULAR
CANCER DIAGNOSISIf you notice a lump in your testicle, see a health care
provider as soon as possible.
If your
provider suspects you might have testicular cancer, they will likely order
tests, such as:
●Testicular ultrasound – This is the initial test
performed to evaluate a suspected testicular mass (lump). Ultrasound is an
imaging test that uses sound waves to measure the size and characteristics of
the testicle and mass, and can determine whether the mass is inside or outside
of the testicle and whether it contains fluid or is a solid mass. Testicular
cancers are solid and begin inside the testicle. Often, the ultrasound will
strongly suggest the diagnosis of testicular cancer.
●Blood tests – Substances produced by a testicular cancer (called
"tumor markers") can be measured in the blood. The three most
important markers are called:
•Alpha fetoprotein (AFP)
•Beta human chorionic gonadotropin (beta-hCG)
•Lactate dehydrogenase (LDH)
High levels of these tumor markers are suggestive of testicular
cancer and can help determine the specific type of cancer. These markers are
also used during and after treatment to monitor how the disease is responding.
●Orchiectomy – The only way to confirm the diagnosis of testicular
cancer is by surgically removing the testicle. This procedure is called a
radical inguinal orchiectomy.
TESTICULAR
CANCER STAGING AND CLASSIFICATIONStaging is used to determine if there is
spread (metastasis) of the cancer beyond the testicle.
●Stage I testicular cancer is defined as cancer that is limited
to the testicle only.
●Stage II testicular cancer has spread (metastasized) to the
retroperitoneal lymph nodes (located in the abdomen).
●Stage III testicular cancer has spread to other organs.
Blood tests
(to measure tumor markers) and imaging (eg, computed tomography [CT] scan) are
used in the process of staging.
Computed tomography scans — Most people with a suspected testicular cancer will undergo an
imaging test called a CT scan of the abdomen and pelvis. A chest X-ray or CT
scan of the chest is also commonly done.
These tests
are done to determine if the suspected cancer has spread beyond the testicle
(metastasized). The most common site of metastasis in testicular cancer is the
lymph nodes in the abdomen; metastasis to the lymph nodes in the chest or neck
or organs such as the lungs, liver, bones, and brain is also possible.
Prognostic classification — People with stage II or III testicular cancer are classified
into "prognostic groups" (good, intermediate, and poor) based on
their chance of survival and cure. People with stage I testicular cancer have
an excellent prognosis and are not included in this classification system.
Following
surgery to remove the testicle (radical inguinal orchiectomy), testicular
cancer is treated based on the type of tumor (seminoma or NSGCT), the stage of
the disease, and the prognosis.
All people
with seminoma are classified as either having a good or intermediate prognosis,
but they are not classified as having a poor prognosis. People with NSGCT are
classified as either having a good, intermediate, or poor prognosis, depending
on the stage of their disease:
●Good prognosis – People with seminoma have a good prognosis if the tumor
has not metastasized to organs other than the lungs and if they have a normal
AFP level in the blood.
People with NSGCTs have a good prognosis if the tumor started in
the testicle or in the area outside or behind the abdominal wall
(retroperitoneal). For a tumor to be classified as having a good prognosis, it
cannot have metastasized (spread) to organs other than the lungs, and the tumor
markers in the blood must be either normal or only slightly elevated.
●Intermediate prognosis – People with seminoma have an
intermediate prognosis if the tumor has metastasized to organs other than the
lungs and their AFP test is normal.
People with NSGCTs have an intermediate prognosis if the tumor
started in one testicle or in the lymph nodes in the back of the abdomen near
the kidneys (retroperitoneum), if the tumor has not spread to organs other than
the lungs, and if tumor markers in the blood are elevated but not to an extreme
level.
●Poor prognosis – People with NSGCTs are classified as having a poor
prognosis if the tumor develops in the center of the chest between the lungs
(called the mediastinum), if it has spread to organs other than the lungs, or
if any of the tumor markers are markedly elevated.
Even for people with a poor prognosis, approximately one-half
are cured with aggressive treatment.
TESTICULAR
CANCER TREATMENTTreatment of both seminomas and nonseminomatous germ cell tumors
(NSGCTs) generally includes surgery to remove the affected testicle. This
surgery is called radical inguinal orchiectomy.
The need
for further treatment depends on the type of cancer, the stage of the cancer,
and the prognosis. Chemotherapy and radiation therapy (RT) are often used in
combination with surgery and can improve the chances of curing the cancer.
Radical inguinal orchiectomy — Radical inguinal orchiectomy is required for diagnosis and is
the first step in treatment. During the surgery, the entire testicle is usually
removed to avoid the risk of spreading the tumor within the scrotum. Tissue
from the testicle is later examined using a microscope.
If you have
one of your testicles removed, you can choose to have an artificial
(prosthetic) testicle implanted to preserve a normal appearance.
Chemotherapy
What is chemotherapy? — Chemotherapy refers to the use of medicines to stop or slow the
growth of cancer cells. Chemotherapy targets growing cells, interfering with
their ability to divide or multiply. Because most of an adult's normal cells
are not actively growing, they are not as affected by chemotherapy as the
cancer cells. However, the cells in bone marrow (where blood cells are
produced), hair follicles, and the lining of the gastrointestinal tract are all
growing. The effects of chemotherapy on these and other normal tissues cause
side effects during treatment, including hair loss, nausea, anemia (lowered red
blood cell count), an increased risk of infection (lowered white blood cell
count), and bleeding (lowered platelet count).
Most drugs
are given intravenously (IV) rather than by mouth. They are not usually taken
daily, but periodically, in cycles. A cycle of chemotherapy refers to the time
it takes to give the drugs and the time required for the body to recover. For
example, a typical chemotherapy regimen could include a one-hour IV infusion of
two chemotherapy medicines given once every three weeks. This three-week period
is one cycle of therapy. If this regimen were repeated for a total of three
months, four cycles of chemotherapy would be given.
Chemotherapy for testicular cancer — Chemotherapy is sometimes given to people with early-stage
testicular cancer. People with more advanced stages of cancer and those who
have a disease relapse after radiation or surgery usually undergo multiple
cycles of combination chemotherapy.
Adjuvant chemotherapy — The term "adjuvant chemotherapy" refers to additional
anticancer treatment that is given after surgery in the absence of detectable
disease by imaging or tumor marker testing. The purpose of adjuvant
chemotherapy is to get rid of any remaining tumor cells in the body (often
termed micrometastases). Adjuvant chemotherapy decreases the chance that the
cancer will return (or recur). As a result, adjuvant chemotherapy has become an
important component of treatment.
Lymph node removal — The most common site
of spread for testicular cancer is the lymph nodes in the back of the abdomen,
called the retroperitoneal lymph nodes. Surgical removal of these nodes (called
retroperitoneal lymph node dissection [RPLND]) is sometimes recommended.
There are
alternatives to RPLND, including periodic physical examination and CT scans
(called active surveillance or watchful waiting), a short course of
chemotherapy, or in the case of seminomas, low-dose RT.
People with
stage II or III testicular cancer may not undergo RPLND at all or may only have
it if there is still cancer present after chemotherapy.
RPLND
requires specialized knowledge and training; people who require this procedure
should seek care in a facility where the surgeon is experienced with RPLND.
Risks of the procedure depend on the amount of surgery needed to remove the
lymph nodes and whether you have had chemotherapy.
Radiation therapy — RT refers to the
exposure of a tumor to high-energy X-rays in order to slow or stop its growth.
Exposure to X-rays damages cells. Unlike normal cells, cancer cells cannot
repair the damage caused by exposure to X-rays, particularly when the radiation
is given over several days. This prevents the cancer cells from growing further
and causes them to eventually die.
RT for
testicular cancer is given as external beam RT, meaning that the radiation beam
is generated by a machine while you lie on a table underneath or in front of
the machine. The high-energy beams are directed at the lymph nodes in the
abdomen and pelvis, not the scrotum.
Exposure to
the beam typically takes only a few seconds (similar to having an X-ray). In
general, treatment is repeated five days per week for approximately three to
six weeks.
RT is
sometimes used after orchiectomy for people with stage I seminoma to decrease
the risk of relapse. However, there are potential risks of RT, including
impaired fertility and development of a different cancer type (ie, secondary
malignancy) later in life . For these reasons, RT is usually reserved for
people who are not good candidates for surveillance, older people, and those
who could not tolerate chemotherapy.
RT may also
be used after orchiectomy for people with stage II seminoma that is defined as
nonbulky (ie, lymph nodes less than 3 cm in size). The dose of radiation used
to treat stage II seminoma is higher than that used for stage I seminoma with
similar or slightly higher risks of treatment.
Surveillance — In some cases, people
with small stage I testicular cancers do not require more treatment after
orchiectomy. However, these people do need to follow up regularly with a health
care provider to monitor for signs of relapse. This approach is called surveillance.
Surveillance
is only appropriate for people who are willing to have follow-up visits over a
period of years. Those who are not able or willing to undergo this active
surveillance may require additional treatment with either RT or chemotherapy.
During
surveillance, you will be seen every few months for a physical examination,
blood tests, and imaging studies (eg, CT scan of the abdomen with or without
pelvis, chest X-ray). Given that the risk of relapse decreases over time, the
schedule of follow-up visits and imaging studies typically decreases in
intensity over time. Eventually, most people are followed annually. While there
is controversy over how long a person should be followed with surveillance,
nearly all expert guidelines recommend at least five years.
Treatment recommendations by tumor type
Seminoma — In general, seminomas
grow slowly and do not spread rapidly to other areas of the body. Surgery
(radical inguinal orchiectomy) is recommended for all people with testicular
seminoma. For stage I seminoma (limited to the testicle), there are three
possible treatment options following surgery, all of which have an excellent
survival rate (approximately 99 percent). Treatment options include
surveillance (watchful waiting), RT, and chemotherapy.
Surveillance
is generally preferred for most people with stage I seminoma who are able to
adhere to the requested follow-up visits and tests. This is because adjuvant
treatment does not always improve overall survival and because the risk of
recurrence with surveillance is approximately 14 to 20 percent. This means that
adjuvant treatment likely "over-treats" a majority of people, putting
them at risk for unnecessary side effects. RT or adjuvant chemotherapy with the
drug carboplatin can be used in
people who are not candidates for surveillance. Retroperitoneal lymph node
dissection is not used for stage I seminoma.
Nonbulky
stage II seminoma (defined as lymph nodes that measure less than 3 cm in size)
can be treated with radiation or chemotherapy. People with bulky stage II
seminoma or stage III seminoma are treated with chemotherapy. Chemotherapy
consists of at least two drugs, one called etoposide and another called cisplatin (EP). In some
cases, a third drug called bleomycin is also added, a regimen known
as BEP.
Nonseminomatous germ cell tumors — Surgery (radical inguinal orchiectomy) is recommended for all
people with testicular NSGCT. NSGCTs are not as sensitive to RT as seminomas.
NSGCTs are also more likely to spread through the bloodstream to other areas of
the body, such as the liver, lungs, and brain.
Many people
with stage I nonseminoma can be followed with surveillance, since there is no
survival benefit to adjuvant treatment. Management is determined based on the
presence of specific risk factors (lymphovascular invasion; invasion of the
spermatic cord or scrotum; predominance of embryonal carcinoma). Surveillance
is preferred for people at low risk of relapse who have none of these risk
factors. For people at higher risk of relapse who have one or more of these
risk factors, options include surveillance; adjuvant chemotherapy with bleomycin, etoposide, and cisplatin; or RPLND.
In people
with nonbulky stage II nonseminoma, treatment options include either RPLND or
three or four cycles of chemotherapy with EP or BEP. People with more advanced
disease are treated with up to three to four cycles of EP or BEP chemotherapy.
The regimen and number of cycles may vary depending on the extent of disease
and the person's individual situation. People who have a mass remaining after
chemotherapy may require surgery to remove it. People who require this type of
surgical treatment are best treated at a cancer center that treats a large
number of people with testicular cancer.
TESTICULAR
CANCER TREATMENT SIDE EFFECTS AND COMPLICATIONSSide effects and
complications related to treatment depend on the type of treatment used and the
severity of the disease.
Fertility issues — Testicular cancer
frequently occurs in younger males who may want to preserve their ability to
get a partner pregnant in the future. Treatment with surgery, radiation therapy
(RT), or chemotherapy can reduce or eliminate sperm production, causing
infertility. For reasons that are not well understood, up to 50 percent of
males with testicular cancer have a low number of sperm even before treatment.
For these
reasons, males preparing to have treatment for testicular cancer may choose to
store their sperm for future use. The storage process is called "semen
cryopreservation" and involves storing semen at very low temperatures.
Cryopreservation requires that a male give several samples of semen. Ideally, a
semen sample should be collected in a clinician's office after masturbation; if
this is not possible, the male may be allowed to collect a sample at home in a
sterile laboratory container or chemical-free condom.
If
possible, collection should be started before surgical removal of the testicle
and before chemotherapy or RT; this allows the most and healthiest sperm to be
stored.
Even males
with very low sperm counts (before cancer treatment) should be encouraged to
store their sperm. Intracytoplasmic sperm injection (ICSI) is a type of
infertility treatment that requires a very small number of sperm.
Males who
are unable to store sperm before treatment may still be able to get a partner
pregnant after treatment, depending on the type and amount of treatment used.
Chemotherapy side effects — There are a number of side effects and complications that can
develop as a result of chemotherapy. These can be divided into acute side
effects (which occur during and shortly after treatment) and long-term risks.
Short-term side effects — People who undergo chemotherapy can have side effects such as
fatigue, hair loss, and nausea or vomiting. Nausea can be prevented or treated
with oral or intravenous (IV) medications, and hair regrows after treatment is
completed. Low blood cell counts can occur in the first few weeks of
chemotherapy, which can increase the risk of infection. This generally does not
require that the dose or schedule of treatment be changed.
Long-term complications — Chemotherapy can cause serious problems in a number of organ
systems within the body, especially when given in combination and if multiple
cycles of chemotherapy are required. The type and severity of these problems
depend on the type and dose of chemotherapy. These problems may be chronic and
may be a problem for people who have been cured of their testicular cancer. A
few of the most common include the following:
●Kidney damage.
●Damage to nerves, causing pain in the arms and feet or hearing
loss.
●Damage to blood vessels in the heart, potentially increasing the
risk of cardiovascular disease. This typically occurs many years after
treatment is completed.
●Lung scarring.
Another
serious long-term risk of testicular cancer treatment is the development of a
second cancer. This is not a metastasis of the testicular cancer but is a new
cancer that develops in the blood or blood-forming organs (leukemia), lungs,
colon, pancreas, kidney, bladder, stomach, or other organ system.
Retroperitoneal lymph node dissection — The most common side effect of retroperitoneal lymph node
dissection (RPLND) is decreased or absent semen with ejaculation. Advances in
surgical techniques with nerve-sparing RPLND have reduced the incidence of this
problem. For those males who do have decreased or absent ejaculatory volume,
infertility treatments are available.
Radiation therapy side effects — During radiation therapy, fatigue is common but usually not
debilitating. Gastrointestinal effects, including nausea, vomiting, increased
stool frequency, and rapid gastric emptying, have been described but are not
typical. Anti-nausea medications may be used for control of nausea and
vomiting. Suppression of bone marrow can occur (potentially causing anemia) but
is usually mild. Mild tanning of the treated skin occurs in the weeks after RT.
MONITORING
AFTER TESTICULAR CANCER TREATMENTRelapses of testicular germ cell tumors
usually occur within two years of the end of treatment, although they can occur
later. As a result, all people who have been successfully treated for
testicular cancer should be monitored for cancer recurrence with blood tests,
X-rays, CT scans, and other imaging tests. Monitoring is generally more
frequent in the first few years after treatment is completed.
Blood
tests, such as beta human chorionic gonadotropin (beta-hCG) and alpha
fetoprotein (AFP), are used to monitor for early signs of a relapse. In 30 to
50 percent of people who relapse, increases in blood tumor markers are the
first sign of a cancer relapse. A man who relapses may have no changes in his
tumor markers, and for this reason, the combination of blood testing, CT scan,
and X-ray is recommended.
Stage I follow-up — The optimal schedule
for surveillance following treatment is controversial. Most experts recommend
frequent monitoring with blood tests and imaging studies (eg, X-ray, CT scan)
every few months for the first few years, decreasing to twice per year for several
years, then once per year for the man's lifetime.
After retroperitoneal lymph node dissection — For people who undergo retroperitoneal lymph node dissection
(RPLND) for limited-stage disease, most experts recommend blood testing for
tumor markers and a chest X-ray every few months initially, decreasing to once
per year after several years. CT scan of the abdomen and pelvis may be done
less frequently because of the decreased risk of retroperitoneal relapse.
Advanced disease follow-up — Follow-up of people with advanced disease is similar to those
with stage I disease. Follow-up does not begin until after the man has a
complete response to chemotherapy. More intensive surveillance may be
recommended for people who undergo chemotherapy for advanced disease followed
by RPLND.
TESTICULAR
CANCER PROGNOSISPeople with stage I, nonbulky stage II, and good-prognosis
disease have an excellent chance for cure when treated appropriately . People
who have an intermediate or poor prognosis also generally respond well to
treatment and require a more aggressive treatment regimen. Even for those with
a poor prognosis, approximately one-half can be cured.
CLINICAL
TRIALSProgress in treating cancer requires that better treatments be
identified through clinical trials, which are conducted all over the world. A
clinical trial is a carefully controlled way to study the effectiveness of new
treatments or new combinations of known therapies. Ask for more information
about clinical trials or read about clinical trials at:
●www.cancer.gov/about-cancer/treatment/clinical-trials
Videos
addressing common questions about clinical trials are available from the
American Society of Clinical Oncology (www.cancer.net/research-and-advocacy/clinical-trials/welcome-pre-act).