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Patient education: Testicular cancer (Beyond the Basics)

Patient education: Testicular cancer (Beyond the Basics)
Author:
Darren Feldman, MD
Section Editor:
Timothy D Gilligan, MD
Deputy Editor:
Sonali M Shah, MD
Literature review current through: Jan 2024.
This topic last updated: Jun 14, 2023.

TESTICULAR CANCER OVERVIEW — Testicular cancer occurs when cancer cells develop in one or both of the testicles. Testicles are the male reproductive glands located within the scrotum (figure 1). 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. (See 'Professional level information' below.)

TYPES OF TESTICULAR CANCER — Approximately 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 SYMPTOMS — Most 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 DIAGNOSIS — If 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. (See 'Radical inguinal orchiectomy' below.)

TESTICULAR CANCER STAGING AND CLASSIFICATION — Staging 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. (See 'Testicular cancer diagnosis' above.)

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. (See 'Radical inguinal orchiectomy' below.)

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 TREATMENT — Treatment of both seminomas and nonseminomatous germ cell tumors (NSGCTs) generally includes surgery to remove the affected testicle. This surgery is called radical inguinal orchiectomy. (See 'Radical inguinal orchiectomy' below.)

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). (See 'Chemotherapy side effects' below.)

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 (figure 2).

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 (see 'Radiation therapy side effects' below). 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. (See 'Seminoma' below and 'Nonseminomatous germ cell tumors' below.)

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 COMPLICATIONS — Side 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. (See "Patient education: Evaluation of infertility in couples (Beyond the Basics)".)

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. (See "Patient education: Treatment of male infertility (Beyond the Basics)".)

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 TREATMENT — Relapses 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 PROGNOSIS — People with stage I, nonbulky stage II, and good-prognosis disease have an excellent chance for cure when treated appropriately (see 'Testicular cancer staging and classification' above). 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 TRIALS — Progress 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

clinicaltrials.gov

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).

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (https://www.wolterskluwer.com/en/solutions/uptodate/who-we-help/individuals/patients-caregivers). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Testicular cancer (The Basics)
Patient education: Preserving fertility after cancer treatment in men (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Evaluation of infertility in couples (Beyond the Basics)
Patient education: Treatment of male infertility (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Anatomy and pathology of testicular tumors
Clinical manifestations, diagnosis, and staging of testicular germ cell tumors
Treatment of stage I seminoma
Epidemiology and risk factors for testicular cancer
Initial risk-stratified treatment for advanced testicular germ cell tumors
Management of stage I nonseminomatous germ cell tumors
Management of stage II nonseminomatous germ cell tumors
Surveillance for stage I testicular germ cell tumors following orchiectomy
Posttreatment follow-up for testicular germ cell tumors
Radical inguinal orchiectomy for testicular germ cell tumors
Retroperitoneal lymph node dissection for early-stage testicular germ cell tumors
Serum tumor markers in testicular germ cell tumors
Approach to surgery following chemotherapy for advanced testicular germ cell tumors
Diagnosis and treatment of relapsed and refractory testicular germ cell tumors
Treatment of stage II seminoma
Treatment-related toxicity in testicular germ cell tumors

The following organizations also provide reliable health information:

American Cancer Society

     (www.cancer.org)

National Cancer Institute

     (www.cancer.gov)

American Society of Clinical Oncology

     (www.cancer.net/cancer-types/testicular-cancer)

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ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges William K Oh, MD, who contributed to earlier versions of this topic review.

Disclaimer: This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms. 2024© UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.
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