Testicular cancer

Testicular cancer is when cells in your testicles start to grow abnormally and in an uncontrolled way. Most testicular cancers (95%) start in the cells that make sperm, which are called germ cells.

Testicular cancer is relatively rare but it’s the most common cancer in males aged 15-44 years. Half of all testicular cancer cases occur in those aged 35 or under but it rarely occurs before puberty. 

The most common testicular cancer symptom is a lump or swelling in one testicle. Most testicular lumps aren’t cancerous, but it’s still important to see a doctor if you notice anything unusual.

Treatment for testicular cancer is effective and most cases are now cured.

Testicles are part of the male sex organs. Men have two testicles, which are oval-shaped and sit either side of the penis in a pouch of skin called the scrotum. Testicles make sperm and the sex hormone testosterone, which is important in male sexual development.

Testicular cancers are grouped according to the type of cell that the cancer starts in. Most testicular cancers start in the germ cells, which are the cells that make sperm. There are two subtypes of germ cell testicular cancer:

• Seminomas — 40-45% of all testicular cancers are of this type, which has become more common in the last 20 years
• Non-seminomas — this includes the cancer subtypes choriocarcinomas, embryonal carcinomas, teratomas and yolk sac tumours

Both types of germ cell testicular cancers can be effectively treated with chemotherapy. 

Rarer types of testicular cancer include: 

• Leydig cell tumours — 1-3% of all testicular cancers
• Sertoli cell tumours — less than 1% of all testicular cancers

Testicular cancer is relatively rare. It accounts for 1% of all cancers in men, with about 2,300 men in the UK diagnosed with this cancer every year. 

Unlike many other cancers, it usually affects younger men and is consequently the most common type of cancer in males aged 15–44.

• A dull ache or sharp pain in a testicle or your scrotum — the ache or pain may come and go
• A heavy feeling in your scrotum
• A painless lump in a testicle — although some people experience testicular pain or tenderness in the affected testicle
• A swollen testicle and/or an increase in the firmness of a testicle
• Any change in the shape or texture of one testicle compared to the other 
• Swollen or tender breasts — this is rare

You should examine your testicles to check for any lumps or swelling and any changes in shape or texture. The best time to do this is after a bath or shower when you are relaxed. Examine each testicle by holding it in the palm of your hand and using your finger and thumb to gently feel it and the surrounding area. A lump may be pea-sized or larger. 

If the cancer spreads, other symptoms can develop including back pain (if it’s spread to your lymph glands) or shortness of breath (if it’s spread to your lungs).

If you notice any of the above symptoms of testicular cancer, you should see your GP.

Testicular cancer is usually not the cause of lumps in the scrotum. Only a small proportion of lumps or swellings in the scrotum are caused by cancer. Common causes include: 

• Epididymal cysts — cysts in the tubes around your testicle
• Varicoceles — swollen blood vessels 

However, it is important to see your GP to get a diagnosis as if you do have testicular cancer, the sooner you get treatment, the more likely you are to be cured. 

Your GP will examine your testicles and may shine a light through your scrotum to identify any lumps that may be cancer — lumps caused by cancer are usually solid so light cannot pass through, but lumps caused by a collection of fluid will let light pass through. If they think it might be cancerous, they’ll refer you for further tests, which may include:

• Blood tests — to detect certain hormones (known as markers) that can be a sign of testicular cancer, such as alpha feto-protein (AFP) and human chorionic gonadotrophin (HCG); if these markers are detected, another blood test may be carried out to find out how active the cancer is by detecting levels of a general marker for cancers called lactate dehydrogenase (LDH)
• Scrotal ultrasound scan — a painless procedure that uses high-frequency sound waves to produce images of the inside of your testicle and find out if a lump is solid or fluid-filled, whether it is cancerous, its position and size

Blood tests and a scrotal ultrasound scan are usually enough to get a diagnosis of testicular cancer. Definitive confirmation is only possible using histology and this is usually only recommended after you have received a diagnosis based on blood tests and a scrotal ultrasound scan. This is because histology requires that you first undergo surgery to remove the testicular lump or whole testicle; the tissue is then processed in a lab and examined under a microscope. Having a testicle removed will not affect your ability to have children or your sex life. 

If cancer is confirmed, you’ll have an X-ray, MRI scan and/or CT scan to check if the cancer has spread to other areas.

Metastatic cancer is cancer that has spread to other parts of the body from where it started. About one in 20 people with testicular cancer will have metastatic cancer, which commonly spreads to lymph nodes in your abdomen or lungs. Lymph nodes are glands that form part of your immune system. In some cases, cancer spreads to the bones, brain and/or liver. 

Symptoms of metastatic cancer include:

• A lump or swelling in your neck
• A persistent cough
• Coughing or spitting up blood 
• Enlarged or swollen breasts
• Lower back pain
• Shortness of breath 

After tests to diagnose your cancer, you will usually be told what stage your cancer is at. The stages of testicular cancer have been organised based on two different systems. The system most widely used in the UK is a three-stage system based on how far your cancer has spread and marker levels in your  blood:

• Stage 1 — cancer is contained in a testicle
• Stage 2 — cancer has spread to nearby lymph nodes
• Stage 3A — cancer has spread to distant lymph nodes and blood marker levels are normal or slightly higher than normal 
• Stage 3B — cancer has spread to nearby lymph nodes and blood marker levels are high, or cancer has spread to distant lymph nodes or the lungs and blood marker levels are high
• Stage 3C — the same criteria as stage 3B except blood marker levels are very high or cancer has spread to the brain or liver

Another system, which is not widely used in the UK, is the TNM system based on:

• T which indicates the size of the tumour
• N which indicates whether cancer has spread to nearby lymph nodes
• M which indicates whether cancer has spread to other parts of the body

It’s unknown what causes most testicular cancers but risk factors that increase your chance of getting it include:

• Family history of testicular cancer — having a close relative with a history of testicular cancer increases your own risk; if your father had testicular cancer, you're four times more likely to develop it or if your brother had it, you're eight times more likely to develop it; the genes that carry this risk have not yet been identified
• HIV/AIDS
• Infertility with an abnormal sperm count
• Klinefelter’s syndrome — a genetic condition where a man has an extra X chromosome
• Previous testicular cancer — if you have previously been diagnosed with testicular cancer, you are 12-18 times more likely to develop it in your other testicle; your doctor will recommend you attend follow-up appointments for five to 10 years to carefully monitor your other testicle for signs of cancer 
• Undescended testicles (cryptorchidism) — testicles usually descend from the abdomen before birth but 3-5% of baby boys are born with testicles still inside their abdomen; although most descend in the first year after birth, in some boys, they do not and this increases the risk of testicular cancer by three times; surgery called orchidopexy can move the testicles down to the correct position, making it easier to examine the testicles and notice changes

Caucasian men also have a higher risk of testicular cancer than men from other ethnic groups.

Your treatment plan will depend on the type of testicular cancer you have eg seminoma or a non-seminoma, and the stage of your testicular cancer. 

In almost all cases, your doctor will advise surgery to completely remove the affected testicle (orchidectomy) — removing only the lump makes it more likely that the cancer will spread, while removal of the whole testicle increases your chance of being cured. This surgery will not affect your fertility or ability to have sex.

About one in 50 people with testicular cancer in one testicle will develop cancer in the other testicle. In these cases, it may be possible to remove part of the testicle rather than the whole testicle. 

Orchidectomy 

Orchidectomy is carried out under general anaesthetic and involves removing the testicle and its attached tubes and blood vessels through a cut made into your groin. An artificial testicle, usually made of silicone, can be inserted so that your appearance is not changed much — although the artificial testicle may be a slightly different size or texture than the testicle that was removed. 

Usually, after orchidectomy, you will need to stay in hospital for a few days. Removing one testicle does not usually cause any long-term side effects. However, removing two testicles causes infertility. If you want to father children and are having both testicles removed, you can save some of your sperm in a sperm bank for future fertility treatments.

Sperm banking

Having both testicles removed is not the only reason you may want to save some of your sperm in a sperm bank. 

In some men, testicular cancer may reduce sperm count. Also, if you need chemotherapy after removal of one of your testicles, there is a chance that this treatment will cause infertility — although this occurs in less than 50% of cases. If you need lumps at the back of your abdomen removed, you may have difficulty ejaculating even though your remaining testicle is still making sperm. 

Sperm banking involves freezing a sample of your sperm for use in the future to impregnate your partner via artificial insemination or in vitro fertilisation (IVF). Before banking your sperm, you may be tested for hepatitis B, hepatitis C and HIV.

You should be offered sperm banking if you are going to have chemotherapy for stage 2 or stage 3 cancer. However, not all men are suitable as the sperm needs to be of a reasonably high quality. In some cases, it may be too risky to delay treatment to make time for sperm banking. 

Testosterone replacement therapy

After surgery to remove one testicle, if you have a healthy testicle remaining, you will most likely not experience any long-term effects of surgery as this testicle will make enough testosterone. However, if the remaining testicle is not healthy, it may not make enough testosterone, which can cause symptoms including: 

• Erectile dysfunction — reduced ability to have or maintain an erection
• Loss of sex drive
• Reduced beard growth
• Tiredness
• Weight gain

If you have both testicles removed, you will definitely experience these symptoms.

Symptoms can be treated with testosterone replacement therapy. This involves being given testosterone either as an injection every two to three months, or as a gel to rub into your skin or a skin patch. Treatment will improve your sex drive and enable you to maintain an erection. Side effects are uncommon but include:

• Breast enlargement and swelling
• Oily skin — this can sometimes cause acne
• Urinary problems — you may need to urinate more often or have difficulty urinating due to an enlarged prostate gland pushing against your bladder

Chemotherapy and radiotherapy

For some types of testicular cancer, you may also receive a short course of chemotherapy and/or radiotherapy after testicle removal. This is to help prevent the cancer returning. Although in most cases the chance of recurrence is low, your doctor may recommend that you have regular check-ups as a precaution.

Radiotherapy uses high-energy beams of radiation to help destroy cancer cells. It may be needed after surgery for seminoma testicular cancers to reduce the chances of the cancer returning. It may also be recommended in stage 2 and stage 3 testicular cancers for those who can't tolerate chemotherapy. If cancer has spread to the lymph nodes, radiotherapy might be needed after chemotherapy. 

Side effects of radiotherapy include:

• Diarrhoea 
• Fatigue
• Feeling sick
• Red, sore skin — similar to sunburn

Chemotherapy uses powerful medicines to kill cancer cells. It may be needed if you have stage 2 or stage 3 testicular cancer or your cancer has spread to other parts of your body. It is also used to reduce the chances of cancer returning. 

It is commonly used to treat seminoma and non-seminoma testicular cancers and is usually injected into your vein. However, in some cases, a special tube (a central line) is inserted into your vein for the length of your treatment so you don't have to keep having needles put in. 

Side effects of chemotherapy include: 

• Breathlessness and fatigue
• Low blood count and greater vulnerability to infection 
• Organ damage — particularly to your kidneys or lungs
• Problems with your gastrointestinal system — a sore mouth, mouth ulcers, nausea and vomiting; you may also experience a loss of appetite
• Problems with your skin and hair — hair loss, skin that bleeds or bruises easily
• Unusual sensations — numbness and tingling in your hands and feet, ringing in your ears (tinnitus)

Infertility is also a potential side-effect of chemotherapy, depending on the type of chemotherapy drug and the dose used. Men should not father children during the course of their chemotherapy or for one year after completing treatment. This is because chemotherapy can temporarily damage your sperm, which can increase the risk of fathering a baby with serious birth defects. 

Most side-effects are temporary and resolve after your treatment completes. However, some side-effects can be serious and have long-term effects eg the chemotherapy drug bleomycin can cause long-term lung damage; your doctor will discuss whether this will cause particular problems for your career or lifestyle.

Lymph node and lung surgery

If cancer has spread to your lymph nodes, you may need surgery under general anaesthetic to remove the affected lymph nodes — testicular cancer most commonly spreads to lymph nodes in the abdomen area. Keyhole surgery called laparoscopic retroperitoneal lymph node dissection (LRPLND) may be carried out to remove your lymph nodes. 

In some cases, surgery can damage the nerves in your abdomen near your lymph nodes, which causes retrograde ejaculation — this is when semen does not ejaculate out of your penis during masturbation or sex but travels backwards into your bladder. You will still experience orgasm during ejaculation but can’t father a child. 

For men who want to father children, there are treatments available for retrograde ejaculation as well as the option to have sperm collected from your urine for use in artificial insemination or in vitro fertilisation (IVF). 

Due to the risk of surgery damaging nerves that regulate ejaculation, a newer surgical procedure called nerve-sparing retroperitoneal lymph node dissection (RPLND) has been developed to remove lymph nodes with a lower risk of causing retrograde ejaculation and infertility.

If cancer has spread to your lungs and chemotherapy has not been completely effective in destroying these tumours, surgery may be needed to remove the tumours. 

Once you have had testicular cancer in one testicle, there is an increased risk that you will develop it in your other testicle. You will therefore need regular follow-up appointments to check if your cancer has returned. This will involve: 

• A chest X-ray
• A CT scan
• A physical examination of your testicle and surrounding area
• Blood tests to check for tumour markers

Testicular cancer is one of the most treatable types of cancer. In England and Wales, 99% of men survive for a year or more after diagnosis and 98% survive for five years or more after diagnosis. Almost all men treated for germ cell testicular cancer are cured and after five years of being cancer-free, it is rare for this cancer to return. 

Most testicular cancers are diagnosed and treated at an early stage, which results in a complete recovery. 

If the cancer has spread to other parts of the body, the chances of being cured are still high as testicular cancer cells can be effectively killed with chemotherapy.