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What is Testicular Cancer?
Testicular cancer, while not common, can occur at any age, with the highest incidence seen between 15 and 45 years old. Typically, the initial indication of this cancer is the presence of a bump or lump on a testicle. The rapid growth of cancer cells often leads to its spread beyond the testicle to other areas of the body.
Fortunately, testicular cancer is highly treatable, even when it metastasizes. Treatment approaches vary based on the specific type of testicular cancer and its stage. Common treatments include surgery and chemotherapy.
The testicles, two small egg-shaped glands situated in a sac below the penis called the scrotum, play a crucial role in the male reproductive system. They produce sperm, which matures and moves through the vas deferens (a tube located behind the testicles) and out the urethra during ejaculation. Additionally, the testicles produce male hormones, such as testosterone, which influence a man's sex drive and contribute to muscle, bone, and body hair growth.
Healthy testicles should feel firm and slightly spongy, with a consistent firmness throughout. Both testicles should be roughly the same size, although slight variations are normal.
Testicular Cancer Prognosis and Survival Rates
In 2024, the American Cancer Society estimates approximately 9,760 new cases of testicular cancer will be diagnosed in the United States, leading to around 500 deaths. While the incidence of testicular cancer, particularly seminomas, has been increasing over the decades, this trend has recently slowed. Despite its relative rarity, affecting about 1 in 250 males during their lifetime, it's worth noting that around 6% of cases occur in children and teens, and 8% occur in men over 55. Thanks to effective treatment options, the lifetime risk of dying from testicular cancer is very low, approximately 1 in 5,000.
It is crucial for men to perform regular self-exams and to seek medical attention if they notice any changes or abnormalities in their testicles. Early detection greatly improves the chances of successful treatment. By recognizing the risk factors and symptoms associated with this disease, individuals can take proactive steps towards early detection and treatment.
Why Come to CU Cancer Center for Testicular Cancer
Patients seeking top-tier care for testicular cancer should consider the University of Colorado Cancer Center for several reasons. As an NCI-designated Comprehensive Cancer Center, CU Cancer Center represents the pinnacle of cancer care and research excellence. This prestigious designation is bestowed upon institutions that demonstrate exceptional expertise in laboratory, clinical, and population-based research. Affiliated with the National Comprehensive Cancer Network (NCCN), CU Cancer Center adheres to the highest standards of cancer care, ensuring that patients receive the most current, evidence-based treatment guidelines.
Moreover, CU Cancer Center's commitment to advancing cancer treatment is exemplified by its robust clinical trial program. Patients benefit from access to cutting-edge therapies and innovative treatment approaches through participation in clinical trials. This not only offers patients the opportunity to receive novel treatments but also contributes to the advancement of cancer care on a global scale. By choosing CU Cancer Center for their testicular cancer treatment, patients can be confident in receiving world-class care that is at the forefront of cancer research and innovation.
Types of Testicular Cancer
Germ cell tumors
Over 90% of testicular cancers originate from germ cells, the cells responsible for sperm production. The two primary types of germ cell tumors (GCTs) found in the testicles are seminomas and non-seminomas, occurring at similar rates. Often, testicular cancers comprise a combination of both seminoma and non-seminoma cells. These mixed germ cell tumors are managed as non-seminomas due to their growth and spreading patterns resembling those of non-seminomas.
Seminomas
Seminomas generally exhibit a slower growth rate and lower tendency to spread compared to non-seminomas. There are two main sub-types of seminomas:
- Classical (or typical) seminomas: Accounting for over 95% of cases, these typically affect men aged 25 to 45.
- Spermatocytic seminomas: This less common type is more prevalent in older men, with an average age of around 65. Spermatocytic tumors tend to grow slowly and are less prone to spreading to other parts of the body than classical seminomas.
Some seminomas can elevate blood levels of a protein called human chorionic gonadotropin (HCG). Monitoring HCG levels through a simple blood test serves as a tumor marker for certain testicular cancers, aiding in diagnosis and treatment assessment.
Non-seminonas
These germ cell tumors typically occur in men between their late teens and early 30s. The four primary types of non-seminoma tumors are embryonal carcinoma, yolk sac carcinoma, choriocarcinoma, and teratoma. While most tumors consist of a mix of different types (sometimes including seminoma cells), the treatment approach for most non-seminoma cancers remains unchanged.
Embryonal Carcinoma:
- Found in about 40% of testicular tumors, but pure cases are rare (3% to 4%).
- Resembles tissues of very early embryos under a microscope.
- Tends to grow rapidly and spread outside the testicle.
- Can elevate blood levels of alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG).
Yolk Sac Carcinoma:
- Cells resemble the yolk sac of an early human embryo.
- Common in children (especially infants), but rare in pure form in adults.
- Responds very well to chemotherapy, even if it has spread.
- Typically increases blood levels of AFP.
Choriocarcinoma:
- Very rare and fast-growing in adults.
- Likely to spread rapidly to other parts of the body.
- Often seen with other types of non-seminoma cells.
- Increases blood levels of HCG.
Teratoma:
- Contains areas resembling each of the three layers of a developing embryo.
- Pure teratomas are rare and do not increase AFP or HCG levels.
- Main types include mature, immature, and teratomas with somatic type malignancy.
- Treatment varies based on the type and may involve surgery, as well as chemotherapy for certain types.
Carcinoma in situ of the testicle
Testicular germ cell cancers can originate from a non-invasive form of the disease known as carcinoma in situ (CIS) or intratubular germ cell neoplasia. In testicular CIS, cells appear abnormal under the microscope but have not yet spread beyond the seminiferous tubules where sperm cells develop. Not all CIS cases progress to invasive cancer.
Detecting CIS before it becomes invasive is challenging because it typically does not cause symptoms or form a palpable lump. Diagnosis usually requires a biopsy, a procedure to remove a small tissue sample for microscopic examination. CIS is sometimes incidentally discovered during a testicular biopsy performed for other reasons, such as infertility.
When CIS progresses to invasive cancer, its cells extend beyond the seminiferous tubules into other structures of the testicle. These cancerous cells can then spread to lymph nodes through lymphatic vessels or the bloodstream to other parts of the body.
Stromal tumors
Tumors can originate in the supportive and hormone-producing tissues, called the stroma, of the testicles, known as gonadal stromal tumors. While they account for less than 5% of adult testicular tumors, they represent up to 20% of childhood testicular tumors. The primary types include Leydig cell tumors and Sertoli cell tumors.
Leydig cell tumors
These tumors originate in the Leydig cells of the testicle, which typically produce male sex hormones (androgens such as testosterone). Leydig cell tumors can occur in both adults and children. While these tumors often produce androgens, they can sometimes produce estrogens (female sex hormones).
The majority of Leydig cell tumors are benign (not cancerous). They rarely extend beyond the testicle and can usually be cured with surgery. However, a small percentage of Leydig cell tumors do metastasize to other parts of the body. These cases typically have a poor prognosis because they often do not respond well to chemotherapy or radiation therapy.
Sertoli cell tumors
Gonadal stromal tumors starting in normal Sertoli cells, which support and nourish the sperm-making germ cells, are typically benign. However, if they metastasize, they often do not respond well to chemotherapy or radiation therapy, similar to Leydig cell tumors.
Causes of Testicular Cancer
Testicular cancer is a relatively rare form of cancer that typically affects men between the ages of 15 and 45, although it can occur at any age. The exact cause of testicular cancer is unknown, but several risk factors have been identified. One such factor is cryptorchidism, a condition in which one or both testicles fail to descend into the scrotum before birth. This condition, which occurs in about 3% of boys, increases the risk of developing testicular cancer. While most undescended testicles will descend on their own within the first year of life, surgical intervention called orchiopexy may be necessary if they do not.
Risk Factors of Testicular Cancer
Men with a family history of testicular cancer, particularly a father or brother with the disease, are also at an increased risk. Klinefelter's syndrome, an inherited disorder that affects males, has been linked to an elevated risk of testicular cancer. Additionally, men with HIV, particularly those with AIDS, and those with a condition called carcinoma in situ in the testicles are at a higher risk.
A personal history of testicular cancer in one testicle increases the risk of developing it in the other. Testicular cancer primarily affects men between the ages of 20 and 34, although it can occur at any age. White, American Indian, and Alaska Native men face a higher risk than Black, Asian American, and Pacific Islander men. Tall men may have a slightly higher risk of testicular cancer, but there is no conclusive link with body weight. The global risk of testicular cancer is highest in the United States and Europe and lowest in Africa and Asia.
Symptoms of Testicular Cancer
Many symptoms that may arise are often attributed to causes other than testicular cancer. Conditions such as testicular injury or inflammation can mimic the symptoms of testicular cancer. Inflammation of the testicle (orchitis) or the epididymis (epididymitis) can lead to swelling and pain in the testicle, with viral or bacterial infections also being potential causes.
In some cases, testicular cancer manifests without any noticeable symptoms, and its detection occurs incidentally during medical examinations for other issues. For example, investigations into infertility may unexpectedly reveal a small testicular cancer.
Many of these symptoms are more likely to be caused by something other than testicular cancer. Several non-cancerous conditions, such as testicle injury or inflammation, can cause symptoms a lot like those of testicular cancer. However, it is crucial to promptly consult a doctor if you experience any of the following signs or symptoms:
- A feeling of heaviness in the scrotum: Men with testicular cancer may also report a sensation of heaviness or a dull ache in the lower abdomen or scrotum.
- Sudden swelling in the scrotum.
- Back pain: This pain can be from cancer spread to the lymph nodes (bean-sized collections of immune cells) behind the belly.
- Presence of a lump or swelling in either testicle: Typically, the primary indication of testicular cancer is the discovery of a lump on the testicle, or the testicle appears swollen or enlarged.
- It's important to note that slight differences in size between testicles are normal, as is one hanging lower than the other. Although some testicular tumors may cause discomfort, they often remain painless.
- Breast growth or tenderness: In rare instances, germ cell tumors can stimulate breast growth or cause breast tenderness. This phenomenon occurs due to certain types of germ cell tumors secreting elevated levels of human chorionic gonadotropin (HCG), a hormone that stimulates breast development. Additionally, some Leydig cell tumors produce estrogen (female sex hormones), leading to breast growth or a decrease in sexual desire.
- Early onset of puberty in boys: Leydig cell tumors can produce androgens (male sex hormones), which may not exhibit symptoms in men but can result in precocious signs of puberty in boys. These signs include a deepening voice and the emergence of facial and body hair at an unusually young age.
Diagnosing Testicular Cancer
Testicular cancer is often detected due to symptoms or incidentally during tests for other conditions. The initial step involves a physical examination by a doctor, who will check for swelling, tenderness, and any lumps in the testicles. They will also examine the abdomen, lymph nodes, and other areas for signs of cancer spread. While these exams typically appear normal except for changes in the testicles, further testing is necessary if a lump or other sign of testicular cancer is found.
Ultrasound is usually the first test if testicular cancer is suspected. It uses sound waves to create images of the body's interior and can determine if a change is a benign condition or a solid tumor that might be cancerous. Blood tests for tumor markers, such as alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG), can also aid in diagnosis. Elevated levels of these markers suggest the presence of a testicular tumor, and the specific marker level can help identify the type of testicular cancer.
Surgery (radical inguinal orchiectomy) is often recommended to remove the tumor if it is suspected to be cancerous based on ultrasound and blood tests. A biopsy is not typically performed due to the risk of spreading cancer. Instead, the entire testicle is sent to a lab for examination by a pathologist. Imaging tests, such as chest X-rays, CT scans, MRI scans, PET scans, and bone scans, may be conducted to determine the extent of the cancer and its spread to other parts of the body.
If testicular cancer is confirmed, further imaging tests are often conducted to assess its stage, evaluate the effectiveness of treatment, and monitor for recurrence.
Staging Testicular Cancer
Once a person is diagnosed with testicular cancer the doctor will want to stage the cancer or see if it has spread. This helps determine the best treatment option. The earliest stage of testicular cancer is stage 0, also known as germ cell neoplasia in situ (GCNIS). The other staging groups are from I to III, with some stages being split further into A, B, etc. to cover more details. There is no stage IV in testicular cancer. As with all cancers, the lower the number, the less the cancer has spread, and earlier letters mean lower stages.
Treatments for Testicular Cancer
The treatment option that is best for a patient’s testicular cancer is determined by their care team after confirming the type and staging of the cancer, as well as the patient’s overall health. Surgery and chemotherapy are the two most common treatment options.
Surgery for Testicular Cancer
Surgery serves as the primary treatment for nearly all cases of testicular cancer. The standard procedure, known as radical inguinal orchiectomy, involves making an incision just above the pubic area to remove the affected testicle, along with the tumor and spermatic cord containing blood and lymph vessels. This step helps prevent the cancer from spreading through these pathways.
Even testicular cancers that have spread are typically treated with radical inguinal orchiectomy. In some cases, additional surgery called retroperitoneal lymph node dissection (RPLND) may be performed. This involves removing lymph nodes around the large blood vessels in the abdomen, either during the initial surgery or in a separate operation. Not all patients require this procedure, so it's essential to discuss its necessity and alternatives with your doctor.
RPLND is a complex and lengthy operation, usually done through a large incision down the middle of the abdomen. However, laparoscopic surgery offers a less invasive option in some cases. This approach uses small incisions and a camera-equipped tube to remove lymph nodes, resulting in quicker recovery, less pain, and earlier resumption of normal activities. Despite these advantages, doctors may recommend chemotherapy following laparoscopic surgery if cancer is found in the lymph nodes, as the procedure's effectiveness in removing all cancerous lymph nodes is uncertain.
Like any surgery, there are risks associated with these procedures, including reactions to anesthesia, bleeding, blood clots, and infections. After an orchiectomy, men may experience some pain, but this can be managed with medications. Losing one testicle generally has no impact on a man's ability to have an erection or engage in sexual activity. However, if both testicles are removed, fertility and testosterone production may be affected. Testosterone supplements can help manage these effects.
Some men may opt for a testicular prosthesis to restore a natural appearance after an orchiectomy. This implant, filled with saline, can be surgically placed in the scrotum. Additionally, lymph node dissection can lead to complications such as infection or bowel obstruction, but these are rare. It's important to note that this surgery does not cause impotence, although it may damage nerves that control ejaculation, potentially leading to retrograde ejaculation. Nerve-sparing surgery is available to help preserve ejaculation function.
Chemotherapy for Testicular Cancer
Chemotherapy is another treatment option for testicular cancer that has spread. It may be used to cure the cancer or reduce the risk of recurrence after surgery. Regular self-exams and awareness of symptoms are crucial for early detection and treatment. While testicular cancer is rare, it is highly treatable, especially when diagnosed early.
Radiation Therapy for Testicular Cancer
Radiation therapy may be used to treat testicular cancer that has spread to lymph nodes. This therapy uses high-energy rays or particles to destroy cancer cells or slow their growth. It is mainly used for seminomas, which are sensitive to radiation. Side effects of radiation therapy can include fatigue, nausea, diarrhea, and skin changes, but these typically improve after treatment. There is a risk of long-term effects, such as damage to nearby organs or an increased risk of developing a second cancer.
Immunotherapy for Testicular Cancer
Immunotherapy uses a medication that helps a patient’s immune system kill cancer cells. Immunotherapy is sometimes used for advanced testicular cancer or as an option when other treatment options have not been successful.
The University of Colorado (CU) Cancer Center partners with UCHealth, Children’s Hospital Colorado, and Rocky Mountain Regional VA to provide clinical care. Please make an appointment with one of our clinical partners to be seen by a CU Cancer Center doctor.
UCHealth Cancer Care - Anschutz Medical Campus
1665 Aurora Court Anschutz Cancer Pavilion
Aurora, CO 80045
720-848-0300
UCHealth Cherry Creek Medical Center
100 Cook Street
Denver, CO 80206
720-848-0000
UCHealth Cancer Center - Highlands Ranch
1500 Park Central Drive
Highlands Ranch, CO 80129
720-516-1100
UCHealth Lone Tree Medical Center
9548 Park Meadows Drive
Lone Tree, CO 80124
720-848-2200
Children's Hospital Colorado:
13123 East 16th Avenue
Aurora, CO 80045
720-777-6740
Rocky Mountain Regional VA Medical Center:
1700 North Wheeling Street
Aurora, CO 80045-7211
303-399-8020
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Information reviewed by Paul Maroni, MD, in April 2024.