Introduction

Cancer of the testicle is one of the less common cancers and tends to mostly affect men between 15 and 49 years of age.

Typical symptoms are a painless swelling or lump in one of the testicle, or any change in shape or texture of the testicles.

It's important to be aware of what feels normal for you.  Get to know your body and see your GP if you notice any chanes.

The testicles

The testicles are the two oval-shaped male sex organs that sit inside the scrotum on either side of the penis.

The testicles are an important part of the male reproductive system because they produce sperm and the hormone testosterone, which plays a major role in male sexual development.

Types of testicular cancer

The different types of testicular cancer are classified by the type of cells the cancer begins in.

The most common type of testicular cancer is "germ cell testicular cancer", which accounts for around 95% of all cases. Germ cells are a type of cell that the body uses to create sperm.

There are two main subtypes of germ cell testicular cancer. They are:

  • seminomas – which have become more common in the past 20 years and now account for 50 to 55% of testicular cancers
  • non-seminomas – which account for most of the rest and include teratomas, embryonal carcinomas, choriocarcinomas and yolk sac tumours

Both types tend to respond well to chemotherapy.

Less common types of testicular cancer include:

  • Leydig cell tumours – which account for around 1 to 3% of cases
  • Sertoli cell tumours – which account for around 1% of cases
  • lymphoma – which accounts for around 4% of cases

This topic focuses on germ cell testicular cancer. You can contact the cancer support specialists at Macmillan for more information about Leydig cell tumour and Sertoli cell tumours. The helpline number is 0808 808 00 00 and is open Monday to Friday, 9am to 8pm.

How common is testicular cancer?

Testicular cancer is a relatively rare type of cancer, accounting for just 1% of all cancers that occur in men. Around 2,200 men are diagnosed with testicular cancer each year in the UK.

Testicular cancer is unusual compared with other cancers because it tends to affect younger men. Although it's relatively uncommon overall, testicular cancer is the most common type of cancer to affect men between the ages of 15 and 49.

For reasons that are unclear, white men have a higher risk of developing testicular cancer than men from other ethnic groups.

The number of cases of testicular cancer diagnosed each year in the UK has roughly doubled since the mid-1970s. Again, the reasons for this are unclear.

Causes of testicular cancer

The exact cause or causes of testicular cancer are unknown, but a number of factors have been identified that increase a man's risk of developing it. The three main risk factors are described below.

Undescended testicles

Undescended testicles (cryptorchidism) is the most significant risk factor for testicular cancer.

Around 3 to 5% of boys are born with their testicles inside their abdomen. They usually descend into the scrotum during the first year of life, but in some boys the testicles don't descend.

In most cases, testicles that don't descend by the time a boy is a year old descend at a later stage. If the testicles don't descend naturally, an operation known as an orchidopexy can be carried out to move the testicles into the correct position inside the scrotum.

It's important that undescended testicles move down into the scrotum during early childhood because boys with undescended testicles have a higher risk of developing testicular cancer than boys whose testicles descend normally. It's also much easier to observe the testicles when they're in the scrotum.

Men with undescended testicles are about three times more likely to develop testicular cancer than men whose testicles descend at birth or shortly after.

Family history

Having a close relative with a history of testicular cancer or an undescended testicle increases your risk of also developing it.

For example, if your father had testicular cancer, you're around 4 times more likely to develop it than someone with no family history of the condition. If your brother had testicular cancer, you're about 8 times more likely to develop it.

Current research suggests a number of genes may be involved in the development of testicular cancer in families where more than one person has had the condition. This is an ongoing area of research in which patients and their families may be asked to take part.

Previous testicular cancer

Men who've previously been diagnosed with testicular cancer are between 4 and 12 times more likely to develop it in the other testicle.

For this reason, if you've previously been diagnosed with testicular cancer, it's very important that you keep a close eye on the other testicle. Read What should my testicles look and feel like?

If you've been diagnosed with testicular cancer, you also need to be observed for signs of recurrence for between 5 and 10 years, so it's very important that you attend your follow-up appointments.

Cancer Research UK has more information about testicular cancer risks and causes.

Outlook

Testicular cancer is one of the most treatable types of cancer, and the outlook is one of the best for cancers.

In England and Wales, almost all men (99%) survive for a year or more after being diagnosed with testicular cancer, and 98% survive for five years or more after diagnosis.

Cancer Research UK has more information about survival rates for testicular cancer.

Almost all men who are treated for testicular germ cell tumours are cured, and it's rare for the condition to return more than five years later.

Treatment almost always includes the surgical removal of the affected testicle – called orchidectomy or orchiectomy – which doesn't usually affect fertility or the ability to have sex.

In some cases, chemotherapy or, less commonly, radiotherapy may be used for seminomas (but not non-seminomas).

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Symptoms

Typical symptoms are a painless swelling or lump in one of the testicles, or any change in shape or texture of the testicles.

The swelling or lump can be about the size of a pea but may be larger.

Most lumps or swellings in the scrotum aren't in the testicle and aren't a sign of cancer, but they should never be ignored.

Other symptoms

Testicular cancer can also cause other symptoms, including:

  • an increase in the firmness of a testicle
  • a difference between one testicle and the other
  • a dull ache or sharp pain in your testicles or scrotum, which may come and go
  • a feeling of heaviness in your scrotum

When to see your GP

See your GP if you notice a swelling, lump or any other change in one of your testicles.

Lumps within the scrotum can have many different causes, and testicular cancer is rare. Your GP will examine you and, if they think the lump is in your testicle, they may consider cancer as a possible cause.

Research has shown that less than 4% of scrotal lumps or swellings are cancerous. For example, varicoceles (swollen blood vessels) and epididymal cysts (cysts in the tubes around the testicle) are common causes of testicular lumps.

If you do have testicular cancer, the sooner treatment begins, the greater the likelihood that you'll be completely cured.

If you don't feel comfortable visiting your GP, you can go to your local sexual health clinic, where a healthcare professional will be able to examine you.

Metastatic cancer

If testicular cancer has spread to other parts of your body, you may also experience other symptoms. Cancer that has spread to other parts of the body is known as metastatic cancer.

Around 5% of people with testicular cancer will experience symptoms of metastatic cancer.

The most common place for testicular cancer to spread to is nearby lymph nodes in your abdomen or lungs. Lymph nodes are glands that make up your immune system. Less commonly, the cancer can spread to your liver, brain or bones.

Symptoms of metastatic testicular cancer can include:

  • a persistent cough
  • coughing or spitting up blood
  • shortness of breath
  • swelling and enlargement of male breasts
  • a lump or swelling in your neck
  • lower back pain
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Diagnosis

See your GP as soon as possible if you notice a swelling, lump or any other change in one of your testicles.

Most lumps within the scrotum aren't cancerous, but it's important to get checked as soon as possible. Treatment for testicular cancer is much more effective when started early.

Physical examination

As well as asking you about your symptoms and looking at your medical history, your GP will usually need to examine your testicles.

They may hold a small light or torch against your scrotum to see whether light passes through it. Testicular lumps tend to be solid, which means light is unable to pass through them. A collection of fluid in the scrotum will allow light to pass through it.

Tests for testicular cancer

If you have a non-painful swelling or lump, or a change in the shape or texture of one of your testicles, and your GP thinks it may be cancerous, you'll be referred for further testing within two weeks.

Some of the tests you may have are described below.

Scrotal ultrasound

A scrotal ultrasound scan is a painless procedure that uses high-frequency sound waves to produce an image of the inside of your testicle. It's one of the main ways of finding out whether or not a lump is cancerous (malignant) or non-cancerous (benign).

During a scrotal ultrasound, your specialist will be able to determine the position and size of the abnormality in your testicle.

It will also give a clear indication of whether the lump is in the testicle or separate within the scrotum, and whether it's solid or filled with fluid. A fluid-filled lump or collection around the testis is usually harmless. A more solid lump may be a sign the swelling is cancerous.

Blood tests

To help confirm a diagnosis, you may need a series of blood tests to detect certain hormones in your blood, known as "markers".

Testicular cancer often produces these markers, so it may indicate you have the condition if they're in your blood.

Markers in your blood that will be tested for include:

  • AFP (alpha feto-protein)
  • HCG (human chorionic gonadotrophin)

A third blood test is also often carried out as it may indicate how active a cancer is. It's called LDH (lactate dehydrogenate), but it isn't a specific marker for testicular cancer.

Not all people with testicular cancer produce markers. There may still be a chance you have testicular cancer even if your blood test results come back normal.

Histology

The only way to definitively confirm testicular cancer is to examine part of the lump under a microscope. These tests and reports are called histology.

Unlike many cancers, where a small piece of the cancer can be removed (a biopsy), in most cases the only way to examine a testicular lump is by removing the affected testicle completely.

This is because the combination of the ultrasound and blood marker tests is usually sufficient to make a firm diagnosis. Also, a biopsy may injure the testicle and spread cancer into the scrotum which isn't usually affected.

Your specialist will only recommend removing your testicle if they're relatively certain the lump is cancerous. Losing a testicle won't affect your sex life or ability to have children.

The removal of a testicle is called an orchidectomy. It's the main type of treatment for testicular cancer, so if you have testicular cancer it's likely you'll need to have an orchidectomy.

Other tests

In almost all cases, you'll need further tests to check whether testicular cancer has spread. When cancer of the testicle spreads, it most commonly affects the lymph nodes in the back of the abdomen or the lungs.

Therefore, you may require a chest X-ray to check for signs of a tumour. You'll also need a scan of your entire body. This is usually a CT scan (computerised X-ray) to check for signs of the cancer spreading. In some cases, a different type of scan, known as a magnetic resonance imaging (MRI) scan, may be used.

Stages of testicular cancer

After all tests have been completed, it's usually possible to determine the stage of your cancer.

There are two ways that testicular cancer can be staged. The first is known as the TNM staging system:

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

Testicular cancer is also staged numerically. The 4 main stages are:

  • Stage 1 – the cancer is contained within your testicle and epididymis (the tube at the back of the testicle)
  • Stage 2 – the cancer has spread from the testicles into the lymph nodes (small glands that help fight infection) at the back of the abdomen
  • Stage 3 – the cancer has spread to the lymph nodes in the middle of the chest or in the neck
  • Stage 4 – the cancer has spread to the lungs or, rarely, to other tissues or organs, such as the liver, bones or brain

Cancer Research UK has more information about testicular cancer stages.

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Treatment

Chemotherapy, radiotherapy and surgery are the three main treatments for testicular cancer.

Your recommended treatment plan will depend on:

  • the type of testicular cancer you have – whether it's a seminoma or a non-seminoma
  • the stage of your testicular cancer

The first treatment option for all cases of testicular cancer, whatever the stage, is to surgically remove the affected testicle (an orchidectomy).

For stage one seminomas, after the testicle has been removed, a single dose of chemotherapy may be given to help prevent the cancer returning. A short course of radiotherapy is also sometimes recommended.

However, in many cases, the chance of recurrence is low and your doctors may recommend that you're very carefully monitored over the next few years. Further treatment is usually only needed for the small number of people who have a recurrence.

For stage one non-seminomas, close follow-up (called surveillance) may also be recommended, or a short course of chemotherapy using a combination of different medications.

For stage two, three and four testicular cancers, three to four cycles of chemotherapy are given using a combination of different medications. Further surgery is sometimes needed after chemotherapy to remove any affected lymph nodes or deposits in the lungs or, rarely, in the liver.

Some people with stage two seminomas may be suitable for less intense treatment with radiotherapy, sometimes with the addition of a simpler form of chemotherapy.

In non-seminoma germ cell tumours, additional surgery may also be required after chemotherapy to remove tumours from other parts of the body, depending on the extent of the spread of the tumour.

Deciding what treatment is best for you can be difficult. Your cancer team will make recommendations, but the final decision will be yours.

Before discussing your treatment options with your specialist, you may find it useful to write a list of questions to ask them. For example, you may want to find out the advantages and disadvantages of particular treatments.

Orchidectomy

An orchidectomy is a surgical procedure to remove a testicle. If you have testicular cancer, the whole of the affected testicle will need to be removed because only removing the tumour may lead to the cancer spreading.

By removing the entire testicle, your chances of making a full recovery are greatly improved. Your sex life and ability to father children won't be affected.

About one in 50 people will get a second new testicular cancer in their remaining testicle. In such circumstances, it's sometimes possible to only remove the part of the testicle containing the tumour. You should ask your surgeon about this if you're in this position.

If testicular cancer is detected in its very early stages, an orchidectomy may be the only treatment you require.

An orchidectomy isn't carried out through the scrotum. It's done by making an incision in your groin through which the testicle is removed with all of the tubes and blood vessels attached to the testicle that pass through the groin into the abdomen. The operation is carried out under general anaesthetic.

You can have an artificial (prosthetic) testicle inserted into your scrotum so that the appearance of your testicles isn't greatly affected. The artificial testicle is usually made of silicone (a soft type of plastic). It probably won't be exactly like your old testicle or the one you still have. It may be slightly different in size or texture.

After an orchidectomy, it's often possible to be discharged quickly, although you may need to stay in hospital for a few days. If only one testicle is removed, there shouldn't be any lasting side effects.

If both testicles are removed (a bi-lateral orchidectomy), you'll be infertile. However, removing both testicles at the same time is very rarely required, and only one in every 50 cases require the other testicle to be removed at a later date.

You may be able to bank your sperm before having a bi-lateral orchidectomy to allow you to father children if you decide to.

Sperm banking

Most people are still fertile after having one testicle removed. However, some treatments for testicular cancer can cause infertility.

Some people with testicular cancer may have low sperm counts because of changes that occur in the testicles before the cancer develops.

For some treatments, such as chemotherapy, infertility may occur, but standard chemotherapies have a less than 50% chance of causing infertility if the remaining testicle is normal.

In people who need to have post-chemotherapy removal of lumps at the back of the abdomen, known as retroperitoneal lymph node dissection (RPLND) (see below), the ability to ejaculate (eject sperm from the penis) may be affected, even though the remaining testicle can still produce sperm.

Before your treatment begins, you may want to consider sperm banking. This is where a sample of your sperm is frozen so that it can be used at a later date to impregnate your partner during artificial insemination. Before sperm banking, you may be asked to have tests for HIV, hepatitis B and hepatitis C.

If you're having complex chemotherapy for stage two to four testicular cancer, you should always be offered sperm banking. Ask if you're concerned about your fertility.

Not all men are suitable for sperm banking. For the technique to work, the sperm has to be of a reasonably high quality. There may also be situations where it's considered too dangerous to delay treatment for sperm banking to take place.

Most NHS cancer treatment centres offer a free sperm banking service. However, it's up to each area of the country to decide whether they store sperm for free of whether you have to pay.

Cancer Research UK has more information about sperm banking, including the cost of sperm storage.

Testosterone replacement therapy

If you still have a remaining healthy testicle, it should make enough testosterone so you won't notice any difference.

If there are any problems with your remaining testicle, you may experience symptoms due to a lack of testosterone. These symptoms can be caused for other reasons but can include:

  • tiredness
  • weight gain
  • loss of libido (sex drive)
  • reduced beard growth
  • reduced ability to achieve or maintain an erection (erectile dysfunction)

Having both testicles removed will definitely stop you producing testosterone and you'll develop the above symptoms.

Testosterone replacement therapy is where you're given testosterone in the form of an injection, skin patch or gel to rub into your skin. If you have injections, you'll usually need to have them every two to three months.

After having testosterone replacement therapy, you'll be able to maintain an erection and your sex drive will improve.

Side effects associated with this type of treatment are uncommon, and any side effects that you do experience will usually be mild. They may include:

  • oily skin, which can sometimes trigger the onset of acne
  • breast enlargement and swelling
  • a change in normal urinary patterns, such as needing to urinate more frequently or having problems passing urine (caused by an enlarged prostate gland that puts pressure on your bladder)

Lymph node and lung surgery

More advanced cases of testicular cancer may spread to your lymph nodes. Lymph nodes are part of your body's immune system, which helps protect against illness and infection.

Lymph node surgery is carried out under general anaesthetic. The lymph nodes in your abdomen are the nodes most likely to need removing.

In some cases, the nerves near the lymph nodes can become damaged, which means that rather than ejaculating semen out of your penis during sex or masturbation, the semen instead travels back into your bladder. This is known as retrograde ejaculation.

If you have retrograde ejaculation, you'll still experience the sensation of having an orgasm during ejaculation, but you won't be able to father a child.

There are a number of ways of treating retrograde ejaculation, including the use of medicines that strengthen the muscles around the neck of the bladder to prevent the flow of semen into the bladder.

Men who want to have children can have sperm taken from their urine for use in artificial insemination or in-vitro fertilisation (IVF).

There are also a number of newer surgical techniques that carry a lower risk of retrograde ejaculation and infertility. These are described below.

Some people with testicular cancer have deposits of cancer in their lungs and these may also need to be removed after chemotherapy if they haven't disappeared or reduced sufficiently in size. This type of surgery is also carried out under general anaesthetic and doesn't usually significantly affect breathing in the long-term.

Nerve-sparing retroperitoneal lymph node dissection

A newer type of lymph node surgery, called nerve sparing retroperitoneal lymph node dissection (RPLND), is increasingly being used because it carries a lower risk of causing retrograde ejaculation and infertility.

In nerve-sparing RPLND, the site of the operation is limited to a much smaller area. This means there's less chance of nerve damage occurring. The disadvantage is that the surgery is more technically demanding. Therefore, nerve-sparing RPLND is currently only available at specialist centres that employ surgeons with the required training.

Laparoscopic retroperitoneal lymph node dissection

Laparoscopic retroperitoneal lymph node dissection (LRPLND) is a type of "keyhole" surgery that can be used to remove the lymph nodes. During LRPLND, the surgeon will make a number of small incisions in your abdomen.

An instrument called an endoscope is inserted into one of the incisions. An endoscope is a thin, long, flexible tube with a light and a camera at one end, enabling images of the inside of your body to be relayed to an external television monitor.

Small, surgical instruments are passed down the endoscope and can be used to remove the affected lymph nodes.

The advantage of LRPLND is that there's less post-operative pain and a quicker recovery time. Also, as with nerve-sparing RPLND, in LRPLND there's a smaller chance that nerve damage will lead to retrograde ejaculation.

However, as LRPLND is a new technique, there's little available evidence regarding the procedure's long-term safety and effectiveness. If you're considering LRPLND, you should understand there are still uncertainties about the safety and effectiveness of the procedure.

Radiotherapy

Radiotherapy uses high-energy beams of radiation to help destroy cancer cells. Sometimes, seminomas may require radiotherapy after surgery to help prevent the cancer returning.

It may also be needed in advanced cases where someone is unable to tolerate the complex chemotherapies that are usually used to treat stage two, three and four testicular cancer.

If testicular cancer has spread to your lymph nodes, you may require radiotherapy after a course of chemotherapy.

Side effects of radiotherapy can include:

  • reddening and soreness of the skin, which is similar to sunburn
  • nausea
  • diarrhoea
  • fatigue

These side effects are usually only temporary and should improve when your treatment is completed.

Chemotherapy

Chemotherapy uses powerful medicines to kill the malignant (cancerous) cells in your body or stop them multiplying.

You may require chemotherapy if you have advanced testicular cancer or it's spread within your body. It's also used to help prevent the cancer returning. Chemotherapy is commonly used to treat seminomas and non-seminoma tumours.

Chemotherapy medicines for testicular cancer are usually injected into a vein. In some cases, a special tube called a central line is used, which stays in a vein throughout your treatment so that you don't have to keep having blood tests or needles placed in a new vein.

Sometimes, chemotherapy medicines can attack your body's normal, healthy cells. This is why chemotherapy can have many different side effects. The most common include:

  • vomiting
  • hair loss
  • nausea
  • sore mouth and mouth ulcers
  • loss of appetite
  • fatigue
  • breathlessness and lung damage
  • infertility
  • ringing in your ears (tinnitus)
  • skin that bleeds or bruises easily
  • low blood counts
  • increased vulnerability to infection
  • numbness and tingling (pins and needles) in your hands and feet
  • kidney damage

These side effects are usually only temporary and should improve after you've completed your treatment.

Side effects, such as infections that occur when you have a low blood count, can be life-threatening, and it's essential that you always call your cancer care team if you're worried between chemotherapy treatments.

Bleomycin

One of the medicines commonly used, called bleomycin, can cause long-term lung damage and you should discuss this with your doctors if damage to your lungs would have specific issues for your career or lifestyle. However, the advice may still be that you should receive it for the best chance of a cure.

Having children

You shouldn't father children while having chemotherapy and for a year after your treatment has finished. This is because chemotherapy medications can temporarily damage your sperm, increasing your risk of fathering a baby with serious birth defects. Therefore, you'll need to use a reliable method of contraception, such as a condom, during this time.

Condoms should also be used during the first 48 hours after having a course of chemotherapy. This is to protect your partner from any potentially harmful effects of the chemotherapy medication in your sperm.

Follow-up

Even if your cancer has been completely cured, there's a risk it will return. The risk of your cancer returning will depend on what stage it was at when you were diagnosed and what treatment you've had since.

Most recurrences of non-seminoma testicular cancer occur within two years of surgery or completion of chemotherapy. In seminomas, recurrences still occur until three years. Recurrences after three years are rare, occurring in less than 5% of people.

Because of the risk of recurrance, you'll need regular tests to check if the cancer has returned. These include:

  • a physical examination
  • blood tests to check for tumour markers
  • a chest X-ray
  • computerised tomography (CT) scan

Follow-up and testing is usually recommended depending on the extent of the cancer and the treatment offered. This is usually more frequent in the first year or two but follow-up appointments may last for up to five years. In certain cases, it may be necessary to continue follow-up appointments for 10 years or longer.

If the cancer returns following treatment for stage one testicular cancer, and it's diagnosed at an early stage, it will usually be possible to cure it using chemotherapy and possibly also radiotherapy. Some types of recurring testicular cancer have a cure rate of over 95%.

Recurrences that occur after previous combination chemotherapy can also be cured, but the chances of this will vary between individuals and you'll need to ask your doctors to discuss this with you.

Cancer Research UK has more information about follow-up for testicular cancer.

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The information on this page has been adapted by NHS Wales from original content supplied by NHS Choices.
Last Updated: 13/07/2018 13:47:51