Risk Factors for Testicular Cancer

Risk factors for testicular cancer include:

• An undescended testicle
• Family history of testicular cancer
• HIV infection
• Carcinoma in situ of the testicle
• Having had testicular cancer before
• Being of a certain race/ethnicity
• Body size

These are discussed in more detail below.

Undescended testicle

One of the main risk factors for testicular cancer is a condition called cryptorchidism, or undescended testicle(s). This means that one or both testicles fail to move from the abdomen (belly) into the scrotum before birth. Males with cryptorchidism are several times more likely to get testicular cancer than those with normally descended testicles.

Normally, the testicles develop inside the abdomen of the fetus and they go down (descend) into the scrotum before birth. In about 3% of boys, however, the testicles do not make it all the way down before the child is born. Sometimes the testicle remains in the abdomen. In other cases, the testicle starts to descend but remains stuck in the groin area.

Most of the time, undescended testicles continue moving down into the scrotum during the child’s first year of life. If the testicle has not descended by the time a child is a year old, it probably won’t go down on its own. Sometimes a surgical procedure known as orchiopexy is needed to bring the testicle down into the scrotum.

The risk of testicular cancer might be a little higher for men whose testicle stayed in the abdomen as opposed to one that has descended at least partway. If cancer does develop, it is usually in the undescended testicle, but about 1 out of 4 cases occur in the normally descended testicle. Because of this, some doctors conclude that cryptorchidism doesn’t actually cause testicular cancer but that there is something else that leads to both testicular cancer and abnormal positioning of one or both testicles.

Orchiopexy may reduce the risk of testicular cancer if it is done when a child is younger, but it is not as clear if it is helpful if the child is older. The best time to do this surgery is not clear. Experts in the United States recommend that orchiopexy be done soon after the child’s first birthday for reasons (such as fertility) that are not related to cancer.

Family history

Having a close blood relative (father or brother) with testicular cancer increases the risk that you will get it, too. But only a small number of testicular cancers occur in families. Most men with testicular cancer do not have a family history of the disease.

HIV infection

Some evidence has shown that men infected with the human immunodeficiency virus (HIV), particularly those with AIDS, are at increased risk. No other infections have been shown to increase testicular cancer risk.

Carcinoma in situ

This condition, described in What is testicular cancer?, often doesn’t cause a lump in the testicles or any other symptoms. It isn’t clear how often carcinoma in situ (CIS) in the testicles progresses to cancer. In some cases, CIS is found in men who have a testicular biopsy to evaluate infertility or have a testicle removed because of cryptorchidism. Doctors in Europe are more likely than the doctors in this country to look for CIS. This may be why the numbers for diagnosis and progression of CIS to cancer are lower in the United States than in parts of Europe.

Since we don’t know how often CIS becomes true (invasive) cancer, it isn’t clear if treating CIS is a good idea. Some experts think that it may be better to wait and see if the disease gets worse or becomes a true cancer. This could allow many men with CIS to avoid the risks and side effects of treatment. When CIS is treated, radiation or surgery (to remove the testicle) is used.

Cancer in the other testicle

A personal history of testicular cancer is another risk factor. About 3% or 4% of men who have been cured of cancer in one testicle will eventually develop cancer in the other testicle.

Age

About half of testicular cancers occur in men between the ages of 20 and 34. But this cancer can affect males of any age, including infants and elderly men.

Race and ethnicity

The risk of testicular cancer among white men is about 4 to 5 times that of black men and that of Asian-American men. The risk for American Indians falls between that of Asians and whites. The reason for these differences is not known. Worldwide, the risk of developing this disease is highest among men living in the United States and Europe and lowest among men living in Africa or Asia.

Body size

Several studies have found that tall men have a somewhat higher risk of testicular cancer, but some other studies have not. Most studies have not found a link between testicular cancer and body weight.

Unproven or controversial risk factors

Prior injury or trauma to the testicles and recurrent actions such as horseback riding do not appear to be related to the development of testicular cancer.

Most studies have not found that strenuous physical activity increases testicular cancer risk. Being physically active has been linked with a lower risk of several other forms of cancer as well as a lower risk of many other health problems.

Can Testicular Cancer Be Prevented?

Many men with testicular cancer have no known risk factors. And some of the known risk factors, such as undescended testicles, white race, and a family history of the disease, can’t be changed. For these reasons, it is not possible now to prevent most cases of this disease.

Experts recommend correcting cryptorchidism in boys for a number of reasons (such as preserving fertility and body image), but it’s not clear how much this changes the child’s risk for testicular cancer.

Do We Know What Causes Testicular Cancer?

The exact cause of most testicular cancers is not known. But scientists have found that the disease is linked with a number of other conditions, which are described in the section What are the risk factors for testicular cancer? A great deal of research is being done to learn more about the causes.

Researchers are learning how certain changes in a cell’s DNA can cause the cell to become cancerous. DNA is the chemical in each of our cells that makes up our genes. Genes tell our cells how to function. They are packaged in chromosomes, which are long strands of DNA in each cell. Most cells in the body have 2 sets of 23 chromosomes (one set of chromosomes comes from each parent), but each sperm or egg cell has only 23 chromosomes. When the sperm and egg combine, the resulting embryo has a normal number of chromosomes in each cell, half of which are from each parent. We usually look like our parents because they are the source of our DNA. But DNA affects more than how we look.

Some genes control when our cells grow, divide into new cells, and die. Certain genes that help cells grow and divide are called oncogenes. Others that slow down cell division or make cells die at the right time are called tumor suppressor genes. Cancers can be caused by changes in chromosomes that turn on oncogenes or turn off tumor suppressor genes.

Most testicular cancer cells have extra copies of a part of chromosome 12 (called isochromosome 12p or i12p). Some testicular cancers have changes in other chromosomes as well, or even abnormal numbers of chromosomes (often too many). Scientists are studying these DNA and chromosome changes to learn more about which genes are affected and how this might lead to testicular cancer.

Signs and Symptoms of Testicular Cancer

If you have any of these signs or symptoms, see your doctor without delay. Many of these symptoms are more likely to be caused by something other than testicular cancer. (For more information about these conditions, see Do I Have Testicular Cancer?)

But if a tumor is the cause, the sooner it is found, the sooner you can start treatment and the more effective it is likely to be.

Lump or swelling in the testicle

Most often, the first symptom of testicular cancer is a lump on the testicle, or the testicle becomes swollen or larger. (It’s normal for one testicle to be slightly larger than the other, and for one to hang lower than the other.) Some testicular tumors might cause pain, but most of the time they do not. Men with testicular cancer can also have a feeling of heaviness or aching in the lower abdomen or scrotum.

Breast growth or soreness

In rare cases, germ cell tumors can make breasts grow or become sore. This occurs because certain types of germ cell tumors secrete high levels of a hormone called human chorionic gonadotropin (HCG), which stimulates breast development.

Some Leydig cell tumors can make estrogens (female sex hormones), which can cause breast growth or loss of sexual desire.

Early puberty in boys

Some Leydig cell tumors can make androgens (male sex hormones). Androgen-producing tumors may not cause any specific symptoms in men, but in boys they can cause signs of puberty at an abnormally early age, such as a deepening voice and the growth of facial and body hair.

Symptoms of advanced testicular cancers

Even if testicular cancer has spread to other parts of the body, many men might not have symptoms right away. But some men might have some of the following symptoms:

• Low back pain, from cancer spread to the lymph nodes (bean-sized collections of immune cells) in back of the belly
• Shortness of breath, chest pain, or a cough (even coughing up blood) may develop from cancer spread in the lungs.
• Belly pain, either from enlarged lymph nodes or because the cancer has spread to the liver.
• Headaches or confusion, from cancer spread in the brain.

A number of non-cancerous conditions, such as testicle injury or inflammation, can cause symptoms similar to those of testicular cancer. Inflammation of the testicle (known as orchitis) and inflammation of the epididymis (epididymitis) can cause swelling and pain of the testicle. Both of these also can be caused by viral or bacterial infections.

Signs of testicular cancer

Some men with testicular cancer have no symptoms at all, and their cancer is found during medical testing for other conditions. Sometimes imaging tests done to find the cause of infertility can uncover a small testicular cancer.

How Is Testicular Cancer Diagnosed?

Testicular cancer is usually found as a result of symptoms that a person is having. It can also be found as a result of tests for another condition. Often the next step is an exam by a doctor.

The doctor will feel the testicles for swelling or tenderness and for the size and location of any lumps. The doctor will also examine your abdomen, lymph nodes, and other parts of your body carefully, looking for any possible signs of cancer spread. Often the results of the exam are normal aside from the testicles. If a lump or other sign of testicular cancer is found, testing is needed to look for the cause.

Ultrasound of the testicles

An ultrasound is often the first test done if the doctor thinks you might have testicular cancer.

This test uses sound waves to produce images of internal organs. A transducer (wand-like instrument) gives off sound waves and picks up the echoes as they bounce off the organs. A computer creates an image on a monitor from the pattern of the echoes.

The pattern of echoes can be used to distinguish certain benign conditions (like hydrocele or varicocele), from a solid tumor that could be a cancer. If the lump is solid, then it’s more likely to be a cancer, so the doctor will recommend further tests or even surgery to remove the testicle.

Ultrasound is an easy test to have and it uses no radiation. You are on your back on a table as the technician moves the transducer along the skin of the scrotum. Usually, the skin is first lubricated with gel.

Blood tests for tumor markers

Some blood tests can help diagnose testicular tumors. Many testicular cancers make high levels of certain proteins called tumor markers, such as alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG). When these tumor markers are in the blood, it suggests that there is a testicular tumor.

Rises in AFP or HCG can also help doctors tell which type of testicular cancer it might be. Non-seminomas often raise AFP and/or HCG levels. Pure seminomas occasionally raise HCG levels but never AFP levels, so any increase in AFP means that the tumor has a non-seminoma component. (Tumors can be mixed and have areas of seminoma and non-seminoma.) Sertoli and Leydig cell tumors do not make these substances. Some cancers are too small to elevate levels of these tumor markers.

A testicular tumor might also increase the levels of an enzyme called lactate dehydrogenase (LDH). LDH levels can also be increased in conditions other than cancer. A high LDH level often (but not always) indicates widespread disease.

Tumor marker tests sometimes are also used for other reasons, such as to help estimate how much cancer is present to follow the patient’s response to treatment, or to look for signs the tumor might have returned.

Surgery to diagnose testicular cancer

Most types of cancer are diagnosed by removing a small piece of the tumor and looking at it under a microscope for cancer cells. This is known as a biopsy. But a biopsy is rarely done for a testicular tumor because it might risk spreading the cancer. The doctor can often get a good idea of whether it is testicular cancer based on the ultrasound and blood tumor marker tests, so instead of a biopsy the doctor will very likely recommend surgery to remove the tumor as soon as possible.

The operation to remove a testicular tumor or cancer is called a radical inguinal orchiectomy. In this procedure, the surgeon makes a cut (incision) just above the pubic area and then removes the entire tumor along with the testicle and spermatic cord. The spermatic cord contains part of the vas deferens, as well as blood and lymph vessels that could act as pathways for testicular cancer to spread to the rest of the body. To lessen the chance that cancer cells will spread, these vessels are tied off early in the operation.

The entire specimen is sent to the lab, where a pathologist (a doctor specializing in laboratory diagnosis of diseases) looks at pieces of the tumor under a microscope. If cancer cells are found, the pathologist sends back a report describing the type and extent of the cancer.

In rare cases, when a diagnosis of testicular cancer is uncertain, the doctor may biopsy the testicle before removing it. This is done in the operating room. The surgeon makes a cut above the pubic area, withdraws the testicle from the scrotum, and examines it without cutting the spermatic cord. If a suspicious area is seen, a portion of it is removed and looked at right away by the pathologist. If cancer is found, the testicle and spermatic cord are then removed. If the tissue is not cancerous, the testicle can often be returned to the scrotum, and treatment will be surgery to remove only the tumor or the use of appropriate medicines.

If testicular cancer is found, your doctor will order imaging tests of other parts of your body to check for spread outside the testicle. These tests may also be ordered before the diagnosis is confirmed by surgery.

Imaging tests

Imaging tests use x-rays, magnetic fields, sound waves, or radioactive substances to create pictures of the inside of your body. Ultrasound of the testicles, described above, is a type of imaging test. Other imaging tests may be done for a number of reasons after a testicular cancer diagnosis, including:

• To learn how far cancer might have spread
• To help determine if treatment has been effective
• To look for possible signs of cancer coming back after treatment

Computed tomography (CT) scan

CT scans can be used to help determine the stage (extent) of the cancer by showing if it has spread to the lymph nodes, lungs, liver, or other organs.

The CT scan uses x-rays to produce detailed cross-sectional images of your body. Instead of taking one picture, like a standard x-ray, a CT scanner takes many pictures of the part of your body being studied as it rotates around you. A computer then combines these pictures into an image of a slice of your body. Before the test, you might be asked to drink a contrast solution and/or get an intravenous (IV) injection of a contrast dye that helps better outline structures in the body. You may need an IV line to inject the contrast dye. The injection can cause some flushing (redness and a warm feeling that often lasts seconds). Some people are allergic to the dye and get hives. Rarely, more serious reactions like trouble breathing and low blood pressure can occur. Medicine can be given to prevent and treat allergic reactions. Be sure to tell the doctor if you have any allergies or if you have ever reacted to any contrast material used for x-rays.

A CT scanner has been described as a large donut, with a narrow table that slides in and out of the middle opening. You need to lie still on the table while the scan is being done. CT scans take longer that regular x-rays, and you might feel a bit confined by the ring you have to lie in while the pictures are being taken.

CT guided needle biopsy: CT scans are sometimes used to guide a biopsy needle precisely into a suspected area of cancer spread. For this procedure, you stay on the CT scanning table while a doctor advances a biopsy needle through the skin toward the mass. CT scans are repeated until the doctor can see that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue) is then removed and examined under a microscope.

Magnetic resonance imaging (MRI) scan

MRI scans are particularly helpful in looking at the brain and spinal cord. They are only done in patients with testicular cancer if the doctor has reason to think the cancer might have spread to those areas.

Like CT scans, MRI scans provide detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body. A contrast material might be injected just as with CT scans. MRI scans take longer than CT scans – often up to an hour – and are a little more uncomfortable. You lie on a table that slides inside a narrow tube, which is confining and can upset people with a fear of enclosed spaces. Special, more open MRI machines can help with this if needed, but the images may not be as sharp in some cases. The MRI machine makes buzzing and clicking noises, so some places will provide earplugs to help block this out.

Positron emission tomography (PET) scan

A PET scan can help spot small collections of cancer cells in the body. It is sometimes useful to see if lymph nodes that are still enlarged after chemotherapy contain cancer or are just scar tissue. PET scans are often more useful for seminomas than for non-seminomas, so they are less often used in patients with non-seminoma.

For this test, a form of radioactive sugar (known as fluorodeoxyglucose or FDG) is injected into a vein (IV). (The amount of radioactivity is very low and will pass out of the body over the next day or so.) Because of the way cancer cells in the body grow rapidly, they often take up and use more of the radioactive sugar. After about an hour, you will be moved onto a table in the PET scanner. You lie on the table for about 30 minutes while a special camera creates a picture of areas of radioactivity in the body. The picture is not finely detailed like a CT or MRI scan, but it can provide helpful information about your whole body.

Many centers have special machines that can do both a PET and CT scan at the same time (PET/CT scan). This lets the doctor compare areas of higher radioactivity on the PET with the more detailed appearance of that area on the CT.

Bone scan

A bone scan can help show if a cancer has spread to the bones. It might be done if there is reason to think the cancer might have spread to the bones (because of symptoms such as bone pain) and if other test results aren’t clear.

For this test, a small amount of low-level radioactive material is injected into a vein (IV). The substance settles in areas of bone changes throughout the entire skeleton over the course of a couple of hours. Then, you lie on a table for about 30 minutes while a special camera detects the radioactivity and creates a picture of your skeleton.

Areas of active bone changes attract the radioactivity and show up as “hot spots.” These areas may suggest metastatic cancer, but arthritis or other bone diseases can also cause the same pattern. To distinguish among these conditions, your cancer care team may use other imaging tests such as plain x-rays or MRI scans to get a better look at the areas that light up, or they may even take biopsy samples of the bone.

How Is Testicular Cancer Staged?

The stage of a cancer describes how far it has spread. For testicular cancer, the stage is based on the results of the surgery to diagnose the cancer, blood tests for tumor markers, and imaging tests, The stage of your cancer is very important for planning your treatment and estimating your prognosis (outlook).

If you have testicular cancer, ask your cancer care team to explain the stage in a way that you can understand. Knowing all you can about the stage of your cancer can help you take a more active role in making decisions about your treatment.

The TNM staging system

A staging system is a standard way for your cancer care team to sum up the extent of your cancer. Testicular cancer is staged using the TNM system created by the American Joint Committee on Cancer (AJCC). It’s based on 4 key pieces of information:

• T refers to how much the main (primary) tumor has spread to tissues next to the testicle.
• N describes how much the cancer has spread to regional (nearby) lymph nodes.
• M indicates whether the cancer has metastasized (spread to distant lymph nodes or other organs of the body).
• S indicates the serum (blood) levels of tumor markers that are made by some testicular cancers.

Letters or numbers appear after T, N, M, and S to provide more details about each piece of information. The numbers 0 through 4 indicate increasing severity. The letters “IS” after the T stand for in situ, which means the tumor is contained in one place and has not yet penetrated to a deeper layer of tissue. The letter X after T, N, M, or S means “cannot be assessed” because the information is not known.

Primary tumor (T)

TX: The primary tumor cannot be assessed

T0: There is no evidence of primary tumor

Tis: Carcinoma in situ (non-invasive cancer cells)

T1: The tumor has not spread beyond the testicle and epididymis (the tubes next to the testicles where sperm mature). The cancer has not reached nearby blood vessels or lymph vessels. The cancer might have grown through the inner layer surrounding the testicle (tunica albuginea), but it has not reached the outer layer covering the testicle (tunica vaginalis).

T2: Similar to T1 except that the cancer has spread to blood or lymph vessels near the tumor, or the tunica vaginalis

T3: The tumor is growing into the spermatic cord (which contains blood vessels, lymph vessels, nerves, and the vas deferens)

T4: The tumor is growing into the skin surrounding the testicles (scrotum)

Regional lymph nodes (N)

NX: Regional (nearby) lymph nodes cannot be assessed

N0: No spread to regional lymph nodes is seen on imaging tests

N1: The cancer has spread to at least one lymph node, but no lymph node is larger than 2 cm (about ¾ inch) across

N2: The cancer has spread to at least one lymph node that is larger than 2 cm but is not bigger than 5 cm (2 inches) across

N3: The cancer has spread to at least one lymph node that is larger than 5 cm across

If the lymph nodes were taken out during surgery, there is a slightly different classification:

pNX: Regional (nearby) lymph nodes cannot be assessed

pN0: Examination of regional lymph nodes removed with surgery reveals no cancer spread

pN1: Examination of regional lymph nodes removed with surgery reveals cancer spread in 1 to 5 lymph nodes, but no lymph node is larger than 2 cm (about ¾ inch) across

pN2: Examination of regional lymph nodes removed with surgery reveals cancer spread in at least one lymph node that is bigger than 2 cm but not larger than 5 cm across; OR spread to more than 5 lymph nodes that aren’t bigger than 5 cm; OR the cancer is growing out the side of a lymph node

pN3: Examination of regional lymph nodes removed with surgery reveals cancer spread in at least one lymph node that is bigger than 5 cm across

Distant metastasis (M)

M0: There is no distant metastasis (no spread to lymph nodes outside the area of the tumor or other organs, such as the lungs)

M1: Distant metastasis is present

• M1a: The tumor has metastasized to distant lymph nodes or to the lung
• M1b: The tumor has metastasized to other organs, such as the liver, brain, or bone

Serum tumor markers (S)

For staging, serum (blood) levels of tumor markers are measured after the testicle containing the cancer has been removed with surgery.

Note: Normal values vary among laboratories. Check with your doctor for your specific ranges.

LDH = lactate dehydrogenase (measured in Units per liter [U/liter])

HCG = human chorionic gonadotropin (measured in milli-International Units per milliliter [mIU/ml])

AFP = alpha-fetoprotein (measured in nanograms per milliliter [ng/ml])

< Means less than; > means more than.

*All the markers must be in the stated range to be considered S1

+Only one marker needs to be in the stated range to be considered S2 or S3

Stage grouping

Once the T, N, M, and S categories have been determined, they are combined in a process called stage grouping to assign an overall stage (using Roman numerals and letters).

Recurrent disease

Recurrent disease means that the cancer has come back (recurred) after treatment. Testicular cancer can recur in the testicle (if it was not removed during surgery), in regional lymph nodes, or in another part of the body.

Testicular Cancer Survival Rates

Doctors often use survival rates as a standard way of discussing a person’s prognosis (outlook). Some patients with cancer may want to know the survival statistics for people in similar situations, while others may not find the numbers helpful, or may even not want to know them. If you don’t want to know them, stop reading here and skip to the next section.

The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. Of course, many people live much longer than 5 years (and many are cured).

Five-year relative survival rates assume that some people will die of other causes and compare the observed survival with that expected for people without the cancer. This is a better way to see the impact of the cancer on survival.

In order to get 5-year survival rates, doctors have to look at people who were treated at least 5 years ago. Improvements in treatment since then may result in a more favorable outlook for people now being diagnosed with testicular cancer.

Survival rates are often based on previous outcomes of large numbers of people who had the disease, but they cannot predict what will happen in any particular person’s case. Many other factors may affect a person’s outlook, such as your age and how well the cancer responds to treatment. Your doctor can tell you how the numbers below may apply to you, as he or she is familiar with your particular situation.

Survival rates, by stage

The SEER database does not divide survival rates by AJCC TNM stage. Instead, it divides cancers into summary stages: localized, regional, and distant:

• Localized means that the cancer is still only in the testicle. This includes most AJCC stage I tumors (stage 0 cancers are not included in these statistics).
• Regional means that the cancer has spread to nearby lymph nodes or tissues. This includes T4 tumors and cancers with lymph node spread (all stage II cancers and some stage IIIB and IIIC cancers).
• Distant means that the cancer has spread to organs or lymph nodes away from the tumor, such as all M1 cancers (which can be stage IIIA, IIIB, or IIIC).

Other prognostic factors

As can be seen in the table above, how far the cancer has spread at the time it’s diagnosed can affect your chances of long-term survival. But in general, the outlook for testicular cancers is very good, and most of these cancers can be cured, even if they have spread.

Some other factors can also affect outlook, such as:

• The type of testicular cancer
• Levels of tumor markers after the testicular tumor has been removed

Ask your doctor how these or other prognostic factors might affect your outlook.

Surgery for Testicular Cancer

Surgery is typically the first treatment for all testicular cancers.

Radical inguinal orchiectomy

This type of surgery removes the testicle (or testicles) containing the cancer. An incision is made just above the pubic area, and the testicle is gently removed from the scrotum through the opening. A cut is made through the spermatic cord that attaches the testicle to the abdomen. The surgeon ties off the blood and lymph vessels in the spermatic cord early in the operation and takes other special precautions to avoid spreading cancer cells into the surgical wound or dislodging them from the tumor into the bloodstream.

All testicular cancers are typically treated with this surgery, even those that have spread.

Retroperitoneal lymph node dissection (RPLND)

Depending on the type and stage of your cancer, some lymph nodes at the back of the abdomen (around the large blood vessels known as the aorta and inferior vena cava) may also be removed at the same time as the orchiectomy or during a second operation. Not all patients with testicular cancer need to have lymph nodes removed, so it’s important to discuss this (and the possible alternatives) with your doctor.

This is a complex and long operation. A large incision is typically made down the middle of the abdomen to remove the lymph nodes. It should be done by a surgeon who does this often. Experience counts.

Laparoscopic surgery: In some cases, the surgeon can remove lymph nodes through very small skin incisions in the abdomen by using a laparoscope (a narrow, lighted tube with a small video camera on the end that lets doctors see inside the abdomen) and other long, thin surgical tools. The surgeon’s hands are not inside the patient’s body during this type of surgery.

In laparoscopic surgery, after being put to sleep, the patient is turned onto his side. Several small incisions are made on the abdomen. A laparoscope and long instruments are inserted through the incisions to remove the lymph nodes. The incisions are then closed and the patient is awakened.

Patients recover much more quickly from this operation than the standard open procedure and are walking soon after surgery. There is usually less pain and patients are eating sooner.

Laparoscopic surgery seems to be a lot easier for the patient, but doctors are not sure if it’s as safe and effective as the standard “open” surgery in removing all of the potentially cancerous lymph nodes. Because of this uncertainty, doctors are more likely to recommend chemotherapy after laparoscopic surgery if cancer is found in the lymph nodes.

This procedure is most often used for patients with early stage non-seminomas to see if the lymph nodes contain cancer. As with the standard open procedure, this is a complex operation that should only be done if the surgeon is very experienced.

Possible risks and side effects of surgery

The short-term risks of any type of surgery include reactions to anesthesia, excess bleeding, blood clots, and infections. Most men will have at least some pain after the operation, which can usually be helped with pain medicines, if needed.

Effects of orchiectomy: Losing one testicle usually has no effect on a man’s ability to get an erection and have sex. But if both testicles are removed, sperm cells cannot be produced and a man becomes infertile. Also, without testicles, a man cannot make enough testosterone, which can decrease sex drive and affect his ability to have erections. Other effects could include fatigue, hot flashes, and loss of muscle mass. These side effects can be avoided by taking testosterone supplements, either in a gel, a patch, or a shot. Pills are generally not reliable sources of testosterone.

Usually men with testicular cancer are young and may be concerned that their appearance has changed. They may be dating and worry about a partner’s reaction, or they may be athletic and feel embarrassed by the missing testicle when in locker rooms.

To restore a more natural look, a man can have a testicular prosthesis surgically implanted in his scrotum. The prosthesis approved for use in the United States is filled with saline (salt water) and comes in different sizes to match the remaining testicle. When in place, it can look like a normal testicle. There can be a scar after the operation, but it’s often partly hidden by pubic hair. Some men might want a prosthesis, while others might not. You should discuss your wishes with your surgeon before considering this surgery. It could also help to talk with someone who has a testicular prosthesis, to hear what it has been like for them.

Effects of lymph node dissection: Surgery to remove retroperitoneal lymph nodes is a major operation. Serious complications are not common, but they can happen. About 5% to 10% of patients have temporary complications after surgery, such as bowel obstruction or wound infections. The standard approach for an RPLND requires a large incision in the abdomen, which will leave a scar and can take some time to heal. Your ability to get up and around after the operation will be limited for some time. This is less likely to be an issue if you have laparoscopic surgery, which uses smaller incisions.

This type of surgery does not cause impotence – a man can still have erections and sexual intercourse. But it might damage some of the nerves that control ejaculation. If these nerves are damaged, when a man ejaculates, the semen is not propelled forward through the urethra to exit the body but rather goes backwards into the bladder. This is known as retrograde ejaculation, and it can make it hard to father children.

To save the normal ejaculation function, surgeons have developed a type of retroperitoneal lymph node surgery called nerve-sparing surgery that is very successful when done by experienced doctors. Testicular cancer often affects men at an age when they may be trying to have children. These men may wish to discuss nerve-sparing surgery with their doctors, as well as sperm banking (freezing and storing sperm cells obtained before treatment). Men with testicular cancer often have lower than normal sperm counts, which can sometimes make it hard to collect a good sperm sample.

Radiation Therapy for Testicular Cancer

Radiation therapy uses a beam of high-energy rays (such as gamma rays or x-rays) or particles (such as electrons, protons, or neutrons) to destroy cancer cells or slow their rate of growth. In treating testicular cancer, radiation is used mainly to kill cancer cells that have spread to lymph nodes.

Radiation therapy delivered from a machine outside the body is known as external beam radiation. The treatment is much like getting an x-ray, but the radiation is more intense. The procedure itself is painless. Before your treatments start, the medical team will take careful measurements to determine the correct angles for aiming the radiation beams and the proper dose of radiation. Each treatment lasts only a few minutes, but the setup time – getting you into place for treatment – usually takes longer.

In general, radiation therapy is mainly used for patients with seminoma, which is very sensitive to radiation. Sometimes it’s used after orchiectomy (the operation to remove the testicle) and is directed at the lymph nodes at the back of the abdomen (the retroperitoneal lymph nodes). This is to kill any tiny bits of cancer in those lymph nodes that can’t be seen. It can also be used to treat small amounts of seminoma that have spread to the nodes (based on changes seen on CT and PET scans).

Radiation is also sometimes used to treat testicular cancer (both seminoma and non-seminoma) that has spread to distant organs (such as to the brain).

Possible side effects

Radiation therapy can affect nearby healthy tissue along with the cancer cells. To reduce the risk of side effects, doctors carefully figure out the exact dose you need and aim the beam as accurately as they can to hit the target. Generally, treatment of testicular cancer uses lower radiation doses than those needed for other types of cancer.

Common side effects can include:

• Fatigue
• Nausea
• Diarrhea

Some men have a skin changes such as redness, blistering, or peeling, but those are uncommon.

These side effects improve after the radiation is finished. If radiation reaches the healthy testicle it can affect fertility (sperm counts), so a special protective device is placed over the remaining testicle to help protect it.

Radiation can also have some long-term effects, such as damage to blood vessels or other organs near the treated lymph nodes and an increased risk of getting a second cancer (outside of the testicle) later in life. These risks were higher in the past when higher doses were used and more tissue was exposed to radiation.

Chemotherapy for Testicular Cancer

Chemotherapy (chemo) is the use of drugs to treat cancer. The drugs can be swallowed in pill form, or they can be injected by needle into a vein or muscle. To treat testicular cancer, the drugs are usually given into a vein. Chemo is systemic therapy. This means that the drug travels throughout the body to reach and destroy the cancer cells. Chemo is an effective way to destroy any cancer cells that break off from the main tumor and travel to lymph nodes or distant organs.

Chemo is often used to cure testicular cancer when it has spread outside the testicle or to decrease the risk of cancer coming back after the testicle is removed. It is not used to treat cancer that is only in the testicle.

Doctors give chemotherapy in cycles, with each period of treatment followed by a rest period to allow the body time to recover. Chemo cycles generally last about 3 to 4 weeks. The main drugs used to treat testicular cancer are:

• Cisplatin
• Etoposide (VP-16)
• Bleomycin
• Ifosfamide
• Paclitaxel
• Vinblastine

Using 2 or more chemo drugs is often more effective than using any single drug. The chemotherapy regimens most commonly used as the initial treatment for testicular cancer are:

• BEP (or PEB): bleomycin, etoposide, and cisplatin
• EP: etoposide and cisplatin (also known as EP)
• VIP: VP-16 (etoposide) or vinblastine plus ifosfamide and cisplatin

Some doctors use more intensive regimens for patients with high-risk disease, and may suggest a different combination of chemotherapy drugs or even a stem cell transplant (see next section).

Possible side effects

Chemo drugs attack cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow (where new blood cells are made), the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells are also likely to be affected by chemo, which can lead to certain side effects.

The side effects of chemo depend on the type and dose of drugs used and how long they are given. These side effects can include:

• Hair loss
• Mouth sores
• Loss of appetite
• Nausea and vomiting
• Diarrhea
• Increased chance of infections (from having too few white blood cells)
• Easy bruising or bleeding (from having too few blood platelets)
• Fatigue (extreme tiredness, often from having too few red blood cells)

Some of the drugs used to treat testicular cancer can have other side effects. For example:

• Cisplatin and ifosfamide can cause kidney damage. This can be lessened by giving lots of fluids (usually into a vein – IV) before and after these drugs are given.
• Cisplatin, etoposide, paclitaxel, and vinblastine can damage nerves (known as neuropathy). This can lead to numbness or tingling sensations in the hands or feet, and sensitivity to cold or heat. In most cases, this improves once treatment is stopped, but it may last a long time in some people.
• Cisplatin can also cause loss of hearing (called ototoxicity)
• Bleomycin can damage the lungs, causing shortness of breath and trouble with physical activity.
• Ifosfamide can cause the bladder to bleed (called hemorrhagic cystitis). To prevent this, the patient is given plenty of fluids and the drug mesna is given along with ifosfamide.

Most side effects are short-term and go away after treatment ends, but some can last a long time and may never go away completely. Report any side effects or changes you notice while getting chemo to your medical team so that you can get prompt treatment for them. There are often ways to prevent or lessen side effects. For example, there are drugs to help prevent or reduce nausea and vomiting. In some cases, the doses of the chemo drugs may need to be reduced or treatment may need to be delayed or stopped to prevent the effects from getting worse.

Some of the drugs used to treat testicular cancer can cause long-term side effects. These include some of the things mentioned earlier, like hearing loss and kidney or lung damage. Development of a second cancer (like leukemia) is a very serious but rare side effect of chemo, occurring in less than 1% of testicular cancer patients treated with chemo. People who have had chemo for testicular cancer seem to have a higher risk of heart problems later in life. Several studies have also suggested that chemotherapy can sometimes cause high blood cholesterol to develop over time, which may later require treatment.

Treatment Options for Testicular Cancer, by Type and Stage

Treatment for testicular cancer is based mainly on the type and stage of the cancer. Among the germ cell tumors, pure seminomas are treated one way, and all other cancers (all types of non-seminomas and mixed germ cell tumors) are treated another way.

Stage 0 germ cell tumors

In this stage, the tumor in the testicle is carcinoma in situ (CIS), the cancer has not spread outside the testicle, and the levels of tumor markers (like HCG and AFP) are not elevated.

If this stage is diagnosed after surgery to remove the testicle, no other treatment is needed.

If the CIS is found after a testicular biopsy (such as for fertility problems), the doctor may recommend that it not be treated right away. Instead, the patient may be watched closely with repeat physical exams, ultrasound of the testicle, and blood tests of tumor marker levels. Treatment may not be needed as long as there are no signs that the CIS is growing or turning into an invasive cancer. If CIS is treated, it is with surgery (to remove the testicle) or with radiation therapy to the testicle.

If tumor marker levels are high, the cancer is not really stage 0 – even when only CIS is found in the testicle and there are no signs of cancer spread. These cases are treated like stage IS cancers.

Stage I germ cell tumors

Stage I seminomas: These cancers can be cured in nearly all patients. They are first treated by surgically removing the testicle and spermatic cord ( radical inguinal orchiectomy). After surgery, there are several treatment choices:

• Careful observation (surveillance): If the cancer has not spread beyond the testicle, often the preferred option is to be watched closely by your doctor for up to 10 years with treatments like radiation or chemo only if cancer spread is found. This means getting physical exams and blood tests every 3 to 6 months for the first year, and less often after that. Imaging tests (CT scans and sometimes chest x-rays) are often done every 3 months for 6 months, and then less often after that. If these tests do not find any signs that cancer has spread beyond the testicle, no other treatment is needed. In about 15% to 20% of patients the cancer will come back as spread to lymph nodes or other organs, but if it does, radiation or chemo can still usually cure the cancer.
• Doctors are less likely to advise surveillance if the tumor invades blood or lymph vessels in the spermatic cord or if it has reached the scrotum. In these cases, either radiation or chemo is likely to be a better option.
• Radiation therapy: Radiation aimed at para-aortic lymph nodes (in the back of the abdomen, around the large blood vessel called the aorta) is another option. Because seminoma cells are very sensitive to radiation, low doses can be used, usually about 10 to 15 treatments (given over 2 to 3 weeks).
• The doctor may recommend this because in about 1 in 5 patients with stage I seminoma, cancer cells have spread outside the testicle but cannot be seen on imaging tests like CT scans. Radiation therapy can usually destroy these hidden (occult) metastases.
• Chemotherapy: An option that works as well as radiation is to give 1 or 2 cycles of chemotherapy (chemo) with the drug carboplatin after surgery.

Stage IS seminomas: In this stage, the level of one or more tumor markers is still high after the testicle containing the seminoma is removed. This is very rare, but it is often treated with radiation.

Stage I non-seminomas: Nearly all of these cancers can be cured, but the standard treatment is different from that of seminomas. As with seminomas, the initial treatment is surgery to remove the testicle and tumor (radical inguinal orchiectomy). Then the treatment choices depend on the stage.

For stage IA (T1) there are 2 choices:

• Careful observation (surveillance): Surveillance might let you avoid the possible side effects of surgery, but it requires a lot of doctor visits and tests. Doctor visits and lab tests are done every 2 months for the first year, with CT scans every 4 to 6 months. Over time, the time between visits and tests gets longer. If the cancer does come back, it is usually within the first year or two. Relapses are generally treated with chemo. Even though more patients will have a relapse with surveillance than with lymph node dissection, the cure rates are similar because the relapses are usually found early enough to be cured.
• Retroperitoneal lymph node dissection (RPLND): Removal of lymph nodes at the back of the abdomen has the advantage of a high cure rate but the disadvantages of major surgery, with its possible complications, including losing the ability to ejaculate normally. After RPLND, if cancer is found in the nodes, chemo may be recommended.

For stage IB (T2, T3, or T4) there are up to 3 options:

• Retroperitoneal lymph node dissection (removal of lymph nodes at the back of the abdomen). If cancer is found in the lymph nodes, chemo is often recommended.
• Chemotherapy with the BEP regimen (bleomycin, etoposide, and cisplatin) for 2 cycles. This has a high cure rate, but it can have side effects (which are mostly short-term). Chemo is used more often in Europe than in the United States.
• Careful observation (surveillance): This requires frequent doctor visits and tests for several years. This may be an option for some patients with T2 tumors.

Stage IS non-seminoma: If the tumor marker levels (like AFP or HCG) are still high even after the testicle/tumor is removed but no tumor is seen on a CT scan, chemo is recommended, with either 3 cycles of BEP or 4 cycles of EP (etoposide and cisplatin).

Stage II germ cell tumors

Stage IIA seminomas: After surgery to remove the testicle (radical inguinal orchiectomy), the preferred treatment is radiation to the retroperitoneal lymph nodes. Usually stage II seminomas are given higher doses of radiation than stage I seminomas. The other option is chemo, with either 4 cycles of EP (etoposide and cisplatin) or 3 cycles of BEP (bleomycin, etoposide, and cisplatin).

Stage IIB seminomas: These seminomas have spread to larger lymph nodes or to several different lymph nodes. After surgery to remove the testicle (radical inguinal orchiectomy), chemo is the preferred treatment. Either 4 cycles of EP (etoposide and cisplatin) or 3 cycles of BEP (bleomycin, etoposide, and cisplatin) may be used. Radiation may be an option instead of chemo for patients who don’t have lymph nodes enlarged from cancer spread.

Stage IIC seminomas: These cancers are treated with radical inguinal orchiectomy, followed by chemo with 4 cycles of EP or 3 or 4 cycles of BEP. Radiation therapy is generally not used for stage IIC seminoma.

Stage II non-seminomas: After radical inguinal orchiectomy to remove the testicle with the tumor, treatment depends on the remaining levels of tumor markers in the blood and the extent of spread to retroperitoneal lymph nodes. There are 2 main options:

• Retroperitoneal lymph node dissection (RPLND): The lymph nodes at the back of the abdomen are removed. This is more often an option for stage IIA disease. If the lymph nodes removed contain cancer, further treatment with chemo may be needed.
• Chemotherapy: For many stage II cancers, the preferred treatment is chemo instead of RPLND. Either 4 cycles of EP (etoposide and cisplatin) or 3 cycles of BEP (bleomycin, etoposide, and cisplatin) may be used.
• After chemo, a CT scan is repeated to see if the lymph nodes are still enlarged. If they are, they are usually removed by RPLND.

Stage III germ cell tumors

Even though stage III germ cell tumors have spread by the time they are found, most of them can still be cured.

Both stage III seminomas and non-seminomas are treated with radical inguinal orchiectomy followed by chemo with either EP (etoposide and cisplatin) for 4 cycles or BEP (bleomycin, etoposide, and cisplatin) for 3 to 4 cycles. 4 cycles of BEP are needed for patients with poor prognosis non-seminomas (usually because they have spread to distant areas other than the lungs or because of very high tumor marker levels). If the patient has medical reasons that make treatment with bleomycin unsafe, then he may be treated with VIP (vinblastine, ifosfamide, and cisplatin).

In cases where very high levels of the tumor marker HCG is found in a man, distant spread of cancer is seen on scans, and there is a high suspicion that he may have a testicular choriocarcinoma, chemo may be started without a biopsy or initial removal of a testicle.

If the cancer has spread to the brain, it will be treated with either surgery (if there are only 1 or 2 tumors in the brain), radiation therapy aimed at the brain, or both. If the tumors in the brain are not bleeding or causing symptoms, some doctors may choose to start the chemo first.

Once chemo is complete, the doctor looks for any cancer that is left. Patients with normal scans and normal tumor marker levels are usually watched carefully after this and may need no further treatment.

Sometimes a few tumors are left. These are most often in the lung or in the retroperitoneal lymph nodes. Further treatment at this point depends on the type of cancer.

Seminomas: Small tumors that are still there after chemo or don’t “light up” on a PET scan, are often watched with CT scans to see if they grow. If they do, further treatment is needed. If the tumors do light up on a PET scan, they could be cancers, and treatment is needed. Treatment may be surgery (such as a retroperitoneal lymph node dissection) or chemo (using a different combination of drugs).

Non-seminomas: Remaining tumors are usually removed surgically, which may result in a cure. If cancer is found in the tumors removed, further chemo (usually for 2 cycles, often with different drugs) might be needed. Another option might be to start by giving further chemo with different drugs. Surgery might be used after this if any tumors remain.

If the cancer is resistant to chemo or has spread to many organs, the usual doses of chemo may not always be enough. Sometimes the doctor might recommend high-dose chemo followed by a stem cell transplant. Patients might also want to consider enrolling in a clinical trial of newer chemo regimens.

Recurrent germ cell tumors

If the cancer goes away with treatment and then comes back, it is said to have recurred or relapsed. If this happens, it’s usually within the first 2 years after treatment. In general, if the cancer recurs, it’s probably best to get a second opinion from a center with extensive experience in treating relapsed testicular cancer before starting treatment.

Treatment of recurrent germ cell tumors depends on the initial treatment and where the cancer recurs. Cancer that comes back in the retroperitoneal lymph nodes can be treated by surgery to remove the nodes (RPLND) if the recurrence is small and if the only surgical treatment given before was orchiectomy. Depending on the results of the surgery, chemo may be recommended as well.

If it looks as if cancer has recurred in a lot of the retroperitoneal lymph nodes or if the cancer has returned elsewhere, chemo is usually recommended. This may be followed by surgery.

If a man’s cancer recurs after chemo or if treatment is no longer working, he will be treated with a different chemo regimen, which typically includes ifosfamide, cisplatin, and either etoposide, paclitaxel, or vinblastine.

The treatment of testicular cancer that has come back after chemo is not always as effective as doctors would like, so some doctors may advise high-dose chemo followed by a stem cell transplant. This may be a better option for some men with recurrent disease, rather than standard chemo. (See the section “ High-dose chemotherapy and stem cell transplant for testicular cancer” for more information.) Clinical trials of newer treatments can also be considered.

Sertoli cell and Leydig cell tumors

Typically, radical inguinal orchiectomy is the treatment for Sertoli cell and Leydig cell tumors. Radiation therapy and chemo are generally not effective in these rare types of testicular tumors. If the doctor suspects the tumor has spread beyond the testicle, the retroperitoneal lymph nodes may be surgically removed.