Testicular cancer arises from the germ cells in the testes. Germ cells are cells that produce gametes (sperm in males). There are other, rare tumours in the testes, such as non-germ cell tumours and secondary metastases.
Testicular cancer is more common in younger men, with the highest incidence between 15 and 35 years.
Testicular cancer can be divided into two types:
- Seminomas
- Non-seminomas (mostly teratomas)
Risk Factors
- Undescended testes
- Male infertility
- Family history
- Increased height
Presentation
The typical presentation is a painless lump on the testicle. Occasionally it can present with testicular pain.
The lump will be:
- Non-tender (or even reduced sensation)
- Arising from testicle
- Hard
- Irregular
- Not fluctuant
- No transillumination
Rarely, gynaecomastia (breast enlargement) can be a presentation of testicular cancer, particularly a rare type of tumour called a Leydig cell tumour. About 2% of patients presenting with gynaecomastia have a testicular tumour.
Investigations
Scrotal ultrasound is the usual initial investigation to confirm the diagnosis.
Tumour markers for testicular cancer are:
- Alpha-fetoprotein – may be raised in teratomas (not in pure seminomas)
- Beta-hCG – may be raised in both teratomas and seminomas
- Lactate dehydrogenase (LDH) is a very non-specific tumour marker
A staging CT scan can be used to look for areas of spread and to stage the cancer.
Royal Marsden Staging System
Testicular cancer is staged with the Royal Marsden staging system:
- Stage 1 – isolated to the testicle
- Stage 2 – spread to the retroperitoneal lymph nodes
- Stage 3 – spread to the lymph nodes above the diaphragm
- Stage 4 – metastasised to other organs
Metastasis
The common places for testicular cancer to metastasise to are:
- Lymphatics
- Lungs
- Liver
- Brain
Management
Management of any cancer is guided by a multidisciplinary team (MDT) meeting to decide the best course of action for the individual patient.
Depending on the grade and stage of testicular cancer, treatment can involve:
- Surgery to remove the affected testicle (radical orchidectomy) – a prosthesis can be inserted
- Chemotherapy
- Radiotherapy
- Sperm banking to save sperm for future use, as treatment may cause infertility
Long term side effects of treatment are particularly significant, as most patients are young and expected to live many years after treatment of testicular cancer. Side effects include:
- Infertility
- Hypogonadism (testosterone replacement may be required)
- Peripheral neuropathy
- Hearing loss
- Lasting kidney, liver or heart damage
- Increased risk of cancer in the future
Prognosis
The prognosis for early testicular cancer is good, with a greater than 90% cure rate. Metastatic disease is also often curable. Seminomas have a slightly better prognosis than non-seminomas.
Patients will require follow-up to monitor for reoccurrence. This usually involves monitoring tumour markers, and may include imaging such as CT scans or chest x-rays.
Last updated May 2021