Testicular CancerLast Updated: April 16, 2009 This section has been reviewed and approved by the Cancer.Net Editorial Board, 03/09 Overview
Testicular cancer begins when normal cells in a testicle begin to change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body). Testicular cancer is almost always curable if found early and is often curable even when at an advanced stage. The testicles are part of the male reproductive system. Each man has two testicles, and they are located under the penis in a sac-like pouch called the scrotum. They can also be called testes or gonads. The testicles produce sperm and testosterone, a hormone which plays a role in the development of the reproductive organs and other male characteristics. Most types of testicular cancer develop in the sperm-producing cells known as germ cells, and are referred to as germ cell tumors. Germ cell tumors most commonly start in the testicles but can also develop in other parts of the body, such as the retroperitoneum (the back of the abdomen near the spine), the mediastinum (the central portion of the chest between the lungs), the lower spine, and very rarely, the pineal gland (a small gland in the brain). There are two different categories of germ cell tumors that occur in the testicles: seminoma and non-seminoma. Generally, seminoma is relatively slow growing, while non-seminoma tends to grow and metastasize (spread) more quickly. Teratoma is a unique type of non-seminoma. Unlike the other types of germ cell tumors, it is not very sensitive to chemotherapy. The primary treatment for teratoma is to remove it with surgery. Although a teratoma is less likely to spread, it needs to be removed because it can become a much more dangerous cancer if left in place. This section provides information only on germ cell tumors (seminoma and non-seminoma) of the testicles. Other, less common types of testicular tumors include Leydig cell tumor, Sertoli cell tumor, and carcinomas of the rete testis. These can often be successfully treated by surgically removing the affected tissue; however, if they spread to other areas of the body, they are more difficult to treat. Other types of cancer, such as lymphoma and leukemia, occasionally spread to the testicles. To find out more about cancer that started in another part of the body and spread to the testicles, read about that specific type of cancer. Statistics In 2009, an estimated 8,400 men in the United States will be diagnosed with testicular cancer. It is estimated that 380 deaths from this disease will occur this year. The deaths are from cancer that has spread to other parts of the body and could not be effectively treated with chemotherapy, radiation therapy, and/or surgery. The overall five-year relative survival rate of people with testicular cancer is 96%. What this means is that, within the first five years after diagnosis, a man’s risk of dying from testicular cancer is about 4%. This number includes all men diagnosed with testicular cancer. The survival rate is higher for men diagnosed with early-stage cancer and lower for men with later-stage cancer. For men with cancer that shows no evidence of having spread beyond the testicles (Stage 1; see Staging), the survival rate is about 99%. For men with cancer that has spread to the back of the abdomen (Stage 2), the survival rate is about 96% but depends on the size and number of tumors. For patients with more widely spread cancer (Stage 3), the survival rate is about 71% overall but for men with advanced stage cancer, the disease is classified into one of three categories - good risk, intermediate risk, and poor risk - to better predict a man’s prognosis (chance of recovery). For men in the good-risk advanced-stage group, the five-year survival rate is 94%. Men in the intermediate-risk group have a five-year relative survival rate of 83%, and men in the poor-risk group have a five-year relative survival rate of 71%. Testicular cancer may be more difficult to treat if it has spread to the liver, bones, or brain, but even in those cases, men can often be cured. Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of cases of this type of cancer in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a man how long he will live with testicular cancer. Because the survival statistics are measured in five-year intervals, they may not represent recent advances made in the treatment or diagnosis of this cancer. Statistics adapted from the American Cancer Society's publication, Cancer Facts & Figures 2009. Find out more about basic cancer terms used in this section. Medical Illustrations
Risk Factors
A risk factor is anything that increases a person’s chance of developing cancer. Some risk factors can be controlled, such as smoking, and some cannot be controlled, such as age and family history. Although risk factors can influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and communicating them to your doctor may help you make more informed lifestyle and health-care choices. Although the cause of testicular cancer is not known, the following factors can raise a man’s risk of developing testicular cancer: Age. Testicular cancer is most common in men between 20 and 45, but men of any age can develop this disease. Family history. A man who has a close relative (particularly a brother) who has had testicular cancer has an increased risk of developing testicular cancer. Personal history. Men who have had cancer in one testicle have an increased risk of developing cancer in the other testicle. Race. Although men of any race can have testicular cancer, white men are more likely than men of other races to be diagnosed with testicular cancer. Cryptorchidism (undescended testicle). Men with this condition, in which one or both testicles do not descend into the scrotum before birth as they normally should, have an increased risk of developing testicular cancer. This risk may be lowered if surgery is performed to correct the condition before the boy reaches puberty. Some doctors have recommended that cryptorchidism be corrected when a boy is very young, between six and 15 months, in order to reduce the risk of infertility (inability to produce children). Because cryptorchidism is corrected at a young age, many men may not know if they had the condition. Klinefelter’s syndrome. Men with this condition have an extra X chromosome, which results in low levels of male hormones, infertility, breast enlargement, and small testicles; it also increases the risk of developing germ cell tumors that begin in the chest, but this is rare. Human immunodeficiency virus (HIV) infection. Men with HIV, the virus that causes acquired immune deficiency syndrome (AIDS), have a slightly higher risk of developing seminoma. Symptoms
Men with testicular cancer may experience a variety of symptoms. Sometimes, men with testicular cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. The first sign of testicular cancer is often a small lump or area of hardness on the testicle, which can be either painless or painful. Other symptoms may go unnoticed until the cancer is advanced and has spread to other parts of the body. Regular testicular self-examinations and examinations by doctors can help detect the cancer at an early stage, when it is more likely to be successfully treated. If you are concerned about a symptom, please talk with your doctor. Symptoms of testicular cancer may include:
Lower back pain, shortness of breath, chest pain, and bloody sputum (phlegm) can be symptoms of advanced testicular cancer, but many other diseases can also cause these symptoms. Early detection: finding testicular cancer early Most cases of testicular cancer can be detected at an early stage, and men often find the cancer themselves while performing self-examinations. Some doctors recommend that men ages 15 to 55 perform a monthly self-examination to identify any changes. However, some testicular cancers may not cause symptoms and may go undetected until they reach an advanced stage. Men who notice a lump, hardness, enlargement, pain, or any other change in one or both of their testicles should visit their doctor immediately. Diagnosis
Doctors use many tests to diagnose cancer and determine if it has metastasized. Some tests may also determine which treatments may be the most effective. When a man develops a testicular lump or something else that could be testicular cancer, the first test that usually is performed is an ultrasound (see below) of the testicles. If the ultrasound shows an abnormality that looks like a tumor, then blood tests are done and the testicle is surgically removed and examined under a microscope to see whether cancer is present. Imaging tests, such as x-rays, computed tomography (CT or CAT) and/or magnetic resonance imaging (MRI) scans, may also be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:
If the doctor suspects testicular cancer, he or she will ask about a man's medical history and general health. The following tests may be used to diagnose testicular cancer: Physical examination. The doctor will feel the testicles for any sign of swelling, tenderness, or hardening. The doctor will also feel the abdomen, neck, upper chest, armpits and groin for evidence of enlarged lymph nodes, which may indicate that the cancer has spread. The breasts and nipples will also be examined to look for enlargement. Ultrasound. An ultrasound uses sound waves to create a picture of the internal organs. This allows doctors to detect growths in the testicles. The sound waves produced by the ultrasound bounce off tissue in the scrotum. The echoes of the sound waves produce an image called a sonogram that can help the doctor detect the presence, size, and solidness of a tumor. Solid tumors are much more likely to be cancerous. Blood tests/tumor markers. A sample of blood may be collected to test for levels of serum tumor markers, which are substances produced by a cancer that are found at abnormally high levels in the blood of a person with cancer. Different types of cancer produce different tumor markers. High levels of any one of three tumor markers may indicate testicular cancer, but it is also possible to have this type of cancer and not have high tumor marker levels. Tumor marker levels can also indicate the type of testicular cancer, such as seminoma or non-seminoma. Alpha-fetoprotein (AFP) is a tumor marker that is not made by seminomas, so an elevated level of AFP indicates that some other type of cancer is probably present. Two other tumor markers, beta human chorionic gonadotropin (hCG) and/or lactase dehydrogenase (LDH), can be higher if a man has a seminoma. Placental alkaline phosphatase (PLAP) is another tumor marker doctors may test for, although it is not commonly measured. Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer, but biopsies are rarely used to diagnose testicular cancer. Instead, if cancer is suspected in a testicle, the standard procedure is to surgically remove the entire testicle. In fact, a biopsy using a needle through the skin should NOT be performed because this can complicate future treatment options. Occasionally, a biopsy may be taken from the lung or the retroperitoneum if it appears that cancer may have spread. Orchiectomy/surgical pathology tests. If testicular cancer is suspected, a surgeon will perform a radical inguinal orchiectomy, in which the entire testicle is removed through an incision in the groin. Then, a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease) will examine the testicle under a microscope to diagnose the type of cancer. For a cancer to be considered a seminoma, it must be pure seminoma. Non-seminoma is diagnosed if any of the following are found in the pathology specimen: choriocarcinoma, embryonal cell carcinoma, yolk sac tumor, or teratoma. Each of these can occur alone or in any combination. Sometimes, seminoma cancer can be found as a part of non-seminoma at any percentage level. For example, a tumor that is 99% seminoma and 1% yolk sac is still diagnosed and treated as non-seminoma. If the man has one testicle to begin with or the diagnosis is uncertain, the surgeon may remove only a small sample of tissue from the testicle. The testicle may still need to be removed if there is evidence of cancerous cells. If the tissue sample does not show cancer, it may be possible to repair the damage from the tissue removal and replace the testicle back into the scrotum if the blood vessels and spermatic cord (the structure that connects the testicle to the rest of the body) were not cut. However, such a procedure is very rare. If cancer is found, other tests may be required to determine the stage of the cancer and whether it has spread to other areas of the body. These tests may include: X-ray. An x-ray is a picture of the inside of the body. For instance, a chest x-ray can help doctors determine if the cancer has spread to the lungs. CT scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Often, a contrast medium (a special dye) is injected into a patient’s vein to provide better detail. MRI scan. An MRI scan uses magnetic fields to create a three-dimensional picture of the inside of the body. A computer then combines the images in a detailed, cross-sectional view that shows any abnormalities or tumors. For men with testicular cancer, CT scans are often preferred to MRIs for imaging the body, but there are certain specific situations when MRI may preferred. Your doctor will explain which test is appropriate for you. Learn more about what to expect when having common tests, procedures, and scans. Find out more about common terms used during a diagnosis of cancer. Staging
Staging is a way of describing where a cancer has spread. Doctors use diagnostic tests, including CT scans and blood tests, to determine the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and helps predict a patient's prognosis. There are different stage descriptions for different types of cancer. There are also two different types of staging for most cancers: clinical staging and pathological staging. In clinical staging, the stage is based on a physical examination of the patient or x-rays, CT scans, and other imaging tests. In pathological staging, the stage is based on evaluating tissue under a microscope after it has been removed during surgery. Both clinical and pathological staging are used to stage testicular cancer. One tool that doctors use to describe the stage is the TNM system. This system uses three criteria to judge the stage of the cancer: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to other parts of the body. For testicular cancer, the TNM staging system also includes information on how highly elevated the three serum (S) tumor markers, AFP, hCG, and LDH, are (see Diagnosis). The results are combined to determine the stage of cancer for each person. There are three stages of testicular cancer: stages I, II, and III (one, two, and three). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments. TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors, plus serum tumor markers, to determine the stage of testicular cancer:
Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail. For most testicular cancers, the T stage can only be determined when tissue removed during surgery is examined under a microscope. This means that the T stage is only determined after the testicle is removed. Specific tumor stage information is below. TX: The primary tumor cannot be evaluated. If a man has not had a radical inguinal orchiectomy (surgical removal of the testicle[s]), the term "TX" is used. T0: There is no evidence of a primary tumor in the testicles. Tis: In this stage, there is intratubular germ cell neoplasia (a precancerous condition in which there are germ cells that appear cancerous but are not yet behaving the way cancer cells do), also called carcinoma in situ (CIS). CIS becomes cancer when the cells spread to areas of the testicle(s) where they do not normally belong. T1: The primary tumor is only in the testicle (with or without involvement of the epididymis), and it has not invaded blood vessels or lymph vessels in the testicles. The tumor may have invaded the tunica albuginea (the inner membrane layer surrounding the testicle) but not the tunica vaginalis (the outer membrane layer surrounding the testicle). T2: The tumor is in the testicle (with or without involvement of the epididymis) and has invaded blood vessels or lymphatic vessels, and/or the tumor has grown through the tunica albuginea and into the tunica vaginalis. T3: The tumor has invaded the spermatic cord. T4: The tumor has invaded the scrotum. Node. The “N” in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. The lymph nodes that receive lymphatic fluid directly from the testicles are called regional lymph nodes. The regional lymph nodes for testicular cancer are the nodes in the retroperitoneum. Lymph nodes in other parts of the body are called distant lymph nodes. If the cancer appears to have spread to lymph nodes based on a CT scan or other imaging test, then the stage is a clinical stage. If the cancer is shown to have spread to the lymph nodes by removing lymph nodes and looking at them under a microscope, then the stage is a pathological stage. To determine the pathological stage for testicular cancer, the lymph nodes are removed using a procedure called a lymph node dissection (surgical removal of lymph nodes) or, less commonly, a tissue sample from a biopsy of a lymph node. Pathological staging is more reliable because a patient can have enlarged lymph nodes on an imaging test, but the lymph nodes may be noncancerous when viewed under the microscope. In such a situation, the cancer would be clinical stage II but pathological stage I. A lowercase p before the N indicates the pathological stage. Most often the “N” is estimated by using CT scans before the tissue is examined under a microscope. NX: The regional lymph nodes (lymph nodes near the testicles) cannot be evaluated. N0: There is no spread to regional lymph nodes. N1: There are enlarged lymph nodes in the retroperitoneum but none are larger than 2 centimeters (cm). pN1: There is metastatic cancer in five or fewer lymph nodes, and none of the involved lymph nodes measures longer than 2 cm in its greatest dimension. N2:There are enlarged lymph nodes (or a lymph node mass) in the retroperitoneum that are larger than 2 cm but none that are larger than 5 cm. pN2: There is metastasis to at least one lymph node with a lymph node mass that is larger than 2 cm but smaller than 5 cm. Or, there is metastasis to more than five lymph nodes but none are larger than 5 cm. N3: There are enlarged lymph nodes or a lymph node mass larger than 5 cm in the retroperitoneum. pN3: There is metastasis to at least one lymph node, and at least one lymph node mass is larger than 5 cm. Distant metastasis. The "M" in the TNM system indicates whether the cancer has spread to other parts of the body. When testicular cancer spreads beyond the regional lymph nodes, the most common sites are the lymph nodes of the chest and pelvis and the lungs. More advanced stages may have spread to the liver and bones. Testicular cancer rarely spreads to the brain. MX: Distant metastasis cannot be evaluated. M0: The disease has not metastasized to distant lymph nodes or other organs. M1: There is distant metastasis. M1a: There is cancer in distant lymph nodes and/or the lungs. M1b: The cancer has spread to organs other than or in addition to the lung. (For example, a cancer that has spread to the liver or the bones is stage M1b.) Serum tumor markers (S). The amount of certain tumor markers in a man’s blood also helps to stage testicular cancer (see Diagnosis). The substances are produced either by the tumor itself or by the body in response to the cancer or certain noncancerous conditions. SX: Tumor marker levels are not available or not performed. S0: Tumor marker levels are normal. S1: Tumor marker levels are above normal (LDH less than 1.5 times the upper limit of the normal range; and hCG [mIu/mL] less than 5,000, and AFP [ng/mL] less than 1,000). S2: Tumor marker levels are substantially above normal (LDH 1.5 to 10 times the upper limit of the normal range, or hCG [mIu/mL]) 5,000 to 50,000 or AFP [ng/mL] 1,000 to 10,000). S3: Tumor marker levels are very highly elevated (LDH more than 10 times the upper limit of the normal range, or hCG [mIu/mL] more than 50,000 or AFP [ng/mL] more than 10,000). Cancer stage grouping Doctors assign the stage of the cancer by combining the T, N, and M classifications and the S level information. Stage 0: Refers to carcinoma in situ, also called intratubular germ cell neoplasia (pTis). Stage I: Cancer is at any T level, and serum marker tests have not been performed or are unavailable, and there is no evidence of spread to either lymph nodes or other organs (any T, N0, M0, SX). Stage IA: Cancer is only in the testicle and has not spread to lymph nodes or distant sites. Serum markers are normal (pT1, N0, M0, S0). Stage IB: Cancer is outside the testicle or has invaded blood or lymphatic vessels within the testicles and has not spread to lymph nodes or distant sites. Serum markers are normal (pT2, pT3, or pT4, N0, M0, S0). Stage IS: Cancer is of any T stage and has not spread to lymph nodes or distant sites. Serum markers remain persistently above normal levels after the cancerous testicle has been removed (ant T, N0, M0, S1, S2, or S3). Stage II: The cancer has spread to any regional lymph nodes but not to lymph nodes in other parts of the body or distant organs. Serum markers are unavailable. Stage IIA: Cancer has spread to retroperitoneal lymph nodes, either clinical or pathological stage N1, but none is larger than 2 cm and, if a lymph node dissection has been performed, no more than five lymph nodes contain cancer. In addition, serum markers are at normal levels or slightly elevated (S0 or S1) and there is no evidence of cancer having spread anywhere other than the retroperitoneum. Stage IIB: Cancer has spread to lymph nodes in the retroperitoneum, at least one of which is greater than 2 cm and none of which are greater than 5 cm (N2); or, if a lymph node dissection has been performed, cancer has spread to more than five nodes, none more than 5 cm. Serum markers are at normal levels or slightly elevated (S0 or S1) and there is no evidence of cancer having spread anywhere other than the retroperitoneum. Stage IIC: Cancer has spread to at least one lymph node that is larger than 5 cm (N3). Serum markers are at normal levels or slightly elevated (S0 or S1) and there is no evidence of cancer having spread anywhere other than the retroperitoneum. Stage IIIA: Cancer has spread to distant lymph nodes or the lungs (M1a). Serum markers are at normal levels or slightly elevated (S0 or S1). Stage IIIB: Cancer has spread to any lymph nodes (N1, N2, or N3) and/or the lungs but not to any other organs, and serum markers are at substantially elevated levels (S2). Stage IIIC: Either or both of the following: (2) The cancer has spread to an organ other than the lungs (M1b). Recurrent: Recurrent cancer is cancer that comes back after treatment. Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New York, www.cancerstaging.net. Advanced testicular cancer: risk group classification If the disease has spread to lymph nodes or other organs, the following system is used to classify germ cell tumors into good-risk, intermediate-risk, or poor-risk groups. This is based on the ability to successfully treat patients with this disease. Patients with poor-risk disease still have about a 50% chance of successful treatment.
Source: Journal of Clinical Oncology. Treatment
The treatment of testicular cancer depends on the type, size, location of the tumor, whether the cancer has spread, and the man’s overall health. In many cases, a team of doctors will work with the patient to determine the best treatment plan, including a urologist (a surgeon who specializes in problems related to the urinary tract and male reproductive organs). This section outlines treatments that are the standard of care (the best treatments available) for testicular cancer. Patients are also encouraged to consider clinical trials as a treatment option when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, visit the Clinical Trials. Most cases of testicular cancer can be successfully treated with surgery, and/or radiation therapy, and/or chemotherapy. Men with testicular cancer may have concerns about how their treatment will affect their sexual function and fertility, and these topics should be discussed with their doctor before treatment begins. Sometimes, more than one treatment option is available. The final decision is often made depending on the patient’s unique situation. Descriptions of the most common treatment options for testicular cancer, followed by treatment options by the cancer’s stage, are listed below. Surgery Radical inguinal orchiectomy Treatment of testicular cancer usually starts with surgery to remove the affected testicle, called radical inguinal orchiectomy. This is done through an incision in the groin (along the beltline). It is used to diagnose and treat both early-stage and later-stage testicular cancer, regardless of the type of tumor. For more advanced cancer, a radical inguinal orchiectomy may not be performed first so chemotherapy can be started sooner. The removal of one testicle typically does not affect a man’s ability to achieve a normal erection and orgasm. However, men with sexual problems after orchiectomy should have their testosterone level checked. It also is very unlikely to make him infertile (unable to bear children) because the remaining testicle will still produce sperm. However, men with testicular cancer are more likely to be infertile than other men, even before being diagnosed with cancer. It appears that the cancer itself may cause some men to become infertile, and sperm counts usually improve after the testicle with cancer is removed. Men can choose to have an artificial testicle implanted in the scrotum that has a weight and texture similar to a normal testicle. A man may develop cancer in both testicles either at the same time or at different times, but this is rare (about 2% of men with testicular cancer). If a bilateral orchiectomy (removal of both testicles) is performed, the man will no longer produce sperm or testosterone and will not be able to biologically produce children. A patient may want to consider storing sperm in a sperm bank prior to surgery, so that he will be able to have children later if he wishes. In addition, if both testicles are removed, testosterone replacement therapy will be needed. Retroperitoneal lymph node dissection (RPLND) This is surgery to remove the retroperitoneal lymph nodes that lie at the back of the abdomen. RPLNDs are performed in two different situations: (1) clinical stage I or IIa nonseminomas and (2) men with retroperitoneal masses that remain after completing chemotherapy for advanced stage disease. Masses that remain after chemotherapy are almost always removed for men with non-seminomas, but for men with pure seminomas, such masses are often left in place and observed for changes with CT scans. RPLNDs are usually performed as open operations with an incision down the middle of the abdomen. Doctors are studying the use of laparoscopic RPLND, which uses several smaller incisions instead of the one large incision, but that approach is not yet widely used. RPLND for stage I and IIa non-seminomas. About 30% of patients with clinical stage I non-seminoma who have an RPLND are found to have lymph nodes with cancer; in other words, the surgery shows that they have stage II disease. If the lymph node involvement is minimal (pN1), about 90% are successfully treated with this surgery alone. If a greater amount of cancer is found (pN2 or pN3), about 50% of patients are successfully treated with surgery alone, while the other 50% will have a recurrence. The advantage of the RPLND is that it can cure most patients with small lymph node metastases, provide a more accurate assessment of the extent of disease, and avoid the need for frequent CT scans of the abdomen during follow-up care. It also reduces the chance that a man with early-stage (stage I) testicular cancer will ever need chemotherapy. Just as RPLND may show cancer in lymph nodes that appeared normal on CT scans for men with clinical stage I non-seminomas, surgery may also show normal lymph nodes for men with clinical stage IIa disease. For men with clinical stage IIa testicular nonseminomas, 20% to 40% will actually have pathological stage I cancer, meaning that the cancer has not spread to any lymph nodes. In these situations, the use of RPLND can help many men avoid unneeded chemotherapy. It is important to remember that the RPLND is a complex operation requiring substantial experience and technical skill in order to remove all of the appropriate lymph nodes and to minimize the side effects of the operation. RPLND should only be done by a surgeon who is highly experienced with this operation. Some patients may experience temporary side effects from RPLND, such as bowel obstruction (blockage) or infection. This procedure should not affect a man's ability to have an erection or orgasm, but it may cause infertility because it can interfere with nerves that control the ejaculation of sperm. There are surgical techniques that are usually successful at sparing the nerves involved with ejaculation, and it is recommended that a man discuss this with his surgeon. The main disadvantage of this surgery is that 70% of patients are cured by removal of the testicle alone, and for these men, a RPLND is of no benefit except, possibly, peace of mind. Also, despite the surgery, about 10% of testicular cancers recur even if the lymph nodes were not found to have cancer. If the RPLND finds that the lymph nodes have cancer, then a decision needs to be made whether to give two courses of chemotherapy (see below) to decrease the chance of recurrence to about 1%. However, it is equally reasonable to “watch and wait” (also called active surveillance, see below) and begin treatment with chemotherapy only if the cancer recurs. This is because this type of cancer has a greater than 95% chance of being completely removed with three cycles of chemotherapy if the recurrence is diagnosed early through regular screening. RPLND to remove residual tumors after chemotherapy. RPLND performed after chemotherapy is a more complex operation and is more likely to result in infertility (due to failure to ejaculate) and other side effects. However, the surgical removal of any masses that remain after chemotherapy for non-seminomas is believed to be an essential part of treating the disease when such an operation can be safely completed. About half of men going through such surgery will be found to have a mass that contains either teratoma (about 40%) or one of the other germ cell cancers (10%). The other half of men will have no tumor. For men found to have teratoma, no additional treatment is given after RPLND. For men found to have one of the other germ cell tumors (seminoma, embryonal carcinoma, yolk sac tumor, or choriocarcinoma), then additional chemotherapy may be given after RPLND. Other types of surgery to remove tumors remaining after chemotherapy After chemotherapy, some men may have tumors remaining in lymph nodes outside the retroperitoneum or in the lungs, liver or other organs. These tumors are often removed if it is safe to do so. This may involve surgery in multiple sites of the body. If only some of the remaining tumors can be removed, then surgery is not usually performed. This type of surgery is complex and requires an experienced team of surgeons. Learn more about cancer surgery. Active surveillance As described above, after having a radical inguinal orchiectomy, one treatment option for clinical stage I seminomas and non-seminomas may be active surveillance. A doctor may recommend this approach, in which the patient is monitored closely and treatment begins only if the cancer recurs. This option involves regular doctor appointments for CT scans, chest x-rays, physical examinations, and blood tests for tumor markers. This approach requires dedication by the doctor and patient to stick to the surveillance schedule so that any recurrence can be detected at an early stage. The main advantage of this approach is that it avoids any further treatment after orchiectomy (such as chemotherapy, radiation therapy, or additional surgery) for the 80% of men with seminoma and 70% of men with non-seminoma who do not require further treatment after surgery. It is worth noting that the surveillance schedule for non-seminomas involves testing every one to two months for the first two years and less often thereafter. The surveillance schedule for seminomas is much less intense, with testing performed every four months for the first three years and less often thereafter. Patients generally have follow-up screening for at least ten years after their diagnosis. Radiation therapy Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. The radiation is generally directed at lymph nodes in the abdomen. Radiation therapy is more effective with seminoma than non-seminoma. The only common use of radiation therapy in testicular cancer is for stage I, IIA, or IIB pure seminomas. Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, loose bowel movements, and peptic ulcers. Medications may be helpful to prevent or reduce nausea and vomiting during radiation therapy. Most side effects go away soon after treatment is finished. Radiation therapy can also cause problems with sperm production and the remaining testicle needs to be shielded if the man wishes to try to preserve fertility. Radiation therapy may cause a small increased risk of secondary cancers many years after treatment and an increased risk of cardiovascular disease and gastrointestinal disease. Chemotherapy Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medications. Some people may receive chemotherapy in their doctor’s office; others may go to the hospital. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a specific time. There are different options to consider when a doctor prescribes chemotherapy for testicular cancer, depending on the stage of the disease. Chemotherapy with bleomycin (Blenoxane), etoposide (VePesid, Etopophos, Lastet), and cisplatin (Platinol) is a common combination, called BEP, used in testicular cancer treatment. The side effects of chemotherapy depend on the individual and the dose used, but can include the following side effects. Most of these side effects usually go away once treatment is finished. Nausea and vomiting. This is common during each cycle of chemotherapy. Vomiting can often be prevented using the appropriate medications. Drugs that prevent nausea and vomiting are given before chemotherapy on each of the days the cisplatin is given. These drugs are very effective. One of these antinausea drugs is a cortisone-like steroid called dexamethasone (multiple brand names). Another class of drugs, called serotonin antagonists, blocks a chemical called serotonin from entering the brain and triggering the part of the brain that controls vomiting. The combination of these drugs almost completely prevents vomiting in a majority of men, although they do not eliminate all nausea. A third drug is metoclopramide (Reglan). The combination of dexamethasone, metoclopramide, and a serotonin antagonist has been shown to be highly effective at preventing vomiting and reducing nausea for patients receiving chemotherapy regimens like BEP. If a stronger antinausea treatment is needed, aprepitant (Emend) can be added to the combination of dexamethasone and a serotonin antagonist. Other drugs, such as prochlorperazine (Compro, Compazine), promethazine (Phenergan), or lorazepam (Ativan, Lorazepam Intensol) may also be helpful. Learn more about preventing nausea and vomiting caused by cancer treatment. Fatigue. Tiredness and loss of energy are among the most common side effects of chemotherapy. Almost all men undergoing chemotherapy for testicular cancer will experience some degree of fatigue, but the extent varies widely from person to person. Reduction in the number of blood cells. Chemotherapy may cause a reduction in the number of white cells (cells that fight infections), red blood cells (cells that carry oxygen), or platelets (cells that cause blood to clot). Because lower levels of these cells can interfere with blood clotting and the body’s ability to fight infections, seek help immediately if bleeding, infection, and/or fever occurs. Infections during chemotherapy can be very serious, and even fatal, if they are not treated immediately, and fever is often the only warning of an infection. Loss of hair. For most patients, hair loss occurs after four weeks. However, it grows back about four months after chemotherapy has ended. At times, it may grow back a different texture (such as curly, if it used to be straight) or a different color. However, patients who are balding before chemotherapy do not grow more hair after completing chemotherapy than they had before chemotherapy. Numbness and tingling. The chemotherapy used for testicular cancer sometimes causes nerve damage that results in a partial loss of sensation in the hands and/or feet. Numbness and tingling after chemotherapy often improves over time but may be permanent. Hearing loss. Chemotherapy can cause loss of hearing for high-pitch sounds and can cause ringing in the ears, which is referred to as tinnitus. Hearing loss, when it occurs, is usually permanent. Kidney damage. Mild reductions in kidney function are common after chemotherapy, but it is unknown whether mild reductions actually cause any medical problems. Rarely, chemotherapy can cause more severe kidney damage that prevents the kidneys’ from functioning adequately. Skin marks. Bleomycin can sometimes leave some brown patches on the skin. Other side effects that can last for a prolonged period after chemotherapy are described in the After Treatment section. Learn more about chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases. Treatment by stage of the cancer The treatment choices for testicular cancer depend on whether the cancer is a seminoma or nonseminoma and the stage of the cancer. After a physical examination, staging tests, and removal of the cancerous testicle, you and your doctor will discuss your treatment options. Treatment options for early stage and advanced stages of seminoma and nonseminoma are described in more detail below. Clinical stage I non-seminoma testicular cancer About one-third of patients with clinical stage I non-seminoma have small metastatic sites of cancer that cannot be seen by CT scans at the time of diagnosis but will grow and become visible with time. The other 70% are cured by having their testicle removed. The options for men with clinical stage I disease are:
Clinical stage I seminoma testicular cancer More than 80% of men with clinical stage I seminoma are cured with orchiectomy alone while the remaining 18% to 20% will experience a recurrence if given no additional treatment. Most recurrences occur about 15 months after treatment and the location of the recurrence is typically in the retroperitoneum. Recurrences of stage I seminoma can almost always be cured with radiation therapy at the time of recurrence, although a small number of men will require chemotherapy.
The disadvantage of radiation therapy for clinical stage I seminoma is that more than 80% of men treated receive treatment that they do not need because they were cured with the orchiectomy.
Metastatic non-seminoma testicular cancer
The likelihood of chemotherapy successfully treating this cancer depends on the risk group category (see Staging). More than half of metastatic non-seminoma testicular cancers are classified as good-risk, and more than 90% of these will be successfully treated with three cycles of BEP chemotherapy or four cycles of chemotherapy using etoposide and cisplatin (EP). About 25% of metastatic non-seminomas are intermediate-risk disease, and 80% of these are successfully treated with four cycles of BEP. Finally, about 15% of metastatic non-seminomas are poor-risk disease, and about 50% of these are cured with four cycles of BEP. For patients with intermediate-risk or poor-risk disease who cannot be given bleomycin due to side effects, the combination of etoposide, ifosfamide (Ifex), and cisplatin (called VIP) has been shown to be just as effective.
During surgery, there is about a 45% chance that only scar tissue will be found, a 45% chance there will be teratoma, and about a 10% chance of some other type of germ cell tumor (for example, embryonal carcinoma, seminoma, yolk sac tumor, or choriocarcinoma). If cancer is found, two more cycles of chemotherapy typically either etoposide and cisplatin, or cisplatin and ifosfamide combined with either vinblastine (Velban) or paclitaxel (Taxol) are usually given. Metastatic seminoma testicular cancer
Advanced testicular cancer with brain metastasis If testicular cancer has spread to the brain, the initial treatment is chemotherapy unless immediate treatment of the brain is medically necessary. Chemotherapy typically shrinks the size of such tumors in the brain. If there are any masses remaining after chemotherapy, they should be surgically removed if possible. Radiation therapy to treat the spread of testicular cancer to the brain is controversial. If immediate treatment of a tumor in the brain is needed due to bleeding or swelling or other issues, then removing the mass surgically is usually preferred if it can be done safely, but radiation therapy may be recommended instead of or in addition to surgery depending on the situation. Recurrent testicular cancer Regular follow-up examinations to check for signs that the cancer may be returning (called recurrent cancer) are extremely important. If testicular cancer returns, treatment usually includes chemotherapy and surgery. Sometimes, high-dose chemotherapy with stem cell transplantation may be used. If the cancer was stage I and returns during active surveillance in only the retroperitoneal lymph nodes, surgical removal alone may be considered or chemotherapy may be used. If the cancer is widespread in the lymph nodes or it returns elsewhere in the body, chemotherapy will be used first and may be followed by surgery to remove any remaining tumors. A recurrence more than two years after prior treatment should be removed if possible, and chemotherapy is usually given, either before or after surgery. Find out more about common terms used during cancer treatment. Clinical Trials Resources
Doctors and scientists are always looking for better ways to treat patients with testicular cancer. A clinical trial is a way to test a new treatment to prove that it is safe, effective, and possibly better than a standard treatment. The clinical trial may be evaluating a new drug, a combination of existing treatments, a new approach to radiation therapy or surgery, or a new method of treatment or prevention. Patients who participate in clinical trials are among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment. Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that finding new drugs and other therapies is the only way to make progress in treating testicular cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with testicular cancer. Generally, clinical trials for advanced testicular cancer are aimed at newer treatments for patients with poor-risk disease (see Staging) or men whose cancer recurs after first-line chemotherapy who have a decreased chance of cure compared with the majority of patients with this type of cancer. To join a clinical trial, patients must participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so that the person understands the standard treatments and how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different than the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. Learn more about clinical trials, including patient safety, phases of a clinical trial, deciding to participate in a clinical trial, questions to ask the research team, and links to find cancer clinical trials. Side Effects of Cancer and Cancer Treatment
Cancer and its treatment can cause a variety of side effects. However, doctors have made major strides in recent years in reducing pain, nausea and vomiting, and other physical side effects of cancer treatments. Many treatments used today are less intensive but as effective as treatments used in the past. Doctors also have many ways to provide relief to patients when such side effects do occur. For more information about the specific side effects of testicular cancer treatment, see the Treatment and After Treatment sections. Fear of treatment side effects is common after a diagnosis of cancer, but it may be helpful to know that preventing and controlling side effects is a major focus of your health-care team. Before treatment begins, talk with your doctor about possible side effects of the specific treatments you will be receiving. The specific side effects that can occur depend on a variety of factors, including the type of cancer, its location, the individual treatment plan (including the length and dosage of treatment), and the person’s overall health. Ask your doctor which side effects are most likely to happen (and which are not), when side effects are likely to occur, and how they will be addressed by the health-care team if they do happen. Also, be sure to communicate with the doctor about side effects you experience during and after treatment. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them. In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Learn more about the importance of addressing these needs, including concerns about managing the cost of your cancer care. Learn more about late effects of long-term side effects by reading the After Treatment section or talking with your doctor. After Treatment
After treatment for testicular cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. Men who had testicular cancer usually receive follow-up screening for at least 10 years after their treatment ends. Below are some of the long-term side effects following treatment for testicular cancer. Talk with your doctor for more information. Long-term side effects. After more than 30 years of experience with chemotherapy and radiation therapy for testicular cancer, researchers continue to investigate the long-term side effects of these treatments. In particular, research studies are trying to determine how often treatments cause secondary cancers. It has long been known that radiation can cause cancer and studies of men treated with radiation therapy have repeatedly shown that these men have a higher risk of developing other cancers than men who have not been diagnosed with testicular cancer. More recently, studies have shown that chemotherapy for testicular cancer also can increase the risk of other cancers and the risk appears to be highest in men who receive both radiation therapy and chemotherapy. Similarly, heart disease has been found to be more common after radiation therapy and/or chemotherapy. However, the men in these studies were treated during a time when treatments for testicular cancer were more intensive. Radiation therapy today treats smaller areas of the body and uses lower doses of radiation compared with radiation therapy that was used 10 or 15 years ago. Similarly, there have been changes to the types of chemotherapy used, and men receive fewer treatments than in the past. Therefore, it is not clear whether current treatments for testicular cancer greatly increase the risk of other cancers or the risk of cardiovascular disease. Also, men who develop other cancers after treatment do not necessarily develop those cancers because of the treatment. It is possible that the unknown factors that led to testicular cancer also cause a higher risk of other cancers. Knowing which cancers were caused by previous cancer treatment and which are caused by other factors is difficult. The information on treatment side effects is important when choosing treatment for stage I seminoma and non-seminoma as these men have a greater than 70% chance of being cured with an orchiectomy alone and thus any side effects from treatment are more difficult to justify than in men who are known to have advanced cancer that requires treatment. Effects of bleomycin on lungs. Nine doses of bleomycin causes lung damage for about 5% of men and is fatal for less than 1% of men receiving the drug. Lung scarring is a potential long-term side effect. The risk factors for lung scarring are age (greater than 70), cigarette smoking, previous lung injury, previous radiation therapy to the chest, impaired kidney function, or receiving additional doses. It is rare to have lung effects without these risk factors. Therefore, if a man has these risk factors and good-risk disease, four cycles of EP can be used instead of three cycles of BEP. If four cycles of chemotherapy are needed, ifosfamide can be used instead of bleomycin, but it is associated with more short-term side effects, such as infections and injury to the bladder. Two particularly important issues are:
Effects of chemotherapy on kidneys. Cisplatin can cause kidney damage. However, it is a very important drug to treat testicular cancer, and has fewer side effects than carboplatin, which has been shown to be less effective. The best way to prevent this problem is for cisplatin to be flushed out by giving the patient at least one liter of IV fluid before and after the cisplatin is given. This reduces the risk of kidney damage. Research studies evaluating kidney function years after the doses have been given have shown low rates of long-term kidney damage and when it does occur, it is generally mild. Effects of chemotherapy on blood vessels and risk factors for heart disease. A condition called Raynaud's phenomenon may be caused by bleomycin. This condition is associated with the blood vessels (especially in the hands) narrowing and the skin turning white, then blue, and then red when exposed to certain triggers, such as cold. Less than 10% of men develop Raynaud’s phenomenon. However, more men developed this condition when vinblastine (Velban) and bleomycin were combined. This regimen is almost never used now. Avoiding the triggers (for example, preventing the fingers from becoming cold) is the main treatment. Men who receive BEP chemotherapy may have higher cholesterol and blood pressure levels and an increased risk of heart disease and/or stroke. Radiation therapy has also been associated with an increased risk of heart disease. The increased risk is small and clearly outweighed by the fact that the treatment is necessary to remove the cancer. However, these side effects are more important when the doctor considers chemotherapy or radiation therapy to prevent the cancer from coming back for men with clinical stage I disease. A healthy diet, exercise, not smoking, and medications (when needed to lower cholesterol, control high blood pressure, or treat diabetes) are ways to reduce the risk of heart disease and stroke. Effects of cisplatin on nerves and hearing. Cisplatin can sometimes damage the nerves, causing feelings of numbness or “pins and needles.” When this occurs, it most often starts during the chemotherapy and lessens and goes away with time. It may take months to completely go away. Rarely, it can affect a person’s functioning, such as being clumsy when buttoning shirt buttons. Sometimes, men who received cisplatin may notice that they can no longer hear high-pitch sounds. This is more common with higher doses, and it is more likely for older men or men with previous hearing problems. It rarely affects young men but may be relevant for musicians or others who depend on having very fine hearing abilities. Secondary cancers. Many researchers from different countries have evaluated tumor registries to determine if there is an increased risk of cancers caused by chemotherapy or radiation therapy. As stated above, the risks are small and probably less now as the doses and medications are more refined. However, research has shown the following information.
Fertility. The issue of fertility in men with testicular cancer is a complex topic because patients with testicular cancer often have a lower sperm count prior to any treatment. A man who has fertility problems should talk with his doctor about these factors:
A low sperm count does not necessarily mean that a man will be infertile after treatment because most patients will develop very low to no sperm counts while receiving chemotherapy. However, the chance of fertility returning after treatment is increases over time but is lower for men with no or low sperm counts before chemotherapy. It is also important to ask about sperm banking before treatment. Effects on testosterone level. In addition to damage to the ability to make sperm, there may be injury to the cells that make testosterone. If a man has a low testosterone level, then hormone replacement therapy can be used. Chemobrain. Men being treated with cisplatin may have trouble concentrating, an effect referred to as chemobrain. One small research study compared men with testicular cancer who received chemotherapy with men with testicular cancer who did not have chemotherapy and those with no history of cancer. In this small study, the men who had received chemotherapy may have had a slightly lower attention span. More research is needed to determine if cisplatin causes this side effect. Most often, any effect to a man’s attention span is small. Although the treatment of testicular cancer can cause some long-term side effects, the chance for a cure, even with disease that has spread, far outweighs these risks. Men recovering from testicular cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about healthy living after cancer. Find out more about common terms used after cancer treatment is complete. Current Research
Research for testicular cancer is ongoing. The following advances may still be under investigation in clinical trials and may not be approved or available at this time. Always discuss all diagnostic and treatment options with your doctor. Since many men with testicular cancer are treated successfully, one of the major goals for the future is to reduce side effects and complications from treatment for men with early-stage or favorable-risk cancers. In addition, treatments for poor-risk and recurrent cancers are being studied in clinical trials, along with basic research studies on the causes and genetics of testicular cancer. High-dose chemotherapy followed by stem cell transplantation. Higher doses of chemotherapy can result in remission (temporary or permanent absence of symptoms) of recurrent testicular cancer. A stem cell transplant is a medical procedure in which diseased bone marrow is replaced by highly specialized cells, called hemotopoietic stem cells. Hematopoietic stem cells are found both in the bloodstream and in the bone marrow. For testicular cancer, a man’s own stem cells are obtained before high-dose chemotherapy is given. After chemotherapy, blood stem cells are infused into the patient’s vein to replace the bone marrow and restore normal blood counts. Despite many studies, this has never been shown to be better than either the standard chemotherapy combination of BEP for first-line therapy for patients with poor-risk disease or the standard chemotherapy regimen of vinblastine, ifosfamide and cisplatin for men who relapse after BEP. Additional clinical trials are being done to investigate whether changes in high-dose chemotherapy can produce better results. Genetic studies. Researchers are analyzing the DNA from tumor samples of men with testicular cancer to determine if any genes are associated with testicular cancer. In addition, there are studies underway to examine possible inherited genetic factors leading to cryptorchidism and risk of testicular cancer. Quality of life. Because more men are surviving testicular cancer, doctors are exploring the long-term effects of high-dose chemotherapy on brain function, such as memory loss, decreased speed of processing information, lowered attention span, anxiety, depression, and fatigue. Other studies focus on sperm quality and heart disease risk for testicular cancer survivors. Questions to Ask the Doctor
Regular communication with your doctor is important in making informed decisions about your health care. Consider asking the following questions of your doctor:
Patient Information Resources
In addition to Cancer.Net, there are other sources of information about this type of cancer available online. Cancer.Net maintains a list of national, not-for-profit organizations that may be helpful in finding additional information, services, and support. As always, be sure to talk with your doctor about questions you may have about information you find about this disease. View organizations that offer information on this specific type of cancer. |
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