Testicular Cancer Treatment (PDQ�)

General Information About Testicular Cancer

Testicular cancer is a disease in which malignant (cancer) cells form in the tissues of one or both testicles.

The testicles are 2 egg-shaped glands located inside the scrotum (a sac of loose skin that lies directly below the penis). The testicles are held within the scrotum by the spermatic cord, which also contains the vas deferens and vessels and nerves of the testicles.

The testicles are the male sex glands and produce testosterone and sperm. Germ cells within the testicles produce immature sperm that travel through a network of tubules (tiny tubes) and larger tubes into the epididymis (a long coiled tube next to the testicles) where the sperm mature and are stored.

Almost all testicular cancers start in the germ cells. The two main types of testicular germ cell tumors are seminomas and nonseminomas. These 2 types grow and spread differently and are treated differently. Nonseminomas tend to grow and spread more quickly than seminomas. Seminomas are more sensitive to radiation. A testicular tumor that contains both seminoma and nonseminoma cells is treated as a nonseminoma.

Testicular cancer is the most common cancer in men 20 to 35 years old.

Health history can affect the risk of developing testicular cancer.

Anything that increases the chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn?t mean that you will not get cancer. People who think they may be at risk should discuss this with their doctor. Risk factors for testicular cancer include:

• Having had an undescended testicle.

• Having had abnormal development of the testicles.

• Having a personal history of testicular cancer.

• Having a family history of testicular cancer (especially in a father or brother).

• Being white.

Possible signs of testicular cancer include swelling or discomfort in the scrotum.

These and other symptoms may be caused by testicular cancer. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:

• A painless lump or swelling in either testicle.

• A change in how the testicle feels.

• A dull ache in the lower abdomen or the groin.

• A sudden build-up of fluid in the scrotum.

• Pain or discomfort in a testicle or in the scrotum.

Tests that examine the testicles and blood are used to detect (find) and diagnose testicular cancer.

The following tests and procedures may be used:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. The testicles will be examined to check for lumps, swelling, or pain. A history of the patient's health habits and past illnesses and treatments will also be taken.

• Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.

• Serum tumor marker test: A procedure in which a sample of blood is examined to measure the amounts of certain substances released into the blood by organs, tissues, or tumor cells in the body. Certain substances are linked to specific types of cancer when found in increased levels in the blood. These are called tumor markers. The following 3 tumor markers are used to detect testicular cancer:

  • Alpha-fetoprotein (AFP).

  • Beta-human chorionic gonadotropin (?-hCG).

  • Lactate dehydrogenase (LDH).

  Tumor marker levels are measured before radical inguinal orchiectomy and biopsy, to help diagnose testicular cancer.

• Radical inguinal orchiectomy and biopsy: A procedure to remove the entire testicle through an incision in the groin. A tissue sample from the testicle is then viewed under a microscope to check for cancer cells. (The surgeon does not cut through the scrotum into the testicle to remove a sample of tissue for biopsy, because if cancer is present, this procedure could cause it to spread into the scrotum and lymph nodes. It's important to choose a surgeon who has experience with this kind of surgery.) If cancer is found, the cell type (seminoma or nonseminoma) is determined in order to help plan treatment.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

• Stage of the cancer (whether it is in or near the testicle or has spread to other places in the body, and blood levels of AFP, ?-hCG, and LDH).

• Type of cancer.

• Size of the tumor.

• Number and size of retroperitoneal lymph nodes.

Testicular cancer can usually be cured.

Treatment for testicular cancer can cause infertility.

Certain treatments for testicular cancer can cause infertility that may be permanent. Patients who may wish to have children should consider sperm banking before having treatment. Sperm banking is the process of freezing sperm and storing it for later use.

Stages of Testicular Cancer

After testicular cancer has been diagnosed, tests are done to find out if cancer cells have spread within the testicles or to other parts of the body.

The process used to find out if cancer has spread within the testicles or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:

• Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.

• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.

• Lymphangiography: A procedure used to x-ray the lymph system. A dye is injected into the lymph vessels in the feet. The dye travels upward through the lymph nodes and lymph vessels, and x-rays are taken to see if there are any blockages. This test helps find out whether cancer has spread to the lymph nodes.

• Abdominallymph node dissection: A surgical procedure in which lymph nodes in the abdomen are removed and a sample of tissue is checked under a microscope for signs of cancer. This procedure is also called lymphadenectomy. For patients with nonseminoma, removing the lymph nodes may help stop the spread of disease. Cancer cells in the lymph nodes of seminoma patients can be treated with radiation therapy.

• Radical inguinal orchiectomy and biopsy: A procedure to remove the entire testicle through an incision in the groin. A tissue sample from the testicle is then viewed under a microscope to check for cancer cells. (The surgeon does not cut through the scrotum into the testicle to remove a sample of tissue for biopsy, because if cancer is present, this procedure could cause it to spread into the scrotum and lymph nodes.)

• Serum tumor marker test: A procedure in which a sample of blood is examined to measure the amounts of certain substances released into the blood by organs, tissues, or tumor cells in the body. Certain substances are linked to specific types of cancer when found in increased levels in the blood. These are called tumor markers. The following 3 tumor markers are used in staging testicular cancer:

  • Alpha-fetoprotein (AFP)

  • Beta-human chorionic gonadotropin (?-hCG).

  • Lactate dehydrogenase (LDH).

  Tumor marker levels are measured again, after radical inguinal orchiectomy and biopsy, in order to determine the stage of the cancer. This helps to show if all of the cancer has been removed or if more treatment is needed. Tumor marker levels are also measured during follow-up as a way of checking if the cancer has come back.

There are three ways that cancer spreads in the body.

The three ways that cancer spreads in the body are:

• Through tissue. Cancer invades the surrounding normal tissue.

• Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.

• Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.

The following stages are used for testicular cancer:

Stage 0 (Carcinoma in Situ)

In stage 0, abnormalcells are found in the tiny tubules where the sperm cells begin to develop. These abnormal cells may become cancer and spread into nearby normal tissue. All tumor marker levels are normal. Stage 0 is also called carcinoma in situ.

Stage I

In stage I, cancer has formed. Stage I is divided into stage IA, stage IB, and stage IS and is determined after a radical inguinal orchiectomy is done.

• In stage IA, cancer is in the testicle and epididymis and may have spread to the inner layer of the membrane surrounding the testicle. All tumor marker levels are normal.

• In stage IB, cancer:

  • is in the testicle and the epididymis and has spread to the blood vessels or lymph vessels in the testicle; or

  • has spread to the outer layer of the membrane surrounding the testicle; or

  • is in the spermatic cord or the scrotum and may be in the blood vessels or lymph vessels of the testicle.

  All tumor marker levels are normal.

• In stage IS, cancer is found anywhere within the testicle, spermatic cord, or the scrotum and either:

  • all tumor marker levels are slightly above normal; or

  • one or more tumor marker levels are moderately above normal or high.

Stage II

Stage II is divided into stage IIA, stage IIB, and stage IIC and is determined after a radical inguinal orchiectomy is done.

• In stage IIA, cancer:

  • is anywhere within the testicle, spermatic cord, or scrotum; and

  • has spread to up to 5 lymph nodes in the abdomen, none larger than 2 centimeters.

  All tumor marker levels are normal or slightly above normal.

• In stage IIB, cancer is anywhere within the testicle, spermatic cord, or scrotum; and either:

  • has spread to up to 5 lymph nodes in the abdomen; at least one of the lymph nodes is larger than 2 centimeters, but none are larger than 5 centimeters; or

  • has spread to more than 5 lymph nodes; the lymph nodes are not larger than 5 centimeters.

  All tumor marker levels are normal or slightly above normal.

• In stage IIC, cancer:

  • is anywhere within the testicle, spermatic cord, or scrotum; and

  • has spread to a lymph node in the abdomen that is larger than 5 centimeters.

  All tumor marker levels are normal or slightly above normal.

Stage III

Stage III is divided into stage IIIA, stage IIIB, and stage IIIC and is determined after a radical inguinal orchiectomy is done.

• In stage IIIA, cancer:

  • is anywhere within the testicle, spermatic cord, or scrotum; and

  • may have spread to one or more lymph nodes in the abdomen; and

  • has spread to distant lymph nodes or to the lungs.

  Tumor marker levels may range from normal to slightly above normal.

• In stage IIIB, cancer:

  • is anywhere within the testicle, spermatic cord, or scrotum; and

  • may have spread to one or more lymph nodes in the abdomen, to distant lymph nodes, or to the lungs.

  The level of one or more tumor markers is moderately above normal.

• In stage IIIC, cancer:

  • is anywhere within the testicle, spermatic cord, or scrotum; and

  • may have spread to one or more lymph nodes in the abdomen, to distant lymph nodes, or to the lungs.

  The level of one or more tumor markers is high.

  or

  Cancer:

  • is anywhere within the testicle, spermatic cord, or scrotum; and

  • may have spread to one or more lymph nodes in the abdomen; and

  • has not spread to distant lymph nodes or the lung but has spread to other parts of the body.

  Tumor marker levels may range from normal to high.

Recurrent Testicular Cancer

Recurrenttesticular cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back many years after the initial cancer, in the other testicle or in other parts of the body.

Treatment Option Overview

There are different types of treatment for patients with testicular cancer.

Different types of treatments are available for patients with testicular cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Testicular tumors are divided into 3 groups, based on how well the tumors are expected to respond to treatment.

Good Prognosis

For nonseminoma, all of the following must be true:

• The tumor is found only in the testicle or in the retroperitoneum (area outside or behind the abdominal wall); and

• The tumor has not spread to organs other than the lungs; and

• The levels of all the tumor markers are slightly above normal.

For seminoma, all of the following must be true:

• The tumor has not spread to organs other than the lungs; and

• The level of alpha-fetoprotein (AFP) is normal. Beta-human chorionic gonadotropin (?-hCG) and lactate dehydrogenase (LDH) may be at any level.

Intermediate Prognosis

For nonseminoma, all of the following must be true:

• The tumor is found in one testicle only or in the retroperitoneum (area outside or behind the abdominal wall); and

• The tumor has not spread to organs other than the lungs; and

• The level of any one of the tumor markers is more than slightly above normal.

For seminoma, all of the following must be true:

• The tumor has spread to organs other than the lungs; and

• The level of AFP is normal. ?-hCG and LDH may be at any level.

Poor Prognosis

For nonseminoma, at least one of the following must be true:

• The tumor is in the center of the chest between the lungs; or

• The tumor has spread to organs other than the lungs; or

• The level of any one of the tumor markers is high.

There is no poor prognosis grouping for seminoma testicular tumors.

Five types of standard treatment are used:

Surgery

Surgery to remove the testicle (radical inguinal orchiectomy) and some of the lymph nodes may be done at diagnosis and staging. (See the General Information and Stages sections of this summary.) Tumors that have spread to other places in the body may be partly or entirely removed by surgery.

Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy or radiation therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

See Drugs Approved for Testicular Cancer for more information.

Watchful waiting

Watchful waiting is closely monitoring a patient?s condition without giving any treatment until symptoms appear or change. This is also called observation.

High-dose chemotherapy with stem cell transplant

High-dose chemotherapy with stem cell transplant is a method of giving high doses of chemotherapy and replacing blood-forming cells destroyed by the cancer treatment. Stem cells (immature blood cells) are removed from the blood or bone marrow of the patient or a donor and are frozen and stored. After the chemotherapy is completed, the stored stem cells are thawed and given back to the patient through an infusion. These reinfused stem cells grow into (and restore) the body?s blood cells.

See Drugs Approved for Testicular Cancer for more information.

New types of treatment are being tested in clinical trials.

Information about clinical trials is available from the NCI Web site.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from NCI's listing of clinical trials.

Follow-up tests may be needed.

Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.

Men who have had testicular cancer have an increased risk of developing cancer in the other testicle. A patient is advised to regularly check the other testicle and report any unusual symptoms to a doctor right away.

Long-term clinical exams are very important. The patient will probably have check-ups frequently during the first year after surgery and less often after that.

Treatment Options by Stage

A link to a list of current clinical trials is included for each treatment section. For some types or stages of cancer, there may not be any trials listed. Check with your doctor for clinical trials that are not listed here but may be right for you.

Stage I Testicular Cancer

Treatment of stage I testicular cancer depends on whether the cancer is a seminoma or a nonseminoma.

Treatment of seminoma may include the following:

• Surgery to remove the testicle, with long-term follow-up.

• Surgery to remove the testicle, with radiation therapy to lymph nodes in the abdomen after the surgery, with long-term follow-up.

• Surgery to remove the testicle, followed by chemotherapy and long-term follow-up.

Treatment of nonseminoma may include the following:

• Surgery to remove the testicle, with long-term follow-up.

• Surgery to remove the testicle and lymph nodes in the abdomen, with long-term follow-up.

• Surgery followed by chemotherapy for patients at high risk of recurrence, with long-term follow-up.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage I malignant testicular germ cell tumor. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

Stage II Testicular Cancer

Treatment of stage II testicular cancer depends on whether the cancer is a seminoma or a nonseminoma.

Treatment of seminoma may include the following:

• When the tumor is 5 centimeters or smaller:

  • Surgery to remove the testicle, followed by radiation therapy to lymph nodes in the abdomen and pelvis.

  • Combination chemotherapy.

  • Surgery to remove the testicle and lymph nodes in the abdomen.

• When the tumor is larger than 5 centimeters:

  • Surgery to remove the testicle, followed by combination chemotherapy or radiation therapy to lymph nodes in the abdomen and pelvis, with long-term follow-up.

Treatment of nonseminoma may include the following:

• Surgery to remove the testicle and lymph nodes, with long-term follow-up.

• Surgery to remove the testicle and lymph nodes, followed by combination chemotherapy and long-term follow-up.

• Surgery to remove the testicle, followed by combination chemotherapy and a second surgery if cancer remains, with long-term follow-up.

• Combination chemotherapy before surgery to remove the testicle, for cancer that has spread and is thought to be life-threatening.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage II malignant testicular germ cell tumor. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

Stage III Testicular Cancer

Treatment of stage III testicular cancer depends on whether the cancer is a seminoma or a nonseminoma.

Treatment of seminoma may include the following:

• Surgery to remove the testicle, followed by combination chemotherapy. If there are tumors remaining after chemotherapy, treatment may be one of the following:

  • Watchful waiting with no treatment unless tumors grow.

  • Watchful waiting for tumors smaller than 3 centimeters and surgery to remove tumors larger than 3 centimeters.

  • A PET scan two months after chemotherapy and surgery to remove tumors that show up with cancer on the scan.

• A clinical trial of chemotherapy.

Treatment of nonseminoma may include the following:

• Surgery to remove the testicle, followed by combination chemotherapy.

• Combination chemotherapy followed by surgery to remove the testicle and all remaining tumors. Additional chemotherapy may be given if the tumor tissue removed contains cancer cells that are growing or if follow-up tests show that cancer is progressing.

• Combination chemotherapy before surgery to remove the testicle, for cancer that has spread and is thought to be life-threatening.

• A clinical trial of chemotherapy.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage III malignant testicular germ cell tumor. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

Treatment Options for Recurrent Testicular Cancer

Treatment of recurrenttesticular cancer may include the following:

• Combination chemotherapy.

• High-dose chemotherapy and stem cell transplant.

• Surgery to remove cancer that has either:

  • come back more than 2 years after complete remission; or

  • come back in only one place and does not respond to chemotherapy.

• A clinical trial of a new therapy.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent malignant testicular germ cell tumor. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

To Learn More About Testicular Cancer

For more information from the National Cancer Institute about testicular cancer, see the following:

• Testicular Cancer Home Page

• Testicular Cancer Screening

• Drugs Approved for Testicular Cancer

• Testicular Cancer: Questions and Answers

For general cancer information and other resources from the National Cancer Institute, see the following:

• What You Need to Know About? Cancer

• Understanding Cancer Series: Cancer

• Cancer Staging

• Chemotherapy and You: Support for People With Cancer

• Radiation Therapy and You: Support for People With Cancer

• Coping with Cancer: Supportive and Palliative Care

• Cancer Library

• Information For Survivors/Caregivers/Advocates

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Changes to This Summary (10/02/2011)

The PDQcancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

Images were added to this summary.

About PDQ

PDQ is a comprehensive cancer database available on NCI's Web site.

PDQ is the National Cancer Institute's (NCI's) comprehensive cancer information database. Most of the information contained in PDQ is available online at NCI's Web site. PDQ is provided as a service of the NCI. The NCI is part of the National Institutes of Health, the federal government's focal point for biomedical research.

PDQ contains cancer information summaries.

The PDQ database contains summaries of the latest published information on cancer prevention, detection, genetics, treatment, supportive care, and complementary and alternative medicine. Most summaries are available in two versions. The health professional versions provide detailed information written in technical language. The patient versions are written in easy-to-understand, nontechnical language. Both versions provide current and accurate cancer information.

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PDQ also contains information on clinical trials.

A clinical trial is a study to answer a scientific question, such as whether one treatment is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. During treatment clinical trials, information is collected about the effects of a new treatment and how well it works. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become "standard." Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Listings of clinical trials are included in PDQ and are available online at NCI's Web site. Descriptions of the trials are available in health professional and patient versions. Many cancer doctors who take part in clinical trials are also listed in PDQ. For more information, call the Cancer Information Service 1-800-4-CANCER (1-800-422-6237).