Diagnosing testicular cancer

Thursday 1 September, 2016

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On this page: Ultrasound | Blood tests | Surgery to remove the testicle (orchidectomy) | CT Scan | Chest x-ray | Further tests | Staging | Prognosis | Which health professionals will I see? | Key points  


You will usually begin by seeing your general practitioner (GP), who will examine your testicles and scrotum for a lump or swelling. You may find the consultation embarrassing, particularly if you have never had a doctor perform this type of examination before, but doctors are used to it and it only takes a few minutes.

If the GP feels a lump, you will have an ultrasound and a blood test (see below). If the results show any sign of testicular cancer, you will be referred to a urologist, who specialises in the urinary and male reproductive systems. If further tests show there is a tumour, you may need to have your testicle removed.

Ultrasound

An ultrasound is a painless scan that uses soundwaves to create a picture of your body. It is a very accurate way to diagnose testicular cancer. It is used to show if cancer is present and how large it is. A gel is spread over your scrotum and a small device called a transducer is pressed into the area. This sends out soundwaves that echo when they meet something dense, like an organ or a tumour. A computer creates a picture from these echoes. The scan is painless and takes about 15–20 minutes.

Blood tests

Blood tests will be taken to check your general health and how well your organs (such as your kidneys) are working. The results of these tests will also help you and your doctors make decisions about your treatment.

Tumour markers

Some types of testicular cancer produce chemicals – also known as hormones or proteins – that are released into the blood. These chemicals can be used as tumour markers, which show that cancer may be present.

If your blood test results show an increase in the levels of tumour markers, you may have testicular cancer. Raised levels are more common in mixed tumours and non-seminoma cancers. However, it is possible to have raised tumour markers due to other factors, such as liver disease or blood disease. Some men with testicular cancer don’t have raised tumour marker levels in their blood. Doctors use the results of your tumour marker levels to plan treatment.

The three most common tumour markers are:

  • alpha-fetoprotein (AFP) – raised in non-seminoma cancers
  • beta human chorionic gonadotropin (beta-hCG) – raised in some seminoma and non-seminoma cancers
  • lactate dehydrogenase (LDH) – raised in non-seminoma and seminoma cancers, and used to help determine the extent of the cancer.

If the diagnosis of testicular cancer is confirmed after surgery, you will have regular blood tests to monitor tumour marker levels throughout treatment and as part of follow-up appointments.

Tumour marker levels will decrease if your treatment is successful, but they will increase if the cancer is active. If this happens, you may need more treatment.

Surgery to remove the testicle (orchidectomy)

None of the tests described on pages 13–14 can definitively diagnose testicular cancer. The only way this can be done is by surgically removing and examining the affected testicle. An orchidectomy is also the main treatment for testicular cancer when it has not spread.

For other types of cancer, a doctor can usually make a diagnosis by removing and examining some tissue from the tumour. This is called a biopsy. However, doctors don’t usually biopsy the testicle because there is a small risk that making a cut through the scrotum can cause cancer cells to spread.

If the urologist strongly suspects testicular cancer after doing a physical examination and other tests, they will usually remove the whole testicle and spermatic cord through a cut in the lower abdomen (see illustration above). This is called an orchidectomy. The spermatic cord is also removed because it contains blood and lymph vessels that may act as a pathway for the cancer to spread to other areas of the body.

The operation usually takes about an hour. You will have a few stitches to close the incision. These will usually dissolve after several weeks. See below for what to expect after surgery.

Tissue that is removed during the orchidectomy is sent to a specialist called a pathologist, who examines the cells under a microscope and provides information about the cancer, such as the type, and whether and how far it has spread (the stage).

Most men have only one testicle removed. It is rare for both testicles to be affected by cancer at the same time.

If the cancer has not spread, an orchidectomy may be the only treatment you need. However, after the operation, you will need to have regular check-ups to ensure there is no recurrence of the disease. This is called surveillance.

Occasionally men with testicular cancer need further surgery. This may be to remove the lymph nodes at the back of the abdomen (retroperitoneal lymph node dissection).

What happens during an orchidectomy
What happens during an orchidectomy

You will be given a general anaesthetic before the orchidectomy.

The surgeon will make a cut (incision) in the groin above the pubic bone. This is shown on the picture opposite with a blue line.

The testicle is then pulled up and out of the scrotum through the cut. In the picture the area removed is shown by a dotted line.

Recovery after surgery

After the orchidectomy, you may stay in hospital overnight; however, many men are able to return home the same day.

Lifting

You’ll probably be advised to avoid strenuous activities, such as heavy lifting, for six weeks. Your doctor will discuss these precautions with you.

Underwear

Your surgeon will probably recommend that you wear underwear that provides cupping support of the scrotum or athletic-type underwear to increase your comfort and provide protection while you recover. This can also reduce swelling.

You can purchase scrotal support underwear at most pharmacies. It is similar to regular underwear and is not noticeable under clothing. You could also wear your usual underwear with padding placed under the scrotum.

Support

You will need someone to take you home and stay with you for the first 24 hours after going home.

Returning to work and driving

You should be able to go back to work when you feel ready and drive after 2–4 weeks.

Side effects of surgery

You may experience some of the following side effects after surgery.

Pain

Your doctor can prescribe you medication to control any pain you have after the operation. Let the doctor or nurses know if the pain worsens – don’t wait until it is severe before asking for more pain relief.

Bruising

You may have some bruising around the wound and scrotum. Blood may collect inside the scrotum (intrascrotal haematoma). If this occurs, the swelling may make it feel like the testicle hasn’t been removed. Scrotal support underwear helps reduce the risk of intrascrotal haematoma. Both the bruising and the haematoma will disappear over time.

Fertility effects

Losing one testicle shouldn’t affect your ability to have children (fertility), as long as the remaining testicle is healthy. Your fertility may be affected if you have chemotherapy after surgery.

Emotional effects

Losing a testicle may cause some men to feel embarrassed or depressed, or suffer from low self-esteem. It may help to talk about how you are feeling with someone you trust, such as a partner or counsellor. See information about support services.

Body image concerns

Some men choose to replace the removed testicle with an artificial one (prosthesis). See below for more information.

Having a prosthesis

You may be given the option of replacing the removed testicle with an artificial one. This is called a prosthesis, and it is a silicone implant intended to have the weight and feel of a normal testicle.

Whether or not you have a prosthesis is a personal decision.

If you choose to have a prosthesis, you can have the operation at the same time as the orchidectomy or later. Your urologist can give you more detailed information about your options and what the procedure involves.

CT scan

If the removal of your testicle and other tests show that you have cancer, you may have a computerised tomography (CT) scan to see whether the cancer has spread to other parts of the body, such as lymph nodes or other organs. Usually your chest, abdomen and pelvis will be scanned. Sometimes this is done before the orchidectomy.

A CT scan is a type of x-ray that takes detailed, three-dimensional pictures of the inside of the body. To make the scan pictures clearer and easier to read, you may have to fast (not eat or drink) for a period of time before your appointment.

Before the scan, you may be given an injection of a dye into a vein in your arm to make the pictures clearer. The injection can make you feel hot all over for a few minutes. You may be asked to drink a liquid instead of having an injection.

You will lie flat on a table while the CT scanner, which is large and round like a doughnut, takes pictures. This painless test takes about 15 minutes.

Chest x-ray

In some cases, you may have a chest x-ray to check if the cancer has spread to the lungs or the lymph nodes in the chest.

Further tests

You may have some other tests, such as MRI or PET scans, if the doctor is not sure of the full extent of the cancer, or if your tumour markers are elevated. These scans may also be used during or after treatment.

MRI scan

An MRI (magnetic resonance imaging) scan uses a powerful magnet and radio waves to create detailed pictures of areas inside the body. Sometimes, dye will be injected into a vein before the scan to help make the pictures clearer.

You will lie on a table that slides into a metal cylinder that is open at both ends. The machine makes a series of bangs and clicks and can be quite noisy. The scan is painless, but some people feel anxious lying in the narrow cylinder. Tell your doctor or nurse beforehand if you are prone to anxiety or claustrophobia. They can suggest breathing exercises or give you medicine to help you relax. The scan takes about 30 minutes, and most people are able to go home as soon as it is over.

PET scan

Before a PET (positron emission tomography) scan, you will be injected with a small amount of a glucose (sugar) solution containing some radioactive material. You will be asked to rest for 30–60 minutes while the solution spreads throughout your body.

You will then be scanned for high levels of radioactive glucose. Cancer cells show up brighter on the scan because they absorb more of the glucose solution than normal cells do.

It may take a few hours to prepare for a PET scan, but the scan itself usually takes about 15 minutes. The radioactive material in the glucose solution is not harmful and will leave your body within a few hours.

Staging

The removal of the testicle and the results of the other tests will help to determine whether the cancer has spread (the stage). There are several staging systems for testicular cancer. A simplified description is provided in the table below.

Staging testicular cancer
  • Stage I: Cancer is found only in the testicle.
  • Stage II or higher: Cancer has spread outside the testicle to the lymph nodes in the abdomen or pelvis, or to other areas of the body.

Prognosis

Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis with your doctor, but it is not possible for anyone to predict the exact course of the disease. Instead, your doctor can give you an idea about common issues that affect men with testicular cancer.

Test results, the type of testicular cancer you have, the stage of the cancer and other factors such as your age, fitness and medical history are all important in assessing your prognosis.

Testicular cancer is the most curable solid organ tumour. Regular follow-up and review is a major factor in the high cure rates of testicular cancer, so it’s important that you attend all your follow-up appointments.

"My doctor said to me, ‘If you’re going to get a cancer, this is the one to get. The cure rate is high, side effects are minimal and life afterwards is pretty normal.’" – Mark

Which health professionals will I see?

After seeing your GP and getting a diagnosis from the urologist, you may be cared for by a range of health professionals who are responsible for different aspects of your treatment.

The health professionals you see will depend on the treatment you have. The multidisciplinary team (MDT) may include some or all of the people listed on the next page.

Health professional Role
urologist (specialist doctor) specialises in treating diseases of the urinary system and the male reproductive system; performs surgery
medical oncologist (specialist doctor) prescribes and coordinates chemotherapy
radiation oncologist (specialist doctor)
prescribes and coordinates radiotherapy
nurses administer drugs and provide care, information and support throughout your treatment
cancer care coordinator or clinical nurse consultant coordinates your care, liaises with other members of the MDT and supports your family throughout treatment
anaesthetist (specialist doctor)
administers anaesthetic before surgery and monitors you during the operation
dietitian
recommends an eating plan for you to follow while you are in treatment and recovery
social worker
links you to support services and helps you with any emotional or practical issues
psychologist, counsellor
provide emotional support and help manage any feelings of anxiety and depression
physiotherapist, occupational therapist assist with physical and practical problems

Key points

  • Your doctor will do an external examination to feel your testicles and scrotum for lumps and swelling.
  • An ultrasound will create a picture of your scrotum and testicles. This is a quick and painless scan.
  • Blood tests will be done to monitor chemicals released into your blood (tumour markers). An increase in tumour markers may indicate that cancer is present. Some men who have testicular cancer do not have raised tumour marker levels.
  • The only way to definitively diagnose testicular cancer is to remove the testicle. This operation is called an orchidectomy. For some men, no further treatment is needed.
  • After an orchidectomy, you will have side effects, such as pain and bruising. These will ease over time. Wearing scrotal- supportive underwear will help.
  • If the removal of the testicle shows you have cancer, you will probably have more tests to see whether the cancer has spread. You may have a CT scan, a chest x-ray and other scans.
  • The doctor will tell you the stage of the cancer, which describes whether and how far it has spread.
  • You will see a range of health professionals, such as a urologist and nurses. They will work together as a multidisciplinary team (MDT) to diagnose and treat you.

Reviewed by: A/Prof Declan Murphy, Urologist, Director of Genitourinary Oncology, Peter MacCallum Cancer Centre, VIC; Gregory Bock, Urology Cancer Nurse Coordinator, WA Cancer & Palliative Care Network, WA; A/Prof Martin Borg, Radiation Oncologist, Adelaide Radiotherapy Centre, SA; A/Prof Joseph McKendrick, Medical Oncologist, Eastern Oncology, Eastern Health and Monash University, VIC; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council Western Australia, WA; Ben Peacock, Consumer; and Deb Roffe, Cancer Council Nurse, Cancer Council SA.