Testicular cancer


Diagnosing testicular cancer

You will usually begin by seeing your GP, who will examine your testicles and scrotum for a lump or swelling. Some men may find this embarrassing, but doctors are used to doing these examinations and it will only take a few minutes.

If the GP feels a lump that might be cancer, you will have an ultrasound. If the lump looks like a tumour on the ultrasound, you will have a blood test and are likely to be referred to a specialist called a urologist. The urologist may recommend removal of the testicle to confirm the diagnosis.

Ultrasound

An ultrasound is a painless scan that uses soundwaves to create a picture of your body. This is a very accurate way to tell the difference between fluid-filled cysts and solid tumours. It can show if a tumour is present and how large it is.

The person performing the ultrasound will spread a gel over your scrotum and then move a small device called a transducer over 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 takes about 5-10 minutes.

Blood tests

Blood tests can check your general health and how well your kidneys and other organs are working. The results of these tests will also help you and your doctors make decisions about your treatment.

Tumour markers

Chemicals known as tumour markers are often produced by cancer cells and released into the blood. If your blood test results show an increase in the levels of certain tumour markers, you may have testicular cancer.

Raised levels of tumour markers 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.

The three most common tumour markers measured in tests for testicular cancer are:

    • alpha-fetoprotein (AFP) - raised in some non-seminoma cancers
    • beta human chorionic gonadotropin (beta-hCG) - raised in some non-seminoma and seminoma cancers
    • lactate dehydrogenase (LDH) - raised in some non-seminoma and seminoma cancers.

Doctors will use your tumour marker levels to assess the risk of the cancer coming back after surgery, and this helps them plan your treatment. 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 drop if your treatment is successful, but they will rise if the cancer is active. If this happens, you may need more treatment.

Surgery to remove the testicle

After doing a physical examination, ultrasound and blood tests (see above), your urologist may strongly suspect testicular cancer. However, none of these tests can give a definite diagnosis. The only way to be sure of the diagnosis is to surgically remove the affected testicle and examine it in a laboratory. The surgery to remove a testicle is called an orchidectomy or orchiectomy.

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.

Tissue removed during the orchidectomy is sent to a laboratory. A specialist called a pathologist 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). This helps doctors plan further treatment.

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

"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

Having an orchidectomy

An orchidectomy is an operation to remove a testicle. This is often done to confirm a diagnosis of testicular cancer. It is also the main treatment for testicular cancer that has not spread.

      • You will be given a general anaesthetic before the orchidectomy.
      • The urologist will make a cut (incision) in the groin above the pubic bone. This is shown below with a blue line.
      • The whole testicle is pulled up and out of the scrotum through this cut.
      • 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 scrotum is not removed but it will no longer contain a testicle. (Some men choose to have an artificial testicle inserted to keep the shape. This is called a prosthesis.)
      • The operation takes about 30 minutes.
      • After the orchidectomy, you can usually go home the same day, but may need to stay in hospital overnight. You will need someone to take you home and stay with you for the first 24 hours.

orchidectomy

What to expect after surgery

After an orchidectomy, you will need to take care while you recover. Talk to your treatment team about managing side effects.

Stitches and bruising

You will have a few stitches to close the incision. These will usually dissolve after several weeks. There may be some bruising around the wound and scrotum. The scrotum can become swollen if blood collects inside it (intrascrotal haematoma). If this occurs, the swelling may make it feel like the testicle hasn't been removed. Both the bruising and the haematoma will disappear over time.

Having pain relief

Your doctor can prescribe medicines 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.

Avoiding strain

You'll probably be advised to avoid strenuous activities, such as heavy lifting and vigorous exercise, for six weeks. It is usually okay to have sex 2-4 weeks after surgery. Your doctor will discuss these precautions with you.

Wearing supportive underwear

For the first couple of weeks, it's best to wear underwear that provides cupping support for the scrotum. This will offer comfort and protection as you recover, and can also reduce swelling.

You can buy 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.

Returning to driving and work

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

Emotional effects

Losing a testicle may cause some men to feel embarrassed or depressed, or could lead to low selfesteem. It may help to talk about how you are feeling with someone you trust, such as a partner, friend or counsellor. See information about finding support services.

Effects on sexuality and body image

Your ability to get an erection and experience orgasm should not be affected by the removal of one testicle. However, some men find that it takes time to adjust to the changes to their body and this may affect how they feel about sex. Some men choose to replace the removed testicle with an artificial one (prosthesis, see below).

Fertility effects

As long as the remaining testicle is healthy, losing one testicle is unlikely to affect your ability to have children (fertility). However, men with testicular cancer have lower fertility rates than the general population. The urologist will advise you to store some sperm at a sperm banking facility before the surgery, just in case you have fertility problems in the future.

Testicular cancer usually occurs in only one testicle, so it is rare to need both testicles removed. However, men who have both testicles removed no longer produce testosterone and will need to take testosterone replacement therapy. They will also be infertile.

Having a prosthesis

You may be able to replace the removed testicle with an artificial one called a prosthesis. The prosthesis is a silicone implant similar in size and shape to the removed testicle. There are different brands and some feel firmer than others.

Whether or not to 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.

Further tests

If the removal of your testicle and initial tests show that you have cancer, you may have further tests to see whether the cancer has spread to other parts of the body, such as lymph nodes or other organs. These tests may also be used during or after treatment to check how well the treatment has worked.

CT scan

You may have a computerised tomography (CT) scan of your chest, abdomen and pelvis. Sometimes this is done before the orchidectomy.

A CT scan uses x-rays to take many pictures of the inside of your body and then compiles them into one detailed, cross-sectional picture. 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.

All tests and scans have risks and benefits, and you should discuss these with your doctor. You should let your medical team know if you have diabetes or kidney disease. It is also important to tell them if you have had an allergic reaction to iodine or dye (the contrast) during a previous scan.

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 might also feel like you need to urinate, but this sensation won't last long. 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. The test is painless and 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.

MRI scan

A magnetic resonance imaging (MRI) 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 positron emission tomography (PET) scan, you will be injected with a small amount of a glucose (sugar) solution containing some radioactive material. You will rest for 30-60 minutes while the solution spreads throughout your body, and you will then be scanned. 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 tests described in this section will help to show whether the cancer has spread (the stage). There are several staging systems for testicular cancer, but the most commonly used is the TNM system (see below). The TNM scores and the levels of tumour markers in the blood are used to work out an overall stage for the cancer. Stage I means that the cancer is found only in the testicle (early-stage cancer). Stage II and above means that the cancer has spread outside the testicle to the lymph nodes in the abdomen or pelvis, or to other areas of the body.

TNM staging system

  • T (tumour): describes whether the cancer is only in the testicle (T1) or has spread into nearby blood vessels or tissue (T2, T3, T4)
  • N (nodes): describes whether the cancer is not in any lymph nodes (N0) or has spread to nearby lymph nodes (N1, N2)
  • M (metastasis): describes whether cancer has not spread to distant parts of the body (M0) or whether cancer has spread to distant lymph nodes, organs or bones (M1)

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.

To assess your prognosis, your doctor will consider:

      • your test results
      • the type of testicular cancer you have
      • the stage of the cancer
      • other factors such as your age, fitness and medical history.

Testicular cancer has the highest survival rates of any cancer (other than common skin cancers). 5 Regular follow-up and review is a major factor in ensuring good outcomes, so it's important that you attend all your follow-up appointments.

Key points about diagnosing testicular cancer

Initial tests

      • Your doctor will examine your testicles and scrotum for a lump and swelling.
      • An ultrasound will create a picture of your scrotum and testicles. This is a quick and painless scan.
      • Blood tests will look for chemicals (tumour markers) in your blood that may indicate cancer. Some men with testicular cancer do not have raised tumour marker levels.

Surgery

      • In most cases, the only way to diagnose testicular cancer with certainty is to remove the testicle. This operation is called an orchidectomy. This is also the main treatment for testicular cancer that has not spread.
      • After an orchidectomy, you will have side effects such as pain and bruising. These will ease over time. Wearing scrotal support underwear will help.

Further tests and staging

      • If the removal of the testicle shows that 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.
      • Testicular cancer usually has high survival rates. It is important to attend regular follow-up appointments.

Expert content reviewers:

A/Prof Nick Brook, Senior Consultant Urologist, Royal Adelaide Hospital and The University of Adelaide, SA; Gregory Bock, Urology Cancer Nurse Coordinator, WA Cancer & Palliative Care Network, WA; Jason Gray, Consumer; Clin A/Prof Peter Grimison, Medical Oncologist, Chris O'Brien Lifehouse, Royal Prince Alfred Hospital and The University of Sydney, NSW; Dr Tanya Holt, Senior Radiation Oncologist, Princess Alexandra Hospital Raymond Terrace (ROPART), and Senior Lecturer, The University of Queensland, QLD; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council WA. Thank you to Bradley Outschoorn for sharing his story about testicular cancer.

5. Australian Institute of Health and Welfare (AIHW), Cancer in Australia 2017, AIHW, Canberra, 2017.

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