In about 90% of testicular cancer cases, men have a lump on a testicle or they may notice the testicle is swollen or larger. Sometimes the lump causes pain, but most of the time there is no pain at all. Men with testicular cancer may mention a feeling of heaviness or aching in the lower abdomen or scrotum.

In rare cases, men with germ cell cancer notice their breasts are sore or have grown. This symptom occurs because certain types of germ cell tumors secrete high levels of a hormone called human chorionic gonadotropin (HCG), which stimulates breast development. Blood tests can measure HCG levels. These tests are important in diagnosis, staging, and follow-up of some testicular cancers.

Like germ cell tumors, Leydig cell tumors and Sertoli cell tumors can also cause a lump in the testicle. The type of tumor can only be diagnosed by examining the tumor cells under a microscope. Leydig cell tumors, however, can produce androgens (male sex hormones) or estrogens (female sex hormones). These hormones may cause symptoms that provide clues to the correct diagnosis. Breast growth or loss of sexual desire is a symptom of estrogen-producing tumors. Androgen-producing tumors may not cause any specific symptoms in men, but in boys they can cause growth of facial and body hair at an abnormally early age.

Even when testicular cancer has spread to other organs, only about 1 man in 4 may have symptoms. Lower back pain can be a sign that the cancer has spread to the lymph nodes in the abdomen. If the cancer has spread to the lungs, the man may notice trouble breathing (shortness of breath), chest pain, or a cough. Sometimes the man may even cough up blood.. Occasionally men will have abdominal pain, either from enlarged lymph nodes or metastasis (spread) to the liver. If the cancer has spread to the brain, it can cause headaches, This is not the way testicular cancer usually spreads.

Some men with testicular cancer have no symptoms at all, and their cancer is found during medical testing for other conditions. Sometimes imaging tests done to find the cause of infertility can uncover a small testicular cancer.

A number of non-cancerous conditions, such as testicle injury or inflammation, can produce symptoms similar to those of testicular cancer. Inflammation of the testicle, known as orchitis, can cause painful swelling. Epididymitis (inflammation of the epididymis) can also cause swelling and pain. Both of these can be caused by viral or bacterial infections. The mumps virus causes orchitis in about 1 man in 5 who contracts mumps as an adult.

If you have any of the signs or symptoms described above, see your doctor without delay. Remember, the sooner you get an accurate diagnosis, the sooner you can start treatment and the more effective your treatment will be. For more information, see the separate American Cancer Society document, Do I Have Testicular Cancer?

Medical History and Physical Exam

The first step is for the doctor to take a complete medical history to check for risk factors and symptoms. During a physical exam, the doctor feels the testicles for swelling or tenderness and for the size and location of any lump. The doctor also feels your abdomen for enlarged lymph nodes, a sign that the cancer has spread to the lymph nodes found in the back of the abdomen (retroperitoneal lymph nodes).

Ultrasound

An ultrasound can help doctors tell if a lump is solid or filled with fluid. This test uses sound waves to produce images of internal organs. A transducer (wand-like equipment) emits the sound waves and picks up the echoes as they bounce off the organs. A computer processes the pattern of echoes to produce an image that is displayed on a monitor. The echoes from most tumors differ from those of normal tissue. These patterns of echoes also can help distinguish some types of benign and malignant tumors from one another.

This is an easy test to have and it uses no radiation, which is why it is often used to look at developing fetuses. For most ultrasound exams, you simply lie on a table and a technician moves the transducer over the part of your body being examined. Usually, the skin is first lubricated with gel. The pattern of echoes reflected by tissues can be useful in distinguishing certain benign conditions (like hydrocele or varicocele) ,from a solid tumor that could be a cancer. If the lump is solid, then it may be a cancer and the doctor may recommend further tests or even immediate surgery to remove the tumor.

Blood Tests

Some blood tests can help diagnose testicular tumors. Many testicular cancers secrete high levels of certain proteins, such as alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG). These proteins (called tumor markers) are important because when they are present in the blood, it suggests that there is a testicular tumor.. A tumor may also increase the levels of an enzyme called lactate dehydrogenase (LDH). However, LDH levels can also be increased in conditions other than cancer.

Nonseminomas often raise AFP and HCG levels. Seminomas occasionally raise HCG levels but never AFP levels. A high LDH often (but not always) indicates widespread disease. Sertoli or Leydig cell tumors do not produce these substances. The levels of these proteins may not be elevated if the tumor is small. These tests are also useful to estimate how much cancer is present, to evaluate the response to therapy, and to make sure the tumor has not returned. For more information on tumor markers, see the section “How Is Testicular Cancer Staged?”

Surgery

If the doctor sees a solid tumor on ultrasound, he or she will recommend surgery to remove it right away. The surgeon will try to remove the entire tumor with the testicle and spermatic cord. The spermatic cord contains blood and lymph vessels that may act as pathways for testicular cancer to spread to the rest of the body. To lessen the chance that cancer cells will spread, these vessels are tied off early in the operation. This is best done by operating through an incision in the groin. This operation is called a radical inguinal orchiectomy.

The entire specimen will be sent to the laboratory where a pathologist (a doctor specializing in laboratory diagnosis of diseases) examines the tissue under a microscope. If cancer cells are present, the pathologist sends back a report describing the type and extent of the cancer.

In rare cases, when a diagnosis of testicular cancer is uncertain, the doctor may perform a biopsy before removing the testicle. This is done in surgery. During this operation, the surgeon makes a cut in the groin, withdraws the testicle from the scrotum, and examines it without cutting the spermatic cord. If suspicious tissue is seen, a portion of the tissue is removed and immediately examined by the pathologist. If cancer is found, the testicle and spermatic cord are removed. If the tissue is not cancerous, the testicle can often be returned to the scrotum, and treatment involves surgery to remove only the tumor or the use of appropriate medicines. Once the diagnosis is made, your doctor will order other imaging tests to see how advanced the cancer is.

Imaging Tests

Chest X-ray

This is a plain x-ray of your chest and can be taken in any outpatient setting. This test is done to see if your cancer has spread to your lungs or the lymph nodes in an area of the chest known as the mediastinum. If the x-ray result is normal, you probably don't have cancer in your lungs. But most doctors feel a computed tomography (CT scan) (see next section) can better judge whether the cancer has spread to the chest.

Computed Tomography

The computed tomography (CT) scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, like a conventional x-ray, a CT scanner takes many pictures of the part of your body being studied as it rotates around you. A computer then combines these pictures into an image of a slice of your body.

CT scans are helpful in staging the cancer. They help tell if your cancer has spread into your lungs, liver, or other organs. They show the lymph nodes and distant organs where metastatic cancer might be present.

Before the first set of pictures is taken you may be asked to drink 1 or 2 pints of a contrast agent. This helps outline the intestine so that certain areas are not mistaken for tumors. You may also receive an IV (intravenous) line through which a different kind of contrast dye is injected. This helps better outline structures in your body.

The injection can cause some flushing (redness and warm feeling that may last hours to days). A few people are allergic to the dye and get hives. Rarely, more serious reactions like trouble breathing and low blood pressure can occur. Medicine can be given to prevent and treat allergic reactions. Be sure to tell the doctor if you have ever reacted to any contrast material used for x-rays or if you have an allergy to shellfish.

CT scans take longer than regular x-rays and you need to lie still on a table while they are being done. But just like other computerized devices, they are getting faster and your stay might be pleasantly short. Also, you might feel a bit confined by the ring you have to lay in when the pictures are being taken.

CT scans are sometimes used to guide a biopsy needle precisely into a suspected metastasis. For this procedure, called a CT-guided needle biopsy, the patient remains on the CT scanning table while a radiologist advances a biopsy needle toward the location of the mass. CT scans are repeated until the doctors are confident that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ˝-inch long and less than 1/8-inch in diameter) is removed and examined under a microscope.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Not only does this produce cross-sectional slices of the body like a CT scanner, it can also produce slices that are parallel with the length of your body. A contrast material might be injected just as with CT scans but is used less often.

MRI scans are particularly helpful in examining the brain and spinal cord. MRI scans are a little more uncomfortable than CT scans. First, they take longer -- often up to an hour. Also, you have to be placed inside a tube, which is confining and can upset people with a fear of enclosed spaces. The machine also makes a thumping noise that you may find disturbing. Some places provide headphones with music to block this sound out. If you have problems with close spaces (claustrophobia), you should let your doctor know before the MRI.

Lymphangiogram

Because of improvements in other diagnostic techniques, lymphangiograms are rarely done today. Most doctors prefer CT scans instead. For a lymphangiogram, a special dye is injected into a lymph vessel in the foot or leg. The dye travels to the lymph nodes. A special monitor displays x-ray images of the lymph system, which doctors can study to detect signs that cancer has spread to the lymph nodes. Lymph nodes are a network of small, bean-shaped collections of white blood cells that fight infection. Enlarged lymph nodes can be a sign of a spreading cancer, but they can also occur if your body is fighting an infection.

CT scans are used to examine lymph nodes more frequently than lymphangiograms. However, the technique is sometimes used for patients with early-stage nonseminomas who are being watched for signs of progression before getting more chemotherapy or radiation.

Positron Emission Tomography

In the positron emission tomography (PET) scan, radioactive glucose (sugar) is injected into the patient’s vein. Because cancers use sugar much faster than normal tissues, the cancerous tissue takes up the radioactive material. A scanner can spot the radioactive deposits. This test has can be helpful for spotting small collections of cancer cells. It is sometimes useful for looking at enlarged lymph nodes that remain after chemotherapy. A PET scan may help the doctor decide if they contain scar tissue or active tumor. Often the PET scan is combined with a CT scan. This helps decide if abnormalities on the CT scan are cancer or something else.