Signs and symptoms of testicular cancer

In most 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 it is not painful. 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. Leydig cell tumors 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. In rare cases, testicular cancer spreads to the brain and can cause headaches.

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. Many of these symptoms are more likely to be caused by something other than testicular cancer. But if a tumor is the cause, the sooner you get an accurate diagnosis, the sooner you can start treatment and the more effective your treatment is likely to be. For more information, see the separate American Cancer Society document, Do I Have Testicular Cancer?

Medical history and physical exam

If you have signs or symptoms that may suggest testicular cancer, your doctor will want to take a complete medical history to check for risk factors and symptoms. During a physical exam, the doctor will feel the testicles for swelling or tenderness and for the size and location of any lumps. The doctor will also examine your abdomen, lymph nodes, and other parts of your body carefully, looking for any signs the tumor has spread. Often the results of the exam are normal aside from the testicular abnormalities.

Ultrasound of the testicles

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 instrument) 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 on a monitor. The echoes from most tumors differ from those of normal tissues. 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. You simply lie on your back on a table and a technician moves the transducer along the skin of the scrotum. Usually, the skin is first lubricated with gel. The pattern of echoes reflected by tissues can be used to distinguish 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 surgery to remove the tumor.

Blood tests for tumor markers

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). When these proteins (called tumor markers) are 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.

Non-seminomas often raise AFP and/or HCG levels. Pure seminomas occasionally raise HCG levels but never AFP levels, so any increase in AFP means that the tumor has a non-seminoma component. (Tumors can be mixed and have areas of seminoma and non-seminoma.) A high LDH often (but not always) indicates widespread disease. Sertoli and Leydig cell tumors do not produce these substances. The levels of these proteins may not be elevated if the tumor is small.

These tests also sometimes help 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 as soon as possible. The surgeon will try to remove the entire tumor along 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 (cut) in the groin. This operation is called a radical inguinal orchiectomy.

The entire specimen is sent to the lab, 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 biopsy the testicle before removing it. 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 looked at 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 will be surgery to remove only the tumor or the use of appropriate medicines.

If the diagnosis of cancer is made, your doctor will order other imaging tests to see if it has spread outside of the testicle.

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 the middle 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 can better judge whether the cancer has spread to the chest.

Computed tomography (CT) scan

The 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 can help tell if your cancer has spread into your lymph nodes, lungs, liver, or other organs.

Before the scan, you may be asked to drink a contrast solution and/or get an intravenous (IV) injection of a contrast dye that helps better outline abnormal areas in the body. You may need an IV line through which the contrast dye is injected.

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.

You need to lie still on a table while the scan is being done. During the test, the table moves in and out of the scanner, a ring-shaped machine that completely surrounds the table. You might feel a bit confined by the ring you have to lie in while 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, you remain on the CT scanning table while a radiologist advances a biopsy needle through the skin 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) is removed and examined under a microscope.

Magnetic resonance imaging (MRI) scan

Like CT scans, MRI scans provide detailed images of soft tissues in the body. But 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. 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. You may be placed inside a large cylindrical tube, which is confining and can upset people with a fear of enclosed spaces. Newer, more open MRI machines can help with this if needed. The MRI machine makes buzzing and clicking noises that you may find disturbing. Some places will provide earplugs to help block this out.

Lymphangiogram

Because of improvements in other imaging tests, 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.

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

Positron emission tomography (PET) scan

For a PET scan, radioactive glucose (sugar) is injected into the patient's vein. The amount of radioactivity is very low. Because cancers use sugar much faster than normal tissues, the cancer cells in the body absorb large amounts of the radioactive substance. A special camera can then be used to create a picture of areas of radioactivity in the body. The picture is not finely detailed like a CT or MRI scan, but it can provide helpful information about your whole body.

This test 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 seen on the CT scan are cancer or something else.

Last Medical Review: 08/03/2009
Last Revised: 08/03/2009