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Causes & diagnosis

Causes of testicular cancer

Around 2000 men a year are diagnosed with testicular cancer in the UK. It is not known exactly what the causes are, but research is going on all the time to attempt to establish them.

Testicular cancer is more common in men who have a testicle that has failed to descend. In the unborn child the testicles develop inside the abdomen between the kidneys and descend into the scrotum at birth or during the first year of life. If this does not happen, the risk of a man developing testicular cancer is increased.

Men with a brother or father who has had testicular cancer are slightly more at risk of developing it (although the risk is still small). Research has shown that a particular gene is the cause of testicular cancer in some men. It is possible that this gene is inherited and may be the reason why testicular cancer sometimes occurs in brothers or sons of men who have had the disease.

Testicular cancer is more common in white men than African-Caribbean or Asian men. It occurs more commonly in wealthier social groups. The reasons for this are not known.

It is not clear whether injury to the testicle can cause a testicular cancer. Vasectomy does not increase the risk of a man developing testicular cancer.

How common is the Testicular cancer in India?

Testicular cancer is a very rare cancer among men from the Indian subcontinent and also worldwide. The incidence (newly diagnosed cases of Cancer in a year) of Testicular Cancer for men from India is less than 1 man per 1,00,000 population1.

In India, between the years 2001-2003, across five urban centers - Mumbai, Delhi, Chennai, Bhopal and Bangalore, and one rural center - Barshi, a total of 403 cases of Testicular Cancer were registered (0.91% of all cancers) for male cancer patients, across all the age groups2.

The TATA Memorial Hospital (T.M.H.) in Mumbai, India registered a grand-total of 10,747 cases of all types of male cancer patients in the year 2006, out of which 158 men (1.5% of the total male cases) were diagnosed with Testicular cancer3.

Seventeen percent of all Genito-urinary cancers among men in the year 2006 at the T.M.H. were attributable to Testicular cancer.

Symptoms of testicular cancer

The most common symptom is swelling in part of one testicle. This is usually painless, but some men may notice an ache in their lower abdomen or in the affected testicle. There may be a feeling of heaviness in the scrotum. In a few men the testicle suddenly becomes swollen and very tender.

When a normal testicle is examined, it is round, soft and smooth. The epididymis can be felt behind it as a separate structure. Cysts and benign swellings in the epididymis are quite common and are usually harmless. Lumps in the body of the testes itself may be benign but can be a cancer. It is sensible to have any swelling examined by a doctor.

A few men may find that their first symptoms (such as backache, stomach ache, or a cough) are caused by spread of the cancer cells to other parts of the body. Rarely, tender nipples may be caused by hormonal changes within the body. If you have any of the above symptoms it is important to let your doctor know but remember, they are more likely to be due to conditions other than cancer.

Cancers that are found early are the most easily treated. The best way to check for testicular cancer is to examine yourself once a month and the best time to do this is after a warm bath or shower, when the scrotal skin is relaxed. If you would like to find out more about testicular self-examination, Cancerbackup can send you a leaflet.

If you find a swelling in a testicle, it is very important that you have it checked by your doctor as soon as possible.

Types of testicular cancer

There are two main types of testicular cancer seminomas and teratomas. They may be called germ cell tumours. Occasionally testicular tumours can be a mix of both types.

Seminomas most commonly occur in men between 25 and 55 years of age.

Teratomas usually affect younger men from 15 to about 35 years.

Sometimes a type of cancer called non-Hodgkin lymphoma can occur in the testicle. This would be treated as a non-Hodgkin lymphoma.

Other rare types of testicular tumour are Leydig and Sertoli cell tumours.

How testicular cancer is diagnosed

Usually you begin by seeing your family doctor (GP), who will examine you and take your medical details. They will then refer you to a hospital specialist for further tests, expert advice and treatment.

The specialist will give you a full physical examination and take your medical history. Often, the doctor can tell by feeling the lump, whether it is likely to be a cancer.

You may have an ultrasound scan of the scrotum and the testes. This test can help to tell whether a lump is a cancer or is due to other causes. An ultrasound scan uses sound waves to build up a picture of the testes and scrotum. However, the only way to confirm that the swelling is cancer is for a surgeon to examine the testicle during an operation.

During the surgery the surgeon can sometimes see whether the lump is a cancer or not. A small piece of tissue is removed and immediately examined under a microscope by a pathologist (this procedure is known as a biopsy). If the biopsy shows that the lump is a cancer, the testicle will be removed (this operation is known as orchidectomy).

The cells are then taken to a laboratory and examined further to find out which type of testicular cancer it is.

You can usually go home the next day. If the cancer has not spread beyond the testicle, this may be the only treatment you will need, although for a few years you will have to attend the hospital regularly for check-ups.

The removal of one testicle does not affect your ability to have an erection or to father children. An artificial testicle (known as an implant or prosthesis) can be inserted into your scrotum to give a normal appearance if you wish. Your specialist can give you more details about this.

Further tests for testicular cancer

If the tests show that you have testicular cancer, you will have some further tests to see if the cancer has spread to other parts of the body.

These tests may include some or all of the following:

Blood tests (tumour markers)
Chest x-ray and computerised tomography (CT) scan
Magnetic resonance imaging (MRI) scan

Blood tests (tumour markers)

Some testicular cancers produce chemicals which are released into the bloodstream. The main chemicals (called tumour markers) are alpha-fetoprotein (AFP), beta human chorionic gonadotrophin (BHCG), lactic dehydrogenase (LDH) and placental alkaline phosphatase (PALP). If these chemicals are present in the blood, they can be used to assess whether the cancer has spread and to measure the effect of treatment on the cancer.

Samples of your blood will also be taken regularly throughout your treatment to check your general health and the effect that any treatment may be having on the normal cells in your blood.

Chest x-ray and computerised tomography (CT) scan

Usually, a chest x-ray or CT scan is done to check for any signs that the cancer has spread to the lungs or to the lymph nodes in your abdomen.

The CT scan takes a series of x-rays, which build up a three-dimensional picture of the inside of the body. You may be given a drink or injection of a dye (iodine) which allows particular areas to be seen more clearly. For a few minutes, this may make you feel hot all over. If you are allergic to iodine or have asthma you could have a more serious reaction to the injection, so it is important to let your doctor know beforehand.

The scan takes from 1030 minutes and you will probably be able to go home as soon as it is over.

Having a CT scan

Magnetic resonance imaging (MRI) scan

This test uses magnetism to build up cross-sectional pictures of the body. Some people are given an injection of dye into a vein in the arm to improve the image.

During the test you will be asked to lie very still on a couch inside a metal cylinder that is open at both ends. The whole test may take up to an hour and is painless, although the machine is very noisy. You will be given earplugs or headphones to wear.

The cylinder is a very powerful magnet, so before going into the room you should remove all metal belongings. You should also tell your doctor if you have ever worked with metal or if you have any metal inside your body (for example, a cardiac monitor, pacemaker, surgical clips or bone pins). You may not be able to have an MRI because of the magnetic fields.

You may feel claustrophobic inside the cylinder so it may help to mention to the radiographer doing the MRI if you do not like enclosed spaces. They can then offer extra support during the test.

Once you have had all the tests you need, the doctor will have a good idea of the type of cancer and the stage (whether it is just within the testicle or has spread).

It will probably take several days for the results of your tests to be ready and a follow-up appointment will be made for you. This waiting period can be a very anxious time and it may help to talk things over with a close friend or relative.

Staging of testicular cancer

The stage of a cancer describes its size and whether it has spread beyond the area of the body where it started. There are several staging systems for testicular cancer.

Knowing the extent of the cancer and the type of cell involved helps the doctors decide on the most appropriate treatment.

A staging system commonly used in the UK, called the TNM system, is described here:

T refers to the tumour size.
N refers to whether lymph nodes are affected.
M refers to whether cancer has spread to other parts of the body (metastases).

Tumour size (T)

TIS (testicular carcinoma in situ) Cancer cells are present within the tubules of the testes but have not moved into the surrounding tissue of the testicle.
T1 The tumour is only in the testicle and epididymis.
T2 The tumour has started to grow into blood vessels or lymph nodes close to the testicle.
T3 The tumour has grown as far as the spermatic cord (and possibly also the blood vessels or lymph nodes).
T4 The tumour has grown into the scrotum.

Lymph nodes (N)

The N refers to whether the cancer cells have spread into the lymph nodes nearby and, if so, what size of lymph node is affected (some are larger than others). If lymph nodes are affected they are said to be positive.

N0 The lymph nodes have no cancer cells.
N1 The lymph nodes affected are smaller than 2cm wide.
N2 At least one affected lymph node is larger than 2cm but smaller than 5cm wide.
N3 At least one affected lymph node is bigger than 5cm wide.

Metastases (M)

Metastases refer to how far the cancer has spread.

M0 The cancer does not appear to have spread to other organs.
M1a The cancer has spread to the lungs or to distant lymph nodes (those furthest away from the testicles such as the collarbone).
M1b Other organs are affected; for example the brain or the liver.

Doctors also take into account the levels of tumour markers, whether the cancer has spread into the chest area and whether it has spread into soft tissues of the body other than the lung.

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