Diagnosis & testing

In order to diagnose testicular cancer a physician will need a full medical history and a physical examination. If a lump or abnormality is detected the doctor will order an ultrasound of the scrotum. If the ultrasound indicates that there is a solid tumor within the testicle then surgery will be required to remove the testicle and test the tumor to see if it is cancerous. Unfortunately, biopsies are not recommended for testicular cancer as the biopsy itself can increase the chances of the cancer spreading to other areas of the body. If the tumor is determined to be cancerous then other tests will be ordered such as a chest x-ray, CT scan and blood work in order to determine how advanced the cancer is and if it has spread.

• Physical Exam: Your physician will examine your testicles by gently rolling them between two fingers and thumb to identify any abnormal lumps. Your physician may also check your groin area, abdomen, armpits and neck to look for swollen lymph nodes. The doctor may also exam you for breast tenderness or enlargement and listen to your lungs.
• Scrotal Ultrasound: The scrotal ultrasound is a painless non-invasive procedure in which high frequency sound waves are used to produce images of inside the scrotum and testicles. It is the same technology that is used in pregnant women when they get a sonogram. The images will show if there are any solid masses, swelling or fluid collections within the scrotum.
• Radical Orchiectomy: Orchiectomy means removal of one or both of the testicles. Radical means that the removal is done by making an incision high up in the groin area. The incision is not made on the scrotum itself. The reason the testicle is removed from higher up is so that there are no changes made to the lymph drainage system. The reason is similar to why the transscrotal biopsy is condemned. Contrary to rumors the removal of a testicle does not affect the ability to achieve an erection and seldom interferes with the ability to father children. Once the testicle is removed a biopsy or a small sample of the tumor is sent to the laboratory to determine if the cells are cancerous (malignant) or non-cancerous (benign).
• Chest X-ray: A front and side chest x-ray are done to see if the cancer has spread to the lungs or chest cavity.
• CT Scan: CT-Scans create three-dimensional pictures of the inside of the body with an x-ray machine. They usually require you to drink a dye and also have a contrast dye injected into you veins in order to see the internal structures better. CT-scans are the most common imaging tests used for testicular cancer. A CT-scan of the abdomen/pelvis is done to see if any lymph nodes in the retroperitoneal area (stomach area) or pelvis have been affected by the cancer. The CT-scan is the most effective imaging test to determine if the cancer has spread and scans may also be done of the chest and/or brain.
• MRI, Bone Scan, PET Scans. CT-scans are the preferred imaging test for testicular cancer patients. However, other tests such as a MRI, Bone Scan or PET scan may be needed in certain situations. If your doctor orders one of the tests you should discuss with him why the test is needed.

• Blood Tests or Tumor Markers: Testicular cancer or germ cell tumors can secrete proteins or hormones into the bloodstream. The levels of these proteins/hormones in the blood can be measured in the laboratory and are often called tumor markers. The levels of the tumor markers can help verify that a diagnosis is correct and/or that a patient is responding to certain treatments. These tumor markers include: AFP (alpha-Fetoprotein), beta-hCG (beta-Human Chorionic Gonadotropin) and LDH (Lactic Acid Dehydrogenase). Not all forms of testicular cancer produce tumor markers or elevate their levels and you can have testicular cancer even if your tumor markers are normal.

  • AFP (alpha-Fetoprotein): AFP may be produced by pure embryonal carcinoma, yolk sac tumor or combined tumors. It is not secreted by pure seminoma or choriocarcinoma. If a diagnosis of seminoma is made but the APF is elevated then the pathology specimen should be reviewed again.
  • Beta-hCG (beta-Human Chorionic Gonadotropin): Beta-hCG is the same substance that helps identify if women are pregnant. However, some testicular cancers can also secrete the substance. These tumors include embryonal carcinoma and choriocarcinoma. Only 5-10% of seminomas secrete beta-hCG and if secreted it is usually done so at lower levels.
  • LDH (Lactic Acid Dehydrogenase): LDH is the least specific tumor marker for testicular cancer. The levels may be elevated for reasons other than testicular cancer. However, monitoring the LDH levels can give your physician more information about your cancer and treatment.
• Transscrotal Biopsy: The procedure of taking a biopsy from outside the scrotum and into the testicle.

Transscrotal Biopsy is to be condemned and SHOULD NOT BE PERFORMED. The lymph system of the testicles drain into the abdomen while the lymph system of the scrotum drains into the lower legs. By doing a biopsy through the scrotum, cancerous cells can be left in the scrotum and the lymph drainage can be altered. This means that any cancer can spread in a way that is not as predictable as normal testicular cancer spread.

Diagnosis & testing

After someone is diagnosed with testicular cancer, doctors will try to figure out if it has spread, and if so, how far. This process is called staging. The stage of a cancer describes how much cancer is in the body (how big the tumor is, how much it has grown and whether it has spread to other areas of the body such as the lymph nodes or other organs). It helps determine how serious the cancer is and how best to treat it.

The earliest stage of testicular cancer is stage 0 (also called germ cell neoplasia in situ, or GCNIS). The other stage groupings range from I (1) through III (3). There is no stage IV (4) testicular cancer. Some stages are split further to cover more details, using capital letters (A, B, etc.).

As a rule, the lower the number, the less the cancer has spread. A higher number, such as stage III, means cancer has spread more. And within a stage, an earlier letter means a lower stage -for example stage IIa is somewhat less severe that stage IIb..

The staging of testicular cancer follows guidelines set up by the American Joint Committee on Cancer (AJC) and the International Union Against Cancer. Staging follows a TNM system (Tumor, Nodes, Metastasis, Serum Tumor Markers) which is based on 4 key pieces of information:

• T (Tumor) – The size and extent of the main tumor (How large is the tumor? Has it grown into nearby structures or organs?)
• N (Nodes) – The spread to nearby lymph nodes (Has the cancer spread to nearby lymph nodes ? How many, and how big are they?)
• M (Metastsis) – The spread (metastasis) to distant sites (Has the cancer spread to distant parts of the body? (The most common sites of spread are distant lymph nodes, the bones, the liver, and the lungs.)
• S (Serum) – serum (blood) levels of tumor markers (Are any tumor marker levels higher than normal?)

Once a person’s T, N, M, and S categories have been determined, this information is combined in a process called stage grouping to assign an overall stage.