Testicular Cancer

01

Risk factors

• Undescended testicle or cryptorchidism.
• Abnormal testicle development.
• Family history of testicular cancer.
• Personal history of testicular cancer in the other testis.
• Infertility.
• Age, especially teens and younger men between 15 and 35 years, though it can occur at any age.

02

Signs and symptoms

• Most common presentation is a painless testicular mass.
• Acute pain may occur due to bleeding within the tumor or rapid growth.
• Vague scrotal discomfort or heaviness.
• Incidental finding on ultrasound or after scrotal trauma.
• Advanced disease may cause flank pain, back pain, breathing difficulty or cough.
• Around 2% of affected men may have gynecomastia.

03

Diagnosis

• Physical examination and medical history.
• Ultrasound examination.
• Serum tumor marker blood tests: AFP, beta-hCG and LDH.
• Tumor markers are measured before inguinal orchiectomy.
• Needle biopsy directly from the scrotum is contraindicated because it may spread tumor cells.
• CT chest and abdomen may evaluate spread.

04

Surgery

05

Chemotherapy and radiotherapy

06

Fertility and sperm banking

Most men can still father children after one testicle is removed. However, chemotherapy, radiotherapy or abdominal lymph node surgery can affect fertility.

Sperm banking before treatment should be discussed. Fertility often recovers after chemotherapy, but some men may have lasting infertility, especially after high-dose treatment.

07

Early recognition and tumor markers

The most common presentation of testicular cancer is a painless testicular lump. Some patients feel heaviness, swelling or discomfort. Advanced disease may cause back pain, flank pain, breathing difficulty or cough depending on spread.

• Ultrasound is the key imaging test for a suspected testicular mass.
• Tumor markers AFP, beta-hCG and LDH are measured before surgery.
• Needle biopsy through the scrotum is avoided because it can spread tumor cells and alter drainage pathways.
• CT chest and abdomen may be used for staging.

08

High inguinal orchidectomy

Removing the affected testicle through a groin incision is usually the first treatment. This operation is called high inguinal orchidectomy or orchiectomy and helps confirm the cancer type.

• The scrotal route is avoided for cancer safety.
• Many early testicular cancers are highly treatable after surgery.
• Further treatment depends on tumor type, stage and marker behavior.

09

Retroperitoneal lymph node dissection

Testicular cancer often spreads first to retroperitoneal lymph nodes along the aorta and inferior vena cava. In non-seminoma patients with residual enlarged nodes after chemotherapy, retroperitoneal lymph node dissection may be needed.

• RPLND removes lymph nodes such as paracaval, precaval, interaortocaval, preaortic and paraaortic nodes.
• Robotic RPLND can reduce morbidity in selected cases compared with traditional open surgery.
• The decision depends on tumor type, chemotherapy response, residual mass and patient fitness.

10

Chemotherapy, radiotherapy and fertility

Chemotherapy treats cancer that has spread outside the testicle, helps prevent recurrence after orchidectomy in selected cases, and treats recurrent disease. Radiotherapy is mainly used for selected seminoma cases involving retroperitoneal lymph nodes.

• Chemotherapy can cause nausea, appetite loss, weight loss, fatigue, lower infection resistance and easy bleeding or bruising.
• Many seminoma patients respond very well to radiotherapy when indicated.
• Most men can father children after one testicle is removed, but chemotherapy, radiotherapy or lymph node surgery can affect fertility.
• Sperm banking should be offered before treatment when fertility may be affected.
• About 70% of men who receive chemotherapy for testicular cancer may later be able to father children, but recovery is not guaranteed for everyone.
• RPLND can sometimes cause retrograde ejaculation, making fertility counseling important.