How Testicular Cancer Is Diagnosed

Testicular cancer is usually first identified by the appearance of a hardened, painless lump in the testicle. In the majority of cases, the lump will not be cancerous but will still need to undergo an evaluation by a doctor. This will usually involve an ultrasound to check for the presence of a tumor and blood tests able to detect proteins know as tumor markers. If cancer is strongly suspected, a surgery known as a radical inguinal orchiectomy may be performed to remove both the tumor and affected testicle for analysis in the lab.

Other imaging tests can be used to determine whether the cancer has spread beyond the site of the initial tumor and to evaluate how effectively cancer treatment may be working.

testicular cancer diagnosis
Illustration by Joshua Seong, Verywell 

Self-Checks

While there is no home testing kit available to diagnose testicular cancer, you can perform what is called a testicular self-exam (TSE). Consider doing this on monthly basis during a shower or bath, as warm water relaxes the testicles and scrotum, making it easier to detect any abnormalities that may be present.

To perform a TSE:

  1. Support each testicle with one hand and examine it with the other.
  2. Gently roll each testicle between your thumb and fingers. Become familiar with its structure. It should feel firm and smooth, like a hard-boiled egg without the shell. Note the rope-like structure (epididymis) that is attached to the back. This allows sperm to pass from the testicle and should not be mistaken for a lump.
  3. Once you have become familiar with the anatomy, feel around for any lumps, masses, or nodules.
  4. If you don’t find anything, try to remember the size, shape, and weight of each testicle and the feel and appearance of the epididymis, so you check for any changes on the next self-exam.
  5. If you do find a lump, take note of the characteristics. Most testicular tumors will be painless. They may be smaller than a pea or larger than a marble and can either be movable or immovable.

Clearly, if you find something, you will need to contact your doctor. While the chances are good that it will not be cancer, only a combination of lab and imaging tests can definitively confirm or rule out cancer as the cause.

Despite the potential benefit of TSE, screening for testicular cancer is neither commonly pursued nor recommended by the U.S. Preventive Services Task Force. Given the high cure rate of the disease (greater than 90 percent) and low mortality risk (less than five percent), the practice has not been shown to improve either statistic.

Imaging

An ultrasound is often the first tool a doctor will use to diagnose testicular cancer. It involves the use of a wand-like device, called a transducer, which emits high-frequency sounds waves to create images of internal organs on a computer display. The readouts can be used to differentiate between a tumor, which would appear more solid, and a benign condition, which would not.

An ultrasound can also help determine whether the testicular tumor is more likely to be benign or malignant. Ninety-five percent of testicular cancers are classified as germ cell tumors, meaning that they originate from the germ cells that produce the precursors of sperm. The other, less common types include sex cord-stromal tumors and mixed tumors (comprised of multiple tumor types).

Germ cell tumors can be further broken down into two key subtypes:

  • Seminomas represent the majority of testicular cancer cases. They typically grow and spread slowly and are more often seen in men ages 25 to 45.
  • Non-seminomas tend to be aggressive and more likely to spread (metastasize). They generally affect men in their late-teens to early-30s.

When viewed on an ultrasound, a seminoma would usually have multiple lobes (lobulation) and appear dark on the display (hyperechoic). By contrast, a non-seminoma would be cyst-like (cystic) and have varying tissue densities (heterogeneous).

Ultrasound is a relatively simple test that doesn't expose you to radiation. You simply lie down on a table as conductivity gel is applied to your scrotum. The technician would then move the transducer along the skin to identify any abnormalities and take occasional "snapshots" for evaluation.

Labs and Tests

A number of simple blood tests can be used to support a testicular cancer diagnosis. They work by detecting proteins produced by the body in response to the cancer, known as tumor markers.

The tests cannot only provide evidence of a cancerous growth, they can also help distinguish between different types of cancer.

Human Chorionic Gonadotropin (hCG)

Human chorionic gonadotropin (hCG) is best known for its role in pregnancy and pregnancy testing. Testicular cancer cells can also stimulate the production of hCG in both seminomas and non-seminomas. With that being said, the level of hCG tends to be low in pure seminomas, registering a detectable result in only one of four cases.

Increased hCG in men can trigger a common symptom of testicular cancer known as gynecomastia, characterized by the abnormal enlargement of breast tissue.

Alpha-Fetoprotein (AFP)

As the name suggests, alpha-fetoprotein (AFP) is a type of protein that plays a role in fetal development. While its function in adults remains unclear, AFP levels commonly increase with non-seminomas but not with pure seminomas. As such, any increase in AFP can be considered a strong indication of a non-seminoma.

Lactase Dehydrogenase Hormone (LDH)

Lactose dehydrogenase hormone (LDH) is a less specific tumor marker but one that is directly involved in tumor initiation and growth. Elevated levels of LDH are not diagnostic of testicular cancer per se, but are strongly suggestive that some sort of cancer is there.

A high LDH may also suggest that the tumor has metastasized, although there is some debate as to whether this applies to all cancers. LDH may also be elevated in response to a heart attack, meningitis, encephalitis, HIV, and certain autoimmune diseases.

Procedures

Many types of cancer are diagnosed by taking a tissue sample, called a biopsy, which can be evaluated under the microscope. This is rarely performed with a testicular tumor as the disruption of cells can cause ​the cancer to spread.

Instead, if the results of the ultrasound and blood tests are strongly suggestive of cancer, a doctor would routinely opt for a procedure known as a radical inguinal orchiectomy. This is the surgical removal of both the tumor and the affected testicle.

For this procedure, the surgeon makes an incision just above the pubic region. In addition to extracting the tumor and testicle, he or she removes the spermatic cord and any blood or lymph vessel that might provide cancer cells an easy route to the rest of the body. These vessels are then tied off as an added precaution.

While an orchiectomy may seem like an extreme step to check for cancer, it is only performed if other tests are strongly indicative of a diagnosis.

If they are not and the diagnosis is uncertain, a surgeon may instead opt to withdraw the testicle from the scrotum without cutting the spermatic cord. A section of suspicious tissue is then removed and rushed to the pathology lab for evaluation. If the lab is unable to find any cancer cells, the testicle is replaced and the scrotum sutured (followed by further investigations to pinpoint the exact cause of the growth). If there are cancer cells, the testicle and spermatic cord are removed. 

After several hours of recovery in the hospital, you should be released. You may be asked to wear a scrotal support for the first 48 hours. During the first two weeks, you'll need to avoid lifting anything heavy or having sex. All told, it usually takes two to three weeks to fully recover, although it can sometimes take longer. 

Disease Staging

If pathology reports indicate a positive result for testicular cancer, the disease is confirmed. The next step is to stage the cancer. Staging is used to determine how far a malignancy may have spread throughout the body which, in turn, informs the course of treatment.

Tests for Staging

In addition to blood tests and tissue evaluations, your doctor will turn to a number of common imaging tests to determine how far the cancer may have spread. Among them:

  • Computed tomography (CT) is a form of X-ray that produces cross-sectional images that give your doctor a better sense of the structure of the tumor. The test may involve an injected or drinkable contrast dye, which can help outline the growth. While effective, the procedure involves radiation. Moreover, the contrast dye will often contain iodine, which may cause a severe allergic reaction in some.
  • Magnetic resonance imaging (MRI) uses radio waves to create high-contrast images for analysis. This form of imaging is especially helpful when checking for cancer in the brain or spinal cord. MRIs can take an hour to perform and, while extremely noisy and disruptive, do not expose you to radiation.
  • Positronic emission tomography (PET) measures metabolic activity in cells and may be used after cancer treatment to check for changes in lymph nodes. The test requires the injection of a radioactive sugar into your blood vein. PET images are not as finely detailed as a CT or MRI scan but can be useful in providing a whole-body look at your condition.

    AJCC Staging

    Based on results of the imaging test, tumor markers, and tissue evaluations, a pathologist will stage the disease. In January 2018, the American Joint Committee on Cancer (AJCC) issued updated guidance on testicular cancer staging, broadly broken down as follows:

    • Stage 1 means that the cancer is confined to the testicles and has not yet spread to nearby tissue or lymph nodes.
    • Stage 2 means that the cancer has spread to nearby lymph nodes and possibly paraaortic lymph nodes just below the diaphragm.
    • Stage 3 means that the cancer has metastasized to distant organs.

    The classification of the tumor (germ cell, stromal sex cord, or mixed), as well as sub-classifications (seminoma versus non-seminoma), would also factor in when deciding upon the appropriate course of treatment.

    Differential Diagnoses

    • Testicular cancer is considered uncommon, affecting an estimated 0.4 percent of men overall. That figure translates to roughly 5.7 cases per 100,000 men per year, according to the National Cancer Institute.
      • From an individual standpoint, this suggests that the risk of cancer is pretty low. To differentiate between testicular cancer and other possible causes, your doctor may conduct additional tests, especially if the results of your ultrasound and blood tumor marker tests are inconclusive.
      • Among the possible investigations:
        • Benign testicular cysts can often be easily differentiated by their appearance on ultrasound. While a testicular tumor will usually be dark, a cyst by its very definition will be fluid-filled.
      • Epididymo-orchitis, the inflammation of the epididymis and testicle, is often caused by a sexually transmitted disease (STD) and will be characterized by inflammation, redness, and pain not commonly seen with testicular cancer. An STD test and an ultrasound (showing an increased blood flow to the affected testicle) can be used to differentiate the two diseases.
      • Hydrocele, in which fluid accumulates in the scrotum, is often caused by an injury or infection. It can be differentiated from testicular cancer by its appearance on an ultrasound in which the mass will be translucent rather than solid and involve the entire testicle, rather than just part of it.
      • A scrotal hernia, in which the bowel bulges through a weak spot beneath the scrotum, can usually be identified by bowel sounds on a stethoscope. The tissue can usually be pushed back easily through the hole, as well. An ultrasound can usually confirm the herniation.
      • Spermatocele is the formation of a "sperm cyst" caused by an obstruction in the epididymis. It can be differentiated from testicular cancer in that the lump will be wholly independent of the testicle and usually located in a specific position (near the upper pole of the testicle).
      • Testicle torsion, the twisting of a testicle in a way that cuts off the blood supply can be differentiated by the sudden onset of pain and the high-riding position of the testicle. An ultrasound can usually tell whether there is any obstruction to the blood supply.
      • Varicoceles, the abnormal enlargement of a blood vessel in the scrotum, can usually be differentiated by the distention of the vein (greater than three centimeters) and the opposite direction of the blood flow.
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