Other imaging tests and labs can help determine whether cancer is present and if it has spread beyond the initial tumor site.
This article reviews how testicular cancer is diagnosed through self-exams, imaging, labs and tests, and procedures. It also discusses cancer staging and differential diagnoses.
Self-Checks
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 it needs to be evaluated by a healthcare provider.
While no home testing kit is available to diagnose testicular cancer, you can perform a testicular self-exam (TSE). Consider doing this on monthly basis during a shower or bath. Warm water relaxes the testicles and scrotum, making it easier to detect abnormalities.
To perform a TSE:
Support each testicle with one hand and examine it with the other. 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. Once you have become familiar with the anatomy, feel around for any lumps, masses, or nodules. If you don’t find any problems, 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. 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.
Contact your healthcare provider if you find anything that’s concerning. While the chances are good that it will not be cancer, you need a medical evaluation to figure out what the problem is.
Despite the potential benefit of TSE, screening for testicular cancer is not recommended by the U.S. Preventive Services Task Force. Given the high cure rate of the disease (greater than 90%) and low mortality risk (less than 0.5%), the practice has not been shown to improve either statistic.
Imaging
An ultrasound is often the first tool a healthcare provider will use to diagnose testicular cancer. It involves the use of a wand-like device, called a transducer, which emits high-frequency sound waves to create images of internal organs on a computer display. The images can be used to differentiate between tumors and other abnormalities.
Ultrasound is a relatively simple test that doesn’t expose you to radiation. You would 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.
An ultrasound can also help determine whether the testicular tumor is more likely to be benign or malignant.
The other, less common types include sex cord-stromal tumors and mixed tumors (comprised of multiple tumor types).
Germ cell tumors include two key subtypes:
Seminomas represent the majority of testicular cancer cases. They typically grow and spread slowly and are more often seen in males ages 25 to 45. Non-seminomas tend to be aggressive and more likely to spread (metastasize). They generally affect males 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 (hyporechoic). By contrast, a non-seminoma would have cystic spaces and have varying tissue densities.
Labs and Tests
A number of blood tests can help in the diagnosis of testicular cancer. They work by detecting proteins produced by the body in response to cancer, known as tumor markers.
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The test results can help your healthcare providers determine whether there is cancerous growth, and 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 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 males can trigger a common symptom of testicular cancer known as gynecomastia, characterized by the abnormal enlargement of breast tissue.
Alpha-Fetoprotein (AFP)
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 that is directly involved in tumor initiation and growth. Elevated levels of LDH are not diagnostic of testicular cancer, 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 with a microscope. This is rarely performed with a testicular tumor because the disruption of cells in this area can cause cancer to spread.
If the results of the ultrasound and blood tests are strongly suggestive of cancer, a healthcare provider would routinely recommend a procedure known as a radical inguinal orchiectomy. This is the surgical removal of both the tumor and the affected testicle.
During this procedure, the surgeon makes an incision just above the pubic region. In addition to the removal of the tumor and testicle, the spermatic cord and any blood or lymph vessel that might provide cancer cells an easy route to the rest of the body are also removed. These vessels are then tied off as an added precaution.
If the diagnosis is uncertain, your surgeon may withdraw the testicle from the scrotum without cutting the spermatic cord. A section of the concerning tissue is then removed and taken to the pathology lab for evaluation while you are still in the operating room. 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. 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 cancer. Staging is used to classify how far a malignancy has spread throughout the body. This helps determine your course of treatment.
Tests for Staging
In addition to blood tests and tissue evaluations, your healthcare provider will use other imaging tests to determine how far your cancer may have spread.
Among them:
Computed tomography (CT) is a form of X-ray that produces cross-sectional images that give your healthcare provider a 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 rarely 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 radioactive sugar into your vein. PET images are not as finely detailed as a CT or MRI scan but they can be useful in providing a whole-body look at your condition.
AJCC Staging
Based on the results of the imaging tests, 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 defined as follows:
The classification of the tumor (germ cell, stromal sex cord, or mixed), as well as sub-classifications (seminoma, non-seminoma), would also factor in when deciding upon the appropriate course of treatment.
Differential Diagnoses
Testicular cancer is considered uncommon, affecting an estimated 0.5% of males overall. That figure translates to roughly 5.9 cases per 100,000 males 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 healthcare provider may conduct additional tests, especially if the results of your ultrasound and blood tumor marker tests are inconclusive.
Among the possible considerations:
Benign testicular cysts can often be differentiated by their appearance on ultrasound. Epididymo-orchitis is inflammation of the epididymis and testicle. It’s 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 can be used to help 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. A scrotal hernia, in which the bowel bulges through a weak spot beneath the scrotum, can usually be identified by bowel sounds that are heard with a stethoscope. The tissue can usually be pushed back easily through the hole. 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 near the upper pole of the testicle. Testicle torsion is the twisting of a testicle in a way that cuts off the blood supply, and it can be differentiated by the sudden onset of pain and the high-riding position of the testicle. An ultrasound can usually identify 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 millimeters) and the opposite direction of the blood flow.
These include:
Chest X-rayComputed tomography (CT)Magnetic resonance imaging (MRI)Positron emission tomography (PET)Bone scintigraphy (bone scan)
