How is testicular cancer diagnosed?

An ultrasound is a painless scan that uses soundwaves to create a picture of your body. This is a very accurate way to tell the difference between fluid-filled cysts and solid tumours. It can show if a tumour is present and how large it is.

The person performing the ultrasound will spread a gel over your scrotum and then move a small device called a transducer over the area. This sends out soundwaves that echo when they meet something dense, like an organ or a tumour. A computer creates a picture from these echoes. The scan takes about 5–10 minutes.

Blood tests can check your general health and how well your kidneys and other organs are working. The results of these tests will also help you and your doctors make decisions about your treatment.

Tumour markers

Some blood tests look for proteins produced by cancer cells. These proteins are called tumour markers. If your blood test results show an increase in the levels of certain tumour markers, you may have testicular cancer.

Raised levels of tumour markers are more common in mixed tumours and non-seminoma cancers. However, it is possible to have raised tumour marker levels due to other factors, such as liver disease or blood disease. Some people with testicular cancer don’t have raised tumour marker levels in their blood.

There are three common tumour markers measured in tests for testicular cancer. These are:

• alpha-fetoprotein (AFP) – raised in some non-seminoma cancers
• beta human chorionic gonadotropin (beta-hCG) – raised in some non-seminoma and seminoma cancers
• lactate dehydrogenase (LDH) – raised in some non-seminoma and seminoma cancers.

Doctors will use your tumour marker levels to assess the risk of the cancer coming back after surgery, and this helps them plan your treatment. If the diagnosis of testicular cancer is confirmed after surgery, you will have regular blood tests to monitor tumour marker levels throughout treatment and as part of follow-up appointments.

Tumour marker levels will drop if your treatment is successful, but they will rise if the cancer is active. If this happens, you may need more treatment.

After doing a physical examination, ultrasound and blood tests, your urologist may strongly suspect testicular cancer. However, none of these tests can give a definite diagnosis. The only way to be sure of the diagnosis is to surgically remove the affected testicle and examine it in a laboratory. The surgery to remove a testicle is called an orchidectomy or orchiectomy.

For other types of cancer, a doctor can usually make a diagnosis by removing and examining some tissue from the tumour. This is called  a biopsy. However, doctors don’t usually biopsy the testicle because there is a small risk that making a cut through the scrotum can cause cancer cells to spread.

Tissue removed during the orchidectomy is sent to a laboratory. A specialist called a pathologist looks at the cells under a microscope and provides information about the cancer, such as the type, and whether and how far it has spread (the stage). This helps doctors plan further treatment. In most cases, only one testicle needs to be removed. It is rare for both testicles to be affected by cancer at the same time.

Having an orchidectomy

An orchidectomy is an operation to remove a testicle. This is often done to confirm a diagnosis of testicular cancer. It is also the main treatment for testicular cancer that has not spread.

• You will be given a general anaesthetic before the orchidectomy.
• The urologist will make a cut (incision) in the groin above the pubic bone.
• The whole testicle is pulled up and out of the scrotum through this cut.
• The spermatic cord is also removed because it contains blood and lymph vessels that may act as a pathway for the cancer to spread to other areas of the body.
• The scrotum is not removed but it will no longer contain a testicle. (You may choose to have an artificial testicle inserted to keep the shape. This is called a prosthesis).
• The operation takes about 30 minutes.
• After the orchidectomy, you can usually go home the same day, but you may need to stay in hospital overnight.
• You will need someone to take you home and stay with you for the first 24 hours.

What to expect after surgery

After an orchidectomy, you will need to take care while you recover. Talk to your treatment team about managing side effects.

• Stitches and bruising – You will have a few stitches to close the incision. These will usually dissolve after several weeks. There may be some bruising around the wound and scrotum. The scrotum can become swollen if blood collects inside it (intrascrotal haematoma). If this occurs, the swelling may make it feel like the testicle hasn’t been removed. Both the bruising and the haematoma will disappear over time.
• Having pain relief – Your doctor can prescribe medicines to control any pain you have after the operation. Let the doctor or nurses know if the pain worsens – don’t wait until it is severe before asking for more pain relief.
• Avoiding strain – You’ll probably be advised to avoid strenuous activities, such as heavy lifting and vigorous exercise, for about six weeks after the operation. It is usually okay to have sex 2– 4 weeks after surgery. Your doctor will discuss these precautions with you.
• Wearing supportive underwear – For the first couple of weeks, it’s best to wear underwear that provides cupping support for the scrotum. This will offer comfort and protection as you recover and can also reduce swelling. You can buy scrotal support underwear at most pharmacies. It is similar to regular underwear and is not noticeable under clothing. You could also wear your usual underwear with padding placed under the scrotum.
• Returning to driving and work – You should be able to drive after 2– 4 weeks and go back to work when you feel ready.
• Fertility effects – As long as the remaining testicle is healthy, losing one testicle is unlikely to affect your ability to have children. However, some people may have fertility problems as the other testicle may be small and make less sperm. The urologist may advise you to store sperm at a sperm banking facility before the surgery, just in case you have fertility problems in the future.

• Emotional effects – Losing a testicle may cause some people to feel embarrassed or depressed, or could lead to low self-esteem. It may help to talk about how you are feeling with someone you trust, such as a partner, friend or counsellor.
• Effects on sexuality and body image – Your ability to get an erection and experience orgasm should not be affected by the removal of one testicle. However, some people find that it takes time to adjust to the changes to their body and this may affect how they feel about sex. Some people choose to replace the removed testicle with an artificial one (prosthesis).

Testicular cancer usually occurs in only one testicle, so it is rare to need both testicles removed. However, people who have both testicles removed no longer produce testosterone and may need to see an endocrinologist who may prescribe testosterone replacement therapy. They will also be infertile.

Having a prosthesis

You may decide to replace the removed testicle with an artificial one called a prosthesis. The prosthesis is a silicone implant similar in size and shape to the removed testicle. There are different brands, and some feel firmer than others. Whether or not to have a prosthesis is a personal decision. If you choose to have one, you can have the operation at the same time as the orchidectomy or at another time. Your urologist can give you more information about your options.

Before you have any surgery, you should ask your doctor for a referral to a fertility specialist if you are wanting to have children in the future. You may be able to store sperm for later use (sperm banking).

If the removal of your testicle and initial tests show that you have cancer, you will have further tests to see whether the cancer has spread to other parts of the body, such as lymph nodes or other organs. These tests may also be used during or after treatment to check how well the treatment has worked.

CT scan

You will have a computerised tomography (CT) scan of your chest, abdomen and pelvis. Sometimes this is done before the orchidectomy.

A CT scan uses x-rays to take pictures of the inside of your body and then compiles them into one detailed, cross-sectional picture. To make the scan pictures clearer and easier to read, you may have to fast (not eat or drink) for a period of time before your appointment.

Before the scan, you may be given an injection of a dye into a vein in your arm to make the pictures clearer. This injection can make you feel hot all over for a few minutes. You might also feel like you need to urinate, but this sensation won’t last long. You may be asked to drink a liquid instead of having an injection.

You will lie flat on a table while the CT scanner, which is large and round like a doughnut, takes pictures. The test is painless and takes about 15 minutes.

MRI scan

In some circumstances, such as if you have an allergy to the dye normally used for a CT scan, you may instead have a magnetic resonance imaging (MRI) scan. An MRI uses a powerful magnet and radio waves to create detailed pictures of areas inside the body. Sometimes, a dye will be injected into a vein before the scan to help make the pictures clearer.

You will lie on a table that slides into a metal cylinder that is open at both ends. The machine makes a series of bangs and clicks and can be quite noisy. The scan is painless, but some people feel anxious lying in the narrow cylinder. Tell your doctor or nurse beforehand if you are prone to anxiety or claustrophobia. They can suggest breathing exercises or give you medicine to help you relax. The scan takes about 30 minutes, and most people are able to go home as soon as it is over.

PET–CT scan

In some circumstances, you may also be given a positron emission tomography (PET) scan combined with a CT scan. You will be injected with a small amount of a glucose (sugar) solution containing some radioactive material, then asked to rest for 30–60 minutes while the solution spreads throughout your body before you have the scan. Cancer cells show up more brightly on the scan because they absorb more of the glucose solution than normal cells do.

It may take a few hours to prepare for a PET–CT scan, but the scan itself usually takes about 15 minutes. The radioactive material in the glucose solution is not harmful and will leave your body within a few hours.