How is testicular cancer diagnosed?
Most men discover testicular cancer themselves, either unintentionally or while doing a testicular self-examination to check for lumps. In other cases, your doctor may detect a lump during a routine physical exam. Doctors use many tests to diagnose cancer and find out if it has spread to another part of the body, called metastasis. Some tests may also determine which treatments may be the most effective.
When a man develops a testicular lump or something else that could be testicular cancer, it is important that he see his primary doctor, who may send him to a urologist. A urologist is a doctor who specializes in treating testicular cancer. A physical examination and an ultrasound of the testicles are usually the first tests performed. If these tests show an abnormality that appears to be a tumor, then blood tests are done. The testicle may need to be surgically removed to look for signs of cancer. Imaging tests, such as computed tomography (CT or CAT) scans and x-rays, may also be used to find out whether the cancer has spread.
This list describes options for diagnosing this type of cancer, and not all tests listed will be used for every person. Your doctor may consider these factors when choosing a diagnostic test:
The following tumor markers are used to help stage and plan treatment for testicular cancer:
• Bone scan
A bone scan can help show if a cancer has spread to the bones. It might be done if there is reason to think the cancer might have spread to the bones (because of symptoms such as bone pain) and other test results aren’t clear. For this test, a small amount of low-level radioactive material is injected into a vein (IV). The substance settles in areas of bone changes throughout the entire skeleton over the course of a couple of hours. You then lie on a table for about 30 minutes while a special camera detects the radioactivity and creates a picture of your skeleton.
Areas of active bone changes attract the radioactivity and show up as “hot spots.” These areas may suggest metastatic cancer, but arthritis or other bone diseases can also cause the same pattern. To distinguish among these conditions, your cancer care team may use other imaging tests such as plain x-rays or MRI scans to get a better look at the areas that light up, or they may even take biopsy samples of the bone.
• Chest x-ray
A plain x-ray of your chest can be done to see if the cancer has spread to your lungs or the lymph nodes in the middle area of the chest known as the mediastinum. If the x-ray is normal, you probably don’t have cancer in your lungs. But most doctors feel a computed tomography (CT) scan can better judge whether the cancer has spread to the chest.
• Computed tomography (CT) scan
CT scans can be used to help determine the stage (extent) of the cancer by showing if it has spread to the lymph nodes, lungs, liver, or other organs. The CT scan uses x-rays to produce detailed cross-sectional images of your body. Instead of taking one picture, like a standard x-ray, a CT scanner takes many pictures of the part of your body being studied as it rotates around you. A computer then combines these pictures into an image of a slice of your body. Before the test, you might be asked to drink a contrast solution and/or get an intravenous (IV) injection of a contrast dye that helps better outline structures in the body. You may need an IV line to inject the contrast dye. The injection can cause some flushing (redness and warm feeling that may last hours to days). Some people are allergic to the dye and get hives. Rarely, more serious reactions like trouble breathing and low blood pressure can occur. Medicine can be given to prevent and treat allergic reactions. Be sure to tell the doctor if you have any allergies or if you have ever reacted to any contrast material used for x-rays.
A CT scanner has been described as a large donut, with a narrow table that slides in and out of the middle opening. You need to lie still on the table while the scan is being done. CT scans take longer that regular x-rays, and you might feel a bit confined by the ring you have to lie in while the pictures are being taken.
CT guided needle biopsy: CT scans are sometimes used to guide a biopsy needle precisely into a suspected area of cancer spread. For this procedure, you stay on the CT scanning table while a doctor advances a biopsy needle through the skin toward the mass. CT scans are repeated until the doctor can see that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue) is then removed and examined under a microscope.
• Magnetic resonance imaging (MRI) scan
MRI scans are particularly helpful in looking at the brain and spinal cord. They are not usually done for testicular cancer unless your doctor has reason to think the cancer might have spread there. Like CT scans, MRI scans provide detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body. A contrast material might be injected just as with CT scans but is used less often. MRI scans take longer than CT scans – often up to an hour – and are a little more uncomfortable. You lie on a table that slides inside a narrow tube, which is confining and can upset people with a fear of enclosed spaces. Special, more open MRI machines can help with this if needed, but the images may not be as sharp in some cases. The MRI machine makes buzzing and clicking noises, so some places will provide earplugs to help block this out.
• Positron emission tomography (PET) scan
A PET scan can help spot small collections of cancer cells in the body. It is sometimes useful for looking at enlarged lymph nodes that remain after chemotherapy. A PET scan may help the doctor decide if they contain scar tissue or active tumor (in which case more treatment would be needed). PET scans are often more useful for seminomas than for non-seminomas, so they are less often used in patients with non-seminoma.
For this test, a form of radioactive sugar (known as fluorodeoxyglucose or FDG) is injected into a vein (IV). (The amount of radioactivity is very low and will pass out of the body over the next day or so.) Because cancer cells in the body grow rapidly, they absorb more of the radioactive sugar. After about an hour, you will be moved onto a table in the PET scanner. You lie on the table for about 30 minutes while a special camera creates a picture of areas of radioactivity in the body. The picture is not finely detailed like a CT or MRI scan, but it can provide helpful information about your whole body. Many centers have special machines that can do both a PET and CT scan at the same time (PET/CT scan). This lets the doctor compare areas of higher radioactivity on the PET with the more detailed appearance of that area on the CT.
• Other imaging tests
Other imaging tests may be done for a number of reasons after a testicular cancer diagnosis, including:
During a physical exam, the doctor will feel the testicles for swelling or tenderness and for the size and location of any lumps. The doctor will also examine your abdomen, lymph nodes, and other parts of your body carefully, looking for any possible signs of cancer spread. Often the results of the exam are normal aside from the testicles.
The surgeon will try to remove the entire tumor along with the testicle and spermatic cord. The spermatic cord contains part of the vas deferens, as well as blood and lymph vessels that could act as pathways for testicular cancer to spread to the rest of the body. To lessen the chance that cancer cells will spread, these vessels are tied off early in the operation. This is best done by operating through an incision (cut) just above the pubic area. This operation is called a radical inguinal orchiectomy.
The entire specimen is sent to the lab, where a pathologist (a doctor specializing in laboratory diagnosis of diseases) looks at pieces of the tumor under a microscope. If cancer cells are found, the pathologist sends back a report describing the type and extent of the cancer.
In rare cases, when a diagnosis of testicular cancer is uncertain, the doctor may biopsy the testicle before removing it. This is done in the operating room. The surgeon makes a cut above the pubic area, withdraws the testicle from the scrotum, and examines it without cutting the spermatic cord. If a suspicious area is seen, a portion of it is removed and looked at right away by the pathologist. If cancer is found, the testicle and spermatic cord are then removed. If the tissue is not cancerous, the testicle can often be returned to the scrotum, and treatment will be surgery to remove only the tumor or the use of appropriate medicines. If testicular cancer is found, your doctor will order imaging tests of other parts of your body to check for spread outside of the testicle.
This is an easy test to have and it uses no radiation, which is why it is often used to look at developing fetuses. You simply lie on your back on a table as the technician moves the transducer along the skin of the scrotum. Usually, the skin is first lubricated with gel.
The pattern of echoes can be used to distinguish certain benign conditions (like hydrocele or varicocele), from a solid tumor that could be a cancer. If the lump is solid, then it’s more likely to be a cancer, so the doctor will recommend further tests or even surgery to remove the testicle.
Testicular Cancer Test and Diagnosis
When a man develops a testicular lump or something else that could be testicular cancer, it is important that he see his primary doctor, who may send him to a urologist. A urologist is a doctor who specializes in treating testicular cancer. A physical examination and an ultrasound of the testicles are usually the first tests performed. If these tests show an abnormality that appears to be a tumor, then blood tests are done. The testicle may need to be surgically removed to look for signs of cancer. Imaging tests, such as computed tomography (CT or CAT) scans and x-rays, may also be used to find out whether the cancer has spread.
This list describes options for diagnosing this type of cancer, and not all tests listed will be used for every person. Your doctor may consider these factors when choosing a diagnostic test:
- Age and medical condition
- Previous test results
- Signs and symptoms
- Type of cancer suspected
Biopsy
A biopsy is the removal of a small amount of tissue for examination under a microscope. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer, but a biopsy of a testicle is almost never used to diagnose testicular cancer. Instead, if cancer is suspected in a testicle, the standard procedure is to surgically remove the entire testicle in a procedure called an orchiectomy. In fact, a biopsy of the testicle using a needle through the skin of the scrotum should NOT be performed because this can complicate future treatment options. Occasionally, a biopsy may be taken from the lung, retroperitoneum, or other location in the body if it appears that cancer may have spread.Blood tests for tumor markers
The levels of serum tumor markers are measured before surgery to remove a testicle. Tumor markers are substances made by a cancer that are found at abnormally high levels in the blood of some people with cancer. For testicular cancer, serum tumor marker levels are used to find out the cancer’s stage and confirm whether a tumor is a pure seminoma. Different types of cancer make different tumor markers. High levels of any one of three tumor markers may indicate testicular cancer. However, it is also possible to have this type of cancer and have normal tumor marker levels.The following tumor markers are used to help stage and plan treatment for testicular cancer:
- Alpha-fetoprotein (AFP) is not made by seminomas, so an elevated level of AFP indicates the tumor is not a pure seminoma, even if it looks like a pure seminoma when examined by a pathologist. However, AFP levels are normal for many men with non-seminomas.
- Beta human chorionic gonadotropin (beta-hCG) can be high from either seminoma or non-seminoma. However, beta-hCG is normal for many men with non-seminomas or seminomas.
- Lactate dehydrogenase (LDH) can be elevated in any type of testicular cancer, as well as in many other cancers and non-cancerous diseases, such as liver disease or heart disease.
- Placental alkaline phosphatase (PLAP) is another tumor marker doctors may test for, although it is not commonly measured.
Imaging tests
If cancer is found, other tests will be needed to determine the stage of the cancer and whether it has spread to other parts of the body. Usually, doctors recommend imaging tests of the abdomen, pelvis and chest. Images of the brain or bones are not as common, but images of the brain may be need for patients who have choriocarcinoma. Imaging tests may include:• Bone scan
A bone scan can help show if a cancer has spread to the bones. It might be done if there is reason to think the cancer might have spread to the bones (because of symptoms such as bone pain) and other test results aren’t clear. For this test, a small amount of low-level radioactive material is injected into a vein (IV). The substance settles in areas of bone changes throughout the entire skeleton over the course of a couple of hours. You then lie on a table for about 30 minutes while a special camera detects the radioactivity and creates a picture of your skeleton.
Areas of active bone changes attract the radioactivity and show up as “hot spots.” These areas may suggest metastatic cancer, but arthritis or other bone diseases can also cause the same pattern. To distinguish among these conditions, your cancer care team may use other imaging tests such as plain x-rays or MRI scans to get a better look at the areas that light up, or they may even take biopsy samples of the bone.
• Chest x-ray
A plain x-ray of your chest can be done to see if the cancer has spread to your lungs or the lymph nodes in the middle area of the chest known as the mediastinum. If the x-ray is normal, you probably don’t have cancer in your lungs. But most doctors feel a computed tomography (CT) scan can better judge whether the cancer has spread to the chest.
• Computed tomography (CT) scan
CT scans can be used to help determine the stage (extent) of the cancer by showing if it has spread to the lymph nodes, lungs, liver, or other organs. The CT scan uses x-rays to produce detailed cross-sectional images of your body. Instead of taking one picture, like a standard x-ray, a CT scanner takes many pictures of the part of your body being studied as it rotates around you. A computer then combines these pictures into an image of a slice of your body. Before the test, you might be asked to drink a contrast solution and/or get an intravenous (IV) injection of a contrast dye that helps better outline structures in the body. You may need an IV line to inject the contrast dye. The injection can cause some flushing (redness and warm feeling that may last hours to days). Some people are allergic to the dye and get hives. Rarely, more serious reactions like trouble breathing and low blood pressure can occur. Medicine can be given to prevent and treat allergic reactions. Be sure to tell the doctor if you have any allergies or if you have ever reacted to any contrast material used for x-rays.
A CT scanner has been described as a large donut, with a narrow table that slides in and out of the middle opening. You need to lie still on the table while the scan is being done. CT scans take longer that regular x-rays, and you might feel a bit confined by the ring you have to lie in while the pictures are being taken.
CT guided needle biopsy: CT scans are sometimes used to guide a biopsy needle precisely into a suspected area of cancer spread. For this procedure, you stay on the CT scanning table while a doctor advances a biopsy needle through the skin toward the mass. CT scans are repeated until the doctor can see that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue) is then removed and examined under a microscope.
• Magnetic resonance imaging (MRI) scan
MRI scans are particularly helpful in looking at the brain and spinal cord. They are not usually done for testicular cancer unless your doctor has reason to think the cancer might have spread there. Like CT scans, MRI scans provide detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body. A contrast material might be injected just as with CT scans but is used less often. MRI scans take longer than CT scans – often up to an hour – and are a little more uncomfortable. You lie on a table that slides inside a narrow tube, which is confining and can upset people with a fear of enclosed spaces. Special, more open MRI machines can help with this if needed, but the images may not be as sharp in some cases. The MRI machine makes buzzing and clicking noises, so some places will provide earplugs to help block this out.
• Positron emission tomography (PET) scan
A PET scan can help spot small collections of cancer cells in the body. It is sometimes useful for looking at enlarged lymph nodes that remain after chemotherapy. A PET scan may help the doctor decide if they contain scar tissue or active tumor (in which case more treatment would be needed). PET scans are often more useful for seminomas than for non-seminomas, so they are less often used in patients with non-seminoma.
For this test, a form of radioactive sugar (known as fluorodeoxyglucose or FDG) is injected into a vein (IV). (The amount of radioactivity is very low and will pass out of the body over the next day or so.) Because cancer cells in the body grow rapidly, they absorb more of the radioactive sugar. After about an hour, you will be moved onto a table in the PET scanner. You lie on the table for about 30 minutes while a special camera creates a picture of areas of radioactivity in the body. The picture is not finely detailed like a CT or MRI scan, but it can provide helpful information about your whole body. Many centers have special machines that can do both a PET and CT scan at the same time (PET/CT scan). This lets the doctor compare areas of higher radioactivity on the PET with the more detailed appearance of that area on the CT.
• Other imaging tests
Other imaging tests may be done for a number of reasons after a testicular cancer diagnosis, including:
- To learn how far cancer might have spread
- To help determine if treatment has been effective
- To look for possible signs of cancer coming back after treatment
Medical history and physical exam
If you have signs or symptoms that may suggest testicular cancer, your doctor will want to take a complete medical history to check for risk factors and to learn more about your symptoms. The doctor will feel the testicles for any sign of swelling, tenderness, or hardening. The doctor will also feel the abdomen, neck, upper chest, armpits and groin for evidence of enlarged lymph nodes, which may indicate that the cancer has spread. The breasts and nipples will also be examined to look for enlargement.During a physical exam, the doctor will feel the testicles for swelling or tenderness and for the size and location of any lumps. The doctor will also examine your abdomen, lymph nodes, and other parts of your body carefully, looking for any possible signs of cancer spread. Often the results of the exam are normal aside from the testicles.
Surgery to diagnose testicular cancer
For most types of cancer, the diagnosis is made by removing a small piece of the tumor and looking at it under a microscope for cancer cells. This is known as a biopsy. But a biopsy is rarely done for a testicular lump because it might risk spreading the cancer and because the doctor can often get a good idea of whether it is cancer based on the ultrasound and blood tumor marker tests. Instead, if the doctor sees a solid tumor on ultrasound, he or she will very likely recommend surgery to remove it as soon as possible, especially if tumor marker levels are also elevated.The surgeon will try to remove the entire tumor along with the testicle and spermatic cord. The spermatic cord contains part of the vas deferens, as well as blood and lymph vessels that could act as pathways for testicular cancer to spread to the rest of the body. To lessen the chance that cancer cells will spread, these vessels are tied off early in the operation. This is best done by operating through an incision (cut) just above the pubic area. This operation is called a radical inguinal orchiectomy.
The entire specimen is sent to the lab, where a pathologist (a doctor specializing in laboratory diagnosis of diseases) looks at pieces of the tumor under a microscope. If cancer cells are found, the pathologist sends back a report describing the type and extent of the cancer.
In rare cases, when a diagnosis of testicular cancer is uncertain, the doctor may biopsy the testicle before removing it. This is done in the operating room. The surgeon makes a cut above the pubic area, withdraws the testicle from the scrotum, and examines it without cutting the spermatic cord. If a suspicious area is seen, a portion of it is removed and looked at right away by the pathologist. If cancer is found, the testicle and spermatic cord are then removed. If the tissue is not cancerous, the testicle can often be returned to the scrotum, and treatment will be surgery to remove only the tumor or the use of appropriate medicines. If testicular cancer is found, your doctor will order imaging tests of other parts of your body to check for spread outside of the testicle.
Ultrasound of the testicles
An ultrasound is often the first test done if the doctor thinks you might have testicular cancer. This test uses sound waves to produce images of internal organs. A transducer (wand-like instrument) gives off sound waves and picks up the echoes as they bounce off the organs. A computer processes the pattern of echoes to create an image on a monitor.This is an easy test to have and it uses no radiation, which is why it is often used to look at developing fetuses. You simply lie on your back on a table as the technician moves the transducer along the skin of the scrotum. Usually, the skin is first lubricated with gel.
The pattern of echoes can be used to distinguish certain benign conditions (like hydrocele or varicocele), from a solid tumor that could be a cancer. If the lump is solid, then it’s more likely to be a cancer, so the doctor will recommend further tests or even surgery to remove the testicle.
Testicular Cancer Test and Diagnosis