Testicular Cancer

Last updated: January 2025 | Medical Reviewer: Oncol.net Editorial Board

Overview

Testicular cancer develops in the testicles (testes), the male reproductive organs that produce sperm and testosterone. While relatively rare overall, it is the most common cancer in men aged 15-35 years. The disease typically affects only one testicle and usually begins in germ cells (cells that produce sperm).

More than 90% of testicular cancers are germ cell tumors, which are divided into two main types: seminomas and non-seminomas. These behave differently and require different treatment approaches. The good news is that testicular cancer is highly treatable and usually curable, especially when detected early.

Types of Testicular Cancer

Seminoma (40-45% of cases)

• Classic seminoma: Most common type, typically occurs in men aged 25-45
• Spermatocytic seminoma: Rare subtype, typically occurs in older men (average age 65), excellent prognosis
• Behavior: Grows and spreads more slowly than non-seminomas
• Treatment response: Very sensitive to radiation therapy
• Tumor markers: May elevate HCG but not AFP (AFP elevation rules out pure seminoma)

Non-Seminoma (55-60% of cases)

Four main subtypes, often mixed together in a single tumor:

• Embryonal carcinoma: Aggressive type, most common component of mixed tumors
• Yolk sac carcinoma: Most common testicular cancer in children, responds well to chemotherapy
• Choriocarcinoma: Rare and aggressive, spreads rapidly, produces high HCG levels
• Teratoma: Contains mature or immature tissues (bone, muscle, hair), may be chemotherapy-resistant

Other Types (Less Common)

• Leydig cell tumors: 1-3% of testicular tumors, develop from hormone-producing cells
• Sertoli cell tumors: 1% of cases, develop from cells that support sperm production
• Lymphoma: Most common testicular cancer in men over 50

Risk Factors

Established Risk Factors

• Cryptorchidism (undescended testicle): 3-8 times higher risk, accounts for 10% of cases
  • Risk remains elevated even after surgical correction (orchiopexy)
  • Risk is higher for abdominal vs inguinal undescended testicles
  • Both testicles have increased risk, not just the undescended one
• Family history: 4-8 times higher risk with affected father or brother
• Personal history: 12-18 times higher risk of developing cancer in the other testicle
• Age: Most common in ages 15-35, but can occur at any age
• Race/ethnicity: White men have 4-5 times higher risk than Black or Asian men
• HIV infection: Slightly increased risk
• Height: Taller men have modestly increased risk

Not Risk Factors

• Vasectomy
• Trauma or injury to the testicles
• Sexual activity
• Masturbation

Signs and Symptoms

Local Symptoms

• Testicular lump or swelling: Usually painless, hard, and doesn't change with pressure
• Heaviness in the scrotum: Feeling of unusual weight or dragging sensation
• Pain or discomfort: Dull ache in testicle or scrotum (10-20% of cases)
• Testicular enlargement: One testicle noticeably larger than the other
• Acute pain: Sudden severe pain (rare, occurs if tumor bleeds)
• Gynecomastia: Breast enlargement or tenderness (hormone-producing tumors)

Advanced Disease Symptoms

• Back pain: Retroperitoneal lymph node enlargement
• Abdominal mass or pain: Large lymph node masses
• Shortness of breath or cough: Lung metastases
• Neck mass: Supraclavicular lymph node involvement
• Lower extremity swelling: Venous or lymphatic obstruction

Self-Examination

Monthly testicular self-examination is recommended, especially for high-risk men:

1. Perform after a warm shower when scrotum is relaxed
2. Examine each testicle separately with both hands
3. Roll testicle between thumbs and fingers
4. Feel for hard lumps, smooth bumps, or changes in size/shape/consistency
5. Note: It's normal for one testicle to be slightly larger or hang lower

Diagnosis

Physical Examination

• Testicular palpation to assess mass characteristics
• Abdominal examination for masses or lymph node enlargement
• Supraclavicular lymph node examination
• Breast examination (gynecomastia assessment)

Imaging Studies

• Scrotal ultrasound: First-line imaging, 95% sensitive and specific
  • Distinguishes between solid masses (likely cancer) and fluid-filled cysts (benign)
  • Can detect tumors as small as 1-2 mm
  • Non-invasive and widely available
• Chest X-ray: Screen for lung metastases
• CT scan (chest/abdomen/pelvis): Stage disease and detect metastases
  • Performed after orchiectomy for staging
  • Identifies retroperitoneal and distant lymph nodes
  • Detects liver and other organ involvement
• Brain MRI or CT: Only if symptoms suggest brain metastases or very high tumor markers

Tumor Markers (Blood Tests)

Measured before and after treatment to guide management:

• AFP (alpha-fetoprotein): Elevated in 50-70% of non-seminomas
  • Never elevated in pure seminoma (if elevated, it's a non-seminoma)
  • Half-life: 5-7 days (should normalize within 4-6 weeks after surgery)
• HCG (human chorionic gonadotropin): Elevated in 40-60% of non-seminomas, 10-20% of seminomas
  • Very high levels suggest choriocarcinoma
  • Half-life: 24-36 hours (should normalize within 5-7 days after surgery)
• LDH (lactate dehydrogenase): Elevated in 40-60% of cases
  • Less specific but correlates with tumor burden
  • High levels indicate worse prognosis

Surgical Diagnosis

• Radical inguinal orchiectomy: Removes testicle and spermatic cord through groin incision
  • Both diagnostic and therapeutic procedure
  • Performed for suspected testicular cancer
  • NOT a biopsy - entire testicle is removed
  • Trans-scrotal biopsy is avoided (risks spreading cancer)
• Pathology examination: Confirms diagnosis and determines specific tumor type

Staging

Stage I (40-50% of cases at diagnosis)

• Cancer limited to testicle
• May invade into blood vessels or lymphatics within testicle
• No lymph node or distant metastases
• Cure rate: >98%

Stage II (20-30% at diagnosis)

• Cancer spread to retroperitoneal lymph nodes
• Substage based on lymph node size:
  • IIA: Nodes ≤2 cm
  • IIB: Nodes 2-5 cm
  • IIC: Nodes >5 cm
• Cure rate: 90-95%

Stage III (20-30% at diagnosis)

• Cancer spread beyond retroperitoneal lymph nodes
• May involve:
  • Lymph nodes above diaphragm (mediastinal, supraclavicular)
  • Lungs (most common distant site - 85% of metastases)
  • Liver, brain, bone (less common)
• Cure rate: 70-90% (varies by risk classification)

Risk Classification for Metastatic Disease (IGCCCG)

International Germ Cell Cancer Collaborative Group classification based on tumor markers and metastases location:

Treatment

Stage I Seminoma

Three excellent options with equivalent cure rates >98%:

• Active surveillance (preferred for compliant patients):
  • CT scans every 3-6 months for first 3 years, then less frequently
  • Tumor markers every visit
  • 15-20% will relapse (usually within 2 years), then receive chemotherapy or radiation
  • Avoids treatment side effects for 80-85%
  • Requires excellent compliance with follow-up schedule
• Radiation therapy:
  • Low-dose radiation (20-25 Gy) to retroperitoneal lymph nodes
  • Relapse rate: 3-5%
  • Historically standard but less used now due to late effects
  • Small increased risk of secondary cancers and cardiovascular disease
• Carboplatin chemotherapy (1-2 cycles):
  • Single-day outpatient treatment, repeated once if 2 cycles given
  • Relapse rate: 3-5%
  • May affect fertility temporarily
  • Good option for patients who want active treatment but prefer to avoid radiation

Stage I Non-Seminoma

Treatment decision based on risk factors:

• Low risk (no lymphovascular invasion): Relapse risk 15-20%
  • Surveillance preferred: CT scans every 3-4 months for 2 years, tumor markers monthly
  • Alternative: 1 cycle BEP chemotherapy (relapse risk <2%)
• High risk (lymphovascular invasion present): Relapse risk 40-50%
  • Surveillance: Acceptable but requires excellent compliance
  • 1 cycle BEP chemotherapy: Reduces relapse risk to <2%
  • RPLND (retroperitoneal lymph node dissection): Surgical removal of lymph nodes
    • Nerve-sparing technique preserves ejaculation in 95-99%
    • Finds cancer in 25-30% of high-risk patients
    • Provides accurate staging and may avoid chemotherapy

Stage II Disease

Seminoma:

• Stage IIA/B: Radiation therapy OR 3 cycles chemotherapy (BEP or EP)
• Stage IIC: 3 cycles chemotherapy (BEP or EP preferred)

Non-Seminoma:

• Stage IIA (small nodes): RPLND OR 3 cycles chemotherapy
• Stage IIB/C: 3-4 cycles chemotherapy (BEP), often followed by RPLND to remove residual masses

Stage III (Metastatic) Disease

Chemotherapy is primary treatment:

• Good risk: 3 cycles BEP or 4 cycles EP
• Intermediate risk: 4 cycles BEP
• Poor risk: 4 cycles BEP or clinical trial

Post-Chemotherapy Management

• Residual masses in non-seminoma:
  • RPLND performed 4-6 weeks after chemotherapy
  • Pathology shows: teratoma (40-50%), necrosis/fibrosis (40-45%), viable cancer (10-15%)
  • Viable cancer requires additional chemotherapy
• Residual masses in seminoma:
  • Observation with PET scan if mass <3 cm (usually just scar tissue)
  • Surgery or continued surveillance if >3 cm

Relapsed/Refractory Disease

• Second-line chemotherapy: VeIP (vinblastine, ifosfamide, cisplatin) or TIP (paclitaxel, ifosfamide, cisplatin)
• High-dose chemotherapy with stem cell rescue: For patients who relapse after standard second-line treatment
• Surgery: May be curative for isolated recurrences
• Clinical trials: Should always be considered

Treatment Side Effects

Orchiectomy

• Loss of one testicle (usually preserves fertility and testosterone with remaining testicle)
• Cosmetic concerns (prosthetic testicle can be placed)
• Psychological impact
• Surgical risks (bleeding, infection) are rare

Chemotherapy (BEP)

• Short-term: Nausea/vomiting, fatigue, hair loss, mouth sores, low blood counts, increased infection risk
• Long-term:
  • Hearing loss: 20-40% (from cisplatin), usually high-frequency, permanent
  • Kidney damage: Mild to moderate in 20-30%
  • Neuropathy: Numbness/tingling in hands/feet, 20-30%, may be permanent
  • Raynaud's phenomenon: Fingers turn white in cold, 20-40%
  • Lung toxicity: Rare (<5%) but can be severe (from bleomycin)
  • Cardiovascular disease: Increased risk 10-20 years later
  • Secondary cancers: Small increased risk (1-2%)
  • Infertility: Temporary in most, permanent in 20-30%

Radiation Therapy

• Short-term: Fatigue, nausea, diarrhea
• Long-term:
  • Temporary reduction in sperm count (usually recovers)
  • Increased risk of secondary cancers in radiation field (1-2%)
  • Slightly increased cardiovascular risk

RPLND Surgery

• Loss of ejaculation if non-nerve-sparing technique (rare with modern surgery)
• Surgical complications: bleeding, infection, bowel injury (<5%)
• Recovery time: 4-6 weeks

Fertility Considerations

Baseline Fertility

• 50-70% of men with testicular cancer have abnormal sperm counts before treatment
• Causes: tumor effects, undescended testicle history, genetic factors
• Semen analysis recommended for all patients

Impact of Treatment

• Orchiectomy alone: Usually preserves fertility if other testicle is normal
• Chemotherapy:
  • Temporary infertility in most patients (sperm count recovers in 1-3 years)
  • Permanent infertility in 20-30% with BEP
  • Higher doses/more cycles increase risk of permanent infertility
• Radiation therapy: Temporary reduction in sperm count, usually recovers in 1-3 years
• RPLND: Preserves fertility with nerve-sparing technique (95-99%)

Fertility Preservation Options

• Sperm banking: Should be offered to all patients before treatment
  • Collect and freeze sperm for future use
  • Can be used for intrauterine insemination or in vitro fertilization
  • Success rate depends on initial sperm quality
• Testicular sperm extraction (TESE): For patients unable to produce semen sample

Follow-Up Care

Surveillance Schedule (After Treatment)

Intensive monitoring in first 2-3 years when relapse is most likely:

Years 1-2:

• Physical exam and tumor markers: every 2-4 months
• CT chest/abdomen/pelvis: every 3-6 months

Years 3-5:

• Physical exam and tumor markers: every 4-6 months
• CT scans: every 6-12 months

Years 5+:

• Annual physical exam
• CT scans generally stopped after 5 years if no evidence of disease

Late Effects Monitoring

• Cardiovascular health: Annual blood pressure, lipids, diabetes screening
• Hearing: Audiometry if hearing problems develop
• Kidney function: Annual creatinine/GFR
• Hypogonadism: Check testosterone if symptoms (fatigue, low libido, erectile dysfunction)
• Second cancers: Age-appropriate cancer screening
• Psychological health: Screen for anxiety, depression, PTSD

Contralateral Testicular Cancer Risk

• 1-3% risk of developing cancer in the remaining testicle
• Risk highest in first 5 years but remains elevated lifelong
• Monthly self-examination strongly encouraged
• Annual exam by healthcare provider

Prognosis and Survival Rates

Overall Survival

• All stages combined: 95% 5-year survival rate
• Localized (Stage I): 99% 5-year survival rate
• Regional (Stage II): 96% 5-year survival rate
• Distant (Stage III): 73% 5-year survival rate

Factors Affecting Prognosis

• Stage at diagnosis (most important)
• Tumor marker levels (especially for metastatic disease)
• Presence of non-pulmonary visceral metastases (liver, bone, brain)
• Response to chemotherapy
• Histology in residual masses after chemotherapy

Relapse Patterns

• 85-90% of relapses occur within 2 years
• 95% occur within 3 years
• Late relapses (>5 years) are rare but can occur
• Most relapses are still curable with additional treatment

Living with and Beyond Testicular Cancer

Physical Health

• Regular exercise to reduce cardiovascular risk
• Heart-healthy diet
• Maintain healthy weight
• Avoid smoking (increases cardiovascular and cancer risk)
• Limit alcohol consumption
• Protect hearing (avoid loud noise if you have cisplatin-related hearing loss)

Sexual Health and Fertility

• Loss of one testicle usually doesn't affect sexual function
• Testosterone production typically normal with one healthy testicle
• Consider testosterone testing if symptoms of low testosterone develop
• Fertility usually preserved or recovers after treatment
• Discuss family planning with healthcare provider
• Prosthetic testicle can be placed for cosmetic concerns

Emotional and Psychological Support

• Anxiety about recurrence is normal
• Depression affects 10-20% of survivors
• Support groups specifically for young adult cancer survivors
• Professional counseling if needed
• Open communication with partner about concerns
• Many survivors experience post-traumatic growth

Financial and Practical Concerns

• Treatment is expensive but usually covered by insurance
• Financial counseling available at most cancer centers
• Work accommodations during and after treatment
• Disclosure to employers (your choice)
• Life insurance may be affected

Frequently Asked Questions

Can testicular cancer be prevented?

Most testicular cancers cannot be prevented because risk factors (family history, cryptorchidism) are not modifiable. Early surgical correction of undescended testicles may reduce risk but doesn't eliminate it. Regular self-examination enables early detection, which is associated with better outcomes and less intensive treatment.

Does testicular cancer run in families?

Yes, there is a genetic component. Men with a father or brother with testicular cancer have a 4-8 times higher risk than the general population. The genetic basis is not fully understood, and no specific gene has been identified for most cases, so genetic testing is not routinely recommended.

Will I be able to have children after treatment?

Many men maintain or regain fertility after treatment. With one healthy testicle remaining after orchiectomy, most men can father children naturally. Chemotherapy causes temporary infertility in most patients, with sperm counts recovering in 1-3 years in 70-80% of men. Sperm banking before treatment is recommended as an insurance policy.

How will losing a testicle affect my testosterone and sex life?

One healthy testicle typically produces adequate testosterone to maintain normal sexual function, muscle mass, bone density, and energy levels. Sexual function is usually not affected by orchiectomy alone. If both testicles are removed or the remaining testicle doesn't function well, testosterone replacement therapy can maintain normal hormone levels.

Should I get a prosthetic testicle?

This is a personal choice. A saline-filled silicone prosthesis can be placed at the time of orchiectomy or later. It's purely cosmetic and doesn't affect health or function. Some men prefer it for symmetry and psychological reasons, while others don't feel the need. Discuss options with your surgeon.

What are the chances the cancer will come back?

Relapse risk depends on stage and treatment. For Stage I disease on surveillance, 15-20% of patients will relapse but can be cured with chemotherapy. For patients treated with chemotherapy for advanced disease, relapse occurs in 10-20%, with most still curable with additional treatment. Overall, >95% of patients are cured.

How often do I need follow-up appointments?

Follow-up is most intensive in the first 2-3 years when relapse is most likely. Initially, you'll have appointments every 2-4 months with tumor markers and periodic CT scans. The frequency decreases over time, with annual checkups recommended after 5 years. You'll also need monitoring for late effects of treatment throughout your life.

Can testicular cancer spread to the other testicle?

Direct spread to the other testicle is extremely rare. However, men who have had testicular cancer in one testicle have a 1-3% risk of developing a new, separate cancer in the remaining testicle. This is why monthly self-examination and annual medical examinations are recommended for life.

What should I tell my employer about my diagnosis?

This is a personal decision. You are not legally required to disclose your diagnosis. However, you may need to discuss time off for treatment and follow-up. Many employers are supportive and can make accommodations. You are protected by the Americans with Disabilities Act and Family and Medical Leave Act.

Is testicular cancer a death sentence?

No. Testicular cancer has one of the highest cure rates of any cancer, even when diagnosed at advanced stages. Overall cure rates exceed 95%. Many young men diagnosed with testicular cancer go on to live completely normal lives after treatment. Modern treatment is highly effective, and the majority of patients are cured.

Sources and References

• National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology: Testicular Cancer
• American Cancer Society: Testicular Cancer Statistics and Information
• National Cancer Institute SEER Database
• International Germ Cell Cancer Collaborative Group (IGCCCG)
• European Association of Urology Guidelines on Testicular Cancer
• American Society of Clinical Oncology (ASCO) Guidelines