Testicular cancer, explained from the guidelines

Testicular cancer starts in the testicles, the two glands in the scrotum that make sperm and the hormone testosterone. According to the EAU, 90 to 95 percent of testicular cancers are germ cell tumors, meaning they grow from the cells that normally develop into sperm. It accounts for only about 1 percent of all adult cancers, but it is the most common solid cancer in men between 20 and 40 years old.

The outlook is very good. The AUA guideline notes that most men are diagnosed when the cancer is limited to the testicle or to the lymph nodes at the back of the abdomen, and that long-term survival for these stages (I to IIB) is 95 percent or better. Even when the cancer has spread further, cisplatin-based chemotherapy cures many patients.

Because most patients are young and will live for decades after treatment, the guidelines put great weight on avoiding treatment that is not needed. That is why careful monitoring, called surveillance, is now the preferred option for many men with stage I disease, and why long-term health (fertility, hormones, heart health and the risk of other cancers) is part of the plan from the start.

This page draws on three guidelines, and each boxed statement names its source. It is educational and does not replace advice from your own care team.

Inside each testicle are tiny coiled tubes where sperm are made. Most germ cell tumors start from abnormal cells in these tubes called germ cell neoplasia in situ, or GCNIS. GCNIS is an early, non-invasive change. The AUA notes that it is found next to the tumor in 80 to 90 percent of men with invasive germ cell tumors, and that men with GCNIS have about a 50 percent chance of developing invasive cancer within 5 years.

Germ cell tumors are divided into two families, seminoma and non-seminoma, and this split shapes almost every treatment decision. Non-seminomas include embryonal carcinoma, yolk sac tumor, choriocarcinoma and teratoma, and most are mixtures of these. A tumor that contains any non-seminoma part is treated as a non-seminoma, even if most of it is seminoma. A tumor that looks like pure seminoma but comes with a raised AFP blood level is also treated as a non-seminoma, because seminoma does not make AFP.

Teratoma deserves special mention. Although it can look harmless under the microscope, the AUA explains that it can keep growing, can occasionally turn into other cancers such as sarcoma, and does not respond to chemotherapy. It can only be cured by removing it, which is one reason lymph node surgery plays a larger role in non-seminoma.

Testicular cancer usually spreads in a predictable order: first to the lymph nodes at the back of the abdomen (the retroperitoneum, near the kidneys and the large blood vessels), and later to the lungs or other organs.

For most men there is no clear cause. The strongest known risk factor is an undescended testicle (cryptorchidism). The AUA notes a four to six fold higher risk in the affected testicle, which falls to two to three fold if the testicle was brought down surgically before puberty.

A personal history of testicular cancer raises the risk of a new cancer in the other testicle about 12-fold, although the actual chance over 15 years is only about 2 percent. Having a father or brother with testicular cancer also raises the risk. The EAU groups several of these factors, together with hypospadias, poor sperm production and infertility, under the term testicular dysgenesis syndrome, a set of developmental problems of the testicle that probably begin before birth.

The AUA reports that in the United States the disease is most common in white men, least common in Black men, and rising fastest among Hispanic men. Inherited gene changes, such as variants in the CHEK2 gene, have been linked to higher risk.

Testicular microlithiasis, tiny specks of calcium seen on ultrasound, often causes worry. The AUA states that microlithiasis on its own, with no mass and no other risk factor, does not need further tests. Men who have microlithiasis plus a risk factor should be counseled, examine themselves regularly and be followed by a clinician.

The typical first sign, according to the AUA, is a painless lump or swelling in one testicle that slowly gets bigger. Some men notice heaviness, hardness or a change in size. Sudden pain is less common; it can happen when bleeding inside a fast-growing tumor stretches the testicle.

The NCCN describes other ways the disease can show up, usually after it has spread: a lump above the collarbone, a mass in the abdomen, breast swelling (from hormones the tumor makes), or a blood clot in a leg or the lungs. Many men first think they have an infection. The NCCN states that antibiotics are never appropriate for a mass that could be a germ cell tumor.

Delays in diagnosis are common, and the AUA notes that both patients and doctors contribute to them. Any firm lump in a testicle deserves a prompt visit and an ultrasound. There is no high-level evidence for screening programs in the general population, according to the EAU.

The first test is a scrotal ultrasound with Doppler, which uses sound waves to look inside both testicles and to show blood flow. It is quick, painless and very accurate. A dark, solid mass with blood flow strongly suggests cancer. The AUA advises against MRI for the first assessment, because it has not been shown to add useful information beyond ultrasound.

Blood is drawn for tumor markers before any treatment, including surgery. Testicular cancer is one of the few cancers with reliable blood markers: alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG) and lactate dehydrogenase (LDH). They help identify the tumor type, set the stage, track the response to treatment and detect relapse. They are repeated after surgery. A marker made only by the tumor in the testicle should fall at a predictable speed (its half-life) once the testicle is removed; a marker that stays up or rises means cancer is present somewhere else.

Markers can also mislead. Small, stable rises can come from other causes. The NCCN advises against basing treatment on AFP below 20 ng/mL, or on mildly raised hCG (generally below 20 IU/L) without further workup, and the AUA asks that borderline rises be confirmed as rising before acting. LDH alone should never drive treatment.

Testicular cancer is usually not biopsied through the scrotum. Instead, removing the testicle through the groin makes the diagnosis and treats the tumor at the same time. Staging then uses a CT scan of the abdomen and pelvis with contrast (or MRI if CT is not possible) and chest imaging. For stage I seminoma the AUA prefers a chest X-ray; a chest CT is used when markers are rising or other tests show spread. The NCCN and EAU recommend a brain MRI when hCG is very high or there are many lung metastases. All three guidelines advise against PET scans for initial staging.

Testicular cancer uses the TNM system with one addition. T describes how far the tumor has grown in and around the testicle, judged after orchiectomy. N describes the lymph nodes at the back of the abdomen, measured on CT. M describes spread beyond those nodes, to distant nodes or the lungs (M1a) or to other organs (M1b). The extra letter, S, stands for serum tumor markers measured after surgery, from S0 (normal) to S3 (very high). It is one of the only cancers whose stage includes blood test results.

In broad terms, stage I means the cancer is confined to the testicle, stage II means it has spread to the lymph nodes at the back of the abdomen, and stage III means it has spread further or the markers are very high. Stage IS is a special case: scans look clear but markers stay up or rise after surgery, which points to hidden cancer elsewhere.

One feature of the tumor matters a great deal for non-seminoma: lymphovascular invasion (LVI), meaning cancer cells seen inside small blood or lymph vessels. It is the strongest single predictor of hidden spread and moves the stage from IA to IB. For stage I seminoma, the AUA and EAU agree that tumor size and rete testis invasion are not reliable enough to decide on extra treatment.

Treatment almost always begins with removing the affected testicle. What happens next depends on whether the tumor is a seminoma or a non-seminoma, the stage, and for non-seminoma, risk features such as lymphovascular invasion. Options range from surveillance alone to a short course of chemotherapy, radiation, surgery to remove lymph nodes (RPLND), or a full course of chemotherapy.

Because survival is excellent with several approaches, many choices are made through shared decision-making. Your team explains the relapse risk, side effects and follow-up burden of each option, and you weigh them against what matters most to you, such as avoiding chemotherapy, lowering the chance of relapse, protecting fertility or reducing scans.

The AUA states that decisions should be made in a multidisciplinary setting with experienced urologists, medical oncologists, radiation oncologists, pathologists and radiologists, and that expert review of the pathology should be considered when it could change treatment. Germ cell tumors can grow quickly, so decisions should rest on imaging from the past 4 weeks and markers from the past 10 days. If lymph nodes look borderline and markers are normal, repeating the scan in six to eight weeks can avoid unnecessary treatment.

Radical inguinal orchiectomy removes the testicle together with its spermatic cord through a cut in the groin, much like a hernia incision, rather than through the scrotum. It is usually a same-day operation. It confirms the diagnosis, gives the T stage and, on its own, cures most men with stage I disease.

The groin route matters because of how testicular cancer spreads. The testicle forms inside the abdomen before birth and later moves down into the scrotum, so its lymph channels run up the spermatic cord to the back of the abdomen. Tying off the cord high in the groin gives the best cancer control and makes it easy to remove the rest of the cord if lymph node surgery is needed later. Cutting through the scrotum can leave tumor cells behind and open new drainage routes. In a review cited by the AUA, 2.5 percent of men whose scrotum was entered had a local recurrence, compared with none after the groin approach, although spread and survival were not different. Men who already had a scrotal procedure should be told about this higher local risk; extra treatment is rarely needed.

A testicular prosthesis, an implant that restores the look and feel of the scrotum, can be placed during the same operation or later. The AUA recommends discussing it before surgery, noting satisfaction above 80 percent, a very low risk of problems such as infection, and surveys showing that nearly half of patients are never offered one.

Removing only the tumor (testis-sparing surgery) is not recommended when the other testicle is normal. The AUA allows it, through the groin, in highly selected men with masses under 2 cm who have uncertain findings and normal markers, a single testicle, or tumors in both testicles. In rare emergencies, when widespread cancer is life-threatening, the EAU and NCCN allow chemotherapy to start first, with orchiectomy afterward.

Fertility problems are common in testicular cancer, even before treatment. The AUA reports that up to 50 percent of men have abnormal semen tests at diagnosis and about 10 percent have no sperm in the semen. Treatment can add to this. After multi-drug cisplatin chemotherapy nearly all men temporarily stop making sperm, with recovery in about 50 percent within 2 years and 80 percent within 5 years. The effect of radiation depends on the dose reaching the remaining testicle, which modern shielding keeps very low. RPLND can affect ejaculation unless nerve-sparing technique is used.

Sperm banking means freezing semen samples for later use. The EAU calls it the most cost-effective way to preserve fertility and recommends discussing it with every man before treatment. The NCCN recommends it before chemotherapy, radiation or RPLND for men who wish to preserve fertility, and before orchiectomy for men with a single testicle or those having both testicles removed.

Samples are usually collected at a sperm bank over a few days, ideally before any further treatment starts, and can be stored for many years. Men who are unsure about having children are often encouraged to consider it, because the option may not exist later. The NCCN also suggests considering a baseline testosterone test.

Stage I seminoma means the cancer is confined to the testicle and markers are normal after surgery. More than 80 percent of these men are cured by orchiectomy alone. The remaining risk comes from tiny deposits in the abdominal lymph nodes that scans cannot yet see.

There are three options. Surveillance means no further treatment, with regular visits and scans so that any relapse is caught early. Adjuvant carboplatin is one, or sometimes two, doses of a single chemotherapy drug. Adjuvant radiation treats the lymph nodes at the back of the abdomen. The AUA reports relapse in 15 to 20 percent of men on surveillance compared with 3 to 9 percent after carboplatin or radiation, but survival is the same, above 98 percent, because relapses are almost always cured. Relapses on surveillance usually appear in the abdominal lymph nodes, at a median of about 14 months, and are found on CT.

All three guidelines prefer surveillance. The AUA gives this a Strong Recommendation and calls radiation and carboplatin less preferred alternatives. The NCCN describes surveillance as strongly preferred for pT1 to pT3 tumors. The EAU recommends surveillance when the patient can attend follow-up reliably, one dose of carboplatin if adjuvant chemotherapy is chosen, and no routine radiation, reserving it for men who cannot have surveillance or chemotherapy. Radiation has been linked to a higher risk of later cancers in the treated area.

Surveillance is not right for everyone. It requires years of appointments and scans, and some men feel more anxious without treatment. Your team should explain the relapse rate, side effects and follow-up of each option so the choice fits your situation.

In stage I non-seminoma, the chance of hidden spread depends mostly on lymphovascular invasion. On surveillance, the AUA reports relapse in 34 to 54 percent of men with LVI and 14 to 26 percent without it; the EAU summarizes this as about 50 percent versus 15 percent. Relapses usually happen within the first 2 years and most are cured, so disease-specific survival in large surveillance series cited by the AUA is 97 percent or higher.

The options are surveillance; one cycle of BEP chemotherapy to lower the chance of relapse; or nerve-sparing RPLND, surgery to remove the lymph nodes where the cancer would most likely spread. The EAU reports relapse of up to 3 percent after one cycle of BEP.

For stage IA (no LVI), the guidelines agree that surveillance is preferred, with one cycle of BEP or RPLND as alternatives for men who decline surveillance or may not keep up with it. For stage IB, the guidelines differ in emphasis. The AUA lists surveillance, RPLND, or one or two cycles of BEP as choices made together with the patient. The NCCN lists surveillance, one cycle of BEP, or nerve-sparing RPLND. The EAU leans toward one cycle of BEP or surveillance, and offers RPLND only to highly selected men who cannot have chemotherapy and do not want surveillance.

Some findings point toward a specific path. If the tumor contains teratoma with somatic-type malignancy (teratoma that has turned into another cancer, such as a sarcoma), all three guidelines favor RPLND, because these cancers respond poorly to chemotherapy. If markers stay up or rise after surgery (stage IS), the cancer has already spread, and the AUA strongly recommends chemotherapy based on IGCCCG risk.

Stage II means the cancer has reached lymph nodes at the back of the abdomen. Stage IIC, with nodes larger than 5 cm, is treated like stage III with chemotherapy. For IIA and IIB, the choice depends on the tumor type, the node size and the markers.

For seminoma with nodes 3 cm or smaller, the AUA recommends either radiation or multi-drug cisplatin-based chemotherapy (BEP or EP), chosen through shared decision-making; both give cancer-specific survival above 97 percent. For men who want to avoid the long-term effects of chemotherapy or radiation, RPLND may be offered. In one multicenter trial cited by the AUA, 81 percent of men were free of relapse 2 years after RPLND, and those who relapsed were treated successfully. For seminoma with a node larger than 3 cm, chemotherapy is recommended. The EAU also recommends chemotherapy or radiation for IIA and IIB, noting that radiation carries higher risks of second cancers and heart problems.

For non-seminoma, markers matter most. If AFP or hCG is raised and rising after orchiectomy, the AUA strongly recommends chemotherapy based on IGCCCG risk. If markers are normal and the nodes are small (IIA), RPLND and chemotherapy are both reasonable, and the EAU recommends nerve-sparing RPLND by an experienced surgeon as the first treatment. If the nodes are larger (IIB) and markers are normal, the AUA recommends chemotherapy and allows RPLND in selected men.

When nodes are only borderline enlarged and markers are normal, the guidelines suggest repeating the scan before deciding (after six to eight weeks in the AUA, six weeks in the EAU and 4 weeks in selected NCCN cases), because some enlarged nodes turn out not to be cancer.

RPLND removes the lymph nodes at the back of the abdomen, around the aorta and the vena cava, where testicular cancer spreads first. It can replace chemotherapy in some early stages, and it is used after chemotherapy to remove masses that remain. It can be done through an open incision or, by surgeons experienced in both germ cell tumors and minimally invasive surgery, with laparoscopic or robotic techniques. The AUA notes that long-term cancer results for the minimally invasive approach are still limited.

The AUA sets out anatomical rules for a high-quality operation: the boundaries of the dissection, when a full bilateral template is needed (for example, when nodes look suspicious) and when a smaller modified template may be used. Nerve-sparing should be offered to men who want to preserve ejaculation, as long as it does not compromise the removal of the nodes.

The main long-term side effect is loss of ejaculation, in which no semen comes out at orgasm. This affects natural fertility but not erections or the sensation of orgasm. The AUA reports it in 80 percent or more of men without nerve-sparing and in 10 percent or fewer when nerve-sparing is possible. Because results depend on experience, the AUA recommends considering referral to an experienced surgeon at a high-volume center.

After RPLND, the pathology report guides what comes next. If cancer that is not pure teratoma is found in the nodes, the AUA recommends surveillance or chemotherapy: surveillance is preferred for small-volume disease (pN1), and cisplatin-based chemotherapy for larger volume (pN2 to pN3). After chemotherapy for non-seminoma, the EAU strongly recommends removing any remaining mass larger than 1 cm when markers are normal or falling, because it may contain teratoma or active cancer.

When the cancer involves large abdominal nodes, the lungs, distant nodes or other organs, the main treatment is cisplatin-based chemotherapy. The regimen and number of cycles are chosen with the International Germ Cell Cancer Collaborative Group (IGCCCG) classification, which sorts patients into good, intermediate or poor risk using the tumor type, where the cancer has spread, and the marker levels just before chemotherapy.

Most men are in the good-risk group. For them, the NCCN lists three cycles of BEP or four cycles of EP as category 1 options. BEP takes about 9 weeks and EP about 12 weeks; a bleomycin-free regimen is favored for men at higher risk of lung injury from bleomycin, such as those over 50 or with reduced kidney function or lung disease. Intermediate- and poor-risk disease is usually treated with four cycles of BEP, or four cycles of VIP for some men. The NCCN prefers that relapsed disease be treated at centers with expertise.

After chemotherapy, scans and markers are repeated. For seminoma, the EAU advises that remaining masses are usually watched, and a PET scan can help judge masses larger than 3 cm if done at least 2 months after chemotherapy. The EAU revalidated the IGCCCG groups in a modern group of patients and reported better survival than the original 1997 figures; the table shows those updated numbers. They are averages for large groups and cannot predict how any one person will do.

Orchiectomy: groin soreness and bruising usually settle within a couple of weeks. Most men with one healthy testicle keep normal testosterone, although the AUA cites data showing a higher rate of low testosterone after orchiectomy alone than in men without testicular cancer.

Surveillance: the main burdens are frequent appointments, repeated scans and the stress of waiting. CT scans involve radiation; the EAU cites an estimate of up to 1 in 300 second cancers from years of CT follow-up, a risk reduced by newer low-dose methods or avoided by using abdominal MRI in experienced centers.

Chemotherapy: short-term effects of BEP and EP include nausea, vomiting, hair loss, tiredness and a weakened immune system with risk of infection. Longer-term, the AUA and NCCN list infertility, numbness or tingling in the hands and feet, high-pitched hearing loss, high blood pressure, heart and blood vessel disease and, rarely, second cancers; cisplatin can also affect the kidneys. Bleomycin can damage the lungs, which is why lung health is checked and bleomycin is avoided in some men. The EAU notes a higher rate of blood clots during chemotherapy for germ cell tumors and advises avoiding central venous lines when possible. A single dose of carboplatin has mostly mild short-term effects, and its long-term impact is not fully known.

Radiation: short-term effects are usually mild and self-limited. The NCCN cites studies showing a higher risk of second cancers inside the treated area that rises with dose, which is why modern fields and doses are smaller. RPLND: besides the usual risks of major abdominal surgery, the main long-term effect is loss of ejaculation, which nerve-sparing technique can often prevent.

Follow-up is built around when relapses tend to happen. The AUA notes that more than 95 percent of relapses in stage I non-seminoma on surveillance occur in the first 2 years, often detected by a rise in tumor markers. Seminoma relapses come a little later (median about 14 months) and are mostly found on abdominal CT, so markers are checked more often for non-seminoma and scans matter more for seminoma.

The schedules below are typical examples from the guidelines. The NCCN stresses that no single plan suits every patient. Men with higher-risk features, such as lymphovascular invasion, are imaged more often. Abdominal MRI can replace CT in experienced centers to reduce radiation, according to the NCCN and EAU.

After 5 years the chance of a late relapse is small: 1 percent or less according to the AUA, and about 0.5 percent in the population data cited by the EAU. Routine scans are generally not needed after that, and the focus shifts to long-term health. Most very late relapses are found because of symptoms, so knowing the warning signs matters.

Most men treated for testicular cancer live long lives, so long-term health is a central part of care. The AUA recommends referral to a survivorship clinic that screens for late effects of treatment. The EAU suggests a written survivorship plan, covering late effects, lifestyle, recurrence risk and follow-up, when specialist follow-up ends.

Hormones and sexual health. Low testosterone (hypogonadism) can cause tiredness, low sex drive, erection problems and mood changes. The AUA notes that up to 10 to 15 percent of men have low testosterone or need testosterone replacement over the long term, with higher risk after chemotherapy (rising with the number of cycles) or radiation. If symptoms appear, the AUA recommends a morning testosterone and LH blood test.

Heart health and second cancers. Men treated with chemotherapy, radiation or both have a higher long-term risk of heart and blood vessel disease and of second cancers. In a study cited by the AUA, 5.6 percent of more than 40,000 survivors developed a second solid cancer, such as cancer of the lung, colon, bladder, pancreas or stomach. The AUA recommends regular care with a primary care doctor to check blood pressure, cholesterol, blood sugar and smoking, and to keep up with cancer screening. The EAU adds that a healthy lifestyle, avoiding tobacco and protecting hearing from noise can reduce some late effects.

Fertility, body image and the other testicle. Many men father children after treatment, with or without banked sperm, and a fertility specialist can recheck semen once treatment is finished. A prosthesis can be placed later if it was not done at orchiectomy. The chance of a new cancer in the remaining testicle is raised but still low, so self-examination remains worthwhile.

Emotional health. The AUA lists anxiety, depression, chronic fatigue and problems with thinking and memory among the conditions survivors may face, and the EAU notes higher unemployment among survivors. Talking about these with your care team, a counselor or a support group is part of recovery.

The NCCN states that the best management of any patient with cancer is in a clinical trial, and it lists trials as the preferred option for some relapsed disease. Current research includes a blood test called microRNA 371 (miR-371a-3p), which the AUA describes as a promising marker that may detect hidden or remaining cancer more accurately than current markers; large trials are being developed. Another active area is surgery instead of chemotherapy or radiation for small-volume seminoma.

Because testicular cancer is uncommon, expert input can make a difference. The AUA recommends considering expert pathology review when it could change treatment, and referral to an experienced, high-volume surgeon for RPLND. The NCCN prefers that men with relapsed disease be treated at centers with expertise. Asking for a second opinion is common and reasonable, and your care team can help arrange it.

Between visits, contact your care team promptly if you notice any of the signs below. Most have other causes, but they deserve a check. The EAU points out that most very late relapses are found because of symptoms, so patient awareness matters.

If you are on surveillance and miss a scan or blood test, reschedule it rather than skipping it: surveillance works because relapses are caught early. Call emergency services for severe chest pain, severe shortness of breath or sudden confusion.