Intro
Testicular cancer is one of the most treatable cancers when found early. It is the most common solid tumour in young men between the ages of 15 and 35, though it can occur at any age. High cure rates — even in advanced disease — reflect the tumour’s sensitivity to chemotherapy. Early recognition and prompt assessment remain the single most important factors in achieving the best outcomes.
Key Points
- Most common cancer in men aged 15–35; highly curable with modern treatment
- Usually presents as a painless, firm lump on the testicle — though heaviness or ache is also common
- Diagnosis is confirmed by ultrasound and blood tumour markers; biopsy via the groin (not the scrotum)
- Most cases are germ cell tumours (seminoma or non-seminoma)
- Treatment usually begins with orchidectomy (surgical removal of the affected testicle)
- Prognosis is excellent — over 95% of men across all stages are cured
- Fertility preservation (sperm banking) should be discussed before chemotherapy or radiotherapy
Background
The testicles produce sperm and testosterone. Testicular cancer most often develops from germ cells — the cells that form sperm. Risk factors include:
- Undescended testicle (cryptorchidism) — the most significant modifiable risk factor
- Family history of testicular cancer in a first-degree male relative
- Personal history of testicular cancer in the other testicle
- Klinefelter syndrome (rare genetic condition)
- Ethnicity — more common in white men than Black or Asian men
The cause of most cases is unknown.
How It Presents
Common presentations
- Painless lump or swelling on one testicle — the most typical early sign; any lump should prompt medical review
- Heaviness or dragging sensation in the scrotum or groin
- Dull ache in the lower abdomen, groin, or scrotum
- A feeling that one testicle has changed in size or texture
Less common presentations
- Back pain — from enlarged abdominal lymph nodes
- Breast tenderness — from hormones produced by some tumour types (beta-hCG)
- Breathlessness or cough — if spread has reached the lungs (uncommon at first presentation)
Not all testicular lumps are cancer. Many are benign — cysts, inflammation, or vascular abnormalities. However, any persistent testicular lump should be professionally assessed rather than observed at home.
Diagnosis
Scrotal ultrasound
This is the first-line investigation — fast, non-invasive, and highly accurate. Ultrasound distinguishes between a lump arising from the testicle itself (higher cancer risk) versus the epididymis or surrounding structures (usually benign).
Tumour markers (blood tests)
Three blood markers are measured before any surgery:
| Marker | Elevated in | Notes |
|---|---|---|
| AFP (alpha-fetoprotein) | Non-seminoma | Never elevated in pure seminoma |
| beta-hCG (beta human chorionic gonadotropin) | Seminoma and non-seminoma | |
| LDH (lactate dehydrogenase) | Both types | Reflects tumour burden |
These markers confirm diagnosis, guide staging, and monitor treatment response.
Orchidectomy (diagnostic and therapeutic)
If ultrasound and markers suggest cancer, surgery to remove the affected testicle — performed via a groin incision, not through the scrotum — is both the definitive diagnosis and the primary treatment. A scrotal approach is avoided because it can spread cancer to different lymph node groups.
Staging
After orchidectomy, CT scan of chest, abdomen, and pelvis assesses for spread to lymph nodes, liver, or lungs. This determines the stage:
- Stage I: confined to the testicle — most common at diagnosis
- Stage II: spread to retroperitoneal (abdominal) lymph nodes
- Stage III: distant spread (lungs, liver, brain) or very elevated markers
Tumour Types
Germ cell tumours (95% of cases)
- Seminoma: slower growing; highly sensitive to radiotherapy and chemotherapy. Average age at diagnosis is 35–40.
- Non-seminoma (includes embryonal carcinoma, teratoma, choriocarcinoma, yolk sac tumour): often grow faster and occur in younger men (average age 20–30). Mixed tumours are common.
Non-germ cell tumours (rare)
Leydig cell and Sertoli cell tumours are uncommon and usually benign.
Treatment
Treatment depends on tumour type, stage, and individual factors.
Stage I seminoma
After orchidectomy, options include:
- Surveillance (active monitoring) — the preferred approach for most men; requires regular follow-up
- Adjuvant chemotherapy (one cycle of carboplatin) — reduces relapse risk
- Adjuvant radiotherapy — effective but used less now due to concerns about secondary cancers
Stage I non-seminoma
After orchidectomy:
- Surveillance — appropriate for lower-risk cases with good compliance
- Nerve-sparing retroperitoneal lymph node dissection (RPLND)
- Adjuvant BEP chemotherapy (bleomycin, etoposide, cisplatin) — one or two cycles
Stage II and III
Most men receive BEP chemotherapy (typically 3–4 cycles). This regimen achieves high cure rates even in metastatic disease. Post-chemotherapy surgery may be needed to remove residual masses.
Fertility Considerations
- Orchidectomy of one testicle preserves hormone production and fertility in most men if the remaining testicle is normal
- Chemotherapy and radiotherapy can impair sperm production — temporarily or permanently
- Sperm banking before treatment is strongly recommended for any man who may want to father children in the future
- Testosterone levels should be monitored after treatment, particularly if both testes are affected or in men with pre-existing low testosterone
See Natural Testosterone Optimisation for context on hormone health in men.
Prognosis
Testicular cancer has exceptional survival outcomes:
| Stage | Approximate 5-year survival |
|---|---|
| Stage I | >99% |
| Stage II | ~95–98% |
| Stage III (good prognosis) | ~90–95% |
| Stage III (poor prognosis) | ~50–70% |
Even men with advanced disease at diagnosis often achieve long-term remission with chemotherapy.
Follow-up After Treatment
Regular monitoring continues for 5+ years after treatment completion:
- Clinical examination and tumour marker blood tests
- CT imaging at defined intervals (frequency decreases over time)
- Testosterone and reproductive health monitoring
- Psychological support — anxiety and fear of recurrence are common and valid; support is available
Further Reading
- Cancer Research UK — Testicular Cancer
- American Cancer Society — Testicular Cancer
- EAU Guidelines on Testicular Cancer