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Please note: This page is intended for healthcare professionals only. It is designed as a general educational guide and does not replace local guidance, senior clinical advice, or individual clinical judgement. Patients should not use this page as medical advice and should seek advice from an appropriate healthcare professional.

Testicular Cancer

Overview & Incidence

  • Testicular cancer is uncommon but the most common solid malignancy in men aged 15–40.
  • Incidence: 3–10 per 100,000 per year in Western countries; rising gradually.
  • 90–95% are germ cell tumours (GCT), divided into seminoma and non-seminomatous germ cell tumours (NSGCT).
  • Tends to have very good outcomes but if it is not diagnosed and treated quickly, it can rapidly progress and spread. Early recognition and treatment is therefore crucial.
  • Testicular cancer is staged as per the TNM staging system and according to tumour markers (S-staging).
 

Classification of Testicular Tumours

Classification of testicular tumours
 

Presentation

  • Painless testicular mass is classic
  • Ache/heaviness; acute pain if haemorrhage
  • Secondary hydrocoele
  • Gynaecomastia (β-hCG–secreting tumours)
  • Back pain → retroperitoneal nodal disease
  • Cough and shortness of breath → lung mets
  • Systemic symptoms – anorexia, malaise, weight loss

Always examine:

  • Both testes carefully
  • Palpate supraclavicular/cervical/axillary nodes; examine abdomen
  • Breast exam to assess for gynaecomastia (if β-hCG suspected)
 

NICE Suspected Cancer Referral for Testicular Cancer

  1. Consider a suspected cancer pathway referral for testicular cancer in men if they have a non-painful enlargement or change in shape or texture of the testis.
  2. Consider a direct access ultrasound scan for testicular cancer in men with unexplained or persistent testicular symptoms.
 

Initial Investigations

  1. Ultrasound testes
    • Identifies solid lesions and microlithiasis
  2. Serum Tumour Markers (pre-orchidectomy)
    • AFP, β-hCG, LDH
    • Essential for diagnosis, staging, IGCCCG risk groups, monitoring
    • Normal markers don’t exclude cancer
    Marker Seen in Key Points Half-Life
    LDH Seminoma + NSGCT Non-specific; reflects tumour bulk; used in IGCCCG ~24 hours
    β-hCG NSGCT + 30% seminomas Causes gynaecomastia; rapid fall expected post-orchidectomy 1–3 days
    AFP NSGCT (never pure seminoma) ↑ AFP = NSGCT by definition 5–7 days
  3. Staging Imaging
    • CT chest–abdomen–pelvis for all confirmed cases
    • +/- Brain and spine MRI (or CT brain if MRI not available) if: high β-hCG, multiple lung metastases, poor-prognosis IGCCCG risk group, neurological symptoms
  4. Sperm banking
    • Should be offered to men who have not completed their family before surgery and chemotherapy.
 

TNM Classification (UICC/AJCC 8th Ed.)

UICC/AJCC 8th edition staging summary for testicular germ cell tumours.

Stage Description
TPrimary Tumour
pT1 Tumour limited to testis/epididymis, no LVI; may invade tunica albuginea but not tunica vaginalis
pT2 Tumour limited to testis/epididymis with LVI, or invasion of hilar soft tissue, or extension through tunica albuginea involving tunica vaginalis
pT3 Spermatic cord invasion
pT4 Scrotal invasion
NRegional Nodes
N1 – Nodes ≤2 cm
N2 – 2–5 cm or >5 nodes
N3 – >5 cm
MMetastasis
M1a – Non-regional nodes/lung
M1b – Other visceral sites
SSerum Markers
S0 – Normal
S1/2/3 – raised AFP/β-hCG/LDH levels
 
 

Management – localised disease

1
Radical Inguinal Orchidectomy +/- prosthesis
  1. Standard first-line treatment – should be booked urgently
    • – Aims to ligate spermatic cord as high as possible
    • – Provides diagnosis, pT stage, and influences risk stratification
    • – Some super specialist centres may offer testis-sparing surgery in very carefully selected cases (solitary testes, indeterminate etc.)
  2. All patients should be counselled about the risks and benefits of testicular prosthesis insertion at the time of orchidectomy – cosmetic benefit vs infection causing delay in chemotherapy
  3. If life-threatening metastatic disease → chemotherapy may precede orchidectomy.
2
After Orchidectomy – all patients should:
  1. Be discussed at the Urology MDT
  2. Testicular tumour markers should be checked 7 days post-operatively if markers raised pre-operatively
    • – They should fall according to half-life
    • – Failure to decline suggests metastatic disease
    • – BUT normalisation does not exclude metastases and staging is always required
3
Referral to Oncology
  1. All patients with confirmed testicular cancer histologically should be referred to oncology and may receive active surveillance and/or adjuvant chemo/radiotherapy. The specific treatment given depends on the histological subtype of the tumour, its staging and tumour markers.
  2. Surveillance may be offered for the lowest risk tumours and a variety of chemotherapy regimens are available for those considered more at risk of relapse.
 

What Happens When Patients Present with Metastatic Disease

Chemotherapy is key and usually comes after an urgent radical orchidectomy

Chemotherapy may precede orchidectomy in emergency cases, such as:

  • Respiratory compromise (lung metastases)
  • Massive retroperitoneal disease compressing vessels/ureter
  • Very high tumour markers
  • Brain metastases
 

Follow-Up

  • Follow-up is long-term due to relapse risk (highest in the first 2 years).
  • Use markers and cross-sectional imaging
  • Follow-up focuses on:
    • Relapse detection
    • Late effects of chemotherapy (cardiac, endocrine, fertility)
    • Contralateral GCNIS risk
    • Survivorship/psychosexual support

References

  1. Patrikidou A, Cazzaniga W, Berney D, Boormans J, de Angst I, Di Nardo D, et al. European Association of Urology Guidelines on Testicular Cancer: 2023 Update. Eur Urol. 2023;84(3):289–301. doi:10.1016/j.eururo.2023.04.010.
  2. European Association of Urology. EAU Guidelines on Testicular Cancer. Limited update April 2024. Arnhem: EAU Guidelines Office; 2024.
  3. National Institute for Health and Care Excellence. Suspected cancer: recognition and referral. NICE guideline NG12. London: NICE; 2015. Last updated 15 April 2026.