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Testicular Cancer - Overview

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

ON THIS PAGE: You will find some basic information about this disease and the parts of the body it may affect. This is the first page of Cancer.Net’s Guide to Testicular Cancer. To see other pages, use the menu on the side of your screen. Think of that menu as a roadmap to this full guide.

Testicular cancer begins when healthy cells in a testicle change and grow uncontrollably, forming a mass called a tumor. A cancerous tumor is malignant, meaning it can grow and spread to other parts of the body.

About the testicles

The testicles are part of a man’s reproductive system. Each man has two testicles, and they are located under the penis in a sac-like pouch called the scrotum. They can also be called testes or gonads. The testicles produce sperm and testosterone. Testosterone is a hormone that plays a role in the development of a man’s reproductive organs and other characteristics.

About testicular cancer

Most types of testicular cancer develop in the sperm-producing cells known as germ cells, and are referred to as germ cell tumors. Germ cell tumors in men can start in several parts of the body:

  • The testicles, which is the most common location

  • The back of the abdomen near the spine, called the retroperitoneum

  • The central portion of the chest between the lungs, called the mediastinum

  • The lower spine

  • Very rarely, a small gland in the brain called the pineal gland

Testicular cancer is almost always curable if found early, and it is usually curable even when at a later stage. Another name for testicular cancer is testis cancer.

Types of testicular cancer

There are two main categories of germ cell tumors that start in the testicles.

  • Seminoma

  • Non-seminoma. A non-seminoma contains any of the following in the tissue:

    • Choriocarcinoma

    • Embryonal carcinoma

    • Yolk sac tumor

    • Teratoma

Each of these can occur alone or in any combination. Sometimes, seminoma cancer can be found as part of a non-seminoma at any percentage level. For example, a tumor that is 99% seminoma and 1% yolk sac tumor is still diagnosed and treated as non-seminoma.

Generally, non-seminomas tend to grow and spread more quickly than seminomas, but prompt diagnosis and treatment are important for both types of tumors. Many germ cell tumors are a mixture of teratoma and other types of germ cell tumors.

Other, less common types of testicular tumors include:

  • Leydig cell tumor

  • Sertoli cell tumor

  • Carcinoma of the rete testis, which is a part of the testicles

This article provides information only on seminomas and non-seminomas of the testicles in men who have reached puberty. Testicular cancer is uncommon in boys who have not yet reached puberty; childhood testicular cancer is approached differently than cancer in teenagers who have been through puberty and adult men.

Other types of cancer, such as lymphoma and leukemia, occasionally spread to the testicles. To find out more about cancer that started in another part of the body and spread to the testicles, read about that specific type of cancer.

Looking for More of an Overview?

If you would like additional introductory information, explore the following item. Please note this link will take you to another section on Cancer.Net:

  • ASCO Answers Fact Sheet: Read a one-page fact sheet (available as a PDF) that offers an easy-to-print introduction to this type of cancer.

The next section in this guide is Statistics and it helps explain how many people are diagnosed with this disease and general survival rates. Or, use the menu on the side of your screen to choose another section to continue reading this guide.  

Testicular Cancer - Statistics

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

ON THIS PAGE: You will find information about how many men are diagnosed with this type of cancer each year. You will also learn some general information on surviving the disease. Remember, survival rates depend on several factors. To see other pages, use the menu on the side of your screen.

This year, an estimated 8,720 men in the United States will be diagnosed with testicular cancer. The average age of diagnosis is 33.

It is estimated that about 380 deaths from this disease will occur this year. These deaths are either from cancer that spread from the testicles to other parts of the body and could not be effectively treated with chemotherapy, radiation therapy, and/or surgery or from complications from treatment.

The 5-year survival rate tells you what percent of men live at least 5 years after the cancer is found. Percent means how many out of 100. The survival rate is higher for men diagnosed with early-stage cancer and lower for men with later-stage cancer. For men with cancer that has not spread beyond the testicles (Stage 1; see Stages), the survival rate is 99%.

For men with cancer that has spread to the lymph nodes in the back of the abdomen, called the retroperitoneal lymph nodes, the survival rate is about 96%. But, this depends on the size of the lymph nodes with cancer. For men with cancer that has spread outside the testicles to areas beyond the retroperitoneal lymph nodes, the survival rate is 73%.

It is important to remember that statistics on how many men survive this type of cancer are an estimate. The estimate comes from data based on thousands of men with this cancer in the United States each year. So, your own risk may be different. Doctors cannot say for sure how long any man will live with testicular cancer. Also, experts measure the survival statistics every 5 years. This means that the estimate may not show the results of better diagnosis or treatment available for less than 5 years. Learn more about understanding statistics.

Statistics adapted from the American Cancer Society's publication, Cancer Facts & Figures 2016 and the NCI Surveillance Epidemiology and End Results (SEER) database (1975-2011).

The next section in this guide is Medical Illustrations. It offers drawings of body parts often affected by this disease. Or, use the menu on the side of your screen to choose another section to continue reading this guide.  

Testicular Cancer - Medical Illustrations

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

ON THIS PAGE: You will find a basic drawing about the main body parts affected by this disease. To see other pages, use the menu on the side of your screen.

The next section in this guide is Risk Factors and it explains what factors may increase the chance of developing this disease. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Testicular Cancer - Risk Factors

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

ON THIS PAGE: You will find out more about the factors that increase the chance of developing this type of cancer. To see other pages, use the menu on the side of your screen.

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

The following factors can raise a man’s risk of developing testicular cancer. However, it is important to note that the cause of testicular cancer is not known.

  • Age. More than half of testicular cancer diagnoses occur in men between the ages of 20 and 45. However, men of any age can develop this disease, including men in their teens and in their 60s, so it is important that any man with symptoms of testicular cancer visit the doctor.

  • Cryptorchidism. Cryptorchidism is an undescended testicle, meaning that one or both testicles do not move down into the scrotum before birth as they should. Men with this condition have an increased risk of developing testicular cancer. This risk may be lowered if surgery is used to correct the condition before the boy reaches puberty. Some doctors recommend surgery for cryptorchidism when a boy is between six and 15 months to reduce the risk of infertility. Infertility is the inability to produce children. Because cryptorchidism is often corrected at a young age, many men may not know if they had the condition.

  • Family history. A man who has a close relative, particularly a brother, who has had testicular cancer has an increased risk of developing testicular cancer.

  • Personal history. Men who have had cancer in one testicle have an increased risk of developing cancer in the other testicle. It is estimated that out of every 100 men with testicular cancer, two will develop cancer in the other testicle.

  • Race. Although men of any race can develop testicular cancer, white men are more likely than men of other races to be diagnosed with testicular cancer. Testicular cancer is rare in black men. However, black men with testicular cancer are more likely to die of the cancer than white men, particularly if the cancer has spread to the lymph nodes or other parts of the body when it is diagnosed.

  • Human immunodeficiency virus (HIV) infection. Men with HIV or acquired immune deficiency syndrome (AIDS) caused by the HIV virus have a slightly higher risk of developing seminoma.

The next section in this guide is Screening and it explains how tests may find cancer before signs or symptoms appear. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Testicular Cancer - Screening

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

ON THIS PAGE: You will find out more about how men may be screened for this type of cancer, including risks and benefits of screening. To see other pages, use the menu on the side of your screen.

Scientists have developed, and continue to develop, tests that can be used to screen a person for specific types of cancer before signs or symptoms appear. The overall goals of cancer screening are to:

  • Lower the number of people who die from the disease, or eliminate deaths from cancer altogether

  • Lower the number of people who develop the disease

Learn more about the basics of cancer screening.

Screening information for testicular cancer

Most often, testicular cancer can be found at an early stage. Many men find the cancer themselves while performing self-examinations. Some doctors recommend that men ages 15 to 55 perform a monthly self-examination to find any changes. Monthly testicular self-examinations, performed after a warm shower, can help detect the cancer at an early stage, when it is more likely to be successfully treated. Men who notice a lump, hardness, enlargement, pain, or any other change in one or both of their testicles should visit their doctor immediately.

The next section in this guide is Symptoms and Signs and it explains what body changes or medical problems this disease can cause. Or, use the menu on the side of your screen to choose another section to continue reading this guide.  

Testicular Cancer - Symptoms and Signs

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

ON THIS PAGE: You will find out more about body changes and other things that can signal a problem that may need medical care. To see other pages, use the menu on the side of your screen.

Men with testicular cancer may experience a variety of symptoms or signs. Sometimes, men with testicular cancer do not show any of these symptoms. In addition, these symptoms can be caused by other conditions besides cancer, so the presence of these symptoms does not mean that a man has cancer.

Usually, the first sign of testicular cancer is enlargement of the testicle or a small lump or area of hardness on the testicle. Any lump, enlargement, hardness, pain, or tenderness of the testicle should be evaluated by a doctor as soon as possible. Other symptoms of testicular cancer usually do not appear until after the cancer has spread to other parts of the body.

Symptoms of testicular cancer may include:

  • Painless lump or swelling on either testicle. If detected early, a testicular tumor may be about the size of a pea or a marble, but it can grow much larger.

  • Pain or discomfort, with or without swelling, in a testicle or the scrotum.

  • Change in the way a testicle feels or a feeling of heaviness in the scrotum. For example, one testicle may become more firm than the other testicle. Or, testicular cancer may cause the testicle to grow bigger or to become smaller.

  • Dull ache in the lower abdomen or groin

  • Sudden buildup of fluid in the scrotum

  • Breast tenderness or growth. Although rare, some testicular tumors produce hormones that cause breast tenderness or growth of breast tissue, a condition called gynecomastia.

  • Lower back pain, shortness of breath, chest pain, and bloody sputum or phlegm can be symptoms of later-stage testicular cancer.

  • Swelling of one or both legs or shortness of breath from a blood clot can be symptoms of testicular cancer. A blood clot in a large vein is called deep venous thrombosis or DVT. A blood clot in an artery in the lung is called a pulmonary embolism and causes shortness of breath. For some young or middle-aged men, developing a blood clot may be the first sign of testicular cancer.

Many symptoms and signs of testicular cancer are similar to those caused by noncancerous conditions. These are discussed below:

  • Change in size or lump

    • A cyst called a spermatocele that develops in the epididymis. The epididymis is a small organ attached to the testicle that is made up of coiled tubes that carry sperm away from the testicle.

    • An enlargement of the blood vessels from the testicle called a varicocele.

    • A buildup of fluid in the membrane around the testicle called a hydrocele.

    • An opening in the abdominal muscle called a hernia.

  • Pain

    • Infection. Infection of the testicle is called orchitis. Infection of the epididymis is called epididymitis. If infection is suspected, a patient may be given a prescription for antibiotics. If antibiotics do not solve the problem, tests for testicular cancer are often needed.

    • Injury

    • Twisting

If you are concerned about one or more of the symptoms or signs discussed in this section, please talk with your doctor. Your doctor will ask how long and how often you’ve been experiencing the symptom(s), in addition to other questions. This is to help find out the cause of the problem, called a diagnosis.

If cancer is diagnosed, relieving symptoms remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.  

The next section in this guide is Diagnosis and it explains what tests may be needed to learn more about the cause of the symptoms. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Testicular Cancer - Diagnosis

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

ON THIS PAGE: You will find a list of the common tests, procedures, and scans that doctors can use to find out what’s wrong and identify the cause of the problem. To see other pages, use the menu on the side of your screen.

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.

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

  • Type of cancer suspected

  • Signs and symptoms

  • Previous test results

When a man develops a testicular lump or something else that could be testicular cancer, it is important that he see his primary care doctor, who may send him to a urologist. A urologist is a doctor who specializes in treating testicular cancer.

The following tests are usually the first performed.

  • Physical examination. 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 and the legs will be examined for swelling. Leg swelling can result from blood clots in veins in the legs, pelvis or abdomen.

  • Ultrasound. An ultrasound uses sound waves to create a picture of the internal organs. The sound waves produced by the ultrasound bounce off tissue in the scrotum. The echoes of the sound waves produce a series of images called a sonogram. These images of the testicle help the doctor find any tumors or other abnormalities. If a tumor is found and is large enough to be seen on an ultrasound, then the sonogram will show the size, location, and solidness of the tumor. A solid tumor inside the testicle is very likely to be cancerous.

If these tests show an abnormality that appears to be a tumor, then blood tests are done. In addition, the testicle may need to be surgically removed to look for signs of cancer.

  • Blood tests/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 (see Stages) and confirm whether a tumor is a pure seminoma (see Overview). Different types of cancer make different tumor markers. 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. 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.

    High levels of these tumor markers may indicate testicular cancer. However, it is also possible to have this type of cancer and have normal tumor marker levels. It is also possible to have higher levels of these markers without having cancer.

    Other tumor markers that may be used for testicular cancer include:

    • Lactate dehydrogenase (LDH) is only used in a specific situation for men with testicular cancer (see Treatment Options). This is because LDH can be elevated in many other cancers and non-cancerous diseases. LDH is not used to find testicular cancer.

    • Placental alkaline phosphatase (PLAP) is another tumor marker doctors may test for, although it is not commonly measured.

    Learn more about tumor markers for testicular cancer.

  • Orchiectomy/surgical pathology tests. If testicular cancer is suspected, a surgeon will perform a radical inguinal orchiectomy, in which the entire testicle is removed through an incision in the groin. Then, a pathologist will examine very thin slices of tissue from the testicle under a microscope to diagnose the type of cancer. A pathologist is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease. For a cancer to be considered a seminoma, it must be pure seminoma.

    If the man has one testicle to begin with or the diagnosis is uncertain, the surgeon may remove only a small sample of tissue from the testicle. The testicle may still need to be removed if there are signs of cancerous cells. If the tissue sample does not show cancer, it may be possible to repair the damage from the tissue removal and replace the testicle in the scrotum during the same surgery. However, this procedure is very rare.

Other 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 (see Stages). 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, which is a type of non-seminoma. Tests that may be used to stage testicular cancer and find out if it has spread include:

  • X-ray. An x-ray is a way to create a picture of the structures inside of the body, using a small amount of radiation. A chest x-ray is used to determine the stage of the cancer and for follow-up screening. If a more detailed picture of the lungs is needed, then the doctor may recommend a chest CT scan (see below) but in many situations an x-ray is preferred.

  • CT scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that can be examined to look for any abnormalities or tumors. A CT scan can also be used to measure a tumor’s size. Sometimes, a special dye called a contrast medium is given before the scan to provide better detail on the image. This dye can be injected into a patient’s vein or given as a pill to swallow. A CT scan is the most common imaging test for men with testicular cancer, and it can be used to evaluate the abdomen, pelvis, chest/lungs, brain and other areas. A CT scan of the brain is rarely needed for testicular cancer because it is uncommon for it to spread to the brain. However, if a scan of the brain is needed, MRI (see below) is generally preferred because the skull bones interfere with the ability of CT scans to show certain parts of the brain.

  • MRI scan. An MRI scan uses magnetic fields to create a three-dimensional picture of the inside of the body. MRI can also be used to measure the tumor’s size. For testicular cancer, MRI is generally only used to examine the brain or the spine. A contrast medium is given before the scan to create a clearer picture. This dye is usually injected into a patient’s vein. For men with testicular cancer, CT scans (see above) are generally preferred to MRI for viewing the abdomen because accurately reading MRI scans of the abdomen requires extensive experience. When MRIs of the abdomen are needed, the contrast medium may be given by mouth.

    MRI is used only in specific situations. For instance, an MRI of the brain might be recommended if a patient is experiencing signs or symptoms that suggest that the cancer may have spread to the brain. In addition, brain MRIs are often recommended for men who have poor-risk metastatic testicular cancer (see Stages) with very high serum tumor markers or if the cancer has spread to the liver, bones, or lungs. Your doctor will explain which test is appropriate for you.

  • PET scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive sugar substance is injected into the patient’s body. This sugar substance is taken up by cells that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body. Studies of PET scans have shown that they are not helpful for diagnosing or staging testicular cancer and should not be used at these times. However, they may be helpful for men with metastatic pure seminoma that does not entirely disappear after chemotherapy, but should not be done until at least six weeks after chemotherapy ends.

  • Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Occasionally, a biopsy may be taken from the lung, retroperitoneum, or other location in the body if it appears that cancer may have spread.

After diagnostic tests are done, your doctor will review all of the results with you. If the diagnosis is cancer, these results also help the doctor describe the cancer; this is called staging.

The next section in this guide is Stages, and it explains the system doctors use to describe the extent of the disease. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Testicular Cancer - Stages

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

ON THIS PAGE: You will learn about how doctors describe a cancer’s growth or spread. This is called the stage. To see other pages, use the menu on the side of your screen.

Staging is a way of describing if and where a cancer has spread. Doctors use diagnostic tests, including CT scans and blood tests, to find out the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and helps predict a patient's prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.

TNM staging system

One tool that doctors use to describe the stage is the TNM system. Doctors use the results from diagnostic tests and scans to answer these questions:

  • Tumor (T): How large is the primary tumor? Where is it located?

  • Node (N): Has the tumor spread to the lymph nodes in the back of the abdomen (retroperitoneum)?

  • Metastasis (M): Has the cancer metastasized to other parts of the body? If so, where and how much?

  • Serum tumor marker (S): Are the serum tumor markers AFP, beta-hCG, and LDH (see Diagnosis) elevated? If so, how high are they?

The results are combined to determine the stage of cancer for each person. There are three stages of testicular cancer: stages I, II, and III (one, two, and three). The stage provides a common way of describing how advanced the cancer is so that doctors can work together to plan the best treatments. Stage I is the least advanced and stage III is the most advanced. Patients with the least advanced stages are more likely to be cured and often need less aggressive treatment than patients with more advanced stage cancers.  

There are also two different types of staging in testicular cancer:

  • Clinical staging. The clinical stage is based on a physical examination or x-rays, CT scans, and other imaging tests (see Diagnosis). For example, clinical stage II testicular cancer means that the retroperitoneal lymph nodes are enlarged when viewed with a CT or MRI scan.

  • Pathological staging. The pathological stage is based on evaluating tissue under a microscope after it has been removed during surgery. For example, pathological stage II testicular cancer means that cancer has been found when tissue removed from the retroperitoneal lymph nodes is examined under a microscope. Pathological staging is more accurate than clinical staging, but it is not always necessary.

Here are more details on each part of the TNM system for testicular cancer:

Tumor (T)

Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail. For testicular cancer, the T stage can only be determined when tissue removed during surgery is examined under a microscope. This means that the T stage is only determined after the testicle is removed, and the T stage is always a pathological stage and never a clinical stage. The “p” before the T stage indicates that it is a pathological stage. Specific tumor stage information is below.

pTX: The primary tumor cannot be evaluated. If a man has not had the testicle(s) surgically removed, the term "TX" is used.

pT0: There is no evidence of a primary tumor in the testicles.

pTis: In this stage, there is intratubular germ cell neoplasia, also called carcinoma in situ (CIS). This is a precancerous condition in which there are germ cells that appear cancerous but are not yet behaving the way cancer cells do. CIS becomes cancer when the cells spread to areas of the testicle(s) where they do not normally belong.

pT1: The primary tumor is only in the testicle with or without involvement of the epididymis or rete testis. It has not grown into blood vessels or lymph vessels in the testicles. The tumor may have grown into the inner membrane layer surrounding the testicle, called the tunica albuginea. It has not spread to the outer membrane layer surrounding the testicle, called the tunica vaginalis.

pT2: The tumor is in the testicle with or without involvement of the epididymis or rete testis. It has grown into blood vessels or lymphatic vessels, and/or it has grown through the tunica albuginea and into the tunica vaginalis.

pT3: The tumor has grown into the spermatic cord.

pT4: The tumor has grown into the scrotum.

Node (N)

The “N” in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph is a fluid that flows from the different tissues and organs of the body and eventually drains into the blood stream. It passes through specialized tubes called lymphatic vessels and is filtered along the way by the lymph nodes. Cancer cells often buildup and grow in lymph nodes before they spread to other parts of the body. The first place the lymphatic fluid from the testicles drains to is the retroperitoneal lymph nodes located in the back of the abdomen in front of the spine, an area called the retroperitoneum. These are called the regional lymph nodes for testicular cancer. Lymph nodes in the pelvis, chest, or other parts of the body are called distant lymph nodes even though the testicles are closer to the pelvis than to the retroperitoneum.

In men with testicular cancer, lymph nodes usually are not biopsied or removed. Instead, the “N” stage is most often estimated by using CT scans. Lymph node stage (N stage) that is based on CT scans is the clinical stage, and N stage based on a biopsy or removal of the lymph nodes is the pathological stage. When a stage has been determined pathologically, the letter “p” is added as the first letter of the stage (for example pN1). The letter "c" stands for clinical stage.

NX: The regional lymph nodes cannot be evaluated.

cN0: There is no spread to regional lymph nodes as seen on imaging tests.

pN0: There is no cancer found in lymph nodes removed during RPLND (see Treatment Options).

cN1: Imaging tests show at least 1 enlarged lymph node in the retroperitoneum, but none of the enlarged lymph nodes are bigger than 2 centimeters (cm).

pN1: There is cancer in 1 to 5 lymph nodes and none is larger than 2 cm.

cN2: Imaging tests show at least 1 enlarged lymph node or lymph node mass in the retroperitoneum that is larger than 2 cm but not larger than 5 cm.

pN2: Either or both of the following conditions:

  • There is cancer in more than 5 lymph nodes but none are larger than 5 cm.

  • There is cancer in at least 1 lymph node that is bigger than 2 cm and smaller than 5 cm

cN3: Imaging tests show at least 1 enlarged lymph node or a lymph node mass in the retroperitoneum larger than 5 cm.

pN3: There is cancer in at least 1 enlarged lymph node or lymph node mass that is larger than 5 cm.

Metastasis (M)

The "M" in the TNM system indicates whether the cancer has spread to other parts of the body, called distant metastasis. When testicular cancer spreads, it most commonly spreads to the lung and the lymph nodes of the chest, pelvis, and the base of the neck. More advanced stages may have spread to the liver and bones. Testicular cancer rarely spreads to the brain unless the primary tumor is a choriocarcinoma. 

MX: Distant metastasis cannot be evaluated.

M0: The disease has not metastasized to distant lymph nodes or other organs.

M1: There is at least 1 distant metastasis.

M1a: There is cancer in distant lymph nodes and/or the lungs.

M1b: The cancer has spread to organs other than a lung. The lungs may or may not also be involved. For example, a testicular cancer that has spread to the liver or the bones is stage M1b.

Serum tumor markers (S)

Serum tumor markers also help to stage testicular cancer. Blood tests for tumor markers will be done before and after surgical removal of the testicle(s). Tumor markers usually decrease after the surgery. Generally, the levels need to be tested until they stop decreasing or begin to rise to determine the correct S stage. For patients who will receive chemotherapy, the tumor marker levels on the first day of chemotherapy are used to determine the patient’s risk group (see below).

SX: Tumor marker levels are not available, or the tests have not been done.

S0: Tumor marker levels are normal.

S1: At least 1 tumor marker level is above normal. This means that LDH is less than 1.5 times the upper limit of the normal range, beta-hCG is less than 5,000 mIu/mL, and/or AFP is less than 1,000 ng/mL.

S2: At least 1 tumor marker level is substantially above normal. This means that LDH is 1.5 to 10 times the upper limit of the normal range, beta-hCG is 5,000 to 50,000 mIu/mL, or AFP is 1,000 to 10,000 ng/mL, and/or none of the tumor markers is elevated high enough to qualify as S3 (see below).

S3: 1 or more tumor marker level is very highly elevated. This means that LDH is more than 10 times the upper limit of the normal range, beta-hCG is more than 50,000 mIu/mL, or AFP is more than 10,000 ng/mL.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications and the S level information.

Stage 0: Refers to carcinoma in situ, also called intratubular germ cell neoplasia (pTis).

Stage I: Cancer is at any T level, and there is no evidence of spread to either lymph nodes or other organs. Serum tumor marker levels have not been done or are not available (any T, N0, M0, SX).

Stage IA: Cancer is in the testicle and may have grown into the rete testis and the epididymis, but it has not grown into the lymphatic or blood vessels in the testis or spread to lymph nodes or distant sites. The tumor in the testis may have grown into the inner membrane surrounding the testis, called the tunica albuginea, but not the outer membrane, called the tunica vaginalis. Serum markers are normal (pT1, N0, M0, S0).

Stage IB: The testicular tumor has grown into the tunica vaginalis, the blood or lymphatic vessels within the testicle, the spermatic cord, or the scrotum. The cancer has not spread to lymph nodes or distant sites. Serum markers are normal (pT2, pT3, or pT4, and N0, M0, S0).

Stage IS: Cancer is of any T stage and has not spread to lymph nodes or distant sites. Serum markers remain above normal levels after the cancerous testicle has been removed (any T, N0, M0, and S1-3). Stage IS non-seminoma testicular cancer is treated the same as stage III testicular cancer.

Stage II: The cancer has spread to any number of regional lymph nodes but not to lymph nodes in other parts of the body or distant organs. Serum markers are unavailable (any T, N1-3, M0, SX).

Stage IIA: Cancer has spread to retroperitoneal lymph nodes, either clinical or pathological stage N1, but none is larger than 2 cm and, if a lymph node dissection has been done, no more than 5 lymph nodes contain cancer. In addition, serum tumor markers are at normal levels or slightly high, and there are no signs of cancer having spread anywhere other than the retroperitoneum (any T, N1, M0, S0 or S1).

Stage IIB: Cancer has spread to lymph nodes in the retroperitoneum, at least 1 of which is bigger than 2 cm but not bigger than 5 cm; or, if a lymph node dissection has been done, cancer has spread to at least 1 lymph node (or lymph node mass) between 2 cm and 5 cm or to more than 5 lymph nodes, none more than 5 cm. Serum markers are at normal levels or slightly high, and there is no evidence of cancer having spread anywhere other than the retroperitoneum (any T, N2, M0, S0 or S1).

Stage IIC: Cancer has spread to at least 1 lymph node (or lymph node mass) that is larger than 5 cm. Serum markers are at normal levels or slightly high and there is no evidence of cancer having spread anywhere other than the retroperitoneum (any T, N3, M0, S0 or S1).

Stage III: Cancer has spread to distant lymph nodes or to any organ, and serum tumor marker levels are unknown (any T, N0-3, M1, SX).

Stage IIIA: Cancer has spread to distant lymph nodes or the lungs. Serum markers are at normal levels or slightly high (any T, N0-3, M1a, S0 or S1).

Stage IIIB: Cancer has spread to any lymph nodes and/or the lungs but not to any other organs. Serum markers are at substantially and persistently high levels (any T, N1-3, M0, S2; or any T, N0-3, M1a, S2).

Stage IIIC: Either or both of the following: 

  • Serum marker levels are highly high, and the cancer has spread to at least 1 lymph node or organ (any T, N1-3, M0, S3; or any T, N0-3, M1a, S3).

  • The cancer has spread to an organ other than the lungs (any T, any N, M1b, any S).

Recurrent: Recurrent cancer is cancer that has come back after treatment. If the cancer does return, there will be another round of tests to learn about the extent of the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis.

Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Seventh Edition published by Springer-Verlag New York, www.cancerstaging.net.

Later-stage testicular cancer: risk group classification

If the disease has spread to lymph nodes or other organs, the following system is used to classify a germ cell tumor into a good-risk, intermediate-risk, or poor-risk group. This helps to determine the treatment plan and the likelihood of cure. Patients in the intermediate and poor-risk groups usually receive more chemotherapy than patients in the good-risk category.

The differences between good-risk, intermediate risk and poor-risk are the same as the differences between stage IIIA, IIIB, and IIIC (above). Stage IIIA is the same as good risk, IIIB is the same as intermediate risk, and IIIC is the same as poor risk.

 

Good Risk

Non-Seminoma

Seminoma

No metastasis to an organ other than the lungs

and

Good marker levels – all of the following:

AFP < 1,000 ng/mL

B-hCG < 5,000 iU/L

LDH < 1.5 x ULN

No metastasis to an organ other than the lungs

and

Normal AFP, any B-hCG, any LDH

 

Intermediate Risk

Non-seminoma

Seminoma

No metastasis to an organ other than the lungs

and

Intermediate markers – any of

AFP >= 1,000 and <= 10,000 ng/mL

B-hCG >= 5,000 and <= 50,000 iU/L

LDH >= 1.5 x ULN and <= 10 x ULN

Metastasis to an organ other than the lungs

and

Normal AFP, any B-hCG, any LDH

 

 

 

 

Poor Risk

Non-seminoma

Seminoma

Metastasis to an organ other than the lungs

or

Poor markers – any of the following:

AFP >= 10,000 ng/mL

B-hCG >= 50,000 iU/L

LDH >= 10 x ULN

There are no patients with poor-risk seminoma.

 

Source: Journal of Clinical Oncology.

Information about the cancer’s stage will help the doctor recommend a specific treatment plan. The next section in this guide is Treatment Options. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Testicular Cancer - Treatment Options

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

ON THIS PAGE: You will learn about the different ways doctors use to treat people with this type of cancer. To see other pages, use the menu on the side of your screen.

This section outlines treatments that are the standard of care (the best known treatments available) for testicular cancer, followed by the treatments used for each type and stage. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new approach to treatment to evaluate whether it is safe, effective, and possibly better than the standard treatment. Clinical trials may test such approaches as a new drug, a new combination of standard treatments, or new doses of current therapies. Your doctor can help you review all treatment options. For more information, see the About Clinical Trials and Latest Research sections.

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. For testicular cancer, this team includes a urologist and medical oncologist. A medical oncologist is a doctor who specializes in treating cancer with medication. Sometimes, patients may also see a radiation oncologist. A radiation oncologist a doctor who specializes in giving radiation therapy to treat cancer. Cancer care teams also include a variety of other health care professionals, including physician assistants, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.

Descriptions of the most common types of treatment used for testicular cancer are listed below, followed by treatment options by the cancer’s stage. Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the man’s preferences and overall health. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care.

Germ cell tumors are highly sensitive to chemotherapy and are therefore usually curable. However, unlike the other types of germ cell tumors, chemotherapy is not very effective for a teratoma. Because many germ cell tumors are a mixture of teratoma and other types of germ cell tumor, successful treatment often requires both chemotherapy and surgery. Most often, testicular cancer can be successfully treated with surgery, chemotherapy, and/or radiation therapy.

Men with testicular cancer usually have concerns about how their treatment will affect their sexual function, fertility, and quality of life, and each man should discuss these topics with his doctor before treatment begins because there is often more than one treatment option available. The final choice of a treatment plan depends on the patient’s specific situation. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Also, talk about the goals of each treatment with your doctor and what you can expect while receiving the treatment. Learn more about making treatment decisions.

Getting care for symptoms and side effects

Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care is any treatment that focuses on reducing symptoms, improving quality of life, and supporting patients and their families. Any person, regardless of age or type and stage of cancer, may receive palliative care. It works best when palliative care is started as early as needed in the cancer treatment process. People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional support, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, or radiation therapy. Talk with your doctor about the goals of each treatment in the treatment plan.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and palliative care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it can be addressed as quickly as possible. Learn more about palliative care.

Active surveillance for clinical stage I testicular cancer

After having a radical inguinal orchiectomy, one option for men with clinical stage I seminomas and non-seminomas may be active surveillance. With active surveillance, the patient is monitored closely and active treatment begins only if the cancer recurs. This option involves regular doctor appointments for CT scans, chest x-rays, physical examinations, and blood tests for tumor markers. This approach requires dedication by the doctor and patient to stick to the surveillance schedule so that any recurrence can be detected at an early stage. It is only considered as an option if the serum tumor markers of AFP and beta-hCG are normal or return to normal after the cancerous testicle is removed.

The main advantage of active surveillance is that it avoids any further treatment after orchiectomy − such as chemotherapy, radiation therapy, or additional surgery − for the 80% of men with seminoma and 75% of men with non-seminoma who are not likely to have the disease return after orchiectomy. For an individual patient, the risk of recurrence may be higher or lower based on certain risk factors determined by the pathologist’s examination of the tumor after the testicle has been removed.

The surveillance schedule for men with non-seminoma involves testing every 1 to 2 months for the first year, every 2 to 3 months in the second year, and less often thereafter. Most visits are to check serum tumor markers. CT scans and chest x-rays are performed less often. The surveillance schedule for men with seminoma is much less intense, with testing performed every 4 months for the first 2 to 3 years and less often thereafter. Patients generally have follow-up screening for at least 10 years after their diagnosis. 

Surgery

Surgery for cancer involves the removal of the tumor and some surrounding healthy tissue during an operation. There are different types of surgery used to treat testicular cancer, each is described further below.

If a decision is made to perform an orchiectomy, a sample of blood will be collected before surgery to test for levels of serum tumor markers because they are often helpful in planning treatment and follow-up care. For example, increasing or consistently high AFP or beta-hCG after surgery is a sign that the cancer has spread. In this situation, a patient usually needs chemotherapy (see below) even if the metastases cannot be seen on imaging tests.

Radical inguinal orchiectomy

Treatment of testicular cancer usually starts with surgery to remove the testicle with cancer, called radical inguinal orchiectomy. This operation is done through an incision in the groin along the beltline. During the surgery, the entire testicle and most of the spermatic cord are removed. The spermatic cord contains the blood supply to the testicle as well as the channel through which sperm travel from the testicle toward the penis. A man may develop cancer in both testicles either at the same time or at different times. However, this is rare, occurring in about 2% of men with testicular cancer. Then, both testicles need to be removed in a procedure called a bilateral orchiectomy.   

Orchiectomy is used to diagnose and treat both early-stage and later-stage seminomas and non-seminomas. For later-stage cancer, a radical inguinal orchiectomy may, occasionally, be delayed until after treatment with chemotherapy is finished. 

Side effects of orchiectomy

The removal of one testicle typically does not affect a man’s testosterone level if he still has the other testicle, and it is a normal size. If a man’s testosterone level is reduced, symptoms may include depression or other mood changes, fatigue, decreased sex drive, inability to achieve a normal erection, especially in the morning, and hot flashes, as well as loss of muscle and bone mass in the long term. Orchiectomy is unlikely to make a man unable to father a biological child because the remaining testicle will still produce sperm. However, about 25% of men with testicular cancer are infertile even before being diagnosed with cancer. It appears that the cancer itself and/or the reason the cancer developed may cause some men to become infertile. Sperm counts often improve after the testicle with cancer is removed.

If the removal of both testicles is performed, the man will no longer produce sperm or testosterone and will not be able to biologically produce children. If the doctor recommends removing the testicle in a man with one testicle, semen is usually analyzed twice before surgery to check if the man’s sperm are fully functioning. If the sperm are functional, then sperm banking is usually recommended, so that he may be able to have children later if he wishes. In addition, for men who have had both testicles removed, testosterone hormone replacement therapy will be needed.

Reconstructive surgery after orchiectomy

Men can decide if they want an artificial or prosthetic testicle implanted in the scrotum that has a weight and texture that is somewhat similar to a normal testicle but not exactly the same. Some men find that a prosthetic testicle is uncomfortable and some prefer not to have one. Each man is encouraged to talk with his doctor about whether he wants one and the best timing of this implantation if wanted. Some men prefer to wait until after the active treatment period is over to give this option full consideration.

Retroperitoneal lymph node dissection (RPLND)

This is surgery to remove the retroperitoneal lymph nodes that lie at the back of the abdomen. RPLND may be considered for men with clinical stage I and IIA non-seminomas and men with retroperitoneal masses that remain after finishing chemotherapy (see below) for stage II or III nonseminomas. In men with non-seminomas, any masses larger than 1 cm that remain after chemotherapy are removed if it is possible. For men with pure seminomas, masses smaller than 3 cm are usually left in place and monitored for changes with CT scans.

RPLND is usually performed as an open operation with an incision down the middle of the abdomen. RPLND is a complex surgery requiring experience and skill in order to remove all of the appropriate lymph nodes and to minimize the side effects of the operation. RPLND should only be done by a surgeon who is highly experienced with this operation. Some surgeons perform laparoscopic RPLND, which uses several smaller incisions instead of the one large incision, but that approach is still being studied, requires a surgeon skilled in the procedure, and may not be as effective.

  • RPLND for stage I and IIA non-seminomas. About 25% of patients with clinical stage I non-seminoma who have an RPLND are found to have lymph nodes with cancer. In other words, the surgery shows that they have stage II disease. For men with clinical stage I disease, the risk of recurrence can be lowered with RPLND. In these situations, RPLND is done as a treatment that reduces the risk of recurrence, in addition to being used to stage the cancer. This makes it possible to determine which men are most likely to need chemotherapy after RPLND. Doctors are now able to better determine which stage I tumors are at a higher risk of having spread to the lymph nodes or beyond, based on the results of the pathology tests performed on the tumor in the testicle after it is removed. Decisions about whether to have an RPLND may be based on the patient’s risk factors. Active surveillance (see above) for patients with low-risk disease and chemotherapy for patients with high-risk disease may be recommended for some, but RPLND is a reasonable treatment option when a patient can see a urologist with extensive experience with RPLND. If an RPLND is chosen for stage I non-seminoma, it is usually done within six weeks after orchiectomy.

    If 5 or fewer lymph nodes have cancer and none are larger than 2 cm (pN1), this surgery alone is successful for 80% to 90% of men, while about 10% to 20% of men will have a recurrence. If more lymph nodes have cancer (pN2 or pN3), surgery alone is successful for about 50% of patients, while the other 50% will have a recurrence. The advantage of the RPLND is that it can cure most patients with small lymph node metastases, provide a more accurate assessment of the extent of disease, and avoid the need for frequent CT scans of the abdomen during follow-up care. It also reduces the chance that a man with early-stage (stage I) testicular cancer will need chemotherapy.

    Just as RPLND may show cancer in lymph nodes that appeared normal on CT scans for men with clinical stage I non-seminomas, surgery may also show that there is no cancer in lymph nodes that were enlarged on a CT scan, called clinical stage II disease. For men with clinical stage IIA testicular non-seminomas, 20% to 40% will actually have pathological stage I cancer, meaning that the cancer has not spread to any lymph nodes. In these situations, RPLND can help many men avoid unneeded chemotherapy.

    The main disadvantage of this surgery for stage I non-seminoma is that 70% of patients are cured by removal of the testicle alone. For these men, a RPLND offers no curative benefit, although it does allow the man to avoid the regular CT scans needed with surveillance, as well as, possibly, peace of mind.

    Despite the surgery, about 10% of testicular cancers recur even if the lymph nodes were not found to have cancer. If the RPLND finds that the lymph nodes have cancer, then a decision needs to be made whether to give 2 courses of chemotherapy (see below) to decrease the chance of recurrence to about 1%. However, surveillance is also an option, beginning treatment with chemotherapy only if the cancer recurs. This is because this type of cancer has a greater than 95% chance of being cured with 3 cycles of chemotherapy if the recurrence is diagnosed early through regular monitoring.

  • RPLND to remove residual tumors after chemotherapy. Removing masses larger than 1 cm that remain after chemotherapy for non-seminomas is believed to be an essential part of treating the disease when it can be safely done. About 35% to 40% of men going through such surgery will have a mass that contains teratoma or about 10% to 15% will have one of the other germ cell cancers. The other 40% to 50% of men will have no mass. Some treatment centers will perform an RPLND after chemotherapy in men who had enlarged retroperitoneal lymph nodes before chemotherapy even if the lymph nodes return to normal size (less than 1 cm) after chemotherapy. Some treatment centers may not recommend RPLND if a CT scan taken after chemotherapy is normal. For men found to have teratoma, no additional treatment is given after RPLND. For men found to have seminoma, embryonal carcinoma, yolk sac tumor, or choriocarcinoma, 2 additional cycles of chemotherapy are generally recommended after RPLND.

Side effects of RPLND

Some patients may experience temporary side effects from RPLND, such as bowel obstruction (blockage) or infection. This procedure should not affect a man's ability to have an erection, orgasm, or sexual intercourse, but it may cause infertility because it can damage the nerves that control ejaculation. RPLND performed after chemotherapy is a more complex surgery and is more likely to cause infertility from being unable to ejaculate and other side effects.

Men are encouraged to bank sperm before RPLND. There are surgical techniques that are usually successful at sparing the nerves involved with ejaculation, and it is recommended that a man discuss this with his surgeon.

Other types of surgery to remove cancer remaining after chemotherapy

After chemotherapy (see below), some men may have cancer remaining in lymph nodes outside the retroperitoneum, in the lungs, liver, or other organs. These tumors should also be removed if it is safe to do so. This may involve surgery in more than one part of the body. This type of surgery is complex and requires an experienced team of surgeons. If only some of the remaining tumors can be removed, then surgery is not usually performed.

Learn more about the basics of cancer surgery.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication.

Chemotherapy for testicular cancer is given directly into a vein so that it enters the bloodstream and reaches cancer cells throughout the body. There are also types of chemotherapy that can be taken by mouth but they are not generally used for testicular cancer.

A chemotherapy regimen (schedule) usually consists of a specific number of cycles of treatment given over a set period of time. A cycle of chemotherapy for testicular cancer typically lasts 3 weeks, and men with testicular cancer may receive 1 to 4 cycles of treatment, depending on the stage of the cancer. During treatment, a patient may receive 1 drug at a time or combinations of different drugs at the same time.

The following drugs are used for testicular cancer, usually in the combinations listed further below. However, the drugs used for testicular cancer change, and drugs other than those mentioned below may be used. Talk with your doctor about your options for chemotherapy.

  • Bleomycin (Blenoxane)

  • Carboplatin (Paraplatin)

  • Cisplatin (Platinol)

  • Etoposide (Toposar, VePesid)

  • Gemcitabine (Gemzar)

  • Ifosfamide (Ifex)

  • Oxaliplatin (Eloxatin)

  • Paclitaxel (Taxol)

  • Vinblastine (Velban)

The following chemotherapy regimens may be used for testicular cancer.

  • BEP: bleomycin, etoposide, and cisplatin

  • Carboplatin

  • EP: etoposide and cisplatin

  • TIP: paclitaxel, ifosfamide, and cisplatin

  • VeIP: vinblastine, ifosfamide, and cisplatin

  • VIP: etoposide, ifosfamide, and cisplatin

  • High-dose carboplatin and etoposide

In general, patients with later-stage disease receive more chemotherapy. The appropriate chemotherapy regimen depends on the stage of the cancer and whether it is a seminoma or a non-seminoma. In addition, how high AFP and beta-hCG levels are helps the doctor determine how much chemotherapy is needed. Chemotherapy regimens for specific stages are discussed further below.

Side effects of chemotherapy

Chemotherapy works very well for testicular cancer but can cause side effects and complications. Most of these side effects usually go away once treatment is finished, but some can show up much later. These are called late effects. Balancing the risks and benefits of chemotherapy is an important issue for men with testicular cancer. However, metastatic testicular cancer (see further below) can generally only be cured with chemotherapy. So, for men with metastatic testicular cancer, the benefits of chemotherapy typically outweigh the risks. On the other hand, men with stage I testicular cancer almost never die of the disease regardless of which treatment they receive, so the risks of chemotherapy may outweigh the benefits for these men. 

Learn more about the basics of chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. For testicular cancer, the radiation is generally directed at lymph nodes in the abdomen for men with stage I or II pure seminomas. Sometimes, the radiation treatment area includes lymph nodes on the same side of the pelvis as the testicle where the cancer started.

Radiation therapy for stage I seminoma is used less often than in the past. Surveillance or, less commonly, carboplatin chemotherapy is usually used instead of radiation therapy as the preferred treatment of stage I seminomas at many treatment centers because of the risk that radiation therapy may cause other cancers and heart disease. However radiation therapy remains an option for stage I, IIA, and IIB pure seminomas. It is also sometimes used to treat brain metastases from either seminomas or non-seminomas, but testicular cancer rarely spreads to the brain.

Side effects from radiation therapy

Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, loose bowel movements, and peptic ulcers. Medications may be helpful to prevent or reduce nausea and vomiting during radiation therapy. Most side effects go away soon after treatment is finished. Radiation therapy may cause problems with sperm production, but this is less common now with newer radiation techniques that can help men to preserve fertility.

Radiation therapy may increase risk of secondary cancers many years after treatment, as well as cardiovascular disease and gastrointestinal disease. Talk with your doctor about your risk of long-term side effects before starting radiation therapy.

Learn more about the basics of radiation therapy.

Treatment by stage of the cancer

The treatment choices for testicular cancer depend on whether the cancer is a seminoma or non-seminoma (see Overview) and the stage of the cancer (see Stages). After a physical examination, staging tests, and the removal of the cancerous testicle, you and your doctor will discuss your treatment options. Treatment options for early stage, later stages, and recurrent seminoma and non-seminoma are described in more detail below.

Clinical stage I non-seminoma testicular cancer

About one-fourth of patients with clinical stage I non-seminoma have small areas of metastatic cancer that cannot be seen by CT scans when diagnosed but will grow and be found with time unless they receive additional treatment after orchiectomy. The rest are cured when the testicle with cancer is removed. Most recurrences of stage I non-seminoma occur within 9 months after diagnosis and occur in the retroperitoneum. The options for men with clinical stage I disease are:

  • Surveillance. This option involves CT scans of the abdomen and pelvis every 3 to 6 months for the first year, every 4 to 9 months in the second year, and every 6 to 12 months in the third to fifth year. Chest x-rays with physical examinations and tumor marker tests to measure beta-hCG and AFP are done every 1 to 2 months for the first 12 months, every 2 to 3 months in the second year, every 3 to 4 months in the third and fourth years, every 6 months in the fifth year, and then annually. If the cancer recurs, 3 cycles of chemotherapy successfully treats more than 95% of men. RPLND may be used to treat recurrent cancer if it is limited to the retroperitoneal lymph nodes.

  • RPLND. As described above, this is surgery to remove the retroperitoneal lymph nodes in the back of the abdomen. After an RPLND, the risk of recurrence is less than 10% if no cancer is found at surgery. Most of these recurrences occur in the lungs or the lymph nodes in the chest and they almost always occur within 2 years after the RPLND.

  • Chemotherapy. This option involves receiving chemotherapy shortly after the testicle has been removed surgically, called adjuvant chemotherapy. The most commonly used approach has been to give 1 or 2 three-week cycles of BEP chemotherapy. The advantage of this approach is that it lowers the recurrence rate from 25% down to less than 3%. The main disadvantage is that 75% of patients do not need chemotherapy because they have already been cured with the surgical removal of the testicle. Therefore, some doctors recommend against using chemotherapy for clinical stage I non-seminoma, while others may recommend using adjuvant chemotherapy only for men who have a higher risk of recurrence so that fewer men receive unnecessary treatment. 

Clinical stage I seminoma testicular cancer

More than 80% of men with clinical stage I seminoma are cured with orchiectomy alone while the remaining 15% to 20% will have a recurrence if given no additional treatment. Most recurrences occur within 12 months after diagnosis and the location of the recurrence is typically in the retroperitoneum. Recurrences of stage I seminoma can almost always be cured with radiation therapy, although a few men will need chemotherapy.

  • Surveillance. Surveillance is the standard method of managing stage I seminoma. Using a surveillance program, the risk of death from stage I seminoma is less than 1%. Unlike surveillance for non-seminoma, surveillance for seminoma does not require frequent visits to the doctor. While this can vary, a common schedule includes doctor visits every 4 months for the first 2 to 3 years, every six months for the next 3 years, and then annually until at least 10 years after the original diagnosis. At each visit, the following are performed: a CT scan of the abdomen and pelvis, a chest radiograph, and a physical examination. Blood tests to measure the serum tumor markers beta-hCG and AFP may be done at the same time, but more research is needed to determine if testing serum tumor markers is helpful for these men. 

  • Adjuvant radiation therapy. This is radiation therapy given after surgery. Seminoma is much different from non-seminoma, and early-stage seminoma can be effectively treated with radiation therapy. The chance of recurrence can be decreased to less than 5% with 10 to 15 treatments of radiation therapy to the retroperitoneum. Additional radiation therapy to the pelvis does not reduce the overall risk of recurrence, but it does reduce the risk of a recurrence in the pelvis. Some doctors prefer to treat only the retroperitoneum. Others prefer to include the pelvis to prevent recurrences in that area and eliminate the need for imaging tests of the pelvis to watch for a recurrence.

  • The disadvantage of radiation therapy for clinical stage I seminoma is that more than 80% of men receive treatment that they do not need because they were cured with the orchiectomy. This is a concern because radiation therapy increases the risk of developing another cancer and heart disease.

  • Adjuvant chemotherapy. This is chemotherapy after surgery. Chemotherapy for stage I seminoma is a newer and more controversial treatment option than surveillance or radiation therapy. Using carboplatin, studies have shown that the risk of recurrence after orchiectomy can be reduced from 18% to about 2% using 2 doses of carboplatin and to about 5% using a single dose of carboplatin. Because the use of carboplatin is a newer approach, there is less information on long-term effects after treatment. Therefore, many experts believe that more information is needed before recommending this treatment approach. On the other hand, many other experts have accepted carboplatin as a new treatment option for stage I seminoma, and it is listed as a standard treatment option in most published testicular cancer treatment guidelines. The hope is that carboplatin will cause fewer complications than radiation therapy, but it won’t be known whether this is the case until the health of the men who have received carboplatin has been monitored for a longer period of time. Complications from cancer treatments sometimes do not appear until 10 to 20 years later.

Metastatic testicular cancer

If cancer has spread to another location in the body, it is called metastatic cancer. The most common place for testicular cancer to spread is the retroperitoneum.

Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer, because there can be different opinions about the best treatment plan. Patients may want to talk with doctors experienced in the treatment of metastatic testicular cancer, including getting a second opinion before starting treatment, so you are comfortable with the treatment plan chosen. This discussion may include clinical trials studying new treatments. However, testicular cancer is fast-growing, so it is important to start treatment right away. If a second is wanted, patients should talk with a doctor within 1 or 2 weeks.

The treatment plan your health care team may recommend is based on many individual factors, including whether the cancer has spread to the brain. In addition, LDH levels may be monitored for men with metastatic disease to determine the stage and how long chemotherapy is needed.

Initial treatment of metastatic testicular cancer is usually chemotherapy except when immediate treatment of the brain is needed, which is rare. Chemotherapy typically shrinks the size of such tumors in the brain and may remove them entirely over time. If there are any masses remaining after chemotherapy, surgery may be recommended. Radiation therapy to treat the spread of testicular cancer to the brain is controversial. If immediate treatment of a tumor in the brain is needed due to bleeding or swelling or other issues, then removing the mass surgically is usually preferred if it can be done safely, but radiation therapy may be recommended instead of or in addition to surgery depending on the situation. Palliative care will also be important to help relieve symptoms and side effects.

Descriptions of the treatment options for metastatic testicular cancer are described by stage below:

Clinical stage II non-seminoma testicular cancer

Surgery to remove the testicle is done first, followed by additional treatment. The choice of treatment after orchiectomy depends on a patient’s serum tumor marker levels, as well as the size of retroperitoneal lymph nodes. The options for men with clinical stage II non-seminoma after surgery are:

  • Chemotherapy. Combination chemotherapy is given after surgery to remove the testicle. Doctors generally recommend using chemotherapy immediately after surgery when serum tumor markers remain high after surgery, there are more than 5 enlarged lymph nodes, and/or there are lymph nodes larger than 2 cm. Men are encouraged to consider sperm banking before chemotherapy begins due to the risk of infertility.

  • RPLND. As described above, this is surgery to remove the retroperitoneal lymph nodes in the back of the abdomen. This is recommended after orchiectomy when the serum tumor marker levels have returned to normal, none of the lymph nodes is larger than 2 cm, and there are no more than 5 enlarged lymph nodes. Chemotherapy may still be needed after RPLND if a large amount of cancer is found in the removed lymph nodes. Men are encouraged to consider sperm banking before RPLND due to the risk of loss of normal ejaculation after surgery.

Clinical stage II seminoma testicular cancer

Surgery to remove the testicle and lymph nodes with cancer is done first, followed by additional treatment, usually chemotherapy. The main factor in the treatment decision after surgery for a stage II seminoma is the size of the retroperitoneal lymph nodes.

  • Chemotherapy. Chemotherapy with a combination of drugs is given after surgical removal of the testicle when the lymph nodes are larger than 5 cm or when there are enlarged lymph nodes spread out over a large area in the back of the abdomen. This is the preferred treatment for men with clinical stage IIC seminoma, as chemotherapy is more likely to get rid of the cancer. Men are encouraged to consider sperm banking before chemotherapy due to the risk of infertility.

  • Radiation therapy. When lymph nodes are less than 5 cm (stages IIA and IIB), surgery may be followed by radiation therapy to the lymph nodes in the abdomen and pelvis. Alternatively, chemotherapy may be used instead of radiation therapy. Experts disagree about whether radiation therapy or chemotherapy is the preferred option for these patients. Both approaches cure over 90% of patients with this stage. Men are encouraged to consider sperm banking before radiation therapy or chemotherapy due to the risk of infertility.

Stage III non-seminoma testicular cancer

  • Chemotherapy. Chemotherapy is used for men with non-seminoma that has spread beyond the testicles. The most common regimen given is BEP, which is a combination of bleomycin, etoposide and cisplatin (see chemotherapy, above). The treatments are given as 3-week cycles and patients receive either 3 or 4 cycles of chemotherapy for a total treatment period of 9 to 12 weeks. Each drug is given by IV. Cisplatin and etoposide are given each day on the first 5 days. IV fluid is given before and after the cisplatin to reduce the risk of damaging the kidneys. The treatment takes about 6 hours on these days. Bleomycin is given once each week, typically on the first, eighth, and 15th day of the 21-day cycles. The treatment takes about 30 minutes on the days when only bleomycin is given. Men are encouraged to consider sperm banking before chemotherapy due to the risk of infertility.
  • The likelihood of chemotherapy successfully treating this cancer depends on the risk group category (see Stages). More than half of metastatic non-seminoma testicular cancers are classified as good-risk, and more than 90% of these will be successfully treated with 3 cycles of BEP chemotherapy or 4 cycles of chemotherapy using etoposide and cisplatin. An important part of the treatment is surgical removal of any remaining masses after chemotherapy ends. About 25% of metastatic non-seminomas are intermediate-risk disease, and 80% of these are successfully treated with 4 cycles of BEP plus surgical removal of any remaining masses. Finally, about 15% of metastatic non-seminomas are poor-risk disease, and about 50% to 70% of these are cured with 4 cycles of BEP plus surgery to remove of any remaining masses. For patients with intermediate-risk or poor-risk disease who cannot be given bleomycin due to side effects, 4 21-day cycles of VIP chemotherapy regimen has been shown to work just as well as 4 cycles of BEP. VIP consists of etoposide, ifosfamide and cisplatin chemotherapy plus a medication called mesna. Each of the medications is given on the first 5 days of the 21-day cycle.

  • Surgery after chemotherapy. After chemotherapy is completed, x-rays and CT scans are repeated to see if there are any masses remaining. If masses are seen, then surgery to remove them is usually performed if this is possible. The chance of the surgery curing the cancer is higher if the serum tumor markers are in the normal range when chemotherapy ends. This surgery is difficult and requires an experienced surgeon who regularly performs such operations. Very rarely, if the mass is pressing on the kidney or major blood vessels in the retroperitoneum, then major surgery, such as removal of the kidney and/or blood vessel grafts, may be needed. Often in this situation the nerves that are responsible for ejaculation cannot be spared. It is recommended that men talk about this with their doctors, in addition to banking sperm, before any chemotherapy is given.

    During surgery, there is about a 40% to 50% chance that only scar tissue will be found, a 35% to 40% chance there will be teratoma, and a 10% to15% chance of some other type of germ cell tumor, such as embryonal carcinoma, seminoma, yolk sac tumor, or choriocarcinoma. If only scar tissue and/or a teratoma is found, then no additional treatment is needed. If cancer is found, 2 more cycles of chemotherapy may be given. The chemotherapy regimen used is typically either EP, TIP, VeIP, or VIP.

  • Clinical trials. Patients with poor-risk disease are also encouraged to consider clinical trials as a treatment option.

Metastatic (stage III) seminoma testicular cancer

  • Chemotherapy. Chemotherapy for metastatic seminoma is the same as for metastatic non-seminoma (see above). About 90% of metastatic seminomas are good-risk disease and are successfully treated with 3 cycles of BEP. Approximately 10% of metastatic seminomas are intermediate-risk disease and are generally treated with 4 cycles of BEP. Men are encouraged to consider sperm banking before chemotherapy due to the risk of infertility.

  • Surgery after chemotherapy/radiation therapy. It is quite common for a mass to be found on imaging tests after chemotherapy or radiation therapy is finished. There is less than a 10% chance that this mass contains cancer and almost no chance that it contains teratoma. The main treatment options are active surveillance or surgery. Such surgery is often very difficult due to a “scar-like” reaction that makes the mass difficult to remove. This is unique to seminoma. Larger masses are more likely to contain cancer, so some believe surveillance should be used when a mass is smaller than 3 cm and surgery should be used for a mass 3 cm or larger. A specific type of positron emission tomography (PET) scan, called an FDG-PET scan may be used. After the FDG-PET scan is done, the surgeon will operate only if the scan results show evidence of cancer in the remaining mass. One study showed that PET scans are more accurate than CT scans for determining if a remaining mass contains cancer, but it should be used only when the remaining mass is larger than 3 cm. The main benefit of PET scans is avoiding unnecessary surgery to remove masses that are noncancerous. If surgery is recommended but the surgeon determines that the mass cannot be removed, then a biopsy is often performed to try to find out whether the mass is cancerous. If cancer (seminoma) is found, then additional chemotherapy, referred to as second-line chemotherapy, is given. If active surveillance is recommended and the mass grows, second-line chemotherapy is the preferred treatment. Surgery can be considered if the mass remains after the chemotherapy. If an RPLND is performed, men should consider sperm banking before surgery because of the risk of infertility from the loss of normal ejaculation.

For most patients, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED. 

A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.

Regular follow-up examinations to check for signs that the cancer may be returning are extremely important. If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence). Testicular cancer does not often return as a local recurrence because the entire testicle is removed. A rising beta-hCG or AFP may be a sign that the cancer has returned and more treatment is needed. Men who have had a testicular cancer recurrence are encouraged to see a doctor who is an expert in treating recurrent testicular cancer.

When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the treatments described above such as surgery, chemotherapy, and radiation therapy, but they may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.

For recurrent testicular cancer, treatment usually includes chemotherapy and surgery. If the cancer was stage I and returns during active surveillance, then the most common treatment is chemotherapy with 3 or 4 cycles of BEP or 4 cycles of EP depending on the stage of the cancer. If the cancer is only in the retroperitoneal lymph nodes and is a pure seminoma, then radiation therapy is the usual treatment. If the cancer is only in the retroperitoneal lymph nodes and is a non-seminoma, RPLND alone may be considered instead of chemotherapy. 

The standard treatment for recurrent testicular cancer that has previously been treated with chemotherapy is 4 cycles of additional chemotherapy. The standard chemotherapy regimens include VeIP and TIP. Sometimes, high-dose chemotherapy with stem cell transplantation may be used but it is not known if high-dose chemotherapy works better than standard-dose chemotherapy. If chemotherapy is given, any remaining masses are managed the same way that they are after initial chemotherapy (see above). A recurrence more than 2 years after treatment should be removed surgically if possible. Chemotherapy may or may not be recommended. A man with recurrent testicular cancer is encouraged to talk with doctors who have experience in treating recurrent testicular cancers before choosing a treatment approach.

People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. Learn more about dealing with a cancer recurrence.

If treatment fails

Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.

This diagnosis is stressful, and advanced cancer is difficult to discuss for many people. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.

Patients who have advanced cancer and who are expected to live less than six months may want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families. Learn more about advanced cancer care planning.

After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

The next section in this guide is About Clinical Trials and it offers more information about research studies that are focused on finding better ways to care for people with cancer. Or, use the menu on the side of your screen to choose another section to continue reading this guide.  

Testicular Cancer - About Clinical Trials

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

ON THIS PAGE: You will learn more about clinical trials, which are the main way that new medical approaches are tested to see how well they work. To see other pages, use the menu on the side of your screen.

What are clinical trials?

Doctors and scientists are often looking for better ways to care for patients with testicular cancer. To make scientific advances, doctors create research studies involving volunteers, called clinical trials. In fact, every drug that is now approved by the U.S. Food and Drug Administration (FDA) was previously tested in clinical trials.

Many clinical trials are focused on new treatments, evaluating whether a new treatment is safe, effective, and possibly better than the current (standard) treatment. These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. Patients who participate in clinical trials are often among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.

There are also clinical trials that study new ways to ease symptoms and side effects during treatment and manage the late effects that may occur after treatment. Talk with your doctor about clinical trials regarding side effects. In addition, there are ongoing studies about ways to prevent the disease.

Deciding to join a clinical trial

Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that these studies are the only way to make progress in treating testicular cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with testicular cancer.

Sometimes people have concerns that, in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” However, placebos are usually combined with standard treatment in most cancer clinical trials. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in cancer clinical trials.

Patient safety and informed consent

To join a clinical trial, patients must participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so that the person understands the standard treatments and how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different than the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment.

Patients who participate in a clinical trial may stop participating at any time, for any personal or medical reason. This may include that the new treatment is not working or there are serious side effects. Clinical trials are also closely monitored by experts who watch for any problems with each study. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trial ends, and/or if the patient chooses to leave the clinical trial before it ends.

Finding a clinical trial

Research through clinical trials is ongoing for all types of cancer. For specific topics being studied for testicular cancer, learn more in the Latest Research section.

Cancer.Net offers a lot of information about cancer clinical trials in other areas of the website, including a complete section on clinical trials and places to search for clinical trials for a specific type of cancer.

In addition, this website offers free access to a video-based educational program about cancer clinical trials, located outside of this guide.

The next section in this guide is Latest Research and it explains areas of scientific research currently going on for this type of cancer. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Testicular Cancer - Latest Research

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

ON THIS PAGE: You will read about the scientific research being done now to learn more about this type of cancer and how to treat it. To see other pages, use the menu on the side of your screen.

Doctors are working to learn more about testicular cancer, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you.

Since treatment is successful for most men with testicular cancer, one of the major goals for the future is to reduce side effects and complications from treatment for men with early-stage or good-risk cancers. In addition, treatments for poor-risk and recurrent cancers are being studied in clinical trials, along with basic research on the causes and genetics of testicular cancer.

  • High-dose chemotherapy followed by stem cell transplantation. Higher doses of chemotherapy can put recurrent testicular cancer into remission. A stem cell transplant is a medical procedure in which diseased bone marrow is replaced by highly specialized cells, called hematopoietic stem cells. Hematopoietic stem cells are blood-forming cells found both in the bloodstream and in the bone marrow. For testicular cancer, a man’s own stem cells are removed from the body before high-dose chemotherapy is given. After chemotherapy, blood stem cells are infused back into the patient’s vein to replace the bone marrow and restore normal blood counts. Despite many studies, this has never been shown to be better than either the standard chemotherapy combination of BEP for first-line therapy for patients with poor-risk disease or the standard chemotherapy regimens of VeIP or TIP for men who have a recurrence after BEP. Researchers are also comparing this to high doses of the drug combination TICE, which is paclitaxel, ifosfamide, carboplatin, and etoposide, along with stem cell transplantation. Additional clinical trials are being done to investigate whether changes in high-dose chemotherapy are more effective.

  • New chemotherapy schedules. Researchers are looking into shorter schedules of BEP for patients with advanced disease.

  • Genetic studies. Researchers are analyzing the DNA from tumor samples of men with testicular cancer to find out if any specific genes are associated with testicular cancer. In addition, there are studies underway to look at possible inherited genetic factors leading to cryptorchidism and risk of testicular cancer.

  • Palliative care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current testicular cancer treatments in order to improve patients’ comfort and quality of life. Because more men are surviving testicular cancer, doctors are exploring the long-term effects of high-dose chemotherapy on brain function, such as memory loss, decreased speed of processing information, lowered attention span, anxiety, depression, and fatigue. Other studies focus on sperm quality and heart disease risk for testicular cancer survivors.

Looking for More About the Latest Research?

If you would like additional information about the latest areas of research regarding testicular cancer, explore these related items that take you outside of this guide:

  • To find clinical trials specific to your diagnosis, talk with your doctor or search online clinical trial databases now.

  • Review research on testicular cancer announced at the 2015 and 2013 ASCO Annual Meeting.

  • Visit ASCO’s CancerProgress.Net website to learn more about the historical pace of research for testicular cancer. Please note this link takes you to a separate ASCO website.

  • Visit the website of the Conquer Cancer Foundation to find out how to help support research for every cancer type. Please note this link takes you to a separate ASCO website. 

The next section in this guide is Coping with Side Effects and it offers some guidance in how to cope with the physical, emotional, and social changes that cancer and its treatment can bring. Or, use the menu on the side of your screen to choose another section to continue reading this guide.  

Testicular Cancer - Coping with Side Effects

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

ON THIS PAGE: You will find out more about steps to take to help cope with physical, social, and emotional side effects. This page includes several links outside of this guide to other sections of this website. To see other pages, use the menu on the side of your screen.

Fear of treatment side effects is common after a diagnosis of cancer, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

There are possible side effects for every cancer treatment, but patients don’t experience the same side effects when given the same treatments for many reasons. That can make it hard to predict exactly how you will feel during treatment. Common side effects from each treatment option for testicular cancer are described in detail within the Treatment Options section. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them. Side effects depend on a variety of factors, including the cancer’s stage, the length and dosage of treatment(s), and your overall health.

Talking with your health care team about side effects

Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them.

And, ask about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with testicular cancer. Learn more about caregiving.

In addition to physical side effects, there may be emotional and social effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies, including concerns about managing the cost of your cancer care

During and after treatment, be sure to tell the health care team about the side effects you experience, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care. Learn more by reading the Follow-up Care section of this guide or talking with your doctor.

The next section in this guide is Follow-up Care and it explains the importance of check-ups after cancer treatment is finished. Or, use the menu on the side of your screen to choose another section to continue reading this guide.  

Testicular Cancer - Follow-Up Care

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

ON THIS PAGE: You will read about your medical care after cancer treatment is completed, and why this follow-up care is important. To see other pages, use the menu on the side of your screen.

Care for people diagnosed with cancer doesn’t end when active treatment has finished. Your health care team will continue to check to make sure the cancer has not returned, manage any side effects, and monitor your overall health. This is called follow-up care.

This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. Men who had testicular cancer usually receive follow-up screening for at least 10 years after their treatment ends. However, even after this specific follow-up period ends, men should let any doctor treating them know that he has a history of testicular cancer. This includes the man’s general or primary care doctor, who can then monitor for possible long-term side effects throughout the man’s lifetime.

Learn more about the importance of follow-up care.

Watching for recurrence

One goal of follow-up care is to check for a recurrence. Cancer recurs because small areas of cancer cells may remain undetected in the body. Over time, these cells may increase in number until they show up on test results or cause signs or symptoms. During follow-up care, a doctor familiar with your medical history can give you personalized information about your risk of recurrence. Your doctor will also ask specific questions about your health. Some people may have blood tests or imaging tests as part of regular follow-up care, but testing recommendations depend on several factors including the type and stage of cancer originally diagnosed and the types of treatment given.

Managing long-term side effects

Most people expect to experience side effects when receiving treatment. However, it is often surprising to survivors that some side effects may linger beyond the treatment period. These are called long-term side effects. In addition, other side effects called late effects may develop months or even years afterwards. Long-term and late effects can include both physical and emotional changes.

Talk with your doctor about your risk of developing such side effects based on the type of cancer, your individual treatment plan, and your overall health. If you had a treatment known to cause specific late effects, you may also have certain physical examinations, scans, or blood tests to help find and manage them.

Below are some of the long-term side effects that are possible after treatment for testicular cancer.

  • Lung problems. Nine doses of bleomycin causes lung damage for about 5% of men and is fatal for less than 1% of men receiving the drug. Lung scarring is a possible long-term side effect. The risk factors for lung scarring are age (older than 70), cigarette smoking, previous lung injury, previous radiation therapy to the chest, impaired kidney function, or receiving additional doses. It is rare to have lung effects without these risk factors. Therefore, if a man has these risk factors and good-risk disease, 4 cycles of EP can be used instead of 3 cycles of BEP. If 4 cycles of chemotherapy are needed, ifosfamide can be used instead of bleomycin, but it is associated with more short-term side effects, such as infections. Bleomycin also makes the lungs more sensitive, and patients who need to receive extra oxygen during surgery may be at increased risk of developing lung damage related to the bleomycin.

    Two particularly important issues are:

    • Patients who smoke should stop smoking for many health reasons, but in particular to reduce the risk of lung injury from bleomycin.

    • The doctor should examine the patient’s lungs before each cycle of chemotherapy and stop giving bleomycin if lung injury is seen.

  • Kidney damage. Cisplatin can cause kidney damage. However, it is a very important drug to treat testicular cancer. Also, cisplatin has fewer side effects than carboplatin, which has also been shown to be less effective. The best way to prevent this problem is for cisplatin to be flushed out by giving the patient at least 1 liter of IV fluid before and after the drug is given. This reduces the risk of kidney damage. Research studies evaluating kidney function years after the doses have been given have shown low rates of long-term kidney damage and when it does occur, it is generally mild.

  • Heart and blood vessel problems. A condition called Raynaud’s phenomenon may be caused by bleomycin. This condition is associated with the blood vessels narrowing and the skin turning white, then blue, and then red when exposed to certain triggers, such as cold. This is especially common in the hands. Less than 10% of men develop Raynaud’s phenomenon. However, more men developed this condition when vinblastine and bleomycin were combined. This regimen is almost never used now. Avoiding the triggers, such as preventing the fingers from becoming cold, is the main treatment.

    Men who receive BEP chemotherapy may have higher cholesterol and blood pressure levels and an increased risk of heart disease and/or stroke. Radiation therapy has also been associated with an increased risk of heart disease. The increased risk is small and outweighed by the fact that it is necessary to treat the cancer. However, these side effects are more important when the doctor considers chemotherapy or radiation therapy to prevent the cancer from coming back for men with clinical stage I disease. A healthy diet, exercise, not smoking, and medications to lower cholesterol, control high blood pressure, or treat diabetes are ways to reduce the risk of heart disease and stroke.

  • Nerve damage. Cisplatin can sometimes damage the nerves, causing feelings of numbness or “pins and needles.” When this occurs, it most often starts during the chemotherapy and lessens and goes away with time. It may take months or even years to completely go away. Rarely, it can affect a person’s functioning, such as being clumsy when buttoning shirt buttons.

  • Hearing problems. Sometimes, men who received cisplatin may notice that they can no longer hear high-pitch sounds. This is more common with higher doses, and it is more likely for older men or men with previous hearing problems. It rarely affects young men but may be relevant for musicians or others who depend on having very fine hearing abilities. Another hearing-related side effect of cisplatin may be tinnitus, which is ringing in the ears.

  • Secondary cancers. Men who receive chemotherapy and/or radiation therapy for testicular cancer have an increased risk of developing other cancers in the future. The thought of developing another cancer can be concerning and difficult to face for many men. However, if the testicular cancer has metastasized (stage II or III), then the cancer is a fatal illness unless it is treated effectively. Chemotherapy and radiation therapy often play important roles in treating testicular cancer when the goal is to cure the disease. Thus, even though they pose some risk, chemotherapy and radiation therapy are sometimes the best options for controlling cancer growth and lengthening your life. The issue of secondary cancers may be particularly important for men with stage I disease and early stage II disease that can be cured with surgery alone. In such cases, men may have a choice between surgery alone versus surgery plus chemotherapy or radiation therapy. Each man needs to talk with his doctor about the role of chemotherapy and radiation therapy in his treatment, including why it is recommended and what the risks and benefits are. 

  • Fertility.The issue of fertility in men with testicular cancer is a complex topic because patients with testicular cancer often have a lower sperm count before any treatment is given. A man who has fertility problems after treatment should talk with his doctor about these factors:

    • Sperm count before chemotherapy

    • Whether he received chemotherapy or radiation therapy

    • How long ago the treatment was given

    • Whether an experienced surgeon performed a nerve-sparing RPLND to preserve ejaculation 

    A low sperm count does not necessarily mean that a man will be infertile after treatment because most patients will develop very low to no sperm counts while receiving chemotherapy. However, the chance of fertility returning after treatment increases over time but is lower for men with no or low sperm counts before chemotherapy. It is also important to ask about sperm banking before treatment.

  • Low testosterone. In addition to damage to the ability to make sperm, the cells that make testosterone may be damaged. If a man has a low testosterone level, then hormone replacement therapy can be used. As outlined in the Treatment Options section, symptoms of a reduced testosterone level include decreased sex drive, inability to achieve a normal erection and orgasm, fatigue, hot flashes, depression, mood changes, muscle and bone loss, as well as metabolic syndrome. Metabolic syndrome is a set of conditions, such as obesity, high levels of blood cholesterol and high blood pressure that increases a person’s risk of heart disease, stroke, and diabetes.

Keeping personal health records

You and your doctor should work together to develop a personalized follow-up care plan. Be sure to ask about any concerns you have about your future physical or emotional health. ASCO offers forms to help create a treatment summary to keep track of the cancer treatment you received and develop a survivorship care plan once treatment is completed.

This is also a good time to decide who will lead your follow-up care. Some survivors continue to see their oncologist, while others transition back to the general care of their family doctor or another health care professional. This decision depends on several factors, including the type and stage of cancer, side effects, health insurance rules, and your personal preferences.

If a doctor who was not directly involved in your cancer care will lead your follow-up care, be sure to share your cancer treatment summary and survivorship care plan forms with him or her, as well as all future health care providers. Details about your cancer treatment are very valuable to the health care professionals who will care for you throughout your lifetime.

The next section in this guide is Survivorship and it describes how to cope with challenges in everyday life after a cancer diagnosis. Or, use the menu on the side of your screen to choose another section to continue reading this guide.  

Testicular Cancer - Survivorship

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

ON THIS PAGE: You will read about how to cope with challenges in everyday life after a cancer diagnosis. To see other pages, use the menu on the side of your screen.

What is survivorship?

The word survivorship means different things to different people. Two common definitions include:

  • Having no signs of cancer after finishing treatment.

  • The process of living with, through, and beyond cancer. According to this definition, cancer survivorship begins at diagnosis and includes people who continue to have treatment over the long term, to either reduce the risk of recurrence or to manage chronic disease.

In some ways, survivorship is one of the most complex aspects of the cancer experience because it is different for every person.

Survivors may experience a mixture of strong feelings, including joy, concern, relief, guilt, and fear. Some people say they appreciate life more after a cancer diagnosis and have gained a greater acceptance of themselves. Others become very anxious about their health and uncertain of how to cope with everyday life.

Survivors may feel some stress when frequent visits to the health care team end following treatment. Often, relationships built with the cancer care team provide a sense of security during treatment, and people miss this source of support. This may be especially true as new worries and challenges surface over time, such as any late effects of treatment, emotional challenges including fear of recurrence, sexuality and fertility concerns, and financial and workplace issues.

Every survivor has individual concerns and challenges. With any challenge, a good first step is being able to recognize your fears and talk about them. Effective coping requires:

  • Understanding the challenge you are facing,

  • Thinking through solutions,

  • Asking for and allowing the support of others, and

  • Feeling comfortable with the course of action you choose.

Many survivors find it helpful to join an in-person support group or an online community of survivors. This allows you to talk with people who have had similar first-hand experiences. Other options for finding support include talking with a friend or member of your health care team, individual counseling, or asking for assistance at the learning resource center of the center where you received treatment.

Changing role of caregivers

Family members and friends may also go through periods of transition. A caregiver plays a very important role in supporting a man diagnosed with testicular cancer, providing physical, emotional, and practical care on a daily or as-needed basis. Many caregivers become focused on providing this support, especially if the treatment period lasts for many months or longer.

However, as treatment is completed, the caregiver's role often changes. Eventually, the need for caregiving related to the cancer diagnosis will become much less or come to an end. Caregivers can learn more about adjusting to life after caregiving in this article.

A new perspective on your health

For many people, survivorship serves as a strong motivator to make positive lifestyle changes.

Men recovering from testicular cancer are encouraged to follow established guidelines for good health, such as not smoking, limiting alcohol, eating well, and managing stress. Regular physical activity can help rebuild your strength and energy level. Your health care team can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about making healthy lifestyle choices.

In addition, it is important to have recommended medical check-ups and tests (see Follow-up Care) to take care of your health. Cancer rehabilitation may also be recommended, and this could mean any of a wide range of services such as physical therapy, career counseling, pain management, nutritional planning, and/or emotional counseling. The goal of rehabilitation is to help people regain control over many aspects of their lives and remain as independent and productive as possible.

Talk with your doctor to develop a survivorship care plan that is best for your needs.

Looking for More Survivorship Resources?

For more information about cancer survivorship, explore these related items. Please note these links will take you to other sections of Cancer.Net:

  • ASCO Answers Cancer Survivorship Guide: This 44-page booklet (available as a PDF) helps people transition into life after treatment. It includes blank treatment summary and survivorship care plan forms.

  • Cancer.Net Patient Education Video: View a short video led by an ASCO expert that provides information about what comes next after finishing treatment.

  • Survivorship Resources: Cancer.Net offers an entire area of this website with resources to help survivors, including for survivors in different age groups.

The next section offers Questions to Ask the Doctor to help start conversations with your cancer care team. Or, use the menu on the side of your screen to choose another section to continue reading this guide.  

Testicular Cancer - Questions to Ask the Doctor

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

ON THIS PAGE: You will find some questions to ask your doctor or other members of your health care team, to help you better understand your diagnosis, treatment plan, and overall care. To see other pages, use the menu on the side of your screen.

Talking often with the doctor is important to make informed decisions about your health care. These suggested questions are a starting point to help you learn more about your cancer care and treatment. You are also encouraged to ask additional questions that are important to you. You may want to print this list and bring it to your next appointment, or download Cancer.Net’s free mobile app for an e-list and other interactive tools to manage your care.

Questions to ask after getting a diagnosis

  • What type of testicular cancer do I have?

  • Are other tests or surgery needed to confirm this diagnosis?

  • What stage is my cancer? What does this mean?

  • Can you explain my pathology report (laboratory test results) to me? Could I have a copy?

Questions to ask about choosing a treatment and managing side effects

  • What treatment options do I have?

  • What clinical trials are open to me? Where are they located, and how do I find out more about them?

  • What treatment plan do you recommend?

  • Is this the standard treatment?

  • What is the goal of each treatment? Is it to eliminate the cancer, help me feel better, or both?

  • How often do you treat men with testicular cancer?

  • Who will be part of my health care team, and what does each member do?

  • Who will be coordinating my overall treatment?

  • What are the possible side effects of each treatment, both in the short term and the long term?

  • How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?

  • Could this treatment affect my sex life? If so, how and for how long?

  • Could this treatment affect my ability to have children? If so, should I talk with a fertility specialist before cancer treatment begins?

  • If I’m worried about managing the costs related to my cancer care, who can help me with these concerns?

  • How can I keep myself as healthy as possible during and after treatment?

  • What support services are available to me? To my family?

  • Whom should I call for questions or problems?

  • Is there anything else I should be asking?

Questions to ask about having surgery

  • What type of surgery will I have? Will lymph nodes be removed?

  • How experienced is the surgeon in orchiectomy and/or RPLNDs?

  • How long will the operation take?

  • How long will I be in the hospital?

  • Can you describe what my recovery from surgery will be like?

  • What are the possible long-term effects of having this surgery?

Questions to ask about having radiation therapy

  • What type of treatment is recommended?

  • What is the goal of this treatment?

  • How long will it take to give this treatment?

  • What side effects can I expect during treatment?

  • What are the possible long-term effects of having this treatment?

  • What can be done to relieve the side effects?

Questions to ask about having chemotherapy

  • What specific drugs are recommended?

  • What is the goal of this treatment?

  • How long will it take to give this treatment?

  • What side effects can I expect during treatment?

  • What are the possible long-term effects of having this treatment?

  • What can be done to relieve the side effects?

Questions to ask about planning follow-up care

  • What is the risk of the cancer returning? Are there signs and symptoms I should watch for?                                      

  • What long-term side effects or late effects are possible based on the cancer treatment I received?

  • What follow-up tests will I need, and how often will I need them?

  • How do I get a treatment summary and survivorship care plan to keep in my personal records?

  • Who will be coordinating my follow-up care?

  • What survivorship support services are available to me? To my family?

The next section in this guide is Additional Resources, and it offers some more resources on this website beyond this guide that may be helpful to you. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Testicular Cancer - Additional Resources

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2015

ON THIS PAGE: You will find some helpful links to other areas of Cancer.Net that provide information about cancer care and treatment. This is the final page of Cancer.Net’s Guide to Testicular Cancer. To see other pages, use the menu on the side of your screen.

Cancer.Net includes many other sections about the medical and emotional aspects of cancer, both for the person diagnosed and their family members and friends. This website is meant to be a resource for you and your loved ones from the time of diagnosis, through treatment, and beyond.

Beyond this guide, here are a few links to help you explore other parts of Cancer.Net:

This is the end of Cancer.Net’s Guide to Testicular Cancer. Use the menu on the side of your screen to select another section to continue reading this guide.