Testicular cancer is a malignant tumour of the testicle. Overall it is a rare cancer, but it is the most common cancer in young men between about 20 and 40 years of age. The most important message is this: any newly noticed hardening, any palpable lump, and any increase in the size of a testicle should be assessed by a urologist promptly — testicular cancer often causes no pain at first, which is exactly why a painless change should not be watched for weeks or pushed aside. At the same time, testicular cancer is one of the most curable cancers: detected early, the chances of a cure are close to 100%, and even when lymph nodes or other organs are already affected, the disease can often still be cured completely. In Switzerland, around 480 men develop testicular cancer every year, at a median age of about 38 — this sets testicular cancer clearly apart from most other cancers, which mainly affect older people.
Seminoma and non-seminoma
Most testicular tumours develop from the germ cells that normally give rise to sperm. These germ cell tumours are divided into two main groups, whose treatment and follow-up differ in some respects.
Seminoma consists of a particular form of degenerated germ cells and tends to occur somewhat later than non-seminoma, often between the ages of 30 and 45. Seminomas often grow a little more slowly and respond particularly well to chemotherapy and, in principle, to radiotherapy too — radiotherapy is used much more cautiously today than in the past, however, because of possible long-term side effects. In a pure seminoma, the tumour marker alpha-fetoprotein (AFP) cannot be raised by the tumour itself; if AFP is clearly elevated, a non-seminomatous component must therefore be assumed.
Non-seminoma is an umbrella term for several germ cell tumours: embryonal carcinoma, yolk sac tumour, choriocarcinoma, teratoma, and mixed germ cell tumours. As soon as a non-seminomatous component is present alongside a seminoma, the tumour as a whole is treated as a non-seminoma. Non-seminomas often occur in younger men and can sometimes grow faster or spread early to lymph nodes and other organs, but they too generally respond very well to cisplatin-based chemotherapy.
Warning signs: which changes should be checked
Testicular cancer usually shows itself as a painless change in a testicle: a newly noticed hardening, a palpable lump, an increase in size, a change in shape or surface, an unusual feeling of heaviness on one side, a pulling or pressure sensation in the testicle or groin, a newly appearing fluid collection in the scrotum, a noticeable change in consistency, a testicle becoming smaller, or persistent, unexplained testicular pain. Pain does not rule out a testicular tumour — some patients experience tenderness or symptoms that can initially look like inflammation. Not every lump in the scrotum is testicular cancer; it is often, for example, an epididymal cyst, a fluid collection, dilated veins, or inflammation, which an ultrasound can usually clarify quickly.
Sudden, severe testicular pain is an emergency. If sudden severe pain, swelling, or an unusually high-riding testicle occurs, an emergency department or a urology practice must be visited immediately. The cause may be testicular torsion, in which the spermatic cord twists and cuts off the testicle's blood supply — it must be treated surgically within a few hours.
Unusual symptoms outside the testicle. Testicular cancer can occasionally cause symptoms that seem to have nothing to do with the testicle: newly developing breast tissue in men, a painful swelling of breast tissue, persistent back or abdominal pain, coughing or shortness of breath, unexplained weight loss, marked fatigue, or swelling in the neck. Newly developing gynaecomastia (enlargement of male breast tissue) can, in rare cases, be caused by the hormone β-hCG produced by the tumour — most often it has other, benign or hormonal causes, but in young men it should still be assessed medically, especially if a testicular change is present at the same time. Back or abdominal pain, too, usually has other causes, but with a testicular tumour it can result from enlarged lymph nodes at the back of the abdomen.
Please come in for a urological examination if you notice a new hardening, a lump, an increase in size, or any other unusual change in a testicle — even if the change doesn't hurt, you otherwise feel completely healthy, the change is only small, you're unsure whether you're just feeling the epididymis, the examination feels uncomfortable to you, or you notice unusual changes outside the testicle such as breast growth. An examination is straightforward, painless, and takes only a few minutes; it is better to have a harmless change checked once too often than to overlook a finding that needs treatment for a long time.
Screening and self-examination
For men without symptoms or particular risk factors, there is no established early-detection programme involving regular ultrasound or blood tests; tumour markers are also unsuitable as a general screening test, since they can remain normal in many early testicular tumours. Young men should nonetheless know their bodies and pay attention to changes in the testicles. An occasional self-examination, for example after a warm shower, can help notice new changes early: each testicle is felt individually and carefully between thumb and fingers. Testicles are normally smooth and of an evenly firm, but not rock-hard, consistency; it is normal for one testicle to hang a little lower or be slightly larger than the other, and at the back, the softer epididymis can be felt as an elongated structure. What matters is not that both testicles are perfectly identical, but whether something has changed compared with before. A self-examination never replaces a medical examination and ultrasound if a finding is noticed.
Risk factors
The precise cause of a testicular tumour usually cannot be determined in an individual case, and many of those affected have no identifiable risk factor. The risk of disease is particularly increased with a congenital undescended testicle (even if it was operated on later), a previous testicular tumour, testicular cancer in a brother or father, a markedly smaller or poorly developed testicle, certain disorders of testicular development, an already confirmed germ cell neoplasia in situ, or possibly reduced fertility or abnormal semen quality. A previous blow or sports injury does not cause testicular cancer — such an event, however, often leads to an already-existing lump being noticed for the first time. Vasectomy, sexual activity, or masturbation do not increase the risk of testicular cancer either.
Diagnosis
For a suspicious change, a physical examination of both testicles is carried out first, followed by a high-resolution ultrasound. This can usually reliably establish whether a change is inside or outside the testicle, whether it is fluid-filled or solid, whether it looks benign or suspicious for a tumour, whether it shows abnormal blood flow, and whether it affects one or more areas; both testicles are always examined.
Tumour markers in the blood. If a testicular tumour is suspected, alpha-fetoprotein (AFP), beta human chorionic gonadotropin (β-hCG), and lactate dehydrogenase (LDH) are measured before surgery. These tumour markers support classification and staging, help assess treatment success after surgery, and are sometimes also monitored during follow-up. Normal tumour markers do not, however, rule out a testicular tumour — especially in an early seminoma, all values can be normal.
Imaging. If the suspicion of testicular cancer is confirmed, a CT scan of the chest, abdomen and pelvis is usually carried out to check whether lymph nodes or other organs are affected. In selected situations, an MRI may be needed instead or in addition.
How is the diagnosis confirmed? With a clearly tumour-suspicious finding, a needle biopsy through the skin of the scrotum is not normally performed. The standard treatment is surgical exposure of the testicle through a small incision in the groin; the affected testicle is removed together with the spermatic cord (inguinal orchiectomy). The tissue is then carefully examined histologically — only this can reliably establish whether a seminoma, a non-seminoma, or another, rarer testicular tumour is present. In special situations — for example a small, potentially benign tumour, a solitary testicle, or bilateral tumours — testis-sparing surgery can be considered at a specialised centre; for a typical germ cell tumour, however, this is not the standard approach.
Fertility, hormone function, and removal of the testicle
Testicular cancer often affects young men whose family planning is not yet complete. The disease itself can already affect sperm quality, and removal of the affected testicle, together with any chemotherapy that may be needed, can reduce fertility later on — which is why we discuss this topic before surgery. We check testosterone levels to document the baseline hormonal situation, and depending on the individual situation, further hormone levels can be measured as well. In young patients, and especially where family planning is not yet complete, we arrange an urgent referral to a fertility centre for sperm cryopreservation before removal of the testicle, in which sperm cells are collected, frozen, and stored for a possible future wish to have children. This option should be discussed even if there is no concrete wish for children at present — the necessary tumour treatment must not, however, be delayed in a medically significant way as a result. With a healthy second testicle, testosterone production, sexual function, and natural fertility are usually preserved after removal of one testicle, though there is no guarantee of this.
What does removal of a testicle mean? With a healthy second testicle, removal usually leads to neither reduced erectile function nor loss of sexual desire; the remaining testicle can usually take over the necessary testosterone production completely. With symptoms such as marked fatigue, reduced performance, decreased sexual desire, or erectile dysfunction, hormone status can be rechecked.
Testicular prosthesis. On request, a testicular prosthesis can be inserted, which replaces the appearance and weight of the removed testicle in the scrotum, but has no hormonal or reproductive function. It can be inserted either during the same operation or at a later time; whether a prosthesis is wanted is a personal decision, discussed calmly before the procedure.
Treatment at stage I
At stage I, the tumour is confined to the testicle, and after removal of the affected testicle, imaging and tumour markers are normal. Many patients are already cured by the surgery; whether additional treatment is needed depends in particular on whether a seminoma or non-seminoma is present and which histological risk factors were found.
Seminoma at stage I. After surgery, active surveillance is often the preferred strategy, with medical check-ups, tumour marker measurements, and CT or MRI scans according to a defined schedule. Active surveillance does not mean doing nothing — it avoids potentially unnecessary additional treatment, but requires that the agreed check-ups are reliably kept. If a relapse occurs, it is usually detected early through structured follow-up and can be treated successfully with a very high probability. In selected situations, a single course of chemotherapy with carboplatin can be considered; preventive radiotherapy is no longer used routinely today, because of possible long-term risks.
Non-seminoma at stage I. Active surveillance can be possible here too. An important risk factor is the detection of tumour cells in the blood or lymphatic vessels of the removed testicle — if such vascular invasion is present, the risk of relapse is higher. Depending on individual risk and personal preference, options include active surveillance, a single preventive cycle of BEP chemotherapy (a combination of the drugs bleomycin, etoposide and cisplatin), or, in rare, selected situations, surgery on the lymph nodes at the back of the abdomen. The benefits and possible short- and long-term side effects are discussed in detail before the decision is made.
Advanced disease and excellent chances of a cure
If the tumour has spread to lymph nodes or other organs, treatment depends on whether a seminoma or non-seminoma is present, the extent of the disease, the level of the tumour markers, the organs affected, the individual prognosis group, and the patient's general health. The most important treatment is usually cisplatin-based combination chemotherapy, often following the BEP regimen; depending on the situation, a different drug combination or additional surgery may be needed. In non-seminoma, tumour masses remaining after chemotherapy can be surgically removed, as they may still contain active tumour tissue or a teratoma; in seminoma, remaining findings are mostly monitored with imaging first, depending on their size and development. Treatment of advanced testicular tumours should take place in close collaboration with an experienced interdisciplinary centre.
Testicular cancer is one of the most curable malignant diseases: if the tumour is confined to the testicle, the chances of a cure are close to 100%. It is particularly important to know that testicular cancer can still be curable even when lymph nodes or other organs are already affected at diagnosis — unlike with many other metastatic cancers, treatment is therefore usually still carried out with the aim of a complete cure. Individual chances of a cure depend, among other things, on the tumour type, its spread, the level of the tumour markers, and the response to treatment; modern cisplatin-based chemotherapies, however, often allow a lasting cure even in advanced disease. A diagnosis of metastases in testicular cancer therefore explicitly does not mean that only palliative treatment is still possible — what matters is rapid, consistent therapy and care in close collaboration with an experienced testicular tumour centre.
Follow-up care
After treatment is completed, regular check-ups take place according to a defined follow-up plan. These can include a medical examination, self-examination of the remaining testicle, monitoring of tumour markers, CT or MRI scans, checking testosterone levels if relevant symptoms occur, counselling on fertility and family planning, and recording any possible long-term effects of treatment. After chemotherapy, particular long-term attention is paid to cardiovascular risk factors, kidney function, hearing, nerve damage, and hormonal changes; a healthy diet, regular exercise, not smoking, and monitoring blood pressure and blood lipids are especially important for former testicular cancer patients.
Changes in the testicles concern a very personal area and are sometimes pushed aside for a long time out of uncertainty or embarrassment. For us, assessing them is a routine part of urological care — if you notice a new hardening, a lump, an increase in size, or any other suspicious change in a testicle, please don't wait. A newly developing enlargement of the male breast or persistent back and abdominal pain can also be reason for an examination. Most palpable changes are benign, and a brief examination together with an ultrasound can usually clarify the situation quickly and reliably. If a testicular tumour is found, we coordinate further diagnostics and treatment in close collaboration with a specialised centre, taking into account not only cure but also the preservation of fertility, hormone function, sexuality, and quality of life.