Testicular cancer

A painless lump or change in a testicle needs prompt examination and ultrasound. Pain does not rule cancer in or out; sudden severe testicular pain is an emergency because torsion can threaten the testicle. Ultrasound examines both testes and distinguishes a solid intratesticular lesion from other scrotal problems.

Most cancers here are germ-cell tumors. Nonseminoma includes embryonal carcinoma, yolk-sac tumor, choriocarcinoma and postpubertal teratoma. A mixed tumor containing a nonseminoma component is managed as nonseminoma even if it also contains seminoma. Teratoma can remain after chemotherapy and has different implications from scar tissue.

Lymphoma, sex-cord stromal tumors and paratesticular tumors are separate diagnoses. Expert pathology review is particularly useful for mixed or unusual findings. This guide focuses on postpubertal germ-cell cancer; childhood tumors can require a different approach.

Measure AFP, beta-hCG and LDH before removing the testicle and repeat them afterwards. Their expected decline matters: a persistently rising level can indicate disease beyond the testicle even when scans are unrevealing. A minor stable elevation can have another cause and should be checked before escalating treatment.

Pure seminoma does not explain a significant AFP elevation. Review the pathology, marker trend and possible non-cancer causes; a hidden nonseminoma component may change the treatment. Conversely, normal AFP and hCG do not exclude active cancer or teratoma.

Staging combines the removed tumor, imaging and serum-marker category. EAU 2026 uses UICC TNM 9; reports using AJCC 8 should identify that system rather than mix editions. For metastatic disease, IGCCCG risk grouping additionally uses histology, primary site, spread and prechemotherapy markers. Seminoma has good- and intermediate-risk groups; nonseminoma also has a poor-risk group.

The usual diagnostic treatment for a suspicious testicular germ-cell tumor is radical inguinal orchiectomy: removal through the groin with the spermatic cord. A routine needle biopsy through the scrotum is generally avoided. Selected small indeterminate lesions, a solitary testis or bilateral tumors may warrant a testis-sparing discussion with specialist pathology support.

Sperm banking should be discussed before treatment, ideally before surgery when feasible; cancer itself may already affect sperm production. Urgent, life-threatening metastatic disease can require chemotherapy before orchiectomy, so fertility and surgical timing must be coordinated rather than delaying critical care.

A testicular prosthesis is optional and addresses appearance, not hormone or sperm production. Ask about placement timing, healing and personal preference. One healthy remaining testicle can often support testosterone production and fertility, but baseline function should not be assumed.

For stage I seminoma with normalized markers and no visible spread, surveillance is generally preferred when reliable follow-up is possible. It avoids unnecessary treatment for people already cured by surgery. Adjuvant carboplatin is an alternative for selected patients; routine adjuvant radiation is usually avoided because late effects matter over a long lifetime.

For stage I nonseminoma, lymphovascular invasion is an important relapse-risk factor. Choices include surveillance, a short adjuvant BEP course or selected retroperitoneal lymph node dissection (RPLND). BEP means bleomycin, etoposide and cisplatin. The decision balances relapse risk, treatment harms and the ability to attend surveillance.

Surveillance is an active treatment strategy with scheduled markers and imaging, not discharge from care. If markers remain truly elevated after their expected decline, the patient may not belong on a stage I surveillance pathway.

Small equivocal retroperitoneal nodes with normal markers may need short-interval reassessment before being called metastases. Confirmed stage II seminoma can be treated with radiation or cisplatin-based chemotherapy according to extent and patient factors.

EAU 2026 also recognizes nerve-sparing RPLND as a primary option for carefully selected marker-negative, low-volume stage IIA/B seminoma with nodes no larger than 3 cm, performed in experienced specialist centers. It can avoid chemotherapy for some patients, but relapse may still require it. This is not an operation for every stage II seminoma.

Marker-negative, limited stage II nonseminoma can also favor RPLND, particularly when teratoma is suspected. Marker-positive or more extensive disease usually requires systemic chemotherapy. Many metastatic cancers are still treated with curative intent.

Chemotherapy intensity follows the risk group. Good-risk disease commonly receives three BEP cycles, or four EP cycles when bleomycin is unsuitable; higher-risk disease requires a different course. Cisplatin should not be casually replaced by carboplatin in curative metastatic treatment. Lung, kidney, hearing and nerve risks should be assessed before treatment.

After seminoma chemotherapy, a residual mass may be scar tissue. For masses larger than 3 cm, appropriately timed FDG-PET can help; EAU advises waiting at least two months after chemotherapy to reduce misleading inflammation. A single positive scan does not by itself prove treatment failure or justify immediate further therapy.

Nonseminoma is different: markers can normalize while teratoma or viable cancer remains. After first-line chemotherapy, a residual mass over 1 cm generally requires surgical assessment and resection when appropriate. PET cannot reliably replace this decision. Smaller residuals and residual disease after salvage treatment need separate specialist judgment.

Recurrence after surveillance is different from progression after cisplatin chemotherapy. Review prior drugs, response, relapse interval, markers and all disease sites. Options can include conventional-dose salvage combinations, high-dose chemotherapy with autologous stem-cell support, and surgery for residual or selected late-relapsing disease.

High-dose treatment is not automatically superior for every first relapse. The TIGER randomized study compares these approaches; do not treat a study being followed as a proven result or an available enrollment place. A germ-cell tumor center should assess the sequence before several unrelated salvage regimens are tried.

Fertility, erections, ejaculation and testosterone are related but distinct. RPLND can affect ejaculation; nerve-sparing techniques may reduce this risk where oncologically appropriate. Chemotherapy can temporarily or permanently affect sperm production. A fertility team can discuss stored sperm and options when a sample cannot be obtained.

During chemotherapy, fever, new breathlessness, chest pain or a swollen painful leg needs urgent advice. Beyond nausea and blood-count changes, discuss bleomycin lung toxicity, cisplatin kidney or hearing problems and neuropathy. Persistent fatigue or sexual symptoms after treatment may warrant a testosterone assessment, not an assumption that they are simply psychological.

Follow-up depends on seminoma versus nonseminoma, stage and previous treatment. It combines clinical review, markers and scheduled imaging. MRI can replace some abdominal CT examinations in experienced centers, reducing radiation exposure. PET is not a routine surveillance test.

A survivorship plan also addresses blood pressure, cardiovascular risk, hearing, kidney function, nerve symptoms, testosterone and fertility. New symptoms still need assessment after the most intensive surveillance period. Keep the pathology, pre- and postoperative marker series, scans, chemotherapy details and fertility records available.

Ask the reviewing team to state the histology, stage and risk group separately; explain the purpose of each proposed treatment; and specify who will arrange follow-up if care crosses countries.