Most often, testicular cancer is diagnosed when a man finds a painless mass in his scrotum and brings it to the attention of his physician. At other times, either the mass will be discovered on a routine health check-up or it will be painful. Painful masses are more likely to be infections, but testicular cancer should still be considered. Prompt diagnosis and treatment are essential, since many testicular cancers grow rapidly. In about 10% of patients, the initial symptoms of testicular cancer may spread to other parts of the body. These symptoms are very variable, and may include back pain, bone pain, cough, shortness of breath, or swollen lymph nodes.

Most testicular cancers belong to a group of tumors known as germ cell tumors (GCT’s). These tumors can also arise in other parts of the body, in which case they are known as extragonadal GCT’s.

The diagnosis and prognosis of testicular cancer includes the following:

Review of Medical History

Your doctor will ask about your symptoms and details of your medical history. He or she will ask if you had any problems with your genitals when you were a child, specifically undescended testicle (cryptorchidism), hydrocele, or inguinal hernia. Similar problems and cancers that occurred in your relatives (particularly first-degree relatives) are also important. He or she will then ask a number of other questions about your symptoms and your general health.

Physical Exam

A complete physical examination is the next step. The most important part of the physician exam will, of course, be an examination of your scrotum and testicles. Your doctor will also carefully examine your groin for swollen lymph nodes.

Diagnostic Testing

Following the history and physical, additional tests will be arranged. They will likely include the following:

Blood tests – a sample of your blood is taken for routine testing and to measure the levels of certain tumor markers. Tumor markers are chemicals that sometimes appear in the blood if cancer is present in the body. Testicular cancer produces two such markers:

  • Alpha fetoprotein (AFP)
  • Human chorionic gonadotropin (beta-hCG)

These chemicals not only help diagnose the disease, they are also used to monitor the success of treatment.

Another substance in the blood, the liver enzyme LDH (lactic dehydrogenase), is usually elevated in advanced cases of cancer. It may also be measured to help diagnosis the disease and to monitor the success of treatments.

Ultrasonography – an ultrasound examination is the key test in diagnosing testicular cancer. It uses sound waves to find tumors, similar to the sonar in submarines. If it shows a mass that is solid, then it is highly likely to be cancerous and the testicle will most likely be surgically removed.

Biopsy of the testicle – (removal of a small portion for examination under the microscope) is rarely done, since it can lead to complications and may even reduce the chance of cure.

Radical inguinal orchiectomy – this is the removal of an entire testicle for laboratory examination to check for cancer. Usually, if a suspicious mass is seen on ultrasound, the testicle is completely removed. This is done by an incision in the groin, not by an incision through the scrotum. The other testicle can perform all the necessary functions, such as producing sperm and male hormones, although some men with testicular cancer are found to have low sperm counts for unclear reasons.

Chest x-ray – this is a series of standard x-ray images of your chest. If cancer is confirmed by biopsy, it may have spread into the lymph nodes in your chest. The chest x-ray is done to check for this spread.

CT scan – this is a type of x-ray that uses a computer to produce cross-sectional images of the inside of the body, and can be used to help determine if the cancer has spread and where it has ended up. Because of the tendency of testicular cancer to spread to lymph nodes in the retroperitoneum (area in the back of the abdomen), a CT scan of the abdomen and pelvis is routinely done.


Cytology is the study of cells. The cytology of cancer cells differs significantly from normal cells, and physicians use the unique cellular features seen on biopsy samples to determine the diagnosis and assess the prognosis of a cancer.

The testicle will be examined under a microscope to determine the precise cytology of the cancer. There are two categories of germ cell tumors: seminoma and non-seminoma. And there are four subcategories of non-seminoma tumors:

  • Embryonal carcinoma
  • Teratoma
  • Choriocarcinoma
  • Endodermal sinus (yolk sac) tumor

Several different types may appear in the same biopsy. With mixed types, treatment is directed toward the most aggressive component. Any testicular cancer with even a small non-seminoma component is treated as a non-seminoma, even if the majority of the tumor is seminoma. Seminomas peak in incidence about ten years later than non-seminomas and are less aggressive. Seminomas respond very well to radiation therapy, while non-seminomas do not.


Staging is the process by which physicians determine the prognosis of a cancer that has already been diagnosed. Staging is essential for making treatment decisions (e.g., surgery vs. chemotherapy). Several features of the cancer are used to arrive at a staging classification, the most common being the size of the original tumor, extent of local invasion, and spread to distant sites (metastasis). Low staging classifications (0 – 1) imply a favorable prognosis, whereas high staging classifications (4 – 5) imply an unfavorable prognosis.

If cancer is found, the prognosis and treatment depend on the type, location, size, and stage of the cancer and your general health. For most stages of testicular cancer the cure rate is currently over 90%.

TNM (Tumor, Node, Metastasis) System:

This system characterizes three aspects of testicular cancer: information about the primary tumor (T), the lymph nodes (N), and the presence of distant metastasis (M). The higher numbers reflect a greater degree of abnormality and spread. In addition to the TNM stage, the blood levels of tumor markers are incorporated in the staging system.

This classification system, created by the American Joint Committee on Cancer (AJCC) and World Health Organization, is the preferred one because it considers many useful factors.

Tumor (T) Stage:

  • TX: primary tumor cannot be assessed
  • T0: no evidence of primary tumor
  • Tis (in situ): intratubular cancer without spread to other areas
  • T1: tumor limited to the testis and epididymis, without spread to nearby blood vessels
  • T2: tumor in the blood vessels or the thin tissue layer surrounding the inside of the scrotum (called the tunica vaginalis)
  • T3: tumor in the spermatic cord
  • T4: tumor in the wall of the scrotum

Nodal (N) Stage:

  • N0: no lymph node involvement
  • N1: spread to lymph node or nodes, each 2 centimeters (cm) or less in size
  • N2: spread to lymph node or nodes, the largest more than 2 cm but no more than 5 cm in size
  • N3: spread to lymph node or nodes, more than 5 cm in size

Metastasis (M) Stage:

  • M0: no distant metastasis; the cancer has not spread
  • M1: distant metastasis; the cancer has spread:
    • M1a: cancer has spread to lymph nodes in other areas of the body (nonregional lymph nodes) or to the lungs
    • M1b: cancer has spread to places other than nonregional lymph nodes and lungs

Serum (Blood) Tumor Markers

The serum tumor marker stage, described in the table below, is based on the blood levels of certain tumor markers:

  • Alpha fetoprotein (AFP)
  • Human chorionic gonadotropin (beta-hCG)
  • Lactic dehydrogenase (LDH)

Serum Tumor Marker StageLDHhCG (mIU/ml)AFP (ng/ml)
S0Within normal limitsWithin normal limitsWithin normal limits
S1Less than 1.5 times N*Less than 5000Less than 1000
S21.5 to 10 times N*5000–50,0001000–10,000
S3More than 10 times N*More than 50,000More than 10,000
N* indicates upper limit of the normal range of the LDH test, which can vary based on the laboratory where the test is done.

Stage Groupings

The above factors (Tumor, Nodes, Metastases, and Serum Tumor Markers) are combined to assign a stage to the tumor. Staging is very important since it will determine the treatment that is recommended and the prognosis.

Overall Stage of Testicular Cancer
StageTumor StageNodal StageMetastasis StageSerum Tumor Marker Stage
Stage 0TisN0M0S0
Stage 1T1–4N0M0S0
Stage ISAny TN0M0S1–3
Stage IIAAny TN1M0S0 or S1
Stage IIBAny TN2M0S0 or S1
Stage IICAny TN3M0S0 or S1
Stage IIIAAny TAny NM1aS0 or S1
Stage IIIBAny TN1–3M0S2
Any TAny NM1aS2
Stage IIICAny TN1–3M0S3
Any TAny NM1aS3
Any TAny NM1bAny S


Prognosis is a forecast of the probable course and/or outcome of a disease or condition. Prognosis is most often expressed as the percentage of patients who are expected to survive over five or ten years. Cancer prognosis is a notoriously inexact process. This is because the predictions are based on the experience of large groups of patients suffering from cancers at various stages. Using this information to predict the future of an individual patient is always imperfect and often flawed, but it is the only method available. Prognoses provided in this monograph and elsewhere should always be interpreted with this limitation in mind. They may or may not reflect your unique situation.

Germ cell tumors may be divided into good, intermediate, and poor prognosis based on the type of tumor, its site of origin and extent of spread, and serum tumor markers:

Good Prognosis

For patients with pure seminomas:

  • Any primary site of tumor (tumors that started in the testicle or elsewhere in the body).
  • If metastases are present in the organs of the body, they are in the lungs only.
  • Normal serum AFP, any serum HCG or LDH.

For patients with non-seminomas:

  • Tumors that start in the testicle or the retroperitoneum (area in back of abdomen).
  • If metastases are present in the organs of the body, they are in the lungs only.
  • Serum AFP less than 1000 ng/ml, HCG less than 5000 mIU/ml, and LDH less than 1.5 times the upper limit of normal.

Intermediate Prognosis

For patients with pure seminomas:

  • Tumors that start in the testicle or retroperitoneum.
  • Metastases to organs other than the lungs (liver, bone, brain, etc.).
  • Normal serum AFP, any HCG or LDH.

For patients with non-seminomas:

  • Tumors that start in the testicle or retroperitoneum.
  • If metastases are present in the organs of the body, they are in the lungs only.
  • Any of the following: AFP 1000-10,000 ng/ml, HCG 5000-50,000 mIU/ml, LDH 1.5 to 10 times the upper limit of normal.

Poor Prognosis

No patients with pure seminomas are in this category.

For patients with non-seminomas:

  • Tumors that start in the mediastinum (center of the chest).
  • Metastases to organs other than the lungs (liver, bones, brain, etc.).
  • Any of the following: AFP more than 10,000 ng/ml, HCG more than 50,000 mIU/ml, LDH more than 10 times the upper limit of normal.