PANPACIFIC UNIVERSITY NORTH PHILIPPINES

Urdaneta City, Pangasinan

College of Nursing

Testicular Cancer

In Partial Fulfillment
of the
Requirements
in
NCM 104
Related Learning Experience
(2nd Rotation)

Submitted by:
Garcia, Neil
Ladio, Jean
Manaois, Jake

Submitted to:
Ms. Ruby-Ruth Pascual, RN
Clinical Instructor

August 2010
I. OVERVIEW

Definition

Malignant testicular tumors primarily affect young to middle-aged

men (15-40 years old) and are the most common solid tumor in this
group. In children, testicular tumors are rare. The cure rate is
greater than 90% for all stages of the disease.

Classifications

Testicular cancers are classified as germinal, nongerminal, and

secondary.

Germinal Tumors may be further classified as Seminomas or

Nonseminomas. Seminomas are tumors that develop from the sperm
producing cells of the testes. These tumors tend to be localized and
are most common at the age of 65 years. Nonseminomas however, are
tumors that grow quickly and tend to develop earlier in life than
seminomas usually occurring in men in their 20’s.

Nongerminal Tumors develop in the supportive and hormone-producing

tissues, or stroma, of the testicles. The two main types of stromal
tumors are Leydig Cell Tumors and Sertoli Cell Tumors. Leydig cell
tumors develop in men and 25% develop in boys. Most tumors of this
type are benign and are treated successfully with surgery. If the
tumor metastasizes, it often does not respond well to radiation or
chemotherapy and the prognosis is poor. Sertoli cell tumors develop
in Sertoli cells that nourish the sperm-producing germ cells. These
tumors are usually benign; metastatic tumors of this type are rare,
yet resistant to treatment.

Secondary tumors in the testicles usually migrate from the lymph or

lymph nodes. Testicular lymphoma is more common than primary
testicular cancer in men over 50. Other cancers (e.g., prostate,
lung, skin, kidney) may also spread to the testicles.

Risk Factors

The major risk factors for testicular cancer are cryptorchidism

(i.e., a condition in which the testes do not descend into the
scrotum; also called undescended testicle) and Klinefelter's
syndrome (i.e., a
congenital disorder caused by an extra X chromosome that results in
failure of the testicles and usually is diagnosed after puberty).
Other risk factors include a family or personal history of
testicular cancer and genetic abnormality of chromosome 12. Race and
ethnicity is also a risk factor. Caucasian men are five times
greater risk than the African American and more than the double the
risk o Asian men. Occupational hazards, including exposure to
chemicals encountered to mining, oil and gas production, and leather
processing have been suggested as possible risk factors.

Causes

The cause of testicular cancer is unknown. One theory suggests that

testicular germ cell tumors form when germ cells develop into sperm
cells with 46 chromosomes. Normally, germ cells with 46
chromosomes develop into sperm cells with 23 chromosomes (during a
process called meiosis).

II. ANATOMY AND PHYSIOLOGY

The testicles (also called testes or gonads) are the male sex
glands. They are located behind the penis in a pouch of skin called
the scrotum. The testicles produce sperm and testosterone. The
testicles are located outside the body because sperm develop best at
a temperature several degrees cooler than normal internal body
temperature.

The germ cells inside the seminiferous tubules (sertoli cells)

create sperm. The sperm move into the epididymis where they mature.
They are stored there for a few weeks until they eventually move up
the vas deferens to combine with fluids from the prostate and
seminal vesicles to form what you normally think of as semen. The
whole process takes about 7 weeks.

The leydig cells distributed throughout the testicle are the body's
main source of testosterone. Testosterone, the male sex hormone, is
essential to the development of the reproductive organs and other
male characteristics such as body and facial hair, low voice, and
wide shoulders. Without enough testosterone, a man will probably
lose his sex drive and suffer from fatigue, depression, hot flashes
and osteoporosis.
III. PATHOPHYSIOLOGY

Risk Factors

Cryptorchidism Hereditary Predisposition Race and Ethnicity

Occupational Hazards Chemical Carcinogens

Genetic Mutation

The risk factors above may interfere with the cell’s genetic
material, interfering with normal gene replication before cell
division takes place

Uncontrolled Cell Growth

Cancer cells keeps growing and

multiplying even after lost cells have
been replaced.

Signs and Symptoms Metastasis

Appear
 mass or lump Cancer cell may
 heaviness in the also spread from
scrotum, inguinal their origin site
area, or lower with following
abdomen signs and symptoms
 backache
 abdominal pain
 weight loss
 general
weakness
 chest pain
 cough
 shortness of
breath
IV. CLINICAL MANIFESTATIONS

Important Facts
Signs of testicular cancer include a lump or mass in the scrotum
 Other symptoms include testicular swelling, enlargement, and
abdominal pain
 Some types of testicular tumors increase hormones and cause
breast enlargement
 Symptoms of testicular cancer that has spread include low back
pain and chest pain

Testicular cancer does not always produce symptoms. Am as s or lump

in the testicle is usually the first sign of the disease. The mass
may or may not be painful. Other symptoms include testicular
swelling, hardness, and a feeling of heaviness or aching in the
scrotum or lower
abdomen.Some types of testicular cancer (e.g., choriocarcinoma,
Leydig cell tumors, Sertoli cell tumors)produce high levels of
hormones (e.g., human chorionic gonadotropin [HCG],
estrogen,testosterone). Increased levels of HCG may cause breast
tenderness and abnormal growth ofbreast tissue (gynecomastia).
Increased levels of estrogen may cause a loss of sexual
desire(libido) and increased levels of testosterone may cause
premature growth of facial and body hair
in boys.
Testicular cancer that has spread to other organs (metastasized) may
cause low back pain, shortness of breath, chest pain, and cough.

V. DIAGNOSIS

Diagnosis of testicular cancer involves a patient history, physical

examination, and diagnostictests. A patient history is taken to
evaluate risk factors. During physical examination the
physician feels (palpates) the testicles and the abdomen to detect a
lump, swelling, or enlarged lymph nodes. Diagnostic tests include
ultrasound, CT scan, and blood tests.

Testicular Self-Examination
Physicians routinely examine the testicles during a physical. But
monthly testicular self-examinations (TSE) are recommended after
puberty, especially for men at increased risk for testicular cancer.
Finding testicular tumors early increases the chance for curing the
disease. The best time to perform the exam is during or after a warm
bath or shower, when the skin of the scrotum is relaxed. Examine
each testicle gently with both hands. The index and middle fingers
should
be placed underneath the testicle, and the thumbs placed on the top.
Roll the testicle gently between the thumbs and fingers.
One testicle may feel larger than the other. This is normal. You
will also feel a cord-like structure on the top and back of the
testicle that stores and transports the sperm. This is the
epididymis and should not be confused with an abnormal lump.

If you find an abnormal lump on the front or the side of the

testicle, make an appointment to see your physician immediately. If
the lump is caused by an infection, the physician can prescribe
treatment. If the lump is not an infection, the physician will
perform tests to determine if it is a tumor.
Differential Diagnosis
To diagnose testicular cancer physicians must rule out the following
conditions:
• Accumulation of fluid in the testicle (hydrocele)
• Cancer of the lymphatic system (lymphoma)
• Cyst on the surface of the testicle that contains sperm
(spermatocele)
• Enlarged veins in the testicle (varicocele)
• Inflammation of the surface of the testicle (epididymitis)
• Twisting of the testicle (testicular torsion)

Ultrasound uses sound waves to produce an image of the testicle on a

computer screen. This test determines if a mass is a benign
condition (e.g.,hydrocele ) or a solid tumor. A solid tumor in the
testicle is usually cancerous. When a solid tumor is detected by
ultrasound, computed tomography (CT scan) of the pelvis, abdomen,
and chest is performed to determine if the cancer has spread to
lymph nodes or other organs.

CT scan uses x-rays and, in some cases, a contrast agent (dye) to

produce a detailed image on a computer screen.

Blood Tests
Certain types of testicular cancer raise the level of substances
(so-called tumor markers) in the blood. For example, nonseminomas
raise the level of proteins (e.g., alpha-feta protein [AFP]);
seminomas
and nonseminomas raise the level of hormones (e.g., human chorionic
gonadotropin [HCG]); and advanced seminomas and nonseminomas usually
raise the level of enzymes (e.g., lactate dehydrogenase [LDH]).
Blood tests that measure the levels of these substances are used to
diagnose
testicular cancer and, in some cases, to determine the extent of the
disease.

Biopsy is performed when other diagnostic tests are inconclusive. In

this procedure, the surgeon makes an incision in the groin
(inguinal incision), removes the testicle from the scrotum without
cutting the spermatic cord, and may remove suspicious tissue for
microscopic examination.

More often the testicle is removed when the mass is shown to be

within the testicle due to the veryhigh incidence of malignancy. If
no cancer is found, the testicle is returned to the scrotum. If
cancer is
detected, the testicle and spermatic cord are removed (called
orchiectomy) and thest age of the disease is determined.

VI. MANAGEMENT

Important Facts
 Treatment for testicular cancer includes surgery, radiation, and
chemotherapy
 Surgery to remove the testicle is called orchiectomy
 Testicular cancer that has spread requires additional surgery
called lymph node dissection

Most cases of testicular cancer can be treated successfully.

Treatment
Treatment for testicular cancer depends on the stage of the disease.
Surgery to remove the testicle is sometimes combined with radiation
and/or chemotherapy. Some patients choose to store frozen sperm
in a sperm bank before treatment to ensure fertility.

Surgery
Radical inguinal orchiectomy is the surgical removal of the testicle
and the spermatic cord through an incision in the groin. Surgery is
performed under general or regional anesthesia and takes
approximately 1 hour. Most patients remain in the hospital
overnight.
If CT scan indicates that testicular cancer has metastasized to the
lymph nodes,retroperitoneal lymph node dissection is often
performed. All of the lymph nodes connected to the affected testicle
are removed in this procedure. Such dissection is usually done at a
later date.

Retroperitoneal lymph node dissection is performed under general

anesthesia, requires a large incision, and usually takes 4 to 6
hours.
Complications associated with surgery include the following:
• Adverse reaction to anesthesia
• Bowel obstruction and inactivity
• Damage to surrounding organs, blood vessels, and nerves
• Infection
• Infertility (caused by nerve damage that results in retrograde
ejaculation)
• Lymph-filled cyst (lymphocele)
Following surgery, patients are usually encouraged to get up as soon
as possible. Pain at the incision site and numbness in the area
surrounding the incision are common, and pain relievers are often
prescribed. Driving and heavy lifting should be avoided for a
several weeks.
Men who have had an orchiectomy may choose to have a testicular
prosthesis surgically implanted into the scrotum. The prosthesis is
filled with saline and is made to look and feel natural.

Radiation
Radiation uses high energy x-rays to destroy cancer cells. In
testicular seminoma, external beam radiation (from a machine outside
of the body) is primarily used after orchiectomy (called adjuvant
therapy) to destroy cancer cells that have spread (metastasized) to
lymph nodes. Testicular seminoma typically requires a lower dose of
radiation than other types of cancer. During treatment, a shield is
placed over the remaining testicle to preserve fertility.
Side effects of radiation include the following:
• Diarrhea
• Fatigue
• Nausea
• Skin irritation that resembles sunburn

Chemotherapy
Chemotherapy is a systemic (i.e., circulates throughout the body via
the bloodstream) cancer treatment that uses toxic drugs to destroy
cancer cells. In testicular cancer cases, it is used to destroy
cancer cells that remain after surgery. Chemotherapy may be
administered intravenously (IV), taken in pill form, or injected
into muscle.
Drugs used alone or in combination to treat testicular cancer
include the following:
• Cisplatin (Platinol®)
• Vinblastine (Velban®)
• Bleomycin (Blenoxane®)
• Cyclophosphamide (Neosar®)
• Etoposide (Etopophos®)
• Ifosfamide (Ifex®)
VII. NURSING CONSIDERATIONS

1. Assessment of the patient’s physical and psychological status and

monitoring of the patient to response to and possible effects of
surgery, chemotherapy, and radiation therapy.
2. The patient needs encouragement to maintain a positive attitude
during the course of therapy
3. Reminding the patient the importance of performing TSE and keeps
on following appointments with the physician