Testicular cancer

Introduction

Malignant testicular tumors, which rank first in cancer deaths among men ages 20 to 35, primarily affect young to middle-aged men; they are the most common solid tumor in this group. (In children, testicular tumors are rare.) Most testicular tumors originate in gonadal cells. About 40% are seminomas— uniform, undifferentiated cells resembling primitive gonadal cells. The rest are nonseminomas—tumor cells showing various degrees of differentiation.
The prognosis varies with the cell type and disease stage. When treated with surgery and radiation, almost all patients with localized disease survive beyond 5 years.

Causes
The cause of testicular cancer isn’t known, but incidence (which peaks between ages 20 and 40) is higher in men with cryptorchidism (even when surgically corrected) and in men whose mothers used diethylstilbestrol during pregnancy. Exposure to certain chemicals, infection with human immunodeficiency virus, and a family history of testicular cancer increase risk. (Testicular cancer accounts for 1% of all cancers in men.)
Testicular cancer spreads through the lymphatic system to the para-aortic, iliac, and mediastinal lymph nodes and may metastasize to the lungs, liver, viscera, and bone.

Signs and symptoms
The first sign is usually a firm, painless, smooth testicular mass, varying in size and sometimes producing a sense of testicular heaviness. When such a tumor causes chorionic gonadotropin or estrogen production, gynecomastia and nipple tenderness may result.
In advanced stages, signs and symptoms include ureteral obstruction, abdominal mass, cough, hemoptysis, shortness of breath, weight loss, fatigue, pallor, and lethargy.

Diagnosis
Two effective means of detecting a testicular tumor are regular self-examinations and testicular palpation during a routine physical examination.

Transillumination can distinguish between a tumor (which doesn’t transilluminate) and a hydrocele or spermatocele (which does). Follow-up measures should include an examination for gynecomastia and abdominal masses.

Diagnostic tests include excretory urography to detect ureteral deviation resulting from para-aortic node involvement, urinary or serum luteinizing hormone levels, ultrasound, and abdominal computed tomography scan.

Serum alpha-fetoprotein and beta-human chorionic gonadotropin levels, indicators of testicular tumor activity, provide a baseline for measuring response to therapy and determining the prognosis.
Surgical excision and biopsy of the tumor and testis permits histologic verification of the tumor cell type—essential for effective treatment. Inguinal exploration determines the extent of nodal involvement.

Treatment
The extent of surgery, radiation, and chemotherapy varies with tumor cell type and stage.

Surgery
Surgical procedures include orchiectomy and retroperitoneal node dissection. Most surgeons remove the testis, not the scrotum (to allow for a prosthetic implant). Hormone replacement therapy may be needed after bilateral orchiectomy.

Radiation
The retroperitoneal and homolateral iliac nodes may receive radiation after removal of a seminoma. All positive nodes receive radiation after removal of a nonseminoma. Patients with retro-peritoneal extension receive prophylactic radiation to the mediastinal and supraclavicular nodes.

Chemotherapy
Chemotherapy combinations are essential for tumors that have progressed beyond the preinvasive stage with evidence of lymph node metastasis and distant metastasis. Chemotherapy and radiation followed by autologous bone marrow transplantation may help unresponsive patients.

Special considerations

• Develop a treatment plan that addresses the patient’s psychological and physical needs.
• Before orchiectomy:
• Reassure the patient that sterility and impotence need not follow unilateral orchiectomy, that synthetic hormones can restore hormonal balance, and that most surgeons don’t remove the scrotum. In many cases, a testicular prosthesis can correct anatomic disfigurement.
• After orchiectomy:
• For the first day after surgery, apply an ice pack to the scrotum and provide analgesics.
• Check for excessive bleeding, swel-ling, and signs of infection.
• Provide a scrotal athletic supporter to minimize pain during ambulation.
• During chemotherapy:
• Give antiemetics, as needed, for nausea and vomiting. Encourage small, frequent meals to maintain oral intake despite anorexia.
• Establish a mouth care regimen and check for stomatitis. Watch for signs of myelosuppression.