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Causes and symptoms
- a lump in either testicle (usually pea-sized, but may be as large as a marble or an egg)
- any enlargement or significant shrinking of a testicle
- a sensation of heaviness in the scrotum
- a dull ache in the groin or lower abdomen
- any sudden collection of fluid in the scrotum
- tenderness or enlargement of the breasts
- pain or discomfort in a testicle or in the scrotum
History and physical
- Stage I. This stage refers to a cancer found only in the testicle, with no spread to the lymph nodes or to distant organs.
- Stage II. This indicates that the cancer has spread to the lymph nodes in the abdomen, but not to lymph nodes in other parts of the body.
- Stage III. In this stage, the cancer has spread beyond the lymph nodes in the abdomen, and/or the cancer is in parts of the body far away from the testicles, such as the lungs or the liver.
- Recurrent. Recurrent disease indicates that the cancer has come back after it has already been treated. Testicular cancer can come back in the same testicle (if it was not surgically removed) or in some other body part.
- nausea and vomiting
- changes in appetite
- hair loss (temporary)
- mouth sores
- increased risk of infections
- bleeding or bruising
- diarrhea or constipation
Preferred treatment plans by stage of disease
testicular cancerLance Armstrong tumor, testicular malignancy, testicular neoplasia Oncology The most common cancer in ♂ age 20 to 35, which is curable if treated early; often first identified by its owner as a lump in the testicle, usually noted after an episode of trauma Risk factors Hx of cryptorchidism, mumps orchitis, inguinal hernia during childhood, or previous TC on other side Management Orchiectomy, RT. See Embryonal carcinoma, Germ cell tumor, Seminoma, Testicular lymphoma.
|Mean LOS:||3.2 days|
|Description:||SURGICAL: Testes Procedures Without CC or Major CC|
|Mean LOS:||6.6 days|
|Description:||MEDICAL: Other Male Reproductive System Operating Room Procedure for Malignancy With CC or Major CC|
The American Cancer Society estimated that in 2013, there were 7,920 new cases of testicular cancer diagnosed and that 370 men died from this disease. The cure rate exceeds 90%, and the 5-year survival rate is 72%. The risk of developing this cancer is 1 in 300.
Testicular cancer is a rare tumor that arises from the germinal cells (cells that produce sperm) of the embryonal tissues and causes less than 1% of all cancer deaths in men. Testicular tumors are classified as seminomas or nonseminomas. Seminomas are composed of uniform, undifferentiated cells that resemble primitive gonadal cells. This type of tumor represents 40% of all testicular cancer and is usually confined to the testes and retroperitoneal nodes. There are two types of seminomas: classical seminomas (occur between the late 30s and early 50s) and spermatocytic seminomas (occur around age 55, grow slowly, and do not metastasize). Nonseminomas show varying degrees of cell differentiation and include embryonal carcinoma (occurs most often between ages 20 and 30, grows rapidly, and metastasizes), teratoma (can occur in children and adults), choriocarcinoma (rare and highly malignant), and yolk cell carcinoma derivatives (most common in children up to age 3 and have a very good prognosis). Sometimes, testicular tumors are “mixed,” containing elements distinctive to both groups.
Although specific causative factors for testicular cancer are unknown, research findings suggest a connection between the incidence of cryptorchidism (failure of testicles to descend) and testicular cancer. If an undescended testis is noted in a child, orchiopexy (surgical descent of the testes into its normal position within the scrotum) is recommended as soon as possible after birth. Although orchiopexy does not completely eliminate the risk of testicular cancer, it is believed that the sooner after birth orchiopexy is performed, the less chance there is of developing testicular cancer later in life. An increased incidence of testicular cancer has been found in men infected with HIV (seminomas) and men with testicular disorders such as Klinefelter’s syndrome.
Exogenous estrogen has also been linked to testicular cancer. Male offspring of mothers who took diethylstilbestrol during their pregnancy have an increased risk of developing testicular cancer. In addition, patients who have had mumps, orchitis, or a childhood inguinal hernia are also considered to be at higher risk for developing testicular cancer. Maternal infection with Epstein-Barr virus and cytomegalovirus may be associated with increased risk for a male offspring with testicular cancer.
Approximately 1% to 3% of men with testicular cancer report a family history of the disease. Brothers of a man affected with testicular cancer are 8 to 10 times more likely to develop the disease, and when a father is affected, his son is 4 times as likely to have the disease as sons of unaffected fathers. There is clearly a familial pattern, and several genes are being investigated. Mutations in the STK11 and KIT genes and deletions at 12q22 have been observed in tumors.
Gender, ethnic/racial, and life span considerations
Testicular cancer most commonly occurs in men ages 15 to 40, but it can affect males from infancy to old age. It is less common in African American and Asian men. The rate of testicular cancer has more than doubled for men with white/European ancestry men in the last 40 years but has not changed for men with African American ancestry. Men with African American ancestry tend to receive treatment later in the course of the disease and, for that reason, tend to have a poorer prognosis.
Global health considerations
The global incidence of testicular cancer is 1.6 per 100,000 males per year. The incidence is three times higher in developed than in developing countries.
Obtain a thorough health history, particularly about the occurrence of risk factors. Any male born between 1940 and 1971 should be asked if his mother took any drugs to maintain her pregnancy. The earliest sign of testicular cancer is a small, hard, painless lump that cannot be separated from the testicle; it is occasionally accompanied by low back pain. Men often describe a feeling of “heaviness” or “dragging” in the testicles. These symptoms are often mistaken for epididymitis or muscle strain. Tenderness in the breast may also be present. Inquire about back pain, vague abdominal pain, nausea and vomiting, anorexia, and weight loss, which are all findings that suggest metastasis. Only 25% of men experience symptoms related to metastasis prior to diagnosis.
The testes may be enlarged and swollen. A hydrocele or hematocele may be present. A testicular tumor can be distinguished from a hydrocele by transillumination (inspection of the testes by passing a light through its walls): A tumor does not transilluminate, whereas a hydrocele appears red and a normal testicle illuminates clearly. Because the tumor produces estrogen, inspect the patient for gynecomastia.
A testicular examination is accomplished by placing the index and middle finger on one side of the testicle with the thumb on the other side. Digital separation of the anterior testes from the posterior elements, including the epididymis and cord, is performed with care so that the intrascrotal contents can be palpated. A gentle rolling motion enables the examiner to palpate each testicle completely. A normal testicle is egg-shaped and feels smooth and firm but not hard. One testicle may naturally be larger than the other. A change in size or the presence of a lump is considered to be an abnormal finding. With testicular cancer, the lump is generally painless. Also, palpate the surrounding area for the presence of enlarged lymph nodes. Lymphadenopathy, especially in the abdominal and supraclavicular regions, is also found in more advanced disease.
The diagnosis of cancer at any time is a lifestyle-altering event, but it is particularly disrupting to the young population. Interruption of school or work schedules, financial coverage for medical expenses, transportation to and from scheduled therapies, and child-care issues are a few of the concerns expressed by patients.
General Comments: Most testicular tumors are found in routine checkups or by self-examination; they often cause no symptoms.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Scrotal ultrasound||Normal size, shape, and configuration of the testicles||Solid, malignant mass is identified||Noninvasive visualization of the testicles|
|Radical orchiectomy, followed by a biopsy||NA||Solid mass is removed, 100% prove to be malignant||Needle biopsy would lead to open spread of the cancer cells, thus the biopsy is done after the testicle is removed|
Other Tests: Serum laboratory analysis of beta-subunit human chorionic gonadotropin and α-fetoprotein, lactic hydrogenase, complete blood count, chest x-ray or computed tomography (CT) for lung metastasis, abdominal and pelvic CT or magnetic resonance imaging to check for retroperitoneal lymph node metastasis, intravenous pyelography to check for urinary tract involvement
Primary nursing diagnosis
DiagnosisPain (acute) related to inflammation, tissue damage, tissue compression, or nerve irritation from tumor metastasis in the perineum, groin, or abdomen
OutcomesPain control; Pain: Disruptive effects; Well-being
InterventionsAnalgesic administration; Pain management; Meditation; Transcutaneous electric nerve stimulation (TENS); Hypnosis; Heat/cold application
Planning and implementation
surgical.The initial treatment for testicular cancer is surgical resection of the involved testicle (orchiectomy). A testicular prosthesis can be placed if the patient so desires. If a bilateral orchiectomy is performed, the patient may need hormonal replacement. It is controversial whether or not the retroperitoneal nodes should be resected or treated with chemotherapy. Surgical resection carries with it the likelihood of impotence. To preserve fertility, nerve-sparing retroperitoneal lymph node surgery protects the nerves and allows for normal ejaculation.
Postoperatively, edema and intrascrotal hemorrhage are the two most common problems. Monitor the patient closely for swelling and bleeding. Elevate the scrotum on a rolled towel and apply ice to assist with discomfort and decrease swelling. Observe for signs of infection. Encourage the patient to wear an athletic supporter during ambulation to minimize discomfort. Usually, the patient is encouraged to do so within 12 hours of surgery.
radiation and chemotherapy.Depending on staging of the disease, radiation or chemotherapy may also be used. Tumors classified as seminomas are especially radiosensitive. External beam radiation is usually given after surgery if the peritoneal lymph system is disease-positive or if the pelvis and mediastinal and supraclavicular lymph nodes are involved. Inform the patient that although the unaffected testicle is shielded during radiation, it does receive some radiation that is scattered, which may decrease spermatogenesis. Nonseminomatous tumors are not radiosensitive, and chemotherapy is the preferred treatment.
|Medication or Drug Class||Dosage||Description||Rationale|
|Cisplatin||20 mg/m2 per day IV for 5 days/cycle||Antineoplastic, alkylating agent||Increases the long-term survival rate when any type of metastasis is found|
|Vinblastine||Individualized using white blood cell count as guide||Antineoplastic, plant alkaloid||Most effective at treating metastasis when given in combination|
|Etoposide||50–100 mg/m2 per day for first five days||Antineoplastic, miscellaneous||Used in combination|
|Acetaminophen/NSAIDs; opioids; combination opioids/NSAIDs||Depends on the drug||Analgesic||Analgesics used are determined by the severity of pain; pain may be postoperative or caused by metastasis|
Nurses can play a role in the early detection of testicular cancer. Patients should be taught how to do a testicular self-examination and should be encouraged to perform the examination monthly. Provide private time for the patient and his partner to ask questions, express concerns, and clarify information. Offer the patient an opportunity for sexuality and fertility counseling after discussing the impact of the surgery on his anatomy and function. Make sure the patient understands the need to perform coughing and deep-breathing exercises to limit pulmonary complications. Before surgery, instruct the patient on the use of an incentive spirometer.
Because stomatitis is a common occurrence, check the mouth regularly for open irritated areas and encourage the patient to use warm mouthwashes. If the patient becomes nauseated, offer small, frequent feedings and eliminate any noxious stimuli such as bad odors. In addition, have the patient drink at least 3 L of fluid per day to ensure adequate hydration. If the patient is receiving radiation, monitor for side effects. Avoid rubbing the skin near the site of radiation to prevent discomfort and skin breakdown.
Ask about pain regularly and assess pain systematically. Believe the patient and family in their reports of pain. Inform the patient and family of options for pain relief as proposed by the National Cancer Institute (pharmacologic, physical, psychosocial, and cognitive-behavior interventions), and involve the patient and family in determining pain relief measures. To manage the discomfort of chemotherapy in addition to medications, consider the use of biofeedback or other alternative relaxation techniques.
The diagnosis of testicular cancer is a devastating one to most men. Discuss the patient’s concerns with him. Explain the role of hormonal replacement in maintaining the secondary sex characteristics. If the patient is at risk for sterility, explain sperm banking procedures before treatment if infertility and impotence may result from surgery. Refer the patient to a support group or ask that another man who has experienced a similar diagnosis and treatment share his experiences to provide support. If the patient or partner is struggling to cope with the diagnosis, arrange for a counselor.
Evidence-Based Practice and Health Policy
Fossa, S.D., Cvancarova, M., Chen, L., Allan, A.L., Oldenburg, J., Peterson, D.R., & Travis, L.B. (2011). Adverse prognostic factors for testicular cancer-specific survival: A population-based study of 27,948 patients. Journal of Clinical Oncology, 29(8), 963–970.
- Investigators examined mortality rates among 27,948 men diagnosed with testicular cancer and found the 10-year cumulative mortality rate was 3.8% (95% CI, 3.6% to 4.1%).
- Mortality was higher among men with nonseminoma testicular cancer (6.6%; 95% CI, 6.1% to 7.1%) compared to men with seminoma testicular cancer (1.7%; 95% CI, 1.5% to 2%). Nonseminoma testicular cancer was present in 42.5% of men, and seminoma testicular cancer was present in 57.5% of men.
- When comparing married men to unmarried men, mortality among cases of nonseminoma testicular cancer was 1.54 times more likely among unmarried men (95% CI, 1.3 to 1.82; p < 0.001), and mortality among cases of seminoma testicular cancer was nearly three times more likely among unmarried men (95% CI, 2.24 to 3.94; p < 0.001). Half of men in this sample were married compared to 41% of men who had never been married.
- Among men with nonseminoma testicular cancer, treatment with retroperitoneal lymph node dissection was associated with an 86% decreased likelihood of mortality at 10 years (95% CI, 0.08 to 0.22; p < 0.001). Among men with seminoma testicular cancer, radiotherapy treatment was associated with a 68% decreased likelihood of mortality at 10 years (95% CI, 0.25 to 0.45; p < 0.001).
- Physical findings: Operative incisions, patency of intravenous lines, healing of incisions, vital signs, testicular assessment findings
- Response to treatments: Side effects from medications or radiation therapy; management and control of symptoms
- Presence of complications: Infection, bleeding, respiratory distress, unrelieved pain or nausea
Discharge and home healthcare guidelines
medications.If hormonal replacement is ordered, be sure the patient understands the dosage, schedule, actions, and side effects of the medication.
prevention.Have the patient demonstrate a testicular self-examination before leaving the hospital. The patient should understand that testicular cancer can recur in the remaining testes and that early detection is a critical factor in the outcome.
sexuality.Inform the patient that if a unilateral orchiectomy was performed, he is still fertile and should not experience impotence. Make sure the patient understands that he has the option of undergoing reconstructive surgery and placement of a testicular prosthesis. Refer the patient to the American Cancer Society to assist with obtaining information and support.
home care.Teach the patient to do the following:
- Avoid prolonged standing because this can increase scrotal edema.
- Wear an athletic supporter or snug-fitting undershorts until the area is completely healed.
- Avoid heavy lifting for 4 to 6 weeks.
- Take a 20-minute tub bath three times a day for 1 week after discharge.