180 Seminars in Oncology Nursing, Vol 28, No 3 (August), 2012: pp 180-189

TESTICULAR CANCER
MELISSA VIATORI

OBJECTIVES: To discuss the presentation, diagnosis, chemotherapy, surgical

options, nursing management, and long-term outcomes of patients with
testicular cancer.
DATA SOURCES: Review and research articles, clinical experience.
CONCLUSION: Testicular cancer is very treatable and the cure rate is
approximately 95%. It is most common in men between the ages of 15 and
35. While early detection, diagnosis, and treatment are all important factors
for treating the disease, fertility and quality of life are also important issues
to address in patients with testicular cancer.
IMPLICATION FOR NURSING PRACTICE: Nurses must provide patient
instruction regarding chemotherapy, surgery, fertility, and side effects of
treatment. Serving as a patient advocate regarding fertility preservation and
promoting quality of life are important factors for health professionals to
consider.
KEY WORDS: Testicular cancer, germ cell tumor, chemotherapy, surgery,
radiation

T
ESTICULAR cancer, although the most and more than three times more common
common malignancy in men aged 15 than in Asian-American or American Indian
to 35, only accounts for 2% of malignan- males. Early diagnosis, treatment, education, and
cies in the general population.1 It is follow-up are extremely important for patients
highly curable and life expectancy is long, to avoid advanced-stage disease. Health care
requiring long-term follow-up of survivors. It is providers must understand the importance of con-
projected that there will be approximately 8,590 ducting testicular exams and educating young
new cases of testicular cancer and 360 deaths in males to routinely perform self-testicular exams
2012.2 Testicular cancer is five times more as many young men are not aware of the risk
common among white males than black males; factors and screening recommendations for testic-
ular cancer.3,4

Melissa Viatori, RN, MSN, FNP-C: Department of RISK FACTORS

Hematology Oncology, University of California San
Francisco Medical Center. Testicular cancer can start in one or both tes-
At the time the paper was written, the author was
ticles, and occurs most frequently in young men.
a Nurse Practitioner in Urologic Oncology at the Stan-
ford Cancer Center, Stanford, CA.
The etiology of testicular cancer is unknown, but
Address correspondence to Melissa Viatori, RN, there are several known risk factors for developing
MSN, FNP-C. e-mail: [email protected] testicular cancer. Males with a history of cryptor-
Ó 2012 Elsevier Inc. All rights reserved. chid testes, even after orchioplexy is performed,
0749-2081/2803-$36.00/0. are at increased risk for developing testicular
doi:10.1016/j.soncn.2012.05.007 cancer.5,6 Additionally, males with a positive
 TESTICULAR CANCER 181

family history (eg, father or brother) of testicular CLASSIFICATION AND STAGING

cancer, testicular atrophy, testicular microlithia-
sis, testicular dysgenesis, or Klinefelter’s syndrome Most testicular cancers are germ cell tumors and
also have an increased risk of developing testicular are classified as seminomas or non-seminomas
cancer.1,7 Unilateral cryptorchidism is associated because they are treated differently and have
with an increased risk of testicular cancer develop- different prognoses. To further classify testicular
ment in both testis, but is more common on the cancer, the disease is broken down histologically
ipsilateral side.8 The cumulative risk of developing into two groups: germ cell tumors (95%) and non-
cancer in the contralateral testis is low, and biopsy germ cell tumors (4% to 5%). Germ cell tumors are
of the contralateral testis may be considered in further delineated into seminoma (40%), which
high-risk patients, including those with testis generally spread through regional lymph nodes to
volume <12 mL, history of cryptorchidism, and other organs and non-seminoma, which tend to
less than 30 years of age.9,10 metastasize through the lymph nodes, particularly
to the liver and lungs (60%).3 Teratomas, yolk sac,
embryonal, and choriocarcinoma make up nonse-
CLINICAL MANIFESTATIONS AND DIAGNOSIS manomatous germ cell tumors.12,13 Mixed germ
cell tumors contain components of two or more
The most common manifestation of testicular germ cell tumor types.12,13 Men with non-seminoma
cancer is a painless, hard swelling or enlargement may have an elevated AFP and bHCG, while those
of the testicle. Testicular masses occur more with seminoma do not have elevated AFP on presen-
frequently on the right side.6 However, patients tation; however, some seminomas (approximately
with advanced disease (approximately 10%) 14%) cause elevated bHCG. High serum levels of
present with extra-gonadal tumors such as medias- LDH may be seen in patients with seminoma or
tinal masses that cause other symptoms, including non-seminoma, although LDH may be elevated for
dyspnea or pain. Masses occurring in the retroper- a variety of reasons and is less specific.14 Approxi-
itoneum may result in abdominal or back pain.5,6,11 mately 90% of patients with germ cell tumors are
Testicular masses should be promptly evaluated by cured and 70% to 80% with advanced diseases have
physical exam and bilateral testicular ultrasound. a complete response to treatment with chemo-
Men with testicular cancer can also present with therapy.1 The histologic subtypes and features of
gynecomastia as a result of hormone secretion.3 germ cell tumors are listed in Table 1.12-14
The National Comprehensive Cancer Network Staging for testicular cancer is helpful in deter-
(NCCN) guidelines specify that the initial work- mining prognosis and treatment. Stage I tumors
up should include computed tomography of the are limited to the testis; whereas stage II tumors
chest, abdomen, and pelvis.1 Additional radio- have spread outside of the testicle and include
graphic imaging should be performed based on the lymph nodes in the retroperitoneum. Stage
patient-reported symptoms. Brain magnetic reso- III tumors include metastatic disease to the lung,
nance imaging is indicated for patients who report liver, or bone. Important factors to consider for
headaches, nausea, vomiting, diplopia, or changes staging include the degree to which the disease
in balance, and bone scan should be performed if has metastasized, elevation of tumor markers,
the patient complains of bone pain or has an and histology (seminoma or non-seminoma).
elevated serum alkaline phosphatase.1 Table 2 identifies the characteristics of tumor
Tumor markers are another important compo- markers in relation to testicular cancer.14
nent of the diagnostic work-up. Beta-human cho- Risk categories for patients post-orchiectomy
rionic gonadotropin (bHCG), alphafetoprotein have been established by the International Germ
(AFP), and lactate dehydrogenase (LDH) levels Cell Cancer Collaborative Group for seminoma
should be checked before and after orchiectomy and non-seminoma based on clinically indepen-
and throughout treatment for germ cell tumors.6 dent prognostic features.15 Patients are catego-
Inguinal orchiectomy is the procedure of choice rized as ‘‘poor risk,’’ ‘‘intermediate risk,’’ or ‘‘good
for pathologic evaluation of suspected testicular risk’’ (Table 3 and 4). These risk categories are
cancer. Biopsy through the scrotum is not recom- based on tumor markers post-orchiectomy, pres-
mended because it may increase the incidence of ence or absence of non-pulmonary visceral metas-
spread to the scrotum or regional lymph nodes.1,6 tases, and the site of the primary tumor.1,14,15
 182
M. VIATORI
TABLE 1.
Histologic Subtypes of Testicular Cancers

Incidence Features

Germ cell tumors

Carcinoma in situ Non-invasive form of germ cell tumor. May progress to invasive form of germ cell tumor over several years
(particularly embryonal or seminoma).
Seminoma Accounts for 30% to 40% of testicular
cancers
Pure seminoma 100% seminoma. Slow growing, slow to metastasize, sensitive to radiation, and do not produce AFP. Mild
elevations in bHCG may be seen in patients with seminoma.
Non-seminoma Accounts for 60% to 70% of testicular
cancers, resistant to radiation
Embryonal cell carcinoma 3% to 4% pure; 40% component in mixed Can occur as pure tumor or mixed germ cell tumor. Percentage of embryonal cell carcinoma in mixed
germ cell tumor germ cell tumor determines the prognosis.
Choriocarcinoma 0.3% pure; 15% component in mixed Rare and aggressive. Occurs in descended and undescended testicles and in extratesticular locations.
germ cell tumor Occurs in postpubertal men through age 69. Pure choriocarcinoma has high mortality rate. Responds
poorly to chemotherapy and radiation therapy.
Yolk sac tumor 1% to 2% pure in adult patients; 42% Most common testicular tumor in children (6 months to 4 years). Can occur as part of mixed germ cell
component in mixed germ cell tumors tumor. Increased AFP may be seen in this type of tumor. Very responsive to chemotherapy.
Teratoma 2% to 7% pure; 50% in mixed germ Germ cell tumors or pure teratoma. Pure teratoma does not cause elevation in serum AFP or bHCG.
cell tumors There are three types of teratoma: mature teratoma, immature teratoma, or teratoma with malignant
transformation.
Mixed seminoma 32% to 60% Mixture of seminoma and non-seminoma components.
Stromal tumors Grow in the cells that make hormones and supportive tissues. Most often benign, but can be metastatic.
Leydig cell tumors 1% to 3% Usually occur in descended and undescended testicles, but not in extratesticular locations. Usually
benign. Can be treated with surgery. If metastatic, does not respond well to radiation or surgery.
Sertoli cell tumors 1% Most are benign, 10% are malignant. Generally do not occur in extratesticular locations. Do not respond
well to chemotherapy or radiation.

Abbreviations: AFP, alphafetoprotein; bHCG, beta-human chorionic gonadotropin.

Data from Levin,12 Sesterhaenn and Davis,13 and the National Cancer Institute.14
 TESTICULAR CANCER 183

TREATMENT OPTIONS
TABLE 2.
Tumor Markers
Orchiectomy is the first step in treating testic-
Tumor ular cancer in men who present with testicular
marker Characteristics tumors. The tissue from the orchiectomy is also
AFP Serum marker produced by non-seminomatous helpful in determining pathologic diagnosis.
cells, never in pure seminoma Although teratomas are not malignant, they
Occurs in any stage of testicular cancer must be surgically resected because they do not
Half-life 5 to 7 days respond to chemotherapy or radiation therapy.11
LDH Found in both seminoma and non-seminoma tumors
Retroperitoneal lymph node dissection (RPLND)
Non-specific. Correlates with tumor burden, growth
rate, and cellular proliferation includes surgically resecting lymph nodes in the
Higher in patients with advanced disease retroperitoneum.17 This may include unilateral
bHCG Present in seminoma and non-seminoma tumors or bilateral lymph node dissection. A unilateral
Half-life 1 to 3 days approach is nerve-sparing and increases the like-
lihood that a patient will maintain normal ejacu-
Abbreviations: AFP, alphafetoprotein; LDH, lactic dehydro-
genase; bHCG, beta-human chorionic gonadotropin.
latory function.6,11 RPLND may be performed
before or after treatment with chemotherapy.
RPLND may also be used as an alternative to
In addition to tumor markers and imaging chemotherapy in patients with stage I or stage
studies to determine staging to establish risk II non-seminoma. The timing of the procedure
status for men with testicular cancer, psychoso- is very patient-specific and is based on staging
cial factors should be considered. Men who were and pathology.1,11 In the case of extragonadal
older than 40, of nonwhite race, unmarried, and germ cell tumors, resection should be performed
of lower socioeconomic status had increased following chemotherapy with cisplatin, etopo-
mortality in a study reviewing 27,948 males with side, and bleomycin (BEP). If there is a residual
testicular cancer from 1978 to 2006.16 mass in the mediastinum or retroperitoneum,

TABLE 3.
Risk Categories for Testicular Cancer

Non-seminoma Seminoma

Good risk (56% of non-seminomas; Location: Testicular/retroperitoneal Location: Any primary site with no non-
90% of seminomas) primary with no non-pulmonary visceral pulmonary visceral metastases
metastases Tumor markers: Normal AFP and any
Tumor markers: AFP <1000 ng/mL bHCG or LDH
bHCG <5000 IU/L
LDH <1.5 times the upper limit of
normal
Intermediate risk (28% of non- Location: Testicular/retroperitoneal Location: Any primary site with non-
seminomas; 10% of seminomas) primary with no non-pulmonary visceral pulmonary visceral metastases
metastases Tumor markers: Normal AFP and any
Tumor markers: AFP $1000 and bHCG or LDH
#10,000 ng/mL or bHCG $5000 IU/L
and #50,000 IU/L or LDH $1.5 x
normal and #10 x normal
Poor risk (16% of non-seminomas; Location: Mediastinal primary or non- None are classified in this category
no seminomas) pulmonary visceral metastases or poor
tumor markers
Tumor markers: AFP >10,000 ng/L or
bHCG >50,000 IU/L or LDH >10 x the
upper limit of normal

Abbreviations: AFP, alphafetoprotein; bHCG, beta-human chorionic gonadotropin; LDH, lactic dehydrogenase.
Modified and reprinted with permission from the International Germ Cell Cancer Collaborative Group.15
184 M. VIATORI

92% disease-free survival.21 This trial included

TABLE 4. 184 patients who were randomized to receive
Five-Year Survival for Good Risk, Intermediate Risk, and either four courses of BEP over 12 weeks versus
Poor Risk Testicular Cancer Patients
three courses over a 9-week period. An initial
Non-seminoma Seminoma disease free-status was achieved in 99% of minimal
extent and 95% in moderate extent patients.
5-Year progression-free Good risk: 89% Good risk: 82%
survival Intermediate Intermediate Ninety-eight percent randomized to three courses
risk: 75% risk: 67% were disease-free and 97% randomized to four
Poor risk: 41% Poor risk: N/A courses were disease-free. In a 5-year follow-up,
5-Year survival Good risk: 92% Good risk: 86% there were five relapses on each arm and 92% of
Intermediate Intermediate
patients in each group remained disease-free
risk: 80% risk: 72%
Poor risk: 48% Poor risk: N/A (follow-up for a minimum of 1 year).20 The
survival benefit of three cycles of BEP are sup-
Modified and reprinted with permission from the International ported by the results of several other large
Germ Cell Cancer Collaborative Group.15 randomized trials.22,23 Four cycles of BEP are war-
ranted if bleomycin cannot be given because of
pulmonary toxicity and if chemotherapy dose-
surgical intervention is necessary to remove such intensity cannot be achieved during the initial
tumors.18 cycles of chemotherapy.23 Additionally, four
Chemotherapy before surgical intervention cycles of BEP are necessary for advanced dissem-
increases the risk of complications. The tumor inated germ cell tumors despite the increased
size, location, and performance status of the dose intensity and toxicity of newer regimens.24
patient following treatment are all factors to Pulmonary toxicity including subacute and
consider. In particular, vascular injury, ureteral chronic interstitial pneumonia have been associ-
injury, and neurologic complications are increased ated with bleomycin therapy.25,26 Some medical
in those undergoing surgery following chemo- centers have taken bleomycin out of the chemo-
therapy.19 Time should be allowed for blood counts therapy regimen and deliver four cycles of etopo-
to recover following chemotherapy to decrease the side, ifosfamide, and cisplatin (VIP) to eliminate
risk of bleeding and infection. the potential pulmonary side effects associated
Chemotherapy including bleomycin, etoposide, with bleomycin.26 A study conducted by the
and cisplatin (BEP) has been used to treat testic- Eastern Cooperative Oncology Group determined
ular cancer since the 1970s.20 BEP is appropriate that treatment with a regimen including bleomy-
in treating patients with stage II or III seminoma cin (BEP or PVB) was more effective than etopo-
and for all stages of non-seminoma, excluding side and cisplatin alone.27 Etoposide, ifosfamide,
some patients with poor risk disease. BEP is not and cisplatin (VIP) demonstrated comparable effi-
effective in patients with stage IA or IB seminoma. cacy and survival in patients with poor-risk germ
These patients may receive radiation therapy to cell tumors, although the substitution of ifosfa-
the para-aortic lymph nodes, single-agent carbo- mide was associated with significantly greater
platin, or be followed with surveillance. Radiation toxicity in a randomized study of 304 patients
therapy is also appropriate for patients with stage with advanced germ cell tumors.24
II seminoma and treatment should be delivered to Tumor markers are expected to decrease
the para-aortic and ipsilateral lymph nodes. Radi- following treatment including surgery and chemo-
ation therapy is not appropriate for patients with therapy.3 In the event that tumor markers do not
non-seminoma because it is not effective in this decrease, patients may require a change in
patient population.1 therapy. The time to normalization of tumor
The number of cycles of BEP a patient receives markers (AFP and bHCG) has been found to
is based on pathology and risk features. Patients predict outcome for patients with testicular
with good-risk disease should receive three cycles cancer. Those with tumor marker normalization
of BEP as opposed to four.19 In 1989, the South- during the first two cycles of chemotherapy were
eastern Cancer Study Group determined that found to have better outcomes than patients
men with good-risk advanced germ cell tumors whose markers did not normalize during the first
treated with three cycles or four cycles of BEP two cycles of chemotherapy.28 Progression-free
had similar response rates and an approximately survival and overall survival were increased in
 TESTICULAR CANCER 185

patients who had tumor marker normalization, as peri-operative fluid management and oxygen
particularly those with advanced non-seminoma- supplementation are managed carefully in
tous germ cell tumors and with poor risk classifica- patients who were treated with bleomycin.19
tion by International Germ Cell Cancer Surgical management has its own complications,
Collaborative Group (IGCCCG) standards.29 including bleeding, infection, pain, bowel obstruc-
Although most patients respond to treatment tion, increased risk of deep venous thrombosis, and
with BEP, some may require further treatment the potential for impaired ejaculatory function.5,6
because of relapse or incomplete response to Radiation therapy may result in decreased sper-
therapy (approximately 30% in men with matogenesis or sterility if given in high doses.5,33
advanced disease).30 Second-line therapy includes
treatment with paclitaxel, ifosfamide, and NURSING IMPLICATIONS
cisplatin (TIP) or vinblastine, ifosfamide, and
cisplatin (VIP). High-dose chemotherapy with Nursing management is a significant factor to
stem cell transplant is also a second-line treat- consider when treating testicular cancer patients.
ment option.30 Preoperative teaching before orchiectomy or
Autologous stem cell transplant following RPLND should include answering the patient’s
carboplatin-based high-dose chemotherapy is questions or concerns regarding the length of the
successful in patients as second- or third-line surgery, length of hospital stay, and potential
therapy in those refractory to cisplatin-based adverse effects. Patients should receive written
chemotherapy. A retrospective study of 184 instructions for preoperative preparation as well
patients at Indiana University Hospital was con- as discharge information.6
ducted on patients who received high-dose Chemotherapy teaching is particularly impor-
chemotherapy with autologous stem cell rescue tant for patients and caregivers. Some facilities
between 1996 and 2004. Those with residual offer a tour of the infusion area and a chemo-
disease following high-dose chemotherapy under- therapy class before treatment begins, which is
went surgery. A 48-month follow-up showed that generally led by an oncology nurse. Males under-
63% were without evidence of disease (116 of going treatment with chemotherapy for testicular
184 patients); 90% of the 116 patients remained cancer should receive a chemotherapy calendar
disease-free for greater than 2 years.31 to ensure that no treatments are missed. The
schedule and side effects of each chemotherapy
TOXICITY OF TREATMENT agent should be reviewed with the patient and
caregivers and the patient should receive written
Adverse effects of treatment are important to information. Additionally, antiemetic regimens
consider and to discuss with patients prior to should be discussed and provided in written form
and during treatment for testicular cancer. Side for further explanation. Patients who are sexually
effects of cisplatin include alopecia, neutropenia, active should be instructed to use contraception
anemia, impaired renal function, ototoxicity, and or to be abstinent during treatment with chemo-
neuropathy.32 Bleomycin may cause lung toxicity therapy. Nurses in the outpatient setting should
because it has the potential to cause pulmonary also provide patients with contact information in
fibrosis. Patients who are older at diagnosis or the event that questions or new symptoms
who have pre-existing lung conditions should not present, and the nurse should be prepared to
receive bleomycin, but rather cisplatin or gemcita- answer symptom management questions that
bine alone for four cycles or standard-dose VIP.1 arise. The oncology nurse may even devise a list
Lung toxicity associated with bleomycin is related of items to discuss with patients and ‘‘check off’’
to oxygen exposure, advanced age, smoking, and before the patient begins chemotherapy.34
cumulative dose.32 Patients may present with
a persistent cough or dyspnea on exertion. Pulmo- FERTILITY ISSUES
nary function testing should be performed and
a decrease by 40% to 60% of the diffusion capacity Fertility preservation is an important consider-
of carbon monoxide is a sign that bleomycin ation for nurses caring for the patient with
should be discontinued. Management generally testicular cancer.6 Many males have impaired
includes steroid therapy. Patients should have spermatogenesis at diagnosis because of hy-
a thorough pulmonary assessment before surgery pogonadism.32 Sperm banking, testicular tissue
186 M. VIATORI

freezing, or testicular sperm extraction should be Health care professionals are not always
discussed before beginning any treatment for comfortable discussing fertility and should be
testicular cancer because RPLND, chemotherapy, familiar with local resources for patients who
and radiation therapy all have the ability to alter wish to explore fertility preservation before or
fertility.33 Health care professionals should following treatment.33 There are many resources
discuss the risk of infertility with cancer treat- available both online and in the community
ments and referral to a fertility specialist may be for patients and health care professionals.
appropriate in some circumstances. Particular Fertilehope.org is an online source that provides
care should be considered when discussing information, financial assistance, and support for
fertility issues with young testicular patients, cancer patients addressing fertility issues. Health
especially minors.35 Young pre-pubertal males care professionals should also be familiar with
are unable to bank sperm; therefore, testicular local resources and where patients can bank
cryopreservation should be discussed.36 Teenage sperm. Taking a tour of the local cryobank may
males may encounter difficulty providing a sperm be helpful to fully understand the process and
sample because of embarrassment, and parents thus better inform patients.
should be advised not to accompany teens to the A study conducted at Vanderbilt University
cryobank center to provide the greatest amount Hospital between 1994 and 2004 aimed to deter-
of privacy possible. Additionally, there are mail- mine the number of patients with testicular
in kits that enable patients to provide a sperm cancer who used banked sperm following treat-
sample at home and mail the specimen to the ment. One hundred twenty-nine patients
sperm bank for storage if privacy is a concern or responded, and 31 of those who responded stated
if the patient lives far from a cryobank.37 that they banked sperm. Of the 31 responders who
Chemotherapy and radiation therapy effect germ banked sperm, only two used the banked sperm
cells that produce sperm and may lead to infertility. and 12 of those who banked sperm had children
Additionally, the hypothalamic pituitary access naturally. Therefore, only 24% of patients chose
may be altered during chemotherapy, radiation, or to bank sperm. Less than 10% used the banked
surgery, and thus impacts sperm production.36 sperm.38 Several factors that inhibited men from
Males who received cisplatin-containing regimens banking sperm included: cost (median initial fee
(such as BEP) recovered spermatogenesis at a rate of $358 and yearly median fee $243), desire to
of approximately 80% at 5 years following treatment. have children, infertility/previous vasectomy, reli-
Men who received cisplatin in higher doses (>600 gious reasons, age, or mental/physical disability.38
mg/m2) had a 50% rate of azoospermia or oligosper- Failure of a health care provider to discuss sperm
mia. Men who are treated with radiation therapy for banking with patients before beginning treatment
seminoma may have a decreased sperm count (oli- is also a barrier to preserving fertility.37 It is
gospermia), which generally recovers in 1 to 2 years important for health care providers to discuss
following treatment.14 High doses of radiation barriers to sperm banking and assess the patient’s
therapy (>200 Gy) may lead to permanent sterility desire to sperm bank. If factors such as cost are of
(azoospermia).33 Several clinical trials studied sper- concern, there are patient assistance programs
matogenesis and spermatozoa concentration in available to assist with funding.
men with malignancies (including testicular cancer, There is conflicting data on the success of
lymphoma, leukemia, and solid tumors) before patients who are able to father children naturally
treatment. It was found that men with testicu- following treatment for testicular cancer. In a study
lar cancer had the lowest sperm motility and involving sending questionnaires to 490 testicular
concentration.38,39 patients who had been treated for testicular cancer
Non-nerve–sparing RPLND (or ‘‘classic RPLND’’) from 1976 to 2002 in Slovenia, 297 patients re-
also has the potential to cause decreased fertility. sponded. The study found that those who attemp-
The resection of lymph nodes from T12-L3 bilater- ted to conceive naturally were successful 49% of
ally may result in anejaculation when sympathetic the time following treatment (all patients under-
ganglia responsible for emission and ejaculation went orchiectomy in addition to radiation therapy,
are damaged.40,41 A nerve-sparing approach chemotherapy, or RPLND). Before treatment, 82%
preserves ejaculatory function in almost all were successful in conceiving naturally. Patients
patients and should thus be performed in patients with non-nerve–sparing RPLND had a success
when appropriate.40 rate of 37%, those with nerve-sparing RPLND had
 TESTICULAR CANCER 187

a conception rate of 62%, and those without RPLND the nerve. Neuropathy manifests as numbness,
had a success rate of 77%. Therefore, non-nerve– tingling, or decreased sensation. Ototoxicity
sparing RPLND was the factor that was most influ- manifests as tinnitus and hearing loss.46,48
ential in regard to fertility.41 Alternately, another Bleomycin has the potential to impair lung func-
study found that although men treated with testic- tion and may cause acute bleomycin pulmonary
ular cancer (including surgery or surgery alone or toxicity or late-effect toxicity.32 Cisplatin- or
in combination with chemotherapy) experience etoposide-based chemotherapy regimens, as well
more distress regarding fertility and difficulty as radiation therapy, have been linked to an
conceiving than men in control groups, they are increased incidence of secondary malignancies
just as likely to father children.42 such as leukemias and solid tumors.14,49 Although
It is unknown if testicular cancer survivors the incidence is low, treatment with radiation or
conceive children who are at a higher risk for cisplatin is linked to an increased risk of devel-
genetic abnormalities because of teratogenicity oping leukemia. Etoposide can also cause
of chemotherapy or chromosomal translocations treatment-induced, leukemia, which may develop
caused by radiation therapy. Generally, patients 5 to 10 years following therapy (0.5% in patients
are instructed to wait from 6 to 18 months to who received # 2 g of etoposide and a 2% inci-
attempt conception to increase the probability dence in those who received >2 g of etoposide).32
that spermatozoa do not have abnormalities.40 Men who were treated for testicular cancer
In addition to fertility, sexual function is a long- with chemotherapy also have an increased inci-
term follow-up issue affecting men who have dence of cardiovascular disease and metabolic
undergone treatment for testicular cancer. Body syndrome.48,50 Vascular complications such as
image and sexual function may be altered following myocardial infarction, pulmonary embolism,
surgery and/or chemotherapy. Additionally, body thrombosis, and Raynaud’s phenomenon are
image may be altered by surgery. Testicular pros- potentially related to vascular injury or increased
theses may be considered in patients with orchiec- cholesterol following treatment with chemo-
tomy and may increase self-esteem and positive therapy and radiation therapy. Metabolic
body image.43 Additionally, RPLND may result in syndrome may be related to hypogonadism. Addi-
ejaculatory dysfunction (although rare following tionally, cigarette smoking may also contribute to
nerve-sparing RPLND) or altered body image.43-45 the development of metabolic syndrome and
Sexual concerns such as decreased libido, erectile smoking cessation should be addressed with
dysfunction, and ejaculatory dysfunction may patients who are smokers.46,48 Anxiety and
also be related to hypogonadism, and testosterone chronic fatigue are more prevalent in testicular
supplementation may be required in some cancer survivors.46,51,52
patients.46,47 Referral to a fertility specialist or Follow-up is important following treatment for
psychiatrist specializing in sexual health may be testicular cancer patients. Health care profes-
of assistance to these patients. sionals should refer to evidence-based guidelines,
such as The National Comprehensive Cancer
SURVIVORSHIP Center Guidelines for Testicular Cancer to deter-
mine the interval between laboratory testing,
Treatment with cisplatin (part of BEP chemo- imaging, and physical exam for the testicular
therapy) may result in impaired renal function, cancer patient following treatment. Patients
neuropathy, or ototoxicity. Nephrotoxicity is should be counseled on the importance of follow-
related to cisplatin and infradiaphragmatic radia- up and the need to inform health care providers
tion therapy. Rarely, renal dysfunction may occur if new symptoms arise in the interim. Patients
following RPLND if ureteral injury or adhesions should also be encouraged to perform self-
occur. Men who receive cisplatin chemotherapy testicular exams in the remaining testicle because
may experience acute or long-term reductions in there is a 1% to 2% chance of developing a second
glomerular filtration rate. Of the men who have primary cancer in the contralateral testicle.6,32
received treatment for testicular cancer, 20% to Quality of life (QOL) is important to consider in
30% experience a long-term decrease in glomer- patients who are undergoing treatment in any
ular filtration rate of up to 30%.46,48 Neuropathy phase, as well as in cancer survivors. Overall, no
is caused by cisplatin as the drug may accumulate significant differences have been found in men
in the dorsal nerve ganglion, causing damage to who were treated with chemotherapy, radiation
188 M. VIATORI

therapy, and surveillance in regard to long-term stand the concerns of patients and the manifesta-
QOL.46,53 Men who undergo treatment for testic- tions caused by treatment.55
ular cancer with chemotherapy experience more
physical effects when compared with control
groups or men who were treated with radiation CONCLUSION
therapy, however relatively similar QOL despite
such symptoms.42 One study demonstrated that Testicular cancer is the most common cancer in
chemotherapy was associated with a temporary men between the ages of 15 and 35. It is a very treat-
decrease in QOL after receiving adjuvant chemo- able disease. Based on pathology, tumor markers,
therapy for non-seminomatous germ cell tumors. and radiologic staging, men receive surgery, chemo-
However, the men who participated in the study therapy, radiation therapy, or a combination of
had no statistically significant QOL difference therapies. Nurses must educate patients regarding
than control groups at 12-month follow-up after side effects and risks of such treatments, as well
treatment, suggesting improved QOL over time.54 consider psychosocial needs during and after treat-
There are many tools available to measure ment. In addition, fertility, QOL, and late effects of
QOL and there is currently no standard used for treatment should also be discussed with patients
clinical practice. The use of such tools may assist and their loved ones. Testicular cancer, while very
the health care professional in understanding treatable, is a disease that will continue to affect
a patient’s perspective and thus providing appro- thousands of men each year and nurses must be
priate support. Such tools should be considered prepared to assist such patients through the process
to maximize symptom management and to under- of diagnosis, treatment, and follow-up.

REFERENCES
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