Testicular Cancer

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Original Editors Brandon Davis as part of the Bellarmine University's Pathophysiology of Complex Patient Problems project.

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Definition/Description

-Testicular cancer is cancer in one or both testicles.  It is most often found in young men.  This type of cancer can be treated and very often cured.

-The testicles

• The testicles (or testes) are part of the male reproductive system.  In adult men, each one is normally a little smaller than a golf ball.  They are held in a sac of skin called the scrotum.  The scrotum hangs beneath the base of the penis.
• The testicles make the male hormones testosterone.  They also make sperm.  Sperm cells are carried from the testicles through small tubes (the vas deferens) to the seminal vesicles.  Fluid from the vesicles and from the prostate gland is added.  During ejaculation (orgasm), this fluid, now called semen, travels through a tube (the urethra) in the center of the penis and out of the body.  See the picture below.

• The testicles have several kinds of cells.  The different cells may develop into one or more types of cancer.  It is important to know which kind of cell the cancer started from because these types of cancer are treated differently.  They also differ in the chance of survival for the patient (prognosis).

-Main types of testicular tumors

• Germ cell tumors are the most common type of testicular tumors.  Germ cell tumors grow in the cells that make sperm.
• Stromal tumors grow in other parts of the testicles like the cells that make hormones.
• Secondary testicular tumors are from cancer that has spread to the testicles from other parts of the body.

-Each of the 3 types is explained in more detail below.

-Germ cell tumors 

• More than 9 out of 10 of cancers of the testicles start in the germ cells.  As used here, the term "germ" means seed. These are the cells that make sperm.
• The 2 main types of germ cell tumors are seminomas and nonseminomas.  These 2 types occur about equally. Seminomas and non-seminomas cells look very different when seen under a microscope.
• Some cancers contain both non-seminoma and seminoma cells.  These are treated as non-seminomas because they grow and spread like non-seminomas.
• Seminomas
  • Seminomas start from germ cells of the testicle that make sperm.  The 2 main subtypes of these tumors are classical (or typical) seminomas and spermatocytic seminomas.  Doctors can tell them apart by how they look under the microscope.  
  • Classical seminoma: More than 95% of seminomas are classical.  These usually occur in men when they are between their late 30s and early 50s.
  • Spermatocytic seminoma: This rare type of seminoma tends to occur in older men.  The average age of men diagnosed with spermatocytic seminoma is about 55.  Spermatocytic tumors tend to grow more slowly and are less likely to spread to other parts of the body than classical seminomas.
  • Some seminomas can increase blood levels of a protein called human chorionic gonadotropin (HCG).  HCG can be detected by a simple blood test and is considered a tumor marker for certain types of testicular cancer.  It can be used for diagnosis and to check for response to therapy.
• Non-seminomas
  • This type of germ cell tumor usually occurs in men between their late teens and early 40s.  There are 4 main types of non-seminoma tumors:
    • Embryonal carcinoma
    • Yolk sac carcinoma
    • Choriocarcinoma
    • Teratoma
    • Most tumors are mixed with at least 2 different types, but this does not change treatment.  All non-seminoma germ cell cancers are treated the same way.
    • Embryonal carcinomas: This type of non-seminoma is present to some degree in about 40% of testicular tumors, but pure embryonal carcinomas occur only 3% to 4% of the time.  When seen under a microscope, these tumors can look like tissues of very early embryos. T his type of non-seminoma tends to grow rapidly and spread outside the testicle. Embryonal carcinoma can increase blood levels of a tumor marker protein called alpha-fetoprotein (AFP), as well as HCG.
    • Yolk sac carcinomas: These are so named because their cells look like the yolk sac of an early human embryo.  Other names for this cancer include yolk sac tumor, endodermal sinus tumor, infantile embryonal carcinoma, or orchidoblastoma.
    • Yolk sac carcinoma is the most common form of testicular cancer in children.  When they occur in children, these tumors usually are treated successfully.  When yolk sac tumors develop in adults, however, they are of more concern, especially if they are "pure" (that is, the tumor does not contain other types of non-seminoma cells).  Yolk sac carcinomas respond very well to chemotherapy, even if they have spread.  This type of tumor almost always increases blood levels of AFP.
    • Choriocarcinomas: This is a very rare and aggressive type of testicular cancer that occurs in adults.  These cancers are likely to spread rapidly to distant organs of the body, including the lungs, bone, and brain.  Pure choriocarcinoma does not often occur in the testicles.  More often, choriocarcinoma cells are present with other types of non-seminoma cells in a mixed germ cell tumor.  This type of tumor increases blood levels of HCG.
    • Teratomas: Teratomas are germ cell tumors with areas that, when seen under the microscope, look like each of the 3 layers of a developing embryo: the endoderm (innermost layer), mesoderm (middle layer), and ectoderm (outer layer).  The 3 main types of these tumors are the mature teratoma, immature teratoma, and teratoma with malignant transformation. Pure teratomas do not increase AFP or HCG levels.
      • Mature teratomas are tumors formed by cells similar to cells of adult tissues.  They are generally benign and rarely spread to nearby tissues and distant parts of the body.  They can usually be cured with surgery.
        • Sometimes deposits of mature teratoma are found after chemotherapy to treat a non-seminomatous mixed germ cell tumor is finished.  These may be the part of a tumor that was left behind after chemotherapy has killed the other components of the tumors.  Some experts believe that chemotherapy can change other types of non-seminoma into teratoma.
      • Immature teratomas are less well-developed cancers with cells that look like those of an early embryo.  Unlike mature teratomas, this type is more likely to grow into (invade) surrounding tissues and to spread (metastasize) outside the testicle.  It can also sometimes recur (come back) years after treatment.
      • Teratoma with malignant transformation is a very rare cancer.  These cancers have some areas that look like mature teratomas but have other areas where the cells have become a type of cancer that develops outside of the testicle, in tissues such as muscles, glands of the lungs or intestines, or the brain.
• Carcinoma in situ
  • Testicular germ cell cancers may begin as a non-invasive form of the disease called carcinoma in situ (CIS) or intratubular germ cell neoplasia.  Carcinoma in situ may not always progress to invasive cancer.  Researchers have estimated that it can take about 5 years for CIS to progress to the invasive form of germ cell cancer.
  • It is hard to find CIS before it develops into invasive cancer because it generally causes no symptoms and often does not form a lump that you or the doctor can feel.  The only way to diagnose testicular carcinoma in situ is to have a biopsy. Some cases are found incidentally (by accident) in men who have a testicular biopsy for some other reason, such as infertility. 
  • When a testicular tumor like CIS becomes invasive, its cells are no longer just in the seminiferous tubules (where sperm cells are formed) but have grown into other structures of the testicle.  These cancer cells can then spread either to the lymph nodes (small, bean-shaped collections of white blood cells that fight infection) through lymphatic channels (fluid-filled vessels that connect the series of lymph nodes), or through the blood circulation to other parts of the body.

-Stromal tumors

• Tumors can also develop in the supportive and hormone-producing tissues, or stroma, of the testicles.  These tumors are known as gonadal stromal tumors.  They make up less than 5% of adult testicular tumors but up to 20% of childhood testicular tumors.  The 2 main types are Leydig cell tumors and Sertoli cell tumors.
  • Leydig cell tumors: These generally benign tumors develop from the Leydig cells in the testicle that normally produce male sex hormones (androgens like testosterone).  Leydig cell tumors can develop in both adults (75% of cases) and children (25% of cases).  They often produce androgens but sometimes produce estrogens (female sex hormones).
    • Most Leydig cell tumors do not spread beyond the testicle and are cured with surgery.  Sometimes, however, these tumors do spread to other parts of the body.  If they do metastasize, Leydig cell tumors have a poor prognosis because they usually do not respond well to chemotherapy or radiation therapy.
  • Sertoli cell tumors: These tumors develop from normal Sertoli cells, which support and nourish the sperm-producing germ cells.  Like the Leydig cell tumors, they are usually benign.  However, if they spread, they tend to be resistant to chemotherapy and radiation therapy.

-Secondary testicular tumors

• Secondary testicular tumors are those that start in another organ and then spread to the testicle.  Lymphoma is the most common secondary testicular cancer.  Testicular lymphoma is more common than primary testicular tumors in men older than 50.  Their prognosis depends on the type and stage of lymphoma.  The usual treatment is surgical removal, followed by radiation and/or chemotherapy.  In boys with acute leukemia, the leukemia cells can sometimes form a tumor in the testicle.
• Cancers of the prostate, lung, skin (melanoma), kidney, and other organs also can spread to the testicles.  The prognosis for these cancers is usually poor because these cancers generally spread widely to other organs as well.  Treatment depends on the specific type of cancer.

-The TNM staging system

• A staging system is a standardized way for your cancer care team to summarize and describe the extent of your cancer. Testicular cancer is staged using the TNM system created by the American Joint Committee on Cancer (AJCC).
• The staging system of testicular cancer contains 4 key pieces of information:
  • T refers to how much the primary tumor has spread to tissues next to the testicle.
  • N describes how much the cancer has spread to regional (nearby) lymph nodes.
  • M indicates whether the cancer has metastasized (spread to distant lymph nodes or other organs of the body).
  • S indicates the serum levels of certain proteins (tumor markers) that are produced by some testicular cancers.
• Primary tumor (T)
  • TX: The primary tumor cannot be assessed
  • T0: There is no evidence of primary tumor
  • Tis: Carcinoma in situ (noninvasive cancer cells)
  • T1: The tumor has not spread beyond the testicle and the narrow tubules next to the testicles where sperm undergo final maturation (epididymis). Cancer cells are not found inside blood vessels or lymph vessels next to the tumor. The cancer may have grown through the inner layer surrounding the testicle (tunica albuginea) but not the outer layer covering the testicle (tunica vaginalis).
  • T2: Similar to T1 except that the cancer has spread to blood or lymph vessels near the tumor, or the tunica vaginalis
  • T3: The tumor invades the spermatic cord (which contains blood vessels, lymph vessels, nerves, and the vas deferens)
  • T4: The tumor invades the skin surrounding the testicles (scrotum)
• Regional lymph nodes (N)
  • NX: Regional (nearby) lymph nodes cannot be assessed
  • N0: No spread to regional lymph nodes is seen on x-rays
  • N1: There is spread to at least one lymph node, but no lymph node is larger than 2 cm (about 3/4 inch) in any dimension
  • N2: There is spread to at least one lymph node that is larger than 2 cm but is not bigger than 5 cm (2 inches) in any dimension
  • N3: There is spread at least one lymph node that is larger than 5 cm in any dimension
• Distant metastasis (M)
  • MX: Distant metastasis cannot be assessed
  • M0: There is no distant metastasis (no spread to lymph nodes outside the area of the tumor or other organs, such as the lungs)
  • M1: Distant metastasis is present
    • M1a: The tumor has metastasized to distant lymph nodes or to the lung
    • M1b: The tumor has metastasized to other organs, such as the liver, brain, or bone
• Serum tumor markers (S)
  • See table below.
    
    

Prevalence

-The American Cancer Society's most recent estimates for the United States: 

• about 8,400 new cases of testicular cancer will be diagnosed during 2009.
• about 380 men will die of testicular cancer

-The rate of testicular cancer has been increasing in many countries, including the United States. 

• The increase is mostly in seminomas. 
• Experts have not been able to find reasons for this increase.
• Lately, the rate of increase has slowed.

-Testicular cancer is not common; a man's lifetime chance of developing testicular cancer is about 1 in 300.

-Because treatment is so successful, the risk of dying from this cancer is very low: about 1 in 5,000.

-Testicular cancer is one of the most curable forms of cancer. 

-According to the National Cancer Institute, the 5-year relative survival rate for all men with this cancer is 95%.

• If the cancer hasn't spread outside the testicle, the 5-year relative survival rate is 99%.  
• Even if the cancer has spread to nearby lymph nodes, the 5-year relative survival rate is 96%. 
• If the cancer has spread beyond the lymph nodes, the 5-year survival rate is around 71%. 
• More than 170,000 men in the United States have survived testicular cancer.

-Testicular cancer is relatively rare and occurs most often in young men between the ages of 15 and 35 years old, although any male can be affected at any time (including infants).DIFF
-Testicular cancer in the most common solid organ tumor in young men.PATHO
-Testicular cancer is the second most common malignancy from age 35 to 39 years with a white-to-black incidence ratio of 5 to 1.PATHO
-According to the National Cancer Institute’s Surveillance, about 8,000 men are diagnosed with testicular cancer each year (390 deaths annually).PATHO
-The incidence of testicular cancer around the world has doubled in the past 30 to 40 years.PATHO
-There are considerable geographic and ethnic variations in the global incidence of  testicular cancer.PATHO
-The disease mainly affects Western populations, with an increasing incidence since the middle of the twentieth century.PATHO
-Average rates in developed areas of the world are six times higher than those in developing areas.PATHO
-Approximately 79,200 new cases of testicular cancer were estimated to occur in the United States in 2007.PATHO

Characteristics/Clinical Presentation

-The most common initial sign of testicular cancer is enlargement of the testis with diffuse testicular pain, swelling, hardness, or some combination of these findings.PATHO

• The condition may go undetected if no pain is experienced and the male is not periodically performing testicular self-examination.PATHO

-Clinial Signs and Symptoms

• A lump in either testicleDIFF
• Any enlargement, swelling, or hardness of a testicleDIFF
  • The enlargement may be accompanied by an ache in the abdomen or scrotum or a sensation of heaviness in the scrotum.PATHO
• Significant loss of size in one of the testiclesDIFF
• Feeling of heaviness in the scrotum and/or lower abdomenDIFF
• Dull ache in the lower abdomen or in the groinDIFF
• Sudden collection of fluid in the scrotumDIFF
• Pain or discomfort in a testicle or in the scrotumDIFF
  • Pain may be the sole presenting symptom in metastasis to the retroperitoneal, cervical, and supraclavicular lymphatic chains.PATHO
    • Approximately 20% of all cases have involved lymph nodes.PATHO
• Enlargement or tenderness of the breastsDIFF
  • This symptom occurs because certain types of germ cell tumors secrete high levels of a hormone called human chorionic gonadotropin (HCG), which stimulates breast development.
• Unexpected fatigue or malaiseDIFF
• InfertilityDIFF
• Metastasis, with little or no local change, is noted in the scrotum.PATHO
• Low back pain (metastases to retroperitoneal lymph nodes) in later stage testicular cancerDIFF
  • Up to 21% of men with testicular germ cell cancer have back pain as the primary presenting symptoms.
  • Retroperitoneal primary tumors may present with back pain and/or groin or pelvic pain (psoas muscle invasion).PATHO
  • Metastatic testicular cancer can present as back pain (may be the primary presenting complaint), abdominal mass, hemoptysis, or neck or supraclavicular adenopathy.PATHO
• Bone metastasis is a late event, often combined with metastasis to the retroperitoneal lymph nodes, lung, and liver.PATHO
  • Even when testicular cancer has spread to other organs, only about 1 man in 4 may have symptoms.
  • If the cancer has spread to the lungs, persistent cough, chest pain, and/or shortness of breath can occur.DIFF
    • Hemoptysis (sputum with blood) may also develop.DIFF
  • In rare cases, testicular cancer spreads to the brain and can cause headaches.

-Symptoms similar to those of testicular cancer

• A number of non-cancerous conditions, such as testicle injury or inflammation, can produce symptoms similar to those of testicular cancer.
  • Inflammation of the testicle, known as orchitis, can cause painful swelling.
    • The mumps virus causes orchitis in about 1 man in 5 who contracts mumps as an adult.
  • Epididymitis (inflammation of the epididymis) can also cause swelling and pain.
  • Both of these can be caused by viral or bacterial infections.
    
    
    

Associated Co-morbidities/Complications

• No associated co-morbidities found.
• Long-term sequelae of cisplatin use may include leukemia, cardiovascular events, and reports that circulating cisplatin can be detected in the plasma as long as 20 years after treatment.PATHO
• The most serious long-term complications of chemotherapy or radiotherapy are cardiovascular toxicity and second malignancies; each has a 25-year risk of approximately 16%.PATHO
• Chemotherapy-related cardiovascular toxicity may be the result of both direct endothelial damage induced by cisplatin and indirect hormonal and metabolic changes.PATHO
• There is an increased incidence of metabolic syndrome in long-term survivors that is most likely caused by the lower testosterone levels.PATHO
• Current therapeutic regimens have significantly improved survival but often adversely affect fertility; cisplatin-based chemotherapy results in 30% to 50% infertility rates in men with testicular cancer who are treated with chemotherapy.PATHO
• Other chemotherapy-induced complications include chronic neurotoxicity (50%), permanent ototoxicity and renal function impairment (30%), pulmonary fibrosis (5% to 10% when treated with bleomycin); and late relapse.PATHO
  

Medications

-No known preventive strategies exist including the use of medications.
-Will research further to see if any oral medications are used in the treatment of testicular cancer.

Diagnostic Tests/Lab Tests/Lab Values

-Medical history and physical exam

• If you have signs or symptoms that may suggest testicular cancer, your doctor will want to take a complete medical history to check for risk factors and symptoms.
• During a physical exam, the doctor will feel the testicles for swelling or tenderness and for the size and location of any lumps.
• The doctor will also examine your abdomen, lymph nodes, and other parts of your body carefully, looking for any signs the tumor has spread.
• Often the results of the exam are normal aside from the testicular abnormalities.

-Ultrasound of the testicles

• An ultrasound can help doctors tell if a lump is solid or filled with fluid.
  • Testicular ultrasound is used to differentiate a variety of scrotal disorders besides cancer (e.g., epididymitis, orchitis, hydrocele, or hematocele).PATHO
• This test uses sound waves to produce images of internal organs.
• A transducer (wand-like instrument) emits the sound waves and picks up the echoes as they bounce off the organs.
• A computer processes the pattern of echoes to produce an image on a monitor.
  • The echoes from most tumors differ from those of normal tissues.
  • These patterns of echoes also can help distinguish some types of benign and malignant tumors from one another.

-Blood tests for tumor markers

• Some blood tests can help diagnose testicular tumors.
• Serum tumor markers are increased in 40% to 60% of all cases and may be used to guide treatment and follow-up.PATHO
• Many testicular cancers secrete high levels of certain proteins, such as alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG).
  • When these proteins (called tumor markers) are in the blood, it suggests that there is a testicular tumor.
• A tumor may also increase the levels of an enzyme called lactate dehydrogenase (LDH).
  • However, LDH levels can also be increased in conditions other than cancer.
• Non-seminomas often raise AFP and/or HCG levels.
• Pure seminomas occasionally raise HCG levels but never AFP levels, so any increase in AFP means that the tumor has a non-seminoma component.
• (Tumors can be mixed and have areas of seminoma and non-seminoma.)
• A high LDH often (but not always) indicates widespread disease.
• Sertoli and Leydig cell tumors do not produce these substances.
• The levels of these proteins may not be elevated if the tumor is small.
• For more information on the values of the serum tumor markers, please refer to the table in Defintion/Description.

-Imaging Tests

• Chest x-ray
  • This test is done to see if your cancer has spread to your lungs or the lymph nodes in the middle area of the chest known as the mediastinum.
  • If the x-ray result is normal, you probably don't have cancer in your lungs.
  • But most doctors feel a computed tomography (CT) scan can better judge whether the cancer has spread to the chest.
• Computed tomography (CT) scan
  • The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body.
  • Instead of taking one picture, like a conventional x-ray, a CT scanner takes many pictures of the part of your body being studied as it rotates around you.
  • A computer then combines these pictures into an image of a slice of your body.
  • CT scans are helpful in staging the cancer.
    • They can help tell if your cancer has spread into your lymph nodes, lungs, liver, or other organs.
  • Before the scan, you may be asked to drink a contrast solution and/or get an intravenous (IV) injection of a contrast dye that helps better outline abnormal areas in the body.
  • CT scans are sometimes used to guide a biopsy needle precisely into a suspected metastasis.
    • For this procedure, called a CT-guided needle biopsy, you remain on the CT scanning table while a radiologist advances a biopsy needle through the skin toward the location of the mass.
  • CT scans are repeated until the doctors are confident that the needle is within the mass.
    • A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue) is removed and examined under a microscope.
      

-A thorough urologic history and physical examination are the basis for making a diagnosis of testicular cancer.PATHO

-A painless testicular mass is highly suggestive of testicular cancer.PATHO

-Transillumination of the scrotum may also reveal a testicular mass.PATHO
-MR lymphography may replace the currently used tomography scanning or MRI used to noninvasively stage retroperitoneal lymph nodes.PATHO
-Biopsy with microscopic examination of testicular tissue by a pathologist is the best way to make a definitive diagnosis.PATHO  

-The American Cancer Society recommends monthly self-exam of the testicles for adolescents and men, starting at age 15.PATHO

-Testicular self-examination is an effective way of getting to know this area of the body and thus detecting testicular cancer at a very early, curable stage.PATHO
-The self-exam is best performed once each month or after a warm bath or shower when the heat has relaxed the scrotum.PATHO

Causes/Risks

-Causes

• The etiology of testicular cancer is not well understood.PATHO
• Although the cause is unknown, hormonal balance at various life stages appear to be related.PATHO
• Congenital and acquired factors have been associated with the development of testicular cancer; familial clustering has been observed particularly among siblings.PATHO
• The first susceptibility gene for testicular cancer has been located and named TGCT1 on the long arm of chromosome X, inherited from the mother; its presence increases a man’s risk of testicular cancer by up to 50 times.PATHO
• There is some evidence that cancer stem cells are derived from normal stem cells that have gradually accumulated various genetic defects; a group of tumor-specific antigens known as cancer/testis antigens (CTAs) may be expressed at early stages during embryogenesis in germ cell precursors eventually leading to testicular cancer.PATHO
• A great deal of research is being done to learn more about the causes.
  • During the past few years, researchers have learned a lot about certain changes in chromosomes and DNA that may cause normal testicular germ cells to develop into germ cell tumors.
    • Meiosis is the process by which germ cells with 46 chromosomes develop into sperm or egg cells with 23 chromosomes.
      • Testicular germ cell tumors may form when something abnormal happens during meiosis.
      • Instead of forming normal sperm cells with 23 chromosomes, all 46 chromosomes remain.
      • Usually, these chromosomes become unstable and progressively more abnormal in their shape and number (often between 69 and 82) as the cells continue to divide.
      • Testicular cancer cells often have extra copies of a part of chromosome 12 (this is called isochromosome 12p).
      • Scientists are studying DNA from this chromosome to learn more about exactly what goes wrong during meiosis and how this might be prevented or reversed.
    • Several other abnormal chromosomes and changes in the factors that regulate cell division and the cell cycle have been associated with testicular cancer, both in animals and in humans.
    • All of these changes are being studied to find the true causes of testicular cancer.

-Risk Factors

• The most significant factor in testicular cancer is the association of cryptorchidism (the testes not descending into the scrotum).PATHO
  • Although most cancers develop in the undescended testicle, about 1 out of 4 cases occur in the normally descended testicle.
  • The incidence of testicular cancer is 35 times higher in males with a cryptoid testis.PATHO
  • Risk is higher than average for boys born with an undescended testicle (cryptorchidism).  The cancer risk for boys with this condition is increased even if surgery is done to move the testicle to the scrotum.DIFF
  • In the case of unilateral cryptorchidism, the risk of testicular cancer is increased in the normal testicle as well.  This fact suggests testicular cancer is due to whatever caused the undescended testicle.DIFF
• Having a brother or father with testicular cancer also increases an individual’s risk.DIFF
  • If a man has the disease, there is an increased risk that one or more of his brothers or sons will also develop it.
  • However, only about 3% of testicular cancer cases are actually found to occur in families.
  • Most men with testicular cancer do not have a family history of the disease.
• A previous history of testicular cancer and history of infertility and poor semen quality or infection have been associated with an increased risk of developing testicular cancer.PATHO
  • A causal relationship has not been established between infertility and infection and testicular cancer.PATHO
  • About 3% or 4% of men who have been cured of cancer in one testicle will eventually develop cancer in the other testicle.
• Age
  • About 9 out of 10 testicular cancers occur in men between the ages of 20 and 54.
  • But this cancer can affect males of any age, including infants and elderly men.
• There is now strong evidence that prenatal or postnatal environmental estrogen exposures (e.g., endocrine-mimicking environmental pollutants, pesticides, industrial chemicals, or chemical contaminants in drinking water) contributes to testicular cancer; this remains under further investigation.PATHO
• Other risk factors still under investigation may include mothers who took exogenous estrogen during pregnancy (diethylstilbestrol), scrotal trauma, exposure to high levels of radiofrequency/microwave radiation in radar technicians, first-born sons, and nonidentical twins.PATHO
• Other risk factors may include occupation (e.g., miners, oil and gas workers, leather workers, food and beverage processing workers, janitors, firefighters, utility workers) and HIV infection.DIFF
  • Some evidence has shown that men infected with the human immunodeficiency virus (HIV), particularly those with AIDS, are at increased risk.
  • No other infections have been shown to increase testicular cancer risk.
• Men with Kleinfelter’s syndrome (a sex chromosome disorder characterized by low levels of male hormones, sterility, breast enlargement, and small testes) are also at greater risk of developing testicular cancer.PATHO
• Lifestyle and occupational exposures occurring later in life may play a role in promoting the disease, but they are not likely involved in the initiation of the cancer development.PATHO
• Race and ethnicity
  • The risk of testicular cancer among white men is about 5 times that of black men and more than 3 times that of Asian-American and American Indian men.
  • The risk for Hispanics is between that of Asians and non-Hispanic whites.DIFF  The reason for this difference is unknown.DIFF
  • The testicular cancer rate has more than doubled among white Americans in the past 40 years but has not changed for African Americans.DIFF
  • Worldwide, the risk of developing this disease is highest among men living in the United States and Europe and lowest among African and Asian men.DIFF

 

Systemic Involvement

-Men can experience back pain (as well as hip, groin, SI, and sacral pain) caused by referred pain from the male reproductive system.
-Back pain, changes in bladder function, and sexual dysfunction are the most common symptoms associated with male reproductive disorders.
-Metastases occur via the blood or lymph system.
-The most common place for the disease to spread is to the lymph nodes in the posterior part of the abdomen.  Therefore, lower back pain is a frequent symptom of later stage testicular cancer.
-If cancer has spread to the lungs, persistent cough, chest pain, and/or shortness of breath can occur.  Hemoptysis (sputum with blood) may also develop.
-Back pain associated with cancer is usually constant, intense, and worse at night or with weight-bearing activities, although vague, diffuse back pain can be an early sign of non-Hodgkins lymphoma and multiple myeloma.
-Pain with metastasis to the spine may become quite severe before any radiologic manifestations appear.
-Back pain associated with malignant retroperitoneal lymphadenopathy or testicular cancers is characterized as persistent, poorly localized low back pain present at night but relieved by forward flexion.
-Pain may be so excruciating while lying down that the patient can sleep only while sitting in a chair hunched forward over a table.
-Typically systemic back pain is not relieved by recumbency.
-In fact the bone pain of metastasis or myeloma tends to be more continuous, progressive, and prominent when the client is recumbent.
-Beware of the client with acute backache who is unable to lie still.
-Almost all clients with regional or nonspecific backache seek the most comfortable position (usually recumbency) and stay in that position.
-In contrast, individuals with systemic backache tend to keep moving trying to find a comfortable position.
-Back pain that is unrelieved by rest or change in position, or pain that does not fit the expected mechanical or neuromusculoskeletal pattern, should raise a red flag.
-When the symptoms cannot be reproduced, aggravated, or altered in any way during the examination, additional questions to screen for medical disease is indicated.
-Pain at night can signal a serious problem such as tumor, infection, or inflammation.
-Long-standing night pain unaltered by positional change suggests a space-occupying lesion, such as a tumor.
-Systemic back pain may get worse at night, especially when caused by vertebral osteomyelitis, septic discitis, Cushing’s disease, osteomalacia, primary and metastatic cancer, Paget’s disease, ankylosing spondylitis, or tuberculosis (of the spine).

Medical Management (current best evidence)

-Management of testicular cancer has changed substantially in the last 20 years, primarily because of the ability of cisplatin-containing combination chemotherapy to cure advanced disease.
-Even over the last 5 years, the management of stage 1 testis cancer has changed tremendously.
-Chemotherapy is used in cases of relapse after radiation therapy or when there is a high risk for occult metastatic disease.
-The recommendation of which therapies to include is based on pathologic findings from the orchidectomy and results of the CT and MRI procedures.
-Second-line conventional-dose or high-dose chemotherapy with stem cell rescue may cure 25% to 50% of men with recurrent testicular tumors.
-New chemotherapeutic agents, including the taxanes gemcitabine and oxaliplatin, may also be used.
-Organ-sparing surgery has become an accepted approach to treat malignant and nonmalignant tumors of a single testis.Combined with adjuvant radiotherapy to the retroperitoneal and ipsilateral pelvic lymph nodes, this approach has proven as effective as orchidectomy.
-Nerve-sparing retroperitoneal lymph node dissection is an integral part of testis cancer management strategies for both early and advanced-stage disease.
-Nerve-sparing techniques help preserve sexual function and prevent incontinence.
-As many as 50% of men with clinical stage 1 testis cancer can be treated with close surveillance instead of immediate adjuvant treatment.
-Testicular-sparing management of testicular cancer is an alternative to radial orchidectomy and allows for preservation of sperm and hormonal function without endangering survival rates.  Sperm collection and cryopreservation before the initiation of therapy is an available reproductive technology.  Only a few sperm are needed for successful in vitro fertilization.

Physical Therapy Management (current best evidence)

Will research further.

Alternative/Holistic Management (current best evidence)

Will research further.

Differential Diagnosis

-Men can experience back pain (as well as hip, groin, SI, and sacral pain) caused by referred pain from the male reproductive system.
-Back pain, changes in bladder function, and sexual dysfunction are the most common symptoms associated with male reproductive disorders.

Case Reports

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Resources

add appropriate resources here

Recent Related Research (from Pubmed)

see tutorial on Adding PubMed Feed