Testicular tumors

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Testicular tumors

• B.Vijay Anand,
• SRMC, Chennai.

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Incidence

• Testicular tumors are rare.
• 1 2 of all malignant tumors.
• Most common malignancy in men in the 15 to 35
  year age group.
• Benign lesions represent a greater percentage of
  cases in children than in adults.

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• Age - 3 peaks
• 2 4 yrs
• 20 40 yrs
• above 60 yrs
• Testicular cancer is one of the few neoplasms
  associated with accurate serum markers.
• Most curable solid neoplasms and serves as a
  paradigm for the multimodal treatment of
  malignancies.

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Etiology

• Cryptorchidism
• Intersex disorder
• Testicular atrophy
• Trauma- prompts medical evaluation
• Chromosomal abnormalities - loss of chromosome
  11, 13, 18, abnormal chromosome 12p.
• Sex hormone fluctuations, estrogen administration
  during pregnancy

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CROSS SECTION OF TESTIS

• Testis
• Stroma Seminiferous Tubules
• (200 to 350 tubules)
• Interstitial Cells Supporting
  Spermatogonia
• Leydig or
• (Androgen)
  Sertoli Cell

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CLASSIFICATION

• I. Primary Neoplasms of Testis.
• A. Germ Cell Tumor.
• B. Non-Germ Cell Tumor .
• II. Secondary Neoplasms.
• III. Paratesticular Tumors.

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Germ cell tumors

• 1. Seminomas - 40
• (a) Classic Typical Seminoma
• (b) Anaplastic Seminoma
• (c) Spermatocytic Seminoma
• 2. Embryonal Carcinoma - 20 - 25
• 3. Teratoma - 25 - 35
• (a) Mature
• (b) Immature
• 4. Choriocarcinoma - 1
• 5. Yolk Sac Tumour

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Classification of germcell tumor (GCT)

• GCTs arise from pluripotential cells, so a
  variety of elements may habitate in primary
  tumor
• More than half of GCTs contain more than one cell
  type and are therefore known as mixed GCTs

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Sex cord/ gonadal stromal tumors ( 5 to
10 )

• 1. Specialized gonadal stromal tumor
• (a) Leydig cell tumor
• (b) sertoli cell tumor
• 2. Gonadoblastoma
• 3. Miscellaneous Neoplasms
• (a) Carcinoid tumor
• (b) Tumors of ovarian epithelial
  sub
• 
  types
  

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II. SECONDARY NEOPLASMS OF TESTIS
A. Reticuloendothelial Neoplasms B. Metastases
III. PARATESTICULAR NEOPLASMS

• A. Adenomatoid
• B. Cystadenoma of Epididymis
• C. Desmoplastic small round cell tumor
• D. Mesothelioma
• E. Melanotic neuroectodermal

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Carcinoma insitu CIS

• Pre invasive precusor of all GCT, except
  spermatocytic seminoma
• Incidence of CIS in the male population is 0.8.
• Testicular CIS develops from fetal gonocytes
  is characterized histologically by seminiferous
  tubules containing only Sertoli cells and
  malignant germ cells.

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Patients at risk of CIS

• History of testicular carcinoma (5 to 6),
• Extra gonadalGCT (40),
• Cryptorchidism (3),
• Contralateral testis with unilateral testis
  cancer (5 to 6),
• Somatosexual ambiguity (25 to 100)
• Atrophic testis 30
• Infertility (0.4 to 1.1)
• TESTICULAR BIOPSY gold standard for diagnoses of
  CIS

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Lymphatic drainage

• The primary drainage of the right testis is
  within the interaortocaval region.
• Left testis drainage , the para-aortic region in
  the compartment bounded by the left ureter, the
  left renal vein, the aorta, and the origin of the
  inferior mesenteric artery.
• Cross over from right to left is possible.

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Lymphatic drainage

• Lymphatics of the epididymis drain into the
  external iliac chain.
• Inguinal node metastasis may result from scrotal
  involvement by the primary tumor, prior inguinal
  or scrotal surgery, or retrograde lymphatic
  spread secondary to massive retroperitoneal lymph
  node deposits.
• Testicular cancer spreads in a predictable and
  stepwise fashion, except choriocarcinoma.
• .

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Clinical features

• Painless Swelling of One testis
• Dull Ache or Heaviness in Lower Abdomen
• 10 - Acute Scrotal Pain
• 10 - Present with Metatstasis
• - Neck Mass / Cough / Anorexia / Vomiting / Back
  Ache/ Lower limb swelling
• 5 - Gynecomastia
• Rarely - Infertility

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Physical Examination

• Examine contralateral normal testis.
• Firm to hard fixed area within tunica albugenia
  is suspicious
• Seminoma expand within the testis as a painless,
  rubbery enlargement.
• Embryonal carcinoma or teratocarcinoma may
  produce an irregular, rather than discrete mass.

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Differential Diagnosis

• Testicular torsion
• Epididymitis, or epididymo-orchitis
• Hydrocele,
• Hernia,
• Hematoma,
• Spermatocele,
• Syphilitic gumma .

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DICTUM FOR ANY SOLID SCROTAL SWELLINGS

• All patients with a solid, Firm Intratesticular
  Mass that cannot be Transilluminated should be
  regarded as Malignant unless otherwise proved.

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Scrotal ultrasound

• Ultrasonography of the scrotum is a rapid,
  reliable technique to exclude hydrocele or
  epididymitis.
• Ultrasonography of the scrotum is basically an
  extension of the physical examination.
• Hypoechoic area within the tunica albuginea is
  markedly suspicious for testicular cancer.
  

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Cystic lesion- epidermoid cyst
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Tumor markers

• TWO MAIN CLASSES
• Onco-fetal Substances AFP HCG
• Cellular Enzymes LDH PLAP
• AFP - Trophoblastic Cells
• HCG - Syncytiotrophoblastic Cells
• ( PLAP- placental alkaline phosphatase, LDH
  lactic acid dehydrogenase)

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AFP ( Alfafetoprotein)

• NORMAL VALUE Below 16 ngm / ml
• HALF LIFE OF AFP 5 and 7 days
• Raised AFP
• Pure embryonal carcinoma
• Teratocarcinoma
• Yolk sac Tumor
• Combined tumors,
• AFP not raised in pure choriocarcinoma , in
  pure seminoma

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HCG ( Human Chorionic Gonadotropin)

• Has ? and ? polypeptide chain
• NORMAL VALUE lt 1 ng / ml
• HALF LIFE of HCG 24 to 36 hours
• RAISED ? HCG -
• 100 - Choriocarcinoma
• 60 - Embryonal carcinoma
• 55 - Teratocarcinoma
• 25 - Yolk Cell Tumour
• 7 - Seminomas

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ROLE OF TUMOUR MARKERS

• Helps in Diagnosis - 80 to 85 of
  Testicular Tumours have Positive Markers
• Most of Non-Seminomas have raised markers
• Only 10 to 15 Non-Seminomas have normal marker
  level
• After Orchidectomy if Markers Elevated means
  Residual Disease .
• Elevation of Markers after Lymphadenectomy
  means a STAGE III Disease

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ROLE OF TUMOUR MARKERS

• Degree of Marker Elevation Appears to be Directly
  Proportional to Tumor Burden
• Markers indicate Histology of Tumor
• If AFP elevated in Seminoma - Means Tumor has
  Non-Seminomatous elements
• Negative Tumor Markers becoming positive on
  follow up usually indicates - Recurrence of
  Tumor
• Markers become Positive earlier than X-Ray studies

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Imaging studies

• Chest X ray
• CECT abdomen retroperitoneal nodes
• PET- No apparent advantage over CT
• MRI - No apparent advantage over CT

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Large left para aortic nodal mass due to GST
causing hydronephrosis
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Tumor staging

• Primary Tumor (T)pTX - Primary tumor cannot be
  assessed (if no radical orchiectomy has been
  performed, TX is used)
• pT0 - No evidence of primary tumor (e.g.,
  histologic scar in testis)
• pTis - Intratubular germ cell neoplasia
  (carcinoma in situ)
• pT1 - Tumor limited to the testis and epididymis
  and no vascular/lymphatic invasion
• pT2 - Tumor limited to the testis and epididymis
  with vascular/lymphatic invasion or tumor
  extending through the tunica albuginea with
  involvement of tunica vaginalis
• pT3 - Tumor invades the spermatic cord with or
  without vascular/lymphatic invasion
• pT4 - Tumor invades the scrotum with or without
  vascular/lymphatic invasion

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Regional Lymph Nodes

• Clinical NX - Regional lymph nodes cannot be
  assessed
• N0 - No regional lymph node metastasis
• N1 - Lymph node mass 2 cm or less in greatest
  dimension or multiple lymph node masses, none
  more than 2 cm in greatest dimension
• N2 - Lymph node mass, more than 2 cm but not more
  than 5 cm in greatest dimension, or multiple
  lymph node masses, any one mass greater than 2 cm
  but not more than 5 cm in greatest dimension
• N3 - Lymph node mass more than 5 cm in greatest
  dimension

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Pathologic node staging

• pN0 - No evidence of tumor in lymph nodes
• pN1 - Lymph node mass, 2 cm or less in greatest
  dimension and 6 nodes positive, none gt2 cm in
  greatest dimension
• pN2 - Lymph node mass, more than 2 cm but not
  more than 5 cm in greatest dimension more than 5
  nodes positive, none gt5 cm evidence of
  extranodal extension of tumor
• pN3 - Lymph node mass more than 5 cm in greatest
  dimension.

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Distant metastasis

• M0 - No evidence of distant metastases
• M1 - Nonregional nodal or pulmonary metastases
• M2 - Nonpulmonary visceral masses

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Serum tumor markers
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PRINCIPLES OF TREATMENT

• Treatment should be aimed at one stage above the
  clinical stage
• Seminomas - Radio-Sensitive. Treat with
  Radiotherapy.
• Non-Seminomas are Radio-Resistant and best
  treated by Surgery
• Advanced Disease or Metastasis - Responds well to
  Chemotherapy

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PRINCIPLES OF TREATMENT

• Radical INGUINAL ORCHIDECTOMY is Standard first
  line of therapy
• Lymphatic spread initially goes to
• RETRO-PERITONEAL NODES
• Early hematogenous spread RARE
• Bulky Retroperitoneal Tumours or Metastatic
  Tumors Initially DOWN-STAGED with CHEMOTHERAPY

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PRINCIPLES OF TREATMENT

• Transscrotal biopsy is to be condemned.
• The inguinal approach permits early control of
  the vascular and lymphatic supply as well as
  en-bloc removal of the testis with all its
  tunicae.
• Frozen section in case of dilemma.

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CHEMOTHERAPY

• Chemotherapy Toxicity
• BEP -
• Bleomycin Pulmonary
  fibrosis
• Etoposide (VP-16)
  Myelosuppression
• 
  Alopecia
• 
  Renal insufficiency (mild)
• 
  Secondary leukemia
• Cis-platin Renal
  insufficiency
• 
  Nausea, vomiting
• 
  Neuropathy

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Lymph Nodes Dissection For Right Left Sided
Testicular Tumours
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CONCLUSION

• Improved Overall Survival of Testicular Tumour
  due to Better Understanding of the Disease,
  Tumour Markers and Cis-platinum based
  Chemotherapy.
• Current Emphasis is on Diminishing overall
  Morbidity of Various Treatment Modalities .

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• THANK YOU