Testicular tumors

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Testicular tumors

• Mostafa El- Haddad

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Anatomie

• Blood Supply?
• Lns distribution
• Cross over from Rt to Lt but not from Lt. to Rt.
• Scrotal Lymphatic's disruption.

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Epidemiology

• Age 20-35ys.
• Seminoma patient is older.
• Dont forget that yolk sac tumor can occur in
  children.
• Where?
• Social problem.

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Etiology and Risk Factors

• Intrauterine exposure to Estrogen.
• Un-descended testis intra-abdminal gt inguinal.
• Family history very important.
• AIDS RPL and stage is difficult to predict.
• Stage for stage is ok.
• Or c h id o p e x y d o e s n o t r e d u c e
  r i s k i n
• al l a g e g r o u ps b u t f a c i l i t a t
  e s
• e x a m i n a t i o

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• Intratubular neoplasm? How we detected?
• Present in the contralateral testis in 10.
• Bilateral testicular tumor do exist.

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Pathology

• Germ Cell tumors.
• Supporting Cell tumors.
• Lymphoma.
• Metastasis including sanctuary site.

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WHO ClassificationAnd British Testicular Tumor
Panel and Registry
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Mixed Germ Cell Tumors Are Considered NSGCT
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Isochromosome 12

• What is isochromosome?
• Value?
• Pathognomonic feature of GCT of all histologic
  types, whether of gonadal or extragonadal origin.
• Can be an early marker (reported in insitu
  tumors).
• The presence of three or more copies of i(12p)
  has been correlated with poor prognosis GCT.

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Natural History

• Seminoma associated with more ureteric
  obstruction?
• NSGCT is more aggressive go blood.

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RT LT
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Other Lymph Nodes

• External Iliacs
• Obturator.
• Inguinal .

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Spermatocytic Seminoma

• Sixth decade.
• Bilateral more.
• Indolent course.
• Treatment surgery.
• -ve PLAB

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Anaplastic Seminoma
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Intratubular Germ cell Neoplasia

• Precursor but not for SS
• Found in high risk group.
• Found adjacent to cancer.
• 50 risk to transform at 5 years.
• 100 risk at 8 years.
• Treatment Radiotherapy 18 to 20Gy.

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Symptoms and Signs

• Pain local, Back.
• Gynecomastia?
• DD testicular torsion, hydrocele, varicocele,
  spermatocele, and epididymitis

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• Orchiectomy may occasionally be delayed in
  metastatic cases to control primary disease .
• Orchiectomy should be done?
• When orchiectomy should not be done?

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Staging and Risk Assessment
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HCG

• HCG alpha unit and beta unit.
• prostate, bladder, ureteral, and renal cancers
  may show increase in B-HCG elevation.
• Spurious elevations have been noted in persons
  using marijuana.
• Cis-platinum-induced testicular atrophy in the
  remaining testis, resulting in lower levels of
  testosterone, with a compensatory hypersecretion
  of LH to stimulate Leydig cell secretion of
  testosterone.

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To Make Life More Complicated

• Neuroendocrine tumors and cancers of the bladder,
  kidney, lung, head and neck, GI tract
• Speci?cally gastric, pancreatic, biliary, and
  colorectal cancers, cervix, uterus, and vulva.

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• In addition, there are case reports of elevations
  in hCG in lymphoma and leukemia.

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• HCG produced by Scincytiotrophoblast.
• Seminoma can produce HCG 5-40 of cases.
• Not more than 100 IU.

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AFP

• Pregnant women (Hamel).
• Hepatitis.
• Hepatocellular carcinoma.
• 3 H

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LDH

• Gene that encodes LDH isoenzyme 1 maps to
  chromosome 12.
• The serum level of LDH isoenzyme 1 has been shown
  to correlate with the number of copies of i(12p)
  in the tumor, a fairly specific genetic marker of
  germ cell malignancies.
• Furthermore, the presence of three or more copies
  of i(12p) has been correlated with a worse
  prognosis.

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Very Important

• Up to 30 of patients with early-stage
  non-seminomatous GCT will have normal serum
  markers, so the absence of marker elevation
  should not influence the decision to perform an
  orchiectomy.
• Eventhough markers should be done before and
  After Surgery.

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PET-CT

• FDG-PET was unable to detect mature teratomas as
  well as lesions smaller than 5 mm in diameter.
  Not routinely used or recommended in initial
  staging.
• Can be used to differentiate between residual
  disease and fibrotic bands?

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Other Investigations

• Brain imaging in Choriocarcinoma.
• In patients with clear clinical examination and
• Elevated markers dont forget to investigate the
  other testis.

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ASCO Guidelines For the Use of Tumor Markers
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Treatment
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Stage I Seminoma

• Orchiectomy PLUS
• 1- Observation When?
• Or
• 2- Radiotherapy When?
• Or
• 3- Chemotherapy What?

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Chemotherapy in advanced Stage

• BEP or EP
• Cisplatin is better than Carboplatin

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• Spermatic cord involvement necessitates a
  radiation field that covers the entire inguinal
  orchiectomy scar, whereas scrotal skin
  involvement mandates radiation to the hemiscrotum

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Residual Disease Post Chemo

• Less than 3 cm or more than 3cm.
• Post chemotherapy field of radiation??

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Radiotherapy Technique
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• Consent.
• Preparation.
• Positioning.
• Simulator.
• 30 degrees rotation of the remaining testis from
  the patients long axises.

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Testicualt Irrdiation

• Intratubular germ cell tumor.
• Testicular leukemia or lymphoma.
• Position is the Key.
• Penis.
• Beam arrangement.
• Energy deep X- Electron, Photon.
• Bolus Where???

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Technical consideration

• Adjuvant radiotherapy to the hemiscrotum and
  ipsilateral inguinal lymph nodes is recom-
  mended.
• The scrotal field is matched to the tattoo at the
  inferior border of the dog-leg field.

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Non Seminoma

• Vascular/lymphatic invasion
• Embryonal carcinoma elements (gt30)
• Absence of yolk sac elements
• Absence of AFP preorchiectomy
• Less than 50 teratoma
• Local extension into paratesticular structures

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