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Sumit testicular tumors
1. By : Dr. Sumit S.Hadgaonkar
Moderator : Prof. S. Rajendra Singh
2. Introduction
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.
Most curable solid neoplasm
3. 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.
5. AETIOLOGY OF TESTICULAR TUMOUR
Cryptorchidism
Intersex disorder – Klinefelter’s syndrome
Testicular atrophy
Trauma- prompts medical evaluation
Chromosomal abnormalities - loss of chromosome 11, 13,
18, abnormal chromosome 12p.
Sex hormone fluctuations, estrogen
administration during pregnancy
Race
Carcinoma in situ
Previous testicular cancer
6. CRYPTORCHIDISM & TESTICULAR TUMOUR
Risk of Carcinoma developing
in undescended testis is
14 to 48 times the normal
expected incidence
7. CRYPTORCHIDISM & TESTICULAR TUMOUR
The cause for malignancy are as follows:
Abnormal Germ Cell Morphology
Elevated temperature in abdomen & Inguinal region
as opposed to scrotum
Endocrinal disturbances
Gonadal dysgenesis
8. Testicular Tumour & Molecular Biology
Molecular & Genetic Research may help Future
patient with Testicular Tumours:
Earlier diagnosis
Identify Susceptible Individuals
10. Testicular germ cell tumour show consistent
expression of both:
Parental alleles of H19
IGF-2 genes.
11. CROSS SECTION OF TESTIS
Testis
Stroma Seminiferous Tubules
(200 to 350 tubules)
Interstitial Cells Supporting
Spermatogonia
Leydig or
(Androgen) Sertoli Cell
12. CLASSIFICATION
I.Primary Neoplasms of Testis.
A. Germ Cell Tumor.
B. Non-Germ Cell Tumor .
II. Secondary Neoplasms.
III .Paratesticular Tumors.
29. Yolk sac tumor
Most common
Infants & children
Adults – in combination
↑ AFP
Pure form
Homogenous yellowish, mucinous
Histology
Embryoid bodies
Resemble 1 to 2 week old embryos (<1 mm)
Treatment
80 % confined to testis at diagnosis
Radical inguinal orchidectomy
Retro peritoneal LN – RPLND
Advanced disease – chemotherapy
R adiotherapy
Residual disease
Failed to respond to chemotherapy
Mean survival – 87% for all stages
30. Non Germ Cell Tumors
Sex cord tumors
1. Leydig cell tumors
2. Sertoli cell tumors
Mixed germ cell and stromal cell tumors
1. Gonadoblastoma
Miscellaneous primary non germ cell tumors
1. Epidermoid cyst
2. Adenocarcinoma of rete testis
3. Adrenal rest tumors
31.
32. Secondary Tumors of Testis
Lymphoma – most common secondary tumor
- most common testicular tumor in patients
above 50 years
- most common variety is histiocytic
Leukamic Infilteration of testis
-primary site of relapse after ALL remission
-occurs mainly in the interstitial space
-biopsy for diagnosis
- no orchidectomy
- testicular irradiation for treatment
Metastases to testis
- rare cases reported (200 cases till now)
33. Tumors of adnexa / Paratesticular tissue
Adenomatoid tumor
-most common paratesticular tumor
-benign in nature
Mesothelioma
-metastatic in 15% cases to inguinal lymph nodes
Cystadenoma
- bilateral cases are associated with Von Hippel
Lindau syndrome
Rhabdomyosarcoma
- most commonly seen in second decade of life
34. Carcinoma in situ {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.
35. 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
36. 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
37. 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.
41. 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.
42. 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.
46. 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
47. HCG – ( Human Chorionic Gonadotropin)
Has and polypeptide chain
NORMAL VALUE: < 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
48. 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 or Stage II or III Disease
Elevation of Markers after Lymphadenectomy means a STAGE
III Disease
49. ROLE OF TUMOUR MARKERS cont...
Degree of Marker Elevation Appears to be Directly
Proportional to Tumour Burden
Markers indicate Histology of Tumour:
If AFP elevated in Seminoma - Means Tumour has Non-
Seminomatous elements
Negative Tumour Markers becoming positive on follow up
usually indicates -
Recurrence of Tumour
Markers become Positive earlier than X-Ray studies
50. Imaging studies
Chest X ray
CECT abdomen – retroperitoneal nodes
PET- No apparent advantage over CT
MRI - No apparent advantage over CT
51. Large left para aortic nodal mass due to GCT
causing hydronephrosis
52. Requirements for staging
To properly Stage Testicular Tumours following
are pre-requisites:
(a) Pathology of Tumour Specimen
(b) History
(c) Clinical Examination
(d) Radiological procedure - USG / CT /
MRI / Bone Scan
(e) Tumour Markers - HCG, AFP
53.
54. Serum tumor markers
LDH HCG
Miu/ml
AFP
Ng/ml
S0 _< N <N <N
S1 <1.5 x N < 5000 < 1000
S2 1.5-10x N 5000 to
50000
1000 to
10000
S3 >10x N > 50000 >10000
55.
56.
57. 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
58. 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
59. 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.
60. Treatment of Seminomas
Stage I, IIA, ?IIB –
Radical Inguinal Orchidectomy followed by
radiotherapy to Ipsilateral Retroperitonium &
Ipsilateral Iliac group Lymph nodes (2500-3500 rads)
Bulky stage II and III Seminomas -
Radical Inguinal Orchidectomy is followed by
Chemotherapy
61. Treatment of Non-Seminoma
Stage I and IIA:
RADICAL ORCHIDECTOMY
followed by RETROPERITONEAL LYMPH NODES
DISSECTION
Stage IIB:
RPLND with possible ADJUVANT CHEMOTHERAPY
Stage IIC and Stage III Disease:
Initial CHEMOTHERAPY followed by SURGERY for Residual Disease
65. 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.
66. STANDARD CHEMOTHERAPY FOR
NON-SEMINOMATOUS GERM CELL TUMOURS
Chemotherapy Toxicity
BEP -
Bleomycin Pulmonary fibrosis
Etoposide (VP-16) Myelosuppression
Alopecia
Renal insufficiency (mild)
Secondary leukemia
Cis-platin Renal insufficiency
Nausea, vomiting
Neuropathy
68. 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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