Testicular tumours by dr abrar


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Testicular tumours by dr abrar

  1. 1. TESTICULAR TUMOURS Dr. Abrar Ahmad
  2. 2. Anatomy of the Scrotum  Scrotum: muscular pouch containing testes  Testis: a network of tightly coiled seminiferous tubules that converge and anastamose into efferent tubules  Encapsulated by tunica albuginea  Epididymis: a structure formed from merged efferent tubules, which attaches along the posterior and upper border of the testis  Described as having head, body & tail  Vas deferens: tube arising from tail of epididymis,  Passes through inguinal canal and joins seminal vesicle duct to form ejaculatory duct, which passes into prostate gland  Spermatic cord: structure formed by vas deferens, testicular arteries, and veins
  3. 3. Introduction• Although rare, is the most common malignancy in men in 15-35 yr age group• Delayed diagnosis• Has become one of the most curable solid tumour – Associated with accurate tumour markers – Origin in germ cells – Capacity to differentiate into histologically more benign forms – Predictable, systematic pattern of spread – Occurrence in young individuals
  4. 4. Etiology/Risk Factors• Congenital Causes: Cryptorchidism Klinefelter’s syndrome• Age: 20-35 years highest risk group• Hormones Maternal hormone ingestion during pregnancy• History of mumps orchitis, inguinal hernia, hydrocele in childhood - Atrophy• High socioeconomic status• Testicular cancer contralateral testis• HIV positive.
  5. 5. CRYPTORCHIDISM & TESTICULAR TUMOUR Risk of Carcinoma developing in undescended testis is 14 to 48 times the normal expected incidence
  6. 6. CRYPTORCHIDISM & TESTICULAR TUMOURThe cause for malignancy are as follows:• Abnormal Germ Cell Morphology• Elevated temperature in abdomen & Inguinal region as opposed to scrotum• Endocrinal disturbances
  7. 7. CLASSIFICATIONI. Primary Neoplasma of Testis A.Germ Cell Tumour (90-95%) B.Non-Germ Cell Tumour (5-10%)II. Secondary Neoplasms.III. Paratesticular Tumours.
  8. 8. PRIMARY NEOPLASMS OF TESTISGerminal Neoplasms : (90 - 95 %) Seminomas - 40% (a) Classic Typical Seminoma (b) Anaplastic Seminoma (c) Spermatocytic Seminoma Teratoma - 25 - 35% (a) Mature (b) Immature Embryonal Carcinoma - 20 - 25% Choriocarcinoma - 1% Yolk Sac Tumour
  9. 9. PRIMARY NEOPLASMS OF TESTISNongerminal Neoplasms : ( 5 to 10% ) Specialized gonadal stromal tumor (a) Leydig cell tumor (b) Sertoli’s cell tumour (c) Granulosa cell tumour (b) Other gonadal stromal tumor Gonadoblastoma Miscellaneous Neoplasms (a) Adenocarcinoma of the rete testis (b) Mesenchymal neoplasms (c) Carcinoid
  10. 10. SECONDARY NEOPLASMS OF TESTISA. Reticuloendothelial NeoplasmsB. Metastases(prostate,lung,colorectal, renal cell carcinoma,thyroid,breast) PARATESTICULAR NEOPLASMSA. AdenomatoidB. Cystadenoma of EpididymisC. Mesenchymal NeoplasmsD. Mesothelioma (Benign & malignant)
  11. 11. SEMINOMA• Typical : 82-85% Thirties Slow growth• Anaplastic: 5-10% More aggressive, potentially more lethal Greater metastatic potential• Spermatocytic Seminoma: 2-12 % Cells closely resemble different phases of maturing spermatogonia B/L tumours have been reported Extremely low metastatic potential Favourable prognosis
  12. 12. NON SEMINOMATOUS GERM CELL TUMOURS• Embryonal carcinoma  Generally discovered as a small, rounded but irregular mass invading the tunica vaginalis• Choriocarcinoma  May occur as palpable nodule or normal testis  Central hemorrhage  High metastatic potential (blood & lymphatic)  Most malignant tumor  Produces HCG
  13. 13. NON SEMINOMATOUS GERM CELL TUMOURS• Teratoma  Contains more than one germ cell layers in various stages of maturation and differentiation  Grosssly large, lobulated, nonhomogenous tumours  Microscopically, cystic & solid componenets• Yolk cell tumours  Most common testicular tumour in infants & children  80% confined to testis at time of diagnosis
  14. 14. Pathogenesis & Natural History of Testicular Tumour Course of Spread of Germ Cell Tumours are predictible once histology of Tumour confirmed Local invasion of epidydimis or spermatic cord is hindered by tunica albugenia Lymphatic Spread has a set pattern depending on site of tumour Seminoma may have non-seminomatous metastasis High Grade Tumours spread by both Vascular invasion & via Lymphatics
  15. 15. Pattern of Spread of Germ Cell Tumour Right sided tumours- intraaortocaval Left sided tumours – left paraaortic & preaortic nodes Then cephalad to cisterna chyli, thoracic duct and supraclavicular (usually left) Epidydimis- External iliac chain
  16. 16. CLINICAL FEATURES• Nodule/Painless Swelling of One Gonad• Dull Ache or Heaviness in Lower Abdomen• 10% - Acute Scrotal Pain• 10% - Present with Metatstasis - Neck Mass / Cough / Anorexia / Back Ache• 5% - Gynecomastia• Infertility
  17. 17. PHYSICAL EXAMINATION• Bimanual Palpation of testis and paratesticular structures• Abdominal examination• Lymph nodes• Chest
  18. 18. WAKE UP All patients with a solid, Firm Intratesticular Mass that cannot beTransilluminated should be regardedas Malignant unless otherwise proved
  19. 19. Differential Diagnosis• Metastasis from • Spermatocele prostate, lung, or • TB, gumma melanoma. • Leukemia• Epididymitis• Lymphoma
  20. 20. Clinical Staging of Testicular TumourStaging A or I - Tumour confined to testis.Staging B or II - Spread to Regional nodes.IIA - Nodes <2 cm in size or < 6 Positive NodesIIB - 2 to 5 cm in size or > 6 Positive NodesIIC - Large, Bulky, abd.mass usually > 5 to 10 cmStaging C or III - Spread beyond retroperitonealNodes or Above Diaphragm or visceral disease
  21. 21. Requirements for stagingTo 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
  22. 22. TNM Staging of Testicular TumourT0 = No evidence of TumourT1s = Intratubular, pre invasiveT1 = Confined to TestisT2 = Limited to testis and epididymis with vascular/ lymphatic invasion or tumour extending through Tunica Albuginea with involvement of tunica vaginalisT3 = Invades Spermatic Cord with/without vascular/ lymphatic invasionT4 = Invades Scrotum with/without vascular/ lymphatic invasionN1 = Single or multiple < 2 cmN2 = Multiple < 5 cm / Single 2-5 cmN3 = Any node > 5 cm Epididymis or Scrotal skin – Lymph drainage to Inguinal Nodes
  23. 23. Investigation1. Ultrasound - Hypoechoic area2. Chest X-Ray - PA and lateral views3. CT Scan4. MRI4. Tumour Markers - AFP - HCG - LDH - PLAP(placental alkaline phosphatase)
  24. 24. Left RightAxial CT Section demonstarating - Left Hydronephrosis, due to large Para-AorticNodal Mass from a Germ cell tumour
  25. 25. Tumour Markers TWO MAIN CLASSES• Onco-fetal Substances : AFP & HCG• Cellular Enzymes : LDH & PLAP ( AFP - Trophoblastic Cells HCG - Syncytiotrophoblastic Cells )
  26. 26. AFP –( Alfafetoprotein ) NORMAL VALUE: Below 16 ngm / ml HALF LIFE OF AFP – 5 and 7 days Raised AFP : • Pure embryonal carcinoma • Teratocarcinoma • Yolk sac Tumour • Combined TumourREMEMBER: AFP Not raised is Pure Choriocarcinoma or Pure Seminoma
  27. 27. HCG – ( Human Chorionic Gonadotropin )Has and polypeptide chainNORMAL VALUE: < 1 ng / mlHALF LIFE of HCG: 24 to 36 hoursRAISED HCG -100 % - Choriocarcinoma60% - Embryonal carcinoma55% - Teratocarcinoma25% - Yolk Cell Tumour7% - Seminomas
  28. 28. Lactate Dehydrogenase (LDH)• Nonspecific tumor marker but is a useful prognostic indicator• Indicator of tumor burden
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. Treatment of SeminomasStage I, IIA, IIB –Radical Inguinal Orichidectomy followed byradiotherapy to Ipsilateral Retroperitonium &Ipsilateral Iliac group Lymph nodesBulky stage II and III Seminomas -Radical Inguinal Orchidectomy is followed byChemotherapy
  34. 34. Treatment of Non-SeminomaStage I and IIA:RADICAL ORCHIDECTOMYfollowed by RETROPERITONEAL LYMPH NODES DISSECTIONStage IIB:RPLND with possible ADJUVANT CHEMOTHERAPYStage IIC and Stage III Disease:Initial CHEMOTHERAPY followed by SURGERY for Residual Disease
  35. 35. Radical Orchiectomy • Inguinal approach • Testicle and spermatic cord are excised then sent for pathologic staging.
  36. 36. Retroperitoneal Lymph Node Dissection• RPLND primary treatment (NSGCTs)• Remove abdominal lymph nodes
  37. 37. Limits of Lymph Nodes Dissection For Right & Left Sided Testicular Tumours
  38. 38. ChemotherapyBEP: (Bleomycin, Etoposide, Cisplatin) 2-4 cycles 21d intervals (4 most common)EP: (Etoposide, Platinol) 4 cycles 21d intervals
  39. 39. Salvage Thearpy• No initial complete response• VIP: (Etoposide, Ifosamide,Mesna, Platinol) 3-4 cycles 21d intervals• High-dose chemotherapy with autologous bone marrow transplantation in selected patients with bulky disease
  40. 40. Complications• Pulmonary toxicity: Bleomycin keep total dose under 400 units.• Nephrotoxicity: Cisplatin- decreased CrCl: Dosed based on CrCl• Neurologic: Cisplatin- Ototoxicity• Cardiovascular: HTN, MI, Angina• Secondary Malignancies: Etoposide
  41. 41. Follow up– physical examinations, chest radiographs and serum tumor markers– CT scans detect recurrence in the retroperitoneum and chest– Follow-up protocols vary by institution, type, stage and treatment
  42. 42. Recommended Exams• Every 2-3 months 1st yr.• Every 3-6 month 2nd yr.• Every 6 month remainder 5 yrs.• CTscans: 3-6 months 1st yr. then annually• Men at high risk: Annually with self-exam monthly
  43. 43. Prognosis Seminoma (at 5 years)• I: 98%• IIA: 92-94%• IIB-III: 33-75% NSGT (at 5 years)• I: 96-100%• IIA: >90%• IIB-III: 55-80%
  44. 44. CONCLUSION• Improved Overall Survival of Testicular Tumour due to Better Understanding of the Disease, Tumour Markers and Cis-platinum based Chemotherapy
  45. 45. Thanks