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Management Of Testicular Tumours

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    Management Of Testicular Tumours Management Of Testicular Tumours Presentation Transcript

    • Management of Testicular Tumours Dr.Sunil Shroff, MS, FRCS (UK ), D.Urol (Lond.) Prof & HOD SriRamachandra Medical College & Research Institution, Chennai
    • TESTICULAR TUMOUR
      • 1% of all Malignant Tumour
      • Affects young adults - 20 to 40 yrs - when Testosterone Fluctuations are maximum
      • 90% to 95% of all Testicular tumours from germ cells
      • 99% of all Testicular Tumours are malignant.
      • Causes Psychological & Fertility Problems in young
    • Survival in Testicular Tumours
      • Improved overall survival in last 15 to 20 years due to -
      • Better understanding of Natural History and Pathogenesis of disease
      • Reliable Tumour Markers
      • Cis-platinum based chemotherapy
    • CROSS SECTION OF TESTIS Testis Stroma Seminiferous Tubules (200 to 350 tubules) Interstitial Cells Supporting Spermatogonia Leydig or (Androgen) Sertoli Cell
    • EPIDEMIOLOGY Incidence : 1.2 per 100,000 (Bombay) 3.7 per 100,000 (USA) Age : 3 Peaks - 20-40 yrs. Maximum - 0 - 10 yrs. - After - 60 yrs. Bilaterality : 2 to 3% Testicular Tumour
    • CLASSIFICATION I. Primary Neoplasma of Testis. A. Germ Cell Tumour B. Non-Germ Cell Tumour II. Secondary Neoplasms. III. Paratesticular Tumours.
    • I. PRIMARY NEOPLASMS OF TESTIS A. Germinal Neoplasms : (90 - 95 %) 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
    • I. PRIMARY NEOPLASMS OF TESTIS B. Nongerminal Neoplasms : ( 5 to 10% ) 1. Specialized gonadal stromal tumor (a) Leydig cell tumor (b) Other gonadal stromal tumor 2. Gonadoblastoma 3. Miscellaneous Neoplasms (a) Adenocarcinoma of the rete testis (b) Mesenchymal neoplasms (c) Carcinoid (d) Adrenal rest “tumor”
    • A. Adenomatoid B. Cystadenoma of Epididymis C. Mesenchymal Neoplasms D. Mesothelioma E. Metastases II. SECONDARY NEOPLASMS OF TESTIS A. Reticuloendothelial Neoplasms B. Metastases III. PARATESTICULAR NEOPLASMS
    • AETIOLOGY OF TESTICULAR TUMOUR 1. Cryptorchidism 2. Carcinoma in situ 3. Trauma 4. Atrophy
    • CRYPTORCHIDISM & TESTICULAR TUMOUR Risk of Carcinoma developing in undescended testis is 14 to 48 times the normal expected incidence
    • 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
    • Testicular Tumour & Molecular Biology
      • Molecular & Genetic Research may help Future patient with Testicular Tumours:
      • Earlier diagnosis
      • Identify Susceptible Individuals
      (Recent Advances)
    • Testicular Tumour & Molecular Biology
      • Seminoma &
      • Embryonal - N-myc expression
      • Carcinoma
      • Seminoma - c-Ki-ras expression
      • Immature
      • Teratomas - c-erb B-1 expression
      PROTO-ONCOGENES in Germ Cell Tumours (Shuin et al)
    • Testicular Tumour & Molecular Biology (Recent Advances)
      • Testicular germ cell tumour show consistent expression of both:
      • Parental alleles of H19
      • IGF-2 genes .
    • Clinical Staging of Testicular Tumour Staging A or I - Tumour confined to testis. Staging B or II - Spread to Regional nodes. IIA - Nodes <2 cm in size or < 6 Positive Nodes IIB - 2 to 5 cm in size or > 6 Positive Nodes IIC - Large, Bulky, abd.mass usually > 5 to 10 cm Staging C or III - Spread beyond retroperitoneal Nodes or Above Diaphragm or visceral disease
    • 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 Requirements for staging
    • TNM Staging of Testicular Tumour T 0 = No evidence of Tumour T 1s = Intratubular, pre invasive T 1 = Confined to Testis T 2 = Invades beyond Tunica Albuginea or into Epididymis T 3 = Invades Spermatic Cord T 4 = Invades Scrotum N 1 = Single < 2 cm N 2 = Multiple < 5 cm / Single 2-5 cm N 3 = Any node > 5 cm Epididymis or Scrotal skin – Lymph drainage to Inguinal Nodes
    • Pathogenesis & Natural History of Testicular Tumour
      • Course of Spread of Germ Cell Tumours are predictible once Histology of Tumour cofirmed
      • Lymphatic Spread has a set pattern depending on side of Tumour
      • Seminoma may have non-seminomatous metastasis
      • High Grade Tumours spread by both Vascular invasion & via Lymphatics
    • Investigation 1. Ultrasound - Hypoechoic area 2. Chest X-Ray - PA and lateral views 3. CT Scan 4. Tumour Markers - AFP -  HCG - LDH - PLAP
    • CLINICAL FEATURES
      • Painless Swelling of One Gonad
      • 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
    • 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
    • Tumour Markers
      • TWO MAIN CLASSES
      • Onco-fetal Substances : AFP & HCG
      • Cellular Enzymes : LDH & PLAP
      • ( AFP - Trophoblastic Cells
      • HCG - Syncytiotrophoblastic Cells )
    • 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 Tumour
      REMEMBER: AFP Not raised is Pure Choriocarcinoma or Pure Seminoma
    • 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
    • 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
    • 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
    • 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
    • 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
    • Treatment of Seminomas
      • Stage I, IIA, ?IIB –
      • Radical Inguinal Orichidectomy 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
    • 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
      • Chemotherapy Toxicity
      • BEP -
      • Bleomycin Pulmonary fibrosis
      • Etoposide (VP-16) Myelosuppression
      • Alopecia
      • Renal insufficiency (mild)
      • Secondary leukemia
      • Cis-platin Renal insufficiency
      • Nausea, vomiting
      • Neuropathy
      STANDARD CHEMOTHERAPY FOR NON-SEMINOMATOUS GERM CELL TUMOURS
    • Left Right Axial CT Section demonstarating - Left Hydronephrosis, due to large Para-Aortic Nodal Mass from a Germ cell tumour
      • Limits of Lymph Nodes Dissection For Right &
      • Left Sided Testicular Tumours
    • THERAPY OF PATIENT WITH SEMINOMA
      • Stage I, IIA, ? IIB Stage IIB, IIC, III
      • B - Bleomycin
      • Abdominal Radiotherapy E - Etoposide (VP-16)  4 cycles
      • P - cis-platin
      • Follow Up Stable/Regress Relapse/Growth
      • F/U ? RPLND
      • ? Chemotherapy
      • ? XRT
    • Therapy of Nonseminomatous Germ Cell Testicular Tumours
      • Radical Inguinal Orchidectomy
      • Stage I, II (minimum)
      • RPLND
      • Stage I, II B1 Stage II B2
      • Observe BEP  2 cycles
      • Bleomycin
      • Etoposide
      • Cis-platin
      • Radical Inguinal Orchidectomy
      • Stage II C (advanced) / III
      • BEP  4 cycles
      • Complete Response Partial Response Progress
      • Observe RPLND VIP or Autologous
      • Bone marrow
      • Transplant
      • Cancer Teratoma / Fibrosis
      • V-Vinblastine
      • I-Ifosfamide OBSERVE
      • P-cis-platin
      Therapy of Nonseminomatous Germ Cell Testicular Tumours
    • PROGNOSIS
      • Seminoma Nonseminoma
      • Stage I 99% 95% to 99%
      • Stage II 70% to 92% 90%
      • Stage III 80% to 85% 70% to 80%
    • 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