Approach To Testicular Cancer

1. Testicular Cancer

2. Plan
• Defining the subject and its Epidemiology
• The Classification and Investigations
• The Treatment

3. What is it?
• Primary Germ Cell Tumors of testis arising by malignant
transformation of primordial germ cells constitute 95% of
testicular neoplasms.
• If GCTs arise from an extra-gonadal site: The mediastinum,
retro peritoneum, and very rarely, the pineal gland.
• It is Notable for:
- 1) young age of afflicted patients.
- 2) Totipotent capacity for differentiation of the tumor cells
- 3) its curability.
• Approximately, 95% of newly diagnosed patients are cured
• Experience in the management of GCTs leads to improved
outcome.

4. Epidemiology
• In 2010,
8480 new cases of testicular GCT were
diagnosed, and only 350 men were died in US
Ages 20-40 years old
Testicular mass > 50 years old regarded as
lymphoma untill proven otherwise
GCT is 4-5 times more common in whites than in
african blacks in US.

5. • Testicular cancer
- Most common malignancy in men in the 15-35
year age group and evokes special interest
- One of most curable solid neoplasm
• Serves as a paradigm for multimodal treatment
- Dramatic improvement in survival:
• Effective diagnostic techniques
• Tumour markers
• Effective multidrug chemotherapeutic regimens
• Modification of surgical technique

6. Classification of Testicular Tumours
• Germ Cell Tumours
- Seminoma
• Classic
• Atypical
• Spermatocytic
- Nonseminomatous
• Embryonal carcinoma
• Teratoma
• Mature
• Immature
• Choriocarcinoma
• Yolk sac tumor

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

8. 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

9. 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

10. 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

11. • Testicular cancer has become one of the most
curable cancers in US because of advances in
medical and surgical therapy
• Cisplatin-based chemotherapy regimens have
improved the response rates for testis cancer

13. Examination
• Detailed evaluation of neck, chest and abdominal
contents.
- Testicular tumors often have a palpable parenchymal testis
mass
• Can be better appreciated if compared with contralateral normal
testicle.
- Needs to differentiate between
• intraparenchymal testis masses often malignant
• extraparenchymal testicular masses often benign.
- Scrotal ultrasound can distinguish intrinsic from extrinsic
testicular lesions with a high degree of accuracy and can
detect intratesticular lesions as small as 1 to 2 mm in
diameter.

14. Examination:
• High-resolution CT scan of the abdomen,
pelvis and chest x-ray.
• Regional metases first appear in the
retroperitoneal lymph nodes
• CT to evaluate retroperitoneum, negative
results, as evidenced by a retroperitoneal
relapse rate of 20% to 25% in men, with
clinical stage I disease who do not undergo
retroperitoneal lymph node dissection RPLND

15. Labs
• Serum marker alpha fetoprotein
• Sb subunit of human chorionic gonadotropin
(Beta-HCG)
• Lactate dehydrogenase
• The differences between them:
- LDH is elevated in 80% to 85% of men with
nonseminomatous GCTs.
- In contrast, serum B-HCG is elevated in fewer than
20% of testicular seminomas
- AFP is not elevated in pure seminomas.

16. • Neither serum B-HCG nor AFP alone or in
combination is sufficiently sensitive or specific
to establish the diagnosis of testicular cancer
in the absence of histologic confirmation.
• Serum LDH concentrations are elevated in
30% to 80% of men with pure seminoma and
In 60% of those with nonseminomatous
tumors.

17. • LDH is a less sensitive and less specific tumor
marker than B-HCG or AFP for men with
nonseminomatous GCTs
- But it may be the only marker that is elevated in
seminomas.
• Significantly elevated serum LDH has
independent prognostic value in men with
advanced seminoma.

18. • Radical inguinal orchiectomy with high ligation of
the spermatic cord near the internal inguinal ring
is performed to permit histologic evaluation of:
- primary tumor and provision of local tumor control.
- Note: Scrotal violation through scrotal incision or an
attempt to biopsy the testicle must be avoided
because of concern for changing the lymphatic
channels available to the testis tumor and potential
poorer outcome.

19. • Serum half-lives of HCG and AFP are 18-36 hours and 5-7 days.
- Testicular cancer produces any of these serum markers
- Following progressive change after radical orchiectomy is an important
consideration in determining the adequacy of therapy.
• Determination of histologic subtype of the testis cancer
• Several parameters may identify patients at high risk for metastasis
to the retroperitoneum
- Despite absence of lymphadenopathy on the staging CT scan
- Nonseminomatous germ cell tumours, those factors include the
following:
1- Vascular lymph invasion
2- Primary tumor (T) Stage T2-T3
3- Embryonal carcinoma component greater than 40% of total tumor volume

21. Treatment
• Patients with these risk factors who have no bulky
retroperitoneal lymphadenopathy
- Have normal tumor markers after radical orchiectomy
maybe candidates for RPLND.
• Principles underlying modern surgical treatment of
testicular GCT
- based on stepwise predictable metastatic pattern of these
tumours
- Notable exception of choriocarcinoma
- RPLND is only reliable method to identify nodal
micrometases
- It is gold standard for providing accurate pathologic staging
of retroperitoneum

22. • Both the number and size of involved
retroperitoneal lymph nodes have prognostic
importance
• Surgical therapy for metastatic testicular
cancer has evolved
- The full bilateral RPLND used in the past evolved
first to a template-type Dissection
- Then to a nerve-sparing modification with a
unilateral template

23. RPLN
Surgical template for modified, left-sided (A)
and right-sided (B) retroperitoneal lymph
node dissection