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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
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
AETIOLOGY OF TESTICULAR TUMOUR
Sex hormone fluctuations, estrogen
administration during pregnancy
Carcinoma in situ
Previous testicular cancer
CRYPTORCHIDISM & TESTICULAR TUMOUR
Risk of Carcinoma developing
in undescended testis is
14 to 48 times the normal
I.Primary Neoplasms of Testis.
A. Germ Cell Tumor.
B. Non-Germ Cell Tumor .
II. Secondary Neoplasms.
III .Paratesticular Tumors.
The commonest variety of testicular tumour
Adults are the usual target (4th and 5th decade); never seen in infancy
Right > Left Testis
Starts in the mediastinum: compresses the surrounding structure.
Patients present with painless testicular mass
30 % have metastases at presentation, but only 3% have symptoms related to
25yr – 35yr
3 – 6 % of TT
Small, rounded irregulr mass
Invading tunica vaginalis
Greyish white, fleshy
Areas of necrosis, hemorrhage
Poorly defined capsule
A rare and aggressive tumour (5yrs survival is 5%)
Typically elevated hCG
Presents with disseminated disease
Metastasis to lungs and brain
Primary is very small and often exhibit NO TESTICULAR
Small palpable nodule may be present.
Prone to hemorrhage, sometimes spontaneous (lungs and brain)
More than one germ cell layer in various stages of maturation &
Large, lobulated, non-homogenous
Variably sized cysts
Gelatinous, mucinous, hyalinized material
Intersposed solid islands – cartilage/ bone/pancreatic/ liver/
intesttinal/ muscle/ neural/ connective tissue
Areas of fibrosis & hemorrhage
Yolk sac tumor
Infants & children
Adults – in combination
Homogenous yellowish, mucinous
Resemble 1 to 2 week old embryos (<1 mm)
Non Germ Cell Tumors
Sex cord tumors
1. Leydig cell tumors
2. Sertoli cell tumors
Mixed germ cell and stromal cell tumors
Miscellaneous primary non germ cell tumors
1. Epidermoid cyst
2. Adenocarcinoma of rete testis
3. Adrenal rest tumors
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)
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
Examine contralateral normal testis.
Firm to hard fixed area within tunica albugenia is
Seminoma expand within the testis as a painless,
Embryonal carcinoma or teratocarcinoma may
produce an irregular, rather than discrete mass.
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.
ROLE OF TUMOUR MARKERS
Helps in Diagnosis - 80 to 85% of Testicular Tumours have
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
Chest x-ray films, posterior/anterior and lateral
Computed tomography (CT) scan of abdomen
CT scan of chest for non seminomas and stage II
Ultrasound of contralateral testis
Serum tumor markers
S0 _< N <N <N
S1 <1.5 x N < 5000 < 1000
S2 1.5-10x N 5000 to
S3 >10x N > 50000 >10000
PRINCIPLES OF TREATMENT
Treatment should be aimed at one stage above the
Seminomas - Radio-Sensitive. Treat with
Non-Seminomas are Radio-Resistant and best
treated by Surgery
Advanced Disease or Metastasis - Responds well to
PRINCIPLES OF TREATMENT
Radical INGUINAL ORCHIDECTOMY is Standard
first line of therapy
Lymphatic spread initially goes to
Early hematogenous spread RARE
Bulky Retroperitoneal Tumours or Metastatic
Tumors Initially “DOWN-STAGED” with
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.
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
Treatment of Non-Seminoma
Stage I and IIA:
followed by RETROPERITONEAL LYMPH NODES
RPLND with possible ADJUVANT CHEMOTHERAPY
Stage IIC and Stage III Disease:
Initial CHEMOTHERAPY followed by SURGERY for Residual Disease
STANDARD CHEMOTHERAPY FOR
NON-SEMINOMATOUS GERM CELL TUMOURS
Bleomycin Pulmonary fibrosis
Etoposide (VP-16) Myelosuppression
Renal insufficiency (mild)
Cis-platin Renal insufficiency
Stage I 99% 95% to 99%
Stage II 70% to 92% 90%
Stage III 80% to 85% 70% to 80%
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