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Part 1 management of testicular carcinoma - dr vandana
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Testicular tumor final

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Testicular tumors

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Testicular tumor final

  1. 1. Dr.Haleemullah H.O
  2. 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. 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.
  4. 4. AETIOLOGY OF TESTICULAR TUMOUR  Cryptorchidism  Klinefelter’s syndrome  Testicular atrophy  Trauma  Sex hormone fluctuations, estrogen administration during pregnancy  Race  Carcinoma in situ  Previous testicular cancer
  5. 5. CRYPTORCHIDISM & TESTICULAR TUMOUR Risk of Carcinoma developing in undescended testis is 14 to 48 times the normal expected incidence
  6. 6. CLASSIFICATION  I.Primary Neoplasms of Testis. A. Germ Cell Tumor. B. Non-Germ Cell Tumor .  II. Secondary Neoplasms.  III .Paratesticular Tumors.
  7. 7. 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
  8. 8. Non Germ Cell Tumors 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
  9. 9. Seminoma  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 metastases
  10. 10.  Cut potato appearance
  11. 11.  Embryonal carcinoma  25yr – 35yr  3 – 6 % of TT  Small, rounded irregulr mass  Invading tunica vaginalis  Cut surface  Greyish white, fleshy  Areas of necrosis, hemorrhage  Poorly defined capsule
  12. 12. Choriocarcinoma  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 ENLARGEMENT  Small palpable nodule may be present.  Prone to hemorrhage, sometimes spontaneous (lungs and brain)
  13. 13. Teratoma  Children – 38% - benign  Adults – 3% - metastatic potential  AFP - ↑ 20% – 25%  Metastasis  Resistent both Chemo, Radiation  Mature Teratoma  Differentiated elements form 2 or more embryonic germ cell layers  ectoderm, endoderm & mesoderm  Immature Teratoma  Undifferentiated primitive tissues  Malignant Teratoma  Malignant changes
  14. 14.  Teratoma  More than one germ cell layer in various stages of maturation & differentiation  Large, lobulated, non-homogenous  Cut surface  Variably sized cysts  Gelatinous, mucinous, hyalinized material  Intersposed solid islands – cartilage/ bone/pancreatic/ liver/ intesttinal/ muscle/ neural/ connective tissue
  15. 15.  Immature Teratoma  Areas of fibrosis & hemorrhage  Mature Teratoma
  16. 16.  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)
  17. 17. 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
  18. 18. 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)
  19. 19. 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
  20. 20. 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.
  21. 21. 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.
  22. 22. Tumor markers Onco-fetal Substances : AFP & HCG Cellular Enzymes : LDH
  23. 23. 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
  24. 24.  Diagnostic Radiology  Chest x-ray films, posterior/anterior and lateral views  Computed tomography (CT) scan of abdomen and pelvis  CT scan of chest for non seminomas and stage II seminomas  Ultrasound of contralateral testis
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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.
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. PROGNOSIS Seminoma Nonseminoma Stage I 99% 95% to 99% Stage II 70% to 92% 90% Stage III 80% to 85% 70% to 80%
  33. 33. 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
  34. 34. Yuvraj Singh –extra gonadal seminoma
  35. 35. Thank you
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Testicular tumors

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