Dr Harshita Mehrotra
Resident, General Surgery
• Testicular tumors are rare.
• 1 – 2 % of all malignant tumors.
• Most common malignancy in men in the 15 to 35 year age group.
• Most curable solid neoplasms and serves as a paradigm for the
multimodal treatment of malignancies.
• Seminoma - most common bilateral primary testicular tumour;
Lymphoma - most common bilateral testicular tumour
• Intersex disorder
• Testicular atrophy
• Chromosomal abnormalities - loss of chromosome 11, 13, 18, abnormal
• Exogenous estrogen administration to mother during pregnancy
• Previous testicular malignancy
• 7 - 10% patients - history of cryptorchidism
• Most common - seminoma
• 5 - 10% tumors - contralateral testis
• Relative risk - Intraabdominal testis (1 in 20) > Intrainguinal
testis (1 in 80)
• Orchidopexy - does not alter malignant potential - facilitates
examination & detection
• Malignancy due to
• Abnormal germ cell morphology.
• Elevated temperature - abnormal spermatocyte maturation.
• Endocrinal disturbances.
• Gonadal dysgenesis.
• Pre malignant precusor of all GCT, except spermatocytic
• Incidence - 0.8%.
• Testicular CIS develops from fetal gonocytes.
• Characterized histologically by seminiferous tubules containing
only Sertoli cells and malignant germ cells.
• Risk Factors for CIS:
• History of testicular carcinoma (5% to 6%),
• Extra gonadalGCT (40%),
• Cryptorchidism (3%),
• Contralateral testis with unilateral testis cancer (5% to 6%),
• Somatosexual ambiguity (25% to 100%)
• Atrophic testis 30 %
• Infertility (0.4% to 1.1%)
• TESTICULAR BIOPSY gold standard for diagnoses of CIS
• Classical: 80 - 85%
• middle age
• PLAP & B-hCG - raised
• slow growing
• good prognosis
• Spermatocytic: 5 - 10%
• age > 50 years
• low metastatic potential
• good prognosis
• Anaplastic: 5 - 10%
• middle age
• higher local & metastatic potential
• high B-hCG production
• Inguinal Orchiectomy + Radiation
Non-Seminomatous Germ Cell
• Embryonal Carcinoma
• 25 - 35 years
• 3 - 6% testicular tumors
• small, rounded, irregular mass
• invades tunica albuginea
• Yolk Sac Tumor/ Endodermal
• most common testicular tumor in
infants & children
• raised AFP
• histologically - cells demonstrate
vacuolated cytoplasm secondary
to fat and glycogen deposition,
resemble 1 - 2 week old embryos
• raised AFP
• resistant to both chemotherapy &
• mature teratoma - differentiated
elements from 2-3 embryonic germ cell
• immature teratoma - undifferentiated
• malignant teratoma - malignant changes
• Chorionic Carcinoma
• pure choriocarcinoma - rare
• second - third decades
• raised PLAP, B-hCG
• high incidence of distant metastases
• Leydig Cell Tumors
• most common non-germ cell cell timor of
testis - 1 - 3% testicular tumours
• bimodal age distribution - 5 - 9 years; 25
- 35 years age
• 25% cases - childhood; bilaterally - 5 -
• presentation - prepubertal children -
virilization; adults - gynecomastia
• elevated serum & urinary 17-
ketosteroids & estrogens
• Sertoli Cell Tumors
• rare; < 1% testicular tumors
• bimodal age distribution - < 1 year; 20 - 45 years
• presentation - testicular mass; virilization in
children; gynecomastia in adults
• seen in patients with gonadal dysgenesis
• age group - 30 years of age
• clinical presentation - gonadal dysgenesis
Secondary Tumors of Testis
• most common testicular tumour
over age of 50 years
• most common secondary
neoplasm of testis
• presentation - painless
enlargement of testis,
constitutional symptoms in 25%
patients; bilateral - 50% patients
• Leukemic Infiltration of Testis
• relapse of children with acute
• bilateral - 50% cases
• treatment - bilateral testicular
irradiation with 20Gy & reinstitution od
• Metastatic Tumor
• most common primary - prostate >
lung > gastrointestinal tract >
melanoma > kidney
• Right Testis - Inter-aortocaval nodes > Precaval > Preaortic > Right common iliac
> Right external iliac
• Left Testis - Left Para-aortic > Preaortic > Left common iliac > Left external iliac
• Cross over from right to left possible.
• Epididymis - external iliac chain.
• Inguinal node metastasis - scrotal involvement by the primary tumor, prior inguinal
or scrotal surgery, or retrograde lymphatic spread secondary to massive
retroperitoneal lymph node deposits.
• Testicular cancer spreads in a predictable and stepwise fashion, except
• Firm to hard fixed area within tunica albugenia - suspicious
• Seminoma expand within the testis as a painless, rubbery
• Embryonal carcinoma or teratocarcinoma may produce an irregular,
rather than discrete mass.
• Choriocarcinoma - no testicular enlargement
• All patients with a solid, firm intra-testicular mass that cannot be
transilluminated should be regarded as malignant unless
• Scrotal Ultrasound -
• rapid, reliable technique
• hypoechoic area within the tunica albuginea - markedly
suspicious for testicular cancer.
Stage T N M S
Stage 0 Tis N0 M0 S0
Stage 1a T1 N0 M0 S0
Stage 1b T2 - T4 N0 M0 S0
Stage 1c any T N0 M0 S1 - S3
Stage IIa any T N1 M0 S0 - S1
Stage IIb any T N2 M0 S0 - S1
Stage IIc any T N3 M0 S0 - S1
Stage IIIa any T any N M1 S0 - S1
Stage IIIb any T any N M0 - M1 S2
any T any N M0 - M1a S3
any T any N M1b any S
• Treatment should be aimed at one stage above clinical stage.
• Seminomas - radio-sensitive - treat with radiotherapy.
• Non-seminomatous - radio-resistant - surgery.
• Advanced diseases/ metastases - chemotherapy.
• RADICAL INGUINAL ORCHIDECTOMY - first line of therapy
• Bulky Retroperitoneal Tumours/ Metastatic Tumors - Initially
“DOWN-STAGED” with CHEMOTHERAPY
• Transscrotal biopsy - 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
Lymph Nodes Dissection For Right &
Left Sided Testicular Tumours
Stage I 99% 95 - 99%
Stage II 70 - 92% 90%
Stage III 80 - 85% 70 - 80%
• Improved Overall Survival of Testicular Tumour due to Better
Understanding of the Disease, Tumour Markers and Cis-platinum
• Current emphasis - diminishing overall morbidity of various