NEOPLASMS OF TESTIS

1. NEOPLASMS OF THE
TESTIS

2. Introduction
• Neoplasms of the testis comprise a morphologically and
clinically diverse group of tumors
• More than 95% of which are germ cell tumors (GCTs).
• GCTs are broadly categorized as seminoma and
nonseminoma (NSGCT) because of differences in natural
history and treatment.
GERM CELL
TUMORS
SEMINOMAS
NON
SEMINOMATOUS
GERM CELL
TUMORS

4. 2016 World Health Organization Classification
of Testis Neoplasms

5. GERM CELL TUMORS
• Most common malignancy among men aged 20 to 40 years and
• Second most common cancer after leukemia among males aged 15 to
19 years.
• Incidence of bilateral GCT is approximately 2%.
• A stage migration of GCT has been observed in several countries
partially because of an increased awareness and earlier diagnosis.

6. RISK FACTORS
• There are five well-established risk factors for testis cancer:
• white race,
• cryptorchidism,
• family history of testis cancer,
• a personal history of testis cancer,
• and germ cell neoplasia in situ (GCNIS), also referred to as intratubular germ
cell neoplasia (ITGCN)
Also, there is evidence of an association between early exposure to endocrine-
disrupting chemicals and an increased risk of testicular germ cell tumors

7. • Cryptorchidism --- 4 to 6 times more likely to have testis cancer in the
affected gonad
• If orchidopexy is performed before puberty- relative risk falls to 2 to 3 .
• Most GCTs arise from a precursor lesion called GCNIS
Exceptions to this are
• prepubertal germ cell tumors
• ovarian cystic teratomas, dermoid cysts, and
• spermatocytic tumors

8. • In men with a history of GCT, the finding of testicular microlithiasis
on ultrasound of the contralateral testis is associated with an
increased risk of GCNIS
• However, the significance of microlithiasis in the general population is
unclear

9. PATHOGENESIS
• The carcinogenesis of GCTs is poorly understood
• Testicular GCTs develop from a precursor lesion- GCNIS, which in turn
appears to develop from arrested primordial germ cells or gonocytes
that failed to differentiate into prespermatogonia
• An increased number of copies of genetic material from the short arm
of chromosome 12 is a universal finding in postpubertal testicular and
extragonadal germ cell tumors except for spermatocytic tumors

10. • Striking features of GCTs - sensitivity to cisplatin-based chemotherapy
• Approximately 5% of postpubertal GCTs are extragondal in
origin,(retroperitoneum and mediastinum are most common).

11. Germ Cell Tumor Neoplasia in Situ
• With the exception of spermatocytic tumor, postpubertal invasive
GCTs arise from GCNIS.
• Consists of undifferentiated germ cells that have the appearance of
seminoma that are located basally within the seminiferous tubules.
• The tubule usually shows decreased or absent spermatogenesis and
normal constituents are replaced by GCNIS.
• GCNIS is much less frequent in pediatric GCTs

12. Seminoma
• Most common type of GCT.
• Occur at an older average age than NSGCT, ( most cases in 4th-5th
decade)
• Sheet-like arrangement of cells with polygonal nuclei and clear
cytoplasm, with the cells divided into nests by fibrovascular septae
that contain lymphocytes.
• Syncytiotrophoblasts, which stain positive for HCG , identified in
about 15% of cases
Negative CD 30 POSITIVE CD 117 STRONGLY POSITIVE PLAP

13. • Seminoma arises from GCNIS and is considered to be the common
precursor for the other NSGCT subtypes .
• This ability of seminoma to transform into NSGCT elements has
important therapeutic implications for the management of seminoma

14. Spermatocytic Tumor
SPERMATOCYTIC SEMINOMA SEMINOMA
DOES NOT ARISE FROM GCNIS ARISE FROM GCNIS
NOT ASSOCIATED WITH
CRYPTORCHIDISM
ASSOCIATED WITH
CRYPTORCHIDISM
NO BILATERALITY 2% BILATERAL
DOESN’T DEMONSTRATE i12p DEMONSTRATE i12p
DOESN’T OCCUR AS PART OF
MIXED GCT
MAY OCCUR AS PART OF MIXED
GCT
DO NOT STAIN FOR OCT 3 / 4,
PLAP, GLYCOGEN
STRONGLY POSITIVE FOR PLAP
PEAK INCIDENCE 6TH DECADE 4TH AND 5TH DECADE
BENIGN- EXCEPT WHEN ASSOC
WITH SARCOMA
MALIGNANAT

15. Non-Seminomas

16. Embryonal Carcinoma
• Most undifferentiated cell type of NSGCT,
• Totipotential capacity to differentiate to other NSGCT cell types
(including teratoma) within the primary tumor or at metastatic sites.
• Grossly, tan to yellow neoplasm that often exhibits large areas of
hemorrhage and necrosis.
• EC consists of undifferentiated malignant cells resembling primitive
epithelial cells from early stage embryos with crowded pleomorphic
nuclei.
AE1/AE3 PLAP OCT 3/4
NEGATIVE
CKIT

17. Choriocarcinoma
• Rare and aggressive tumor that typically is seen with extremely highly
elevated serum HCG levels and disseminated disease.
• Typically poor-risk (stage IIIC) at diagnosis
• Spreads by hematogenous routes,
• common sites of metastases- lungs, liver, and brain
• Microscopically, the tumor is composed of syncytiotrophoblasts and
cytotrophoblasts
• Prone to hemorrhage, sometimes spontaneously and immediately
after chemotherapy

18. • Choriocarcinomas are associated with hormonal disturbances
• HCG shares identical alpha sub-unit with TSH & LH.
• Stimulation of TSH & LH receptors can lead to HYPERTHYROIDISM and
elevated androgen production

19. Teratoma
• Contain well or incompletely differentiated elements of at
least two of the three germ cell layers: endoderm,
mesoderm, and ectoderm.
• In adolescent and adult males- no clinical significance to
the distinction between mature and immature teratomas
• Associated with normal serum tumor markers, but they
may cause mildly elevated serum AFP levels
• Resistant to chemotherapy

20. • Teratomas may grow uncontrollably, invade surrounding structures,
and become unresectable.
• Histologically benign but genetically unstable. Thus - unpredictable
biology.
• On rare occasions, teratoma may transform into a somatic malignancy
• rhabdomyosarcoma,
• adenocarcinoma, or
• primitive neuroectodermal tumor

21. Signs and Symptoms
• M/C presentation of testis cancer is a painless testis mass.
• Regional or distant metastasis
• 2% of men have gynecomastia
• Any firm area within the testis should be considered suspicious for
malignancy and should prompt further investigations.
• A hydrocele may accompany a testis cancer.
• Look for supraclavicular lymphadenopathy, and auscultation of the
chest for intrathoracic disease.

22. Diagnostic Testing and Initial Management
• considered an extension of the physical
examination
• Look for sonographic evidence of
• Intratesticular lesions (discrete nodule, stellate scar,
coarse calcification) because GCNIS and residual
teratoma are frequently encountered.
In men with advanced GCT and a normal testicular
examination, rule out the presence of a small, impalpable
scar or calcification, indicating a “burned-out” primary
testis tumor

23. Magnetic Resonance Imaging
• In cases in which the sonographic findings are equivocal or
suboptimal,
• Advantages
• helpful tool to distinguish between testicular versus extratesticular lesions
• neoplastic versus non-neoplastic entities

24. Serum Tumor Markers
• LDH, AFP, and HCG are essential in diagnosis and management
• Serum tumor marker levels should be obtained
•at diagnosis,
•after orchiectomy, to monitor for response to chemotherapy, and
•to monitor for relapse in patients on surveillance and after completion of
therapy

25. AFP
• At diagnosis, AFP levels are elevated in 50% to 70% of low-stage (CS I,
IIA, IIB) NSGCTs and 60% to 80% of advanced (CS IIC, III) NSGCTs.
• EC and yolk sac tumors secrete AFP.
• Choriocarcinomas and seminomas do not produce AFP.
• Patients with pure seminoma in the primary tumor with an elevated
serum AFP are considered to have NSGCT.
• The half-life of AFP is 5 to 7 days.

26. HCG
• HCG levels are elevated in 20% to 40% of low-stage NSGCTs and 40%
to 60% of advanced NSGCTs.
• Approximately 15% of seminomas secrete HCG.
• HCG is also secreted by choriocarcinoma and EC.
• Levels above 5000 IU/L are usually associated with NSGCT.
• The half-life of HCG is 24 to 36 hours

27. LDH
• LDH levels are elevated in approximately 20% of low-stage GCT and
20% to 60% of advanced GCT.
• Of the five isoenzymes of LDH, LDH-1 is the most frequently elevated
isoenzyme in GCT.
• LDH-1 levels are correlated with the chromosome arm 12p copy
number, which is frequently amplified in GCT.
• The serum half-life of LDH is 24 hours.

28. TNM STAGING

30. Extragonadal Germ Cell Tumor
• Approximately 5% of GCTs are extragonadal.
• Of the patients with metastatic GCT without a testis mass, only one-
third definitively have a primary extragonadal GCT.
• The majority of these cases represent a “burned-out” primary
testicular tumor that has undergone spontaneous regression
• GCT should be considered in any young male with a midline mass.
• Presence of elevated serum AFP and/or HCG with a normal testicular
evaluation is sufficient for the diagnosis of GCT, and histologic
confirmation by biopsy is not necessary before starting treatment

31. Clinical Staging
• CS I is defined as disease clinically confined to the testis,
• CS II indicates the presence of regional (retroperitoneal) lymph node
metastasis, and
• CS III represents non-regional lymph node and/or visceral metastasis.

32. • The most common route of disease dissemination is via lymphatic
channels from the primary tumor to the retroperitoneal lymph nodes
and subsequently to distant sites.
• Choriocarcinoma has a propensity for hematogenous dissemination.
• The retroperitoneum is the initial site of metastatic spread in 70% to
80% of patients with GCT

33. Lymphatic drainage
• The pattern of lymph drainage in the retroperitoneum is from right to left
• More caudal deposits of metastatic disease usually reflect retrograde
spread to distal iliac and inguinal lymph nodes secondary to large volume
disease
• Retroperitoneal lymphatics drain into the cisterna chyli behind the right
renal artery and right crus of the diaphragm
Right Testis
Inter-aortocaval LN
Para caval LN
Para-Aortic LN
Left Testis
Para-Aortic LN
Interaortocaval LN

34. Prognostic Classification of Advanced Germ
Cell Tumor
• The IGCCCG risk group should be determined for each patient with
metastatic GCT
• This should be used to guide treatment decision making on the choice
of chemotherapy

36. Non seminoma
Good Prognosis:
• Testis or retroperitoneal
primary
• No Nonpulmonary
visceral metastasis
• AFP<1000ng/ml;
hCG<5000IU/L;
LDH<1.5times upper
limit.
Intermediate prognosis:
• Testis or retroperitoneal
primary,
• No nonpulmonary
visceral metastasis
• Any of:
• AFP1000-
10,000ng/ml; hCG5000-
50,000IU/L; LDH1.5-10
times upper limit
Poor prognosis:
Any of the following
criteria:
• Mediastinal primary
• Nonpulmonary visceral
metastasis
• AFP>10,000ng/ml;
hCG>50,000IU/L;
• LDH>10 times upper
limit.

37. SEMINOMA VS. NONSEMINOMA
• Compared with NSGCT, seminoma is associated with an indolent
natural history
• No poor-risk prognostic category exists for metastatic seminoma
• Seminoma is associated with increased sensitivity to radiation therapy
and platin-based chemotherapy compared with NSGCT.
• Serum HCG is elevated in only 15% of patients with metastatic
seminoma, and serum tumor marker levels are not used to guide
treatment decisions

38. SEMINOMA STAGE I
Stage 1 T1-
3N0M0S0
Spematocytic
seminoma: age
>65yrs; exclude
sarcoma,
benign tumor
No adjuvant
tratment
Typical and anaplastic
seminoma
Risk stratification
-size >4cm
-stromal invasion of rete testis
No risk
factors
surveillance
Risk factors
present
Radiation-
low dose,
abdominal
and pelvic
Chemotherapy
single agent-
carboplatin

39. Primary Chemotherapy With Single-Agent
Carboplatin.
• 1 to 2 cycles of single-agent carboplatin
• Regardless of the number of cycles, the optimal dosing of carboplatin
is calculated by the formula
• 7 × (Glomerular filtration rate [GFR,mL min]+ 25)mg

40. PRIMARY RADIOTHERAPY
• Treatment for CS I seminoma had been primary radiotherapy to the
retroperitoneum and ipsilateral pelvis, termed dog-leg (DL)
configuration.
• The optimal radiation dose has not been defined and most centers
use 25 to 35 Gy in 15 to 20 daily fractions
The most common sites of recurrence are the thorax and left
supraclavicular fossa.

41. SURVEILLANCE
• Surveillance schedules employ assessments
•every 2 to 4 months in years 1 to 3,
•every 6 months in years 4 to 7,
•then annually thereafter
Platin-based chemotherapy and infradiaphragmatic radiotherapy are
associated with an increased risk of late cardiovascular toxicity and
secondary malignant neoplasms (SMN)

42. SEMINOMA STAGE II/III

43. Clinical Stage IIA and IIB Seminoma
• Approximately 15% to 20% of seminoma patients have CS II disease,
70% of whom have CS IIA-B.
• DL radiotherapy using 25 to 30 Gy (including a 5 to 10 Gy boost to
involved areas) is employed at most centres
• Relapses are cured in almost all cases with first-line chemotherapy,
and disease-specific survival approaches 100%. Routine surveillance
CT imaging is not necessary after complete resolution of disease.
• Induction chemotherapy is preferentially given to patients with bulky
(>3 cm) and/or multiple retroperitoneal masses as the risk of relapse
is lower than DL radiotherapy

44. Clinical Stage IIC and III Seminoma
• regimen and number of cycles determined by the IGCCCG risk.
• Ninety percent of patients with advanced seminoma are classified as
good-risk
• After first-line chemotherapy, 58% to 80% of patients have
radiologically detectable residual masses.
Management of residual mass-
• Spontaneous resolution of these masses is reported in 50% to 66% of
cases, (30-50% for masses >3cm)
• The histology of residual masses is necrosis in 90% and viable
malignancy in 10% of cases

45. • PCS for seminoma is technically difficult (and frequently not feasible)
because of the desmoplastic reaction that occurs after chemotherapy
with resultant increased perioperative morbidity
• Post-chemotherapy radiotherapy has no role in the management of
residual masses

46. Relapsed Seminoma
• Chemotherapy-naïve relapse occurs in men with CS I seminoma on surveillance
and in those with CS I-IIB seminoma treated with primary radiotherapy.
• For CS I Patients, DL radiotherapy is employed for treatment of relapse in 73% to
88% of patients and cure rates of 70% to 90% are reported.
• Patients with bulky (>3 cm) retroperitoneal masses and systemic relapse should
receive first-line chemotherapy and salvage rates approach 100%.
• Patients who relapse after single-agent carboplatin should receive first-line
cisplatin-base chemotherapy

47. Post-Chemotherapy Seminoma Relapse—
Early
• An estimated 15% to 20% of advanced seminoma patients relapse
after induction chemotherapy.
• An important consideration for advanced seminoma patients who
relapse after first-line chemotherapy is the potential for teratoma at
the site of relapse.
• Thus patients with normal serum tumor markers should undergo
biopsy before starting second-line chemotherapy.

48. Post-Chemotherapy Seminoma Relapse—Late
• pure seminoma accounts for fewer than 8% of late relapse events
• Thus late relapse of seminoma may have a favorable prognosis,
particularly among patients without prior exposure to cisplatin.

49. NSGCT STAGE I

50. Clinical Stage IS Nonseminoma Germ Cell
Tumor
• CS IS defined as the presence of elevated post-orchiectomy serum
tumor markers without clinical or radiographic evidence of metastatic
disease
• treated similar to those with CS IIC-III and receive induction
chemotherapy
• BEPx1 is the standard regimen used for patients with CS I NSGCT who
choose to receive chemotherapy

51. NSGCT STAGE IIA & IIB
Elevated AFP OR
HCG or bulky
nodes >3cm

52. NSGCT STAGE IIc AND III

53. Clinical Stage IIA and IIB Nonseminoma Germ
Cell Tumor
• RPLND (+/- adjuvant chemotherapy) and induction chemotherapy (+/-
postchemotherapy RPLND) are accepted treatment options with
survival rates exceeding 95%
• there is consensus that CS IIA-B NSGCT patients with elevated AFP or
HCG or bulky lymph nodes (>3 cm) should receive induction
chemotherapy.
• Treatment considerations for CS IIA-B NSGCT include the risk of occult
systemic disease, risk of retroperitoneal teratoma, short- and long-
term treatment-related morbidity, and the need for double-therapy

54. Clinical Stage IIC and III Nonseminoma Germ
Cell Tumor
• Induction chemotherapy with cisplatin-based regimens is the initial
approach used for the treatment of CS IIC and III NSGCT
• Chemotherapy for Good-Risk Nonseminoma Germ Cell Tumor- BEPx3
became the standard regimen for good-risk GCT.
• Chemotherapy for Intermediate- and Poor-Risk Nonseminoma Germ
Cell Tumor- BEPx4 has been the standard regimen

55. Management of Post-Chemotherapy Residual
Masses in Nonseminoma Germ Cell Tumor
• Patients are classified into the following categories based on their response
to chemotherapy:
(1) complete response (CR), defined by normalization of serum tumor
markers and resolution of radiographic disease (usually defined as residual
masses ≤1 cm);
(2) Partial remission- marker negative
(3) partial remission– marker positive; and
(4) Disease progression

56. • Residual masses larger than 1 cm after first-Line chemotherapy
should undergo post-chemotherapy surgery (PCS)
• patients undergoing PCS for residual masses after first-line
chemotherapy have consistently reported evidence of persistent GCT
elements in the resected specimens
• histology of resected specimens
NECROSIS TERATOMA VIABLE MALIGNANCY
(WITH OR WITHOUT
TERRATOMA)
40% 45% 15%

57. • teratoma is resistant to chemotherapy and is present at metastatic sites in
15% of more of patients with disseminated NSGCT
• integration of chemotherapy and PCS is necessary in the majority
of patients with metastatic GCT
• The outcome of metastatic teratoma is related to the completeness of
surgical resection, and long-term survival is reported in 75% to 90% of
patients who undergo PCS for residual teratoma
• Predictors of necrosis in PCS specimens
• The absence of teratoma in the primary tumor,
• the percentage reduction in the retroperitoneal mass with chemotherapy, and
• the size of the residual mass

58. Brain Metastases
• About 1% of men with disseminated GCT have brain metastases
detected before initiating chemotherapy
• Brain metastases are associated with choriocarcinoma and should be
suspected in any patient with a very high serum HCG level
• Men who relapse in the brain after achieving a complete response to
chemotherapy appear to have a worse prognosis than those with
brain involvement at diagnosis
• Patients with brain metastases at diagnosis should receive BEPx4
chemotherapy followed by resection of residual masses.

59. TREATMENT SEQUALE
Early Toxicity
• Cisplatin-based chemotherapy is associated with numerous early
complications and side effects, including fatigue, myelosuppression,
infection, peripheral neuropathy, hearing loss, diminished renal
function, and death.
• Early complications of radiation therapy include fatigue, nausea and
vomiting, leukopenia, and dyspepsia

60. DRUG TOXICITY
Bleomycin Pulmonary fibrosis
Etoposide (VP-16) Myelosuppression
Alopecia
Renal insufficiency(mild)
Secondary leukemia
Cis-platin Renal insufficiency
Nausea, vomiting
Neuropathy

61. Late Toxicity
Numerous long-term sequelae have been reported in GCT survivors,
peripheral neuropathy,
Raynaud phenomenon,
hearing loss,
hypogonadism, infertility,
secondary malignant neoplasms, and cardiovascular disease
Patients treated with both radiation and chemotherapy have the
highest risk of death from nonmalignant causes- GI AND
CARDIOVASCULAR CAUSES

62. Sperm Cryopreservation
• Although infertility is an uncommon presentation for GCT,
•up to 52% of men have oligospermia at diagnosis and
•10% are azoospermic
• The germinal epithelium is exquisitely sensitive to platin-based
chemotherapy and radiation therapy
• Recovery of spermatogenesis after radiation therapy for seminoma
may take to 2 to 3 years or more.
• Men planning future paternity are recommended to undergo sperm
cryopreservation before treatment is initiated

63. NON–GERM CELL TUMORS
Sex Cord-Stromal Tumors
• Rare, 0.4% to 4% of testis neoplasms.
• Refers to neoplasms containing
• Leydig cells,
• Sertoli cells,
• granulosa cells, or
• thecal cells
• Approximately 90% are benign and 10% are malignant.
• Histology of malignant tumors- Tumor size larger than 5 cm, necrosis,
vascular invasion, nuclear atypia, high mitotic index, increased MIB-1
expression, infiltrative margins, extension beyond the testicular
parenchyma, and DNA ploidy

64. Leydig Cell Tumors
• Isosexual precocious puberty (prominent external genitalia, pubic hair
growth, and masculine voice).
• No association with cryptorchidism.
• Occur in adult males between 30 and 60 years, although
approximately one-fourth occur in children.
• Painless testis mass, SOMETIMES testicular pain, gynecomastia (as a
result of androgen excess and peripheral estrogen conversion),
impotence, decreased libido, and infertility.

65. • In the past- inguinal orchidectomy was the treatment of choice
• If diagnosis is known pre-op- testis sparing surgery (for <3cm)
• Completion orchiectomy should be performed if GCT histology is
seen
• The most frequent metastatic sites are the retroperitoneum and the
lung.
• Metastatic Leydig cell tumors are resistant to chemotherapy and
radiation therapy, and survival is poor
• Ortho-para-DDD, a potent inhibitor of steroidogenesis may produce
partial response.

66. Sertoli Cell Tumor
• Less than 1% of testis neoplasms
• Median age at diagnosis is 45 years
• In rare cases, these tumors are associated with Peutz-Jeghers syndrome
and androgen insensitivity syndrome and are frequently bilateral
• Tumors are well circumscribed, yellow-white or tan, with uniform
consistency.
• Microscopically, the tumors contain epithelial elements resembling Sertoli
cells with varying amounts of stroma organized into tubules
• No association with cryptorchidism. Gynecomastia SEEN in 1/3rd of
patients
• <3cm- testis sparing surgery
• >3cm- intra op frozen section>>>> radical inguinal orchiectomy

67. Granulosa Cell Tumors
• The juvenile type is benign and is the most frequent congenital testis
tumor
• The adult-type resembles granulosa cell tumors of the ovary
• Gynecomastia and increased estrogen secretion are common
• Treatment of the primary tumor is curative as these tumors appear to
have limited metastatic potential.

68. Gonadoblastoma
• Mixed germ cell-sex cord-stromal tumor composed of seminoma-like germ cells and sex
cord cells showing Sertoli differentiation.
• Occur almost exclusively in patients with dysgenic gonads and intersex syndromes.
• 80% are phenotypic females- have primary amenorrhoea
• 20% are phenotypic males- cryptorchidism, hypospadias and some form of female
internal genitalia
• Considered an in situ form of malignant GCT; approximately 50% will develop an invasive
GCT (usually seminoma, although yolk sac tumor and EC can occur)
• Bilateral orchiectomy is required because of the risk of bilateral tumors (40%)

69. Miscelaneous tumors
Dermoid and Epidermoid Cyst
These rare benign neoplasms that are thought to arise from benign germ
cells with retrained embryonic properties or from displaced metaplastic
mesothelial cells
• Grossly, they are well-circumscribed, unilocular cystic masses filled with
keratinized debris that may have a laminated appearance that gives them
the characteristic “onion peel” or target appearance on ultrasound
• Typically <3cm
• Dermoid cysts are differentiated from epidermoid cysts by the presence of
adnexal structures such as glandular elements, adipose tissue, and
cartilage
• Enucleation or partial orchiectomy may be performed

70. Adenocarcinoma of the Rete Testis
• rare but highly malignant neoplasm arising from the collecting system
of the testis
• The usual presentation is a painless testis mass with hydrocele. More
than 50% of patients have metastatic disease, and the overall median
survival is 1 year.
• RPLND may be curative in patients with limited retroperitoneal lymph
node metastasis.
• Chemotherapy and radiation therapy are ineffective.

71. Secondary Tumors of the Testis
Lymphoma
• Primary testicular non-Hodgkin lymphoma (NHL) is a rare tumor and
represents only 1% to 2% of all cases of lymphoma.
• Most commonly, lymphoma involves the testis through dissemination from
extratesticular sites
• NHL is the most common testicular neoplasm in men over age 50. Bilateral
testicular involvement occurs in 35% of cases
• Approximately 25% of men have systemic symptoms (fever, night sweats,
weight loss). Central nervous system involvement at diagnosis is reported
in 10% of men.
• The initial treatment is radical inguinal orchiectomy

72. Leukemic Infiltration
• The testis is a frequent site of relapse in boys with acute lymphocytic
leukemia
• The diagnosis can usually be made by biopsy, and orchiectomy is
unnecessary.
• Local control can be achieved with low-dose radiotherapy (20 Gy),
and treatment should include the contralateral testis because of the
frequent risk of bilateral involvement.
• the prognosis is poor because most have associated systemic disease.

73. TUMORS OF THE TESTICULAR ADNEXA
Adenomatoid Tumor
• Adenomatoid tumor is of mesothelial origin and is the most common
paratesticular tumor, 75% of which involve the epididymis (although
these tumors may also arise within the testicular tunics or the
spermatic cord).
• presentation is a small (0.5–5 cm), painless paratesticular mass
• These tumors are benign and managed by inguinal exploration and
surgical excision

74. Cystadenoma
• Cystadenoma of the epididymis corresponds to benign epithelial
hyperplasia
• Approximately one-third of cases, which are usually bilateral, occur in
patients with von Hippel-Lindau syndrome.
• The lesions are usually small and painless and are detected on routine
examination in a young adult

75. Mesothelioma
• Paratesticular mesothelioma arises from the tunica vaginalis and
usually is seen as a painless paratesticular mass or tunical vegetations
in association with a hydrocele
• Benign and malignant mesothelioma have been described, with the
distinction based on atypia, mitotic activity, and invasion
• Treatment is radical inguinal orchiectomy and hemiscrotectomy.
• Retroperitoneal, pelvic, and inguinal lymph node dissection may be
considered in patients with malignant tumors without widespread
metastatic disease

76. Sarcomas
• Sarcomas of the spermatic cord, epididymis, and testis are the most
common genitourinary sarcomas in adults.
• Liposarcoma is the most common histologic subtype in adults,
followed by leiomyosarcoma, malignant fibrous histiocytoma,
rhabdomyosarcoma, and fibrosarcoma
• Embryonal rhabdomyosarcoma is the most common histologic
subtype in men under age 30
• Sarcomas most commonly arise from the spermatic cord and are
located in the intrascrotal region; primary mesenchymal tumors of
the testis are exceedingly rare.

77. • Liposarcomas of the spermatic cord in the inguinal canal —CT or MRI is helpful to
distinguish from inguinal hernia/lipoma
• Managed initially through an inguinal approach with wide excision of the
spermatic cord and testis with high ligation.
• Systemic chemotherapy should be given to patients with evidence of
retroperitoneal or distant metastases.
• In the presence of a normal metastatic evaluation, patients with sarcomas other
than liposarcoma should undergo RPLND and postoperative chemotherapy
should be given to patients with retroperitoneal lymph node metastasis

78. Surgery of testicular tumors
RADICAL ORCHIECTOMY
• In patients in whom a testicular malignancy is suspected, radical
orchiectomy is the diagnostic and therapeutic treatment of choice.
• The approach is via an inguinal incision, allowing for early control of
the spermatic cord and complete removal of the ipsilateral testis,
epididymis, and spermatic cord to the level of the internal inguinal
ring.

79. Partial Orchiectomy
• Partial orchiectomy can be considered in
• tumor is polar,
• measures 2 cm or less, and
• contralateral testicle is compromised or absent.
TECHNIQUE-
• After the mass is localized, the tunica albuginea is sharply incised with a
scalpel. The approach will vary depending on the mass’s location.
• A vertical incision along the long axis of the testicle is generally preferred
for an approach from the ventral midline,
• whereas incisions medial or lateral to the ventral midline ideally should be
oriented horizontally, minimizing injury to the segmental arteries that
course just deep to the tunica albuginea

80. • Mass excised, ideally including a small rim of normal seminiferous
tubules to facilitate a negative surgical margin.
• If a germ cell tumor (GCT) is confirmed and the surrounding
parenchyma demonstrates intratubular germ cell neoplasia It is
advocated to proceed to radical orchiectomy
• Any patient who develops ipsilateral local recurrence of GCT should
undergo completion radical orchiectomy regardless of prior adjuvant
therapy or residual testicular function

81. Delayed Orchiectomy
• a minority of cases may present with diffuse metastatic and/or
symptomatic GCT that requires early initiation of systemic
chemotherapy.
• In these circumstances, diagnosis may be pursued via biopsy of a
metastatic site or even made presumptively based on the clinical
features with or without serologic studies.
• For such cases, a delayed radical orchiectomy is recommended for all
patients regardless of response to therapy in the retroperitoneum or
elsewhere

82. RETROPERITONEAL
LYMPH NODE
DISSECTION
Primary RPLND: After orchiectomy for high-risk clinical stage
(CS) 1 or low-volume CS II (N1) NSGCT with normal STMs
PC-RPLND: Refers to an RPLND performed after induction
chemotherapy. often performed when there is a residual
mass > 1 cm in the retroperitoneum and the STMs post-
chemotherapy are normal.
Salvage PC-RPLND: RPLND performed after both induction
and salvage chemotherapy
Desperation PC-RPLND: RPLND performed after
chemotherapy where there is elevated STMs

83. • Reoperative RPLND: RPLND performed after a prior RPLND
• Resection of late relapse: RPLND performed for relapse of disease >
24 months after a complete response (CR) from primary
chemotherapy

84. Technique of RPLND
• A midline incision is carried from the level of the xyphoid to a couple of
centimeters below the umbilicus
Exposure of the Retroperitoneum-
• The plane between the mesentery and retroperitoneal fat is developed.
• Identification of the plane may be facilitated by identification of the
gonadal vein and ureter and staying anterior to these structures.
Split and Roll Technique
• The split is started at the 12 o’clock position on the aorta just below the
left renal vein, and this plane is continued caudally to identify the IMA

86. Left Para-Aortic Packet-
• Dissection of the left para-aortic lymphatic packet in a template Dissection
is facilitated by rolling the descending colon medially (through division of
the white line of Toldt)
Interaortocaval Packet
• In a right-sided nerve-sparing procedure, the next step is a split-and-roll on
the anterior surface of the IVC including ligation of the gonadal vein.
• If a non–nerve-sparing procedure is performed and if one starts on the
aorta first, then the medial side of the aorta can be controlled before
proceeding to the IVC side of the dissection

87. Right Paracaval Packet-
• The right paracaval packet is often the smallest and easiest to remove. If a
bilateral dissection is performed in a split and roll maneuver,
• It is often fruitful to release the packet at the level of the right renal artery
to allow it to begin passing medially underneath the vena cava en-bloc with
the interaortocaval packet
GONADAL VEIN
• To remove the residual gonadal vein to the previously removed testicle, the
peritoneum overlying it should be incised. In addition, the ureter (which is
often previously freed) should be swept off from its posterior location.

89. AUXILLARY PROCEDURES
• Nephrectomy
• Major Vascular Reconstruction
• Inferior Vena Cava Resection
• Aortic reconstruction
• Hepatic resections
• Pelvic resections