testicular tumors have high rates in Scandinavian countries and low prevalence in blacks compared to whites

1. PATHOLOGY OF TESTICULAR
TUMORS
By Nebiyou S. R-I
Moderator-Dr.Ashebir
(consultant surgeon)
Jimma university,2017

2. Outline
• Embryogenesis & gross anatomy
 Epidemiology and Etiology
 Carcinoma in situ of Testis
 Testicular Neoplasms Classification
 Discussion of Pathologic classes
 Natural history & patterns of spread
 Clinical features & Staging
 Treatment overview
 Summary

3. Testes: Embryogenesis
 Descend from dorsal
abdominal wall to
deep inguinal ring
during 9th to 12th fetal
weeks
 Processus vaginalis,
out pouching of
peritoneum ,the later
tunica vaginalis, and
gubernaculum guide
it
 Final descent before
or shortly after birth

4. Testes : Anatomy
 Suspended by spermatic cord in the
scrotum
 Produce spermatozoa (Seminiferous
tubules) and hormones (testosterone)
 Tunica vaginalis: visceral and parietal
layers
 Outer cover, tunica albuginea, beneath
the vaginalis
 Testicular arteries arise from
abdominal aorta and come through
spermatic cord.

5. Testes: Anatomy cont’d…
 Testicular veins form
pampiniform venous
plexus, thermoregulatory
system of the testes. Left TV
drains to Left renal vein
and the Right one to IVC.
 Lymphatic drainage is to
Lumbar and Pre-aortic
lymph nodes.
 Nerve supply is Vagal for
parasympathetic and
afferent; sympathetics
from T7

6. Epidemiology
 High rates in Scandinevia,German & Switzerland and
low in Africa and Asia
 Ethiopia?
 More common in whites than blacks –five fold
 Higher incidence in relatives, ? Recessive inheritance
 More common on the Rt side
 2-3% bilateral

7. Etiology
 Multifactorial
 Genetic (i12p) Vs environmental
 Four well established risk factors
 Cryptorchidism-
 Family history of testicular cancer-RR higher in brothers than sons
 Personal history of testicular cancer- 12X risk
 Intratubular germ cell neoplasia- 50% in 5 yrs ,70% in 7 yrs for GCT

8. Cont’d…
 Congenital
 Cryptorchidism = 4-6X
 In 7-10 % of patients
 Risk rate=2-3X if orchidopexy
done before puberty
 Testicular dysgenesis
syndrome
 Acquired
 Trauma?
 Hormones
 Inutero DES exposure
 Atrophy
 Environmental

9. Carcinoma In Situ (CIS)/ITGCN
 Preinvasive precursor of all testicular GCTs except
spermatocytic seminoma
 Incidence 0.8%(Denmark)
 Two models- arrested gonocyte Vs aberrant chromatid
exchange
 Risk factors include: testicular ca hx, EGCT,
cryptorchidism, somatosexual ambiguity and
inferitility
 Characterized by Seminiferous tubules with sertoli
cells and malignant germ cells limited to the basement
membrane

10. Pathologic classification

11. Classification Cont’d…

12. Classification Cont’d…

13. Classification Cont’d…

14. Classification cont’d…

15. Pathologic Classes
General pathologic classification:
1. Germ Cell Tumors
2. Non-Germinal Tumors
Germ Cell Tumors account for 95% of all testicular
tumors
Non-Germinal Tumors include Stromal and Sex-
cord tumors

16. Germ Cell Tumors (GCT)
They are composed of five
basic cell types:
1. Seminoma
2. Embryonal Cell
Carcinoma
3. Yolk Sac Tumor
4. Teratoma
5. Choriocarcinoma
About 50-60% of GCTs are
mixed
Non-Seminomatous
GCTs

17. GCT cont’d…
 Seminoma
 Make 50% of GCTs
 Peak incidence in 30s
 Mainly thru
lymphatic route
 3 subtypes
 Classic
 Anaplastic
 Spermatocytic

18. GCT cont’d…
 Classic /Typical Seminoma
 82-85% of all seminomas, men in their 30s
 Grossly homogenous, lobulated, gray-white mass
devoid of hemorrhage or necrosis, intact tunica
albuginea
 Histology islands or sheets of large cells with clear
cytoplasm and densely staining nucleoli, lymphocytic
infiltrate
 10-15% are β-hCG producing ( presence of
syncytiotrophoblasts)

19. GCT cont’d…

20. GCT cont’d…
 Anaplastic Seminoma
 5-10% of seminomas
 Same age distribution as classic seminoma
 features suggestive include
 More mitotic activity
 More local invasion rate & metastatic spread
 Higher incidence of β-hCG production

21. GCT cont’d…
 Spermatocytic
Seminoma
 2-12% of all seminomas
 50% occur in men in
their 50s
 Low metastatic
potential
 Favorable prognosis

22. NSGCTs
 Embryonal Carcinoma
 Peak incidence 3rd & 4th decades
 More aggressive than seminomas
 Grossly variegated, grayish whit, fleshy tumor with
necrosis or hemorrhage and poorly defined capsule.
 Histologically malignant epitheloid cells in glands or
tubules
 Highly malignant, hence pleomorphism and high
mitotic figures are common
 most undifferentiated cell type of NSGCT(totipotential)
 May be positive for β-hCG & AFP

23. NSGCTs cont’d…

24. NSGCTs cont’d…
 Teratoma
 a neoplasm exhibiting simultaneous
differentiation along endodermal, mesodermal
and ectodermal lines.
 Occur at any age; tend to be mature in children
and act as benign but in post-pubertal males
they are malignant whether mature or immature.
 Mature elements resemble derivatives of the 3
germ layers
 Immature elements are undifferentiated and
resemble primitive tissues.

25. NSGCTs cont’d…
 Grossly large lobulated and
non- homogenous. Cut
surface consists of cysts
with solid tissues in
between, cartilage and bone.
 Histologically different
types of specialized cells.

26. NSGCTs cont’d…

27. NSGCTs cont’d…
Figure 18-9 Teratoma. Testicular teratomas contain mature cells from endodermal, mesodermal, and ectodermal lines.
Pictured here are four different fields from the same tumor containing neural (ectodermal) (A), glandular (endodermal)
(B), cartilaginous (mesodermal) (C), and squamous epithelial (D) elements.

28. NSGCTs cont’d…
Yolk sac / Endodermal
Sinus Tumor
 Seen commonly in infants
and young kids
 Grossly variegated gray
white like embryonal cell
carcinoma
 Microscopically – 3
patterns: Microcystic,
Endodermal sinus and
Solid.

29. NSGCTs cont’d…

30. NSGCTs cont’d…
Choriocarcinoma
 Highly malignant, composed of both cyto and
syncytiotrophoblastic cells.
 Usually mixed with other types.
 Primary tumor is usually small but may present with distant
metastasis(extensive LVI)
 Grossly present with central hemorrhage with viable grayish
whit tumor at periphery
 Histologically polygonal uniform cytotrophoblastic cells in
sheets and cords mixed with syncytiotrophoblasts
 May bleed like GTD-catastrophic if in lung&brain
 Positive for β-hCG

31. NSGCTs cont’d…

33. Non-Germinal Tumors
 Sex cord- Stromal Tumors- 90% are benign
 Leydig / Interstitial Cell Tumors
 2% of all testicular tumors; may occur 20-60 yrs.
 Produce androgens and other steroids
 Masculinising-sexual precocity
 10% metastatic or invade
 Sertoli Cell Tumors / Androblastoma
 uncommon, most benign
 May elaborate estrogens or androgens but in small amounts
 Feminising-gynecomastia,loss of libido
 10% invade or metastatasis

34. Non-Germinal Tumors cont’d…
 Testicular lymphoma
 5% of all testicular tumors
 Most common in people above 60 yrs.
 Most are diffuse, large B cell NHL which disseminates widely
 Poor prognosis

35. Natural history and Patterns of
spread
 ITGCN after malignant transformation involves the
testicular parenchyma
 Local -involvement of epididymis or spermatic cord is
hindered by tunica vaginalis; hence, hematogenous or
lymphatic spread may occur first(RPLNs)
 Lymphatic-main route for all except choriocarcinoma
 Hematogenous spread to lung, bones or liver mainly
choriocarcinoma

36. Clinical Features & Staging
 Symptoms
 Nodule or painless swelling, dull ache (30-40%) or
heavy sensation
 Acute pain (10%)-hemorrhage into tumor
 Metastatic symptoms(10%)- neck mass, respiratory
symptoms, GI symptoms, Lumbar back pain, bone
pain, CNS manifestations
 Gynecomastia (5%)

37. Clinical Features cont’d…
Signs
 Mass in the testis
 Do bimanual
examination
 Look for examination
NB: Any patient with a
solid, firm,
intratesticular mass,
Testicular Ca must be
the diagnosis UPO

38. Clinical Staging
 Clinical staging is based on pathologic analysis of
primary tumor and imaging studies of chest and
retroperitoneum
 Investigation
 CXR (PA,lateral)
 CT(abdominopelvic )
 Tumor markers
 AFP
 β-hCG
 LDH

40. Clinical staging Cont’d…

41. Risk classification and prognosis

42. Treatment overview
 Testicular cancer has become one of the most curable
solid neoplasms and serves as a paradigm for the
multimodal treatment of malignancies.
 The broad distinction between seminomas and
nonseminomas has been particularly important in
determining management strategies for
retroperitoneal lymph node metastasis.
 Modalities of treatment include radical/ inguinal
orchiectomy+ RPLND, radiation and chemotherapy

43. Summary
 Most common tumors in men aged between 15-35 yrs.
 Broadly classified into: germ cell (95%) and Non-
germinal tumors
 Two classes of GCTs: Seminomatous and Non-
seminomatous.
 Testicular self examination
 Staging is based on TNM and serum markers
 Most curable solid neoplasm with multimodal
treatment-model for curable neoplasm

44. REFERENCES

45. QUESTIONS & COMMENTS
8/24/2019

46. THANKYOU!
8/24/2019