The document discusses recent advances in the management of testicular tumors. It covers the anatomy, classification, clinical features, investigations, staging, and treatment options including surgery, radiotherapy, chemotherapy, and retroperitoneal lymph node dissection. Treatment depends on the histology (seminoma vs. non-seminoma), stage, and response to initial treatment. The presentation provides an overview of diagnostic and therapeutic approaches for testicular cancer.

1. RECENTADVANCES INTHEMANAGEMENT
OFTESTICULAR TUMOR
PRESENTER:
Dr.Manharsinh Rajput
December 16 1
Recent advances in the management of
Testicular tumor

2. Testicular Descent
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Recent advances in the management of
Testicular tumor

3. ANATOMY
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Recent advances in the management of
Testicular tumor
Fig 5. Anatomy of the testis

4. BLOOD SUPPLY
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Recent advances in the management of
Testicular tumor
Fig 6. Blood supply of testis

5. LYMPHATIC DRAINAGE
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Recent advances in the management of
Testicular tumor
Fig. 7 Lymphatic drainage

6. INTRODUCTION
• Testicular cancer accounts for
only about 1% of all human
neoplasms.
• Testicular cancer although rare,
is the most common malignancy
in men in 15-35 years age group
and accounts for approximately
23% of all cancers in this group.
• Risk factors
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Recent advances in the management of
Testicular tumor

7. WHO CLASSIFICATION
Germ cell tumors:
Precursor lesions- Intratubular malignant germ cell tumor
(carcinoma in situ)
Tumors of one histologic type (pure forms)
Seminoma
variant- seminoma with syncitiotrophoblastic cells
Spermatocytic seminoma
variant- spermatocytic seminoma with sarcoma
Embryonal carcinoma
Yolk sac tumor
Polyembryoma
Trophoblastic tumors- choriocarcinoma
Teratoma
Mature teratoma
Dermoid cyst
Immature teratoma
Teratoma with malignant areas
Mixed tumors
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Recent advances in the management of
Testicular tumor

8. CLASSIFICATION CONT..
Sex cord/ Gonadal Stromal Tumors:
Pure forms
Leydig’s cell tumor
Sertoli’s cell tumor
large cell calcifying
lipid rich cell
Granulosa cell tumor
Adult type granulosa cell tumor
Juvenile type granulosa cell tumor
Tumors of thecoma / fibroma group
Incompletely differentiated sex cord/ gonadal stromal tumors
Mixed forms
Unclassified forms
Tumors containing both germ cell and sex cord/gonadal stromal elements
-Gonadoblastoma
-Mixed germ cell- sex cord/ gonadal stromal tumors, unclassified
Miscellaneous tumors
-Carcinoid tumors
-Tumors of ovarian epithelial types
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Recent advances in the management of
Testicular tumor

9. CLASSIFICATION CONT..
Lymphoid and hematopoietic tumors:
-Lymphoma
- Plasmacytoma
- Leukemia
Tumors of collecting duct and rete:
-Adenoma
-Carcinoma
Tumors of tunica, epididymis, spermatic cord, supporting structures,
and appendices:
Adenomatoid tumor
Mesothelioma
Adenoma
Carcinoma
Melanotic neuroectodermal tumor.
Soft tissue tumors
Unclassified tumors
Secondary tumors
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Recent advances in the management of
Testicular tumor

10. SEMINOMA
 Age of presentation
3rd and 4th decade
 Presentation
present with uniform
testicular swelling
 Serum markers are rarely
elevated. AFP never rises.
 Lymphatic spread
 Good prognosis
NON SEMINOMA
 2nd and 3rd decade
 present with multinodular
testicular swelling.
 Serum markers are
commonly elevated.
 Lymphatic as well as
hematogenous.
 Worse prognosis
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Recent advances in the management of
Testicular tumor

11. CLINICAL FEATURES
Painless Swelling of Testes
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
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Recent advances in the management of
Testicular tumor

12. • Physical Examination
• Careful examination of the affected and the normal contralateral testis
• Examine for any evidence of palpable abdominal mass, inguinal
lymphadenopathy, supraclavicular lymphadenopathy.
• Chest examination for intrathoracic disease.
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Recent advances in the management of
Testicular tumor

13. INVESTIGATIONS
1. Scrotal Ultrasound
2. CT Thorax / Chest X-Ray - PA and lateral views
3. CT Scan Abdomen & Pelvis
4. Tumour Markers
- AFP
-  HCG
- LDH
- PLAP
5. MRI/PET Scan
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Recent advances in the management of
Testicular tumor

14. ROLE OF FNAC & BIOPSY
• In patients with an atrophic testis, history of cryptorchidism, or age
younger than 40 years, the prevalence of ITGCN in the contralateral testis
has been reported to be 36%.
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Recent advances in the management of
Testicular tumor

15. CLINICAL STAGING
Stage I - Tumour confined to testis.
Stage II - Spread to Regional nodes.
Stage III - Spread beyond retroperitoneal
Nodes or Above Diaphragm or visceral disease
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Recent advances in the management of
Testicular tumor

16. TNM STAGING
T0 = No evidence of Tumour
T1s = Intratubular, pre invasive
T1 = Confined to Testis
T2 = Invades beyond Tunica Albuginea or into
Epididymis
T3 = Invades Spermatic Cord
T4 = Invades Scrotum
N1 = Single < 2 cm
N2 = Multiple < 5 cm / Single 2-5 cm
N3 = Any node > 5 cm
Mo = No distant metastasis
M1 = Distant metastasis(M1a = Nonregional or
pulmonary , M1b = sites other than m1a)
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Recent advances in the management of
Testicular tumor

17. December 16 17
Recent advances in the management of
Testicular tumor

18. TREATMENT
After obtaining serum AFP & B-HCG levels in suspected
case of malignant germ cell tumor.
Radical inguinal orchiectomy with high ligation of
spermatic cord is done, it is both diagnostic &
therapeutic.
Further management depends on, pathology & stage of
disease.
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Recent advances in the management of
Testicular tumor

19. SEMINOMA
Stage I,IIA Stage IIB,IIC,III
Retroperitoneal
irradiation
BEP / EP
1.Non responder or discrete
residual mass>3 cm– Excision
2.35% residual mass harbours
active disease—salvage
chemotherapy
Responder
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Recent advances in the management of
Testicular tumor

20. NSGCT
Stage I,IIA Stage IIB,IIC,III
RPLND
BEP / EP
1.Partial response 
RPLND/Excision of lung nodule
2.Residual disease with raised
tumor marker  Salvage
chemotherapy
Complete
ResponseSurveillance
Follow up
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Recent advances in the management of
Testicular tumor

21. SURGERY
• Radical orchiectomy
• Diagnostic and Therapeutic treatment of choice.
• Complete removal of ipsilateral epididymis and spermatic cord to the level
of the internal inguinal ring.
• Partial orchiectomy
• Considered in patient with polar tumor measuring 2 cm or less & abnormal
or absent c/l testis.
• Adjuvant radiotherapy is given postoperatively.
• Delayed orchiectomy
• Advanced NSGCT based on biopsy of metastatic site without primary
orchiectomy.
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Recent advances in the management of
Testicular tumor

22. RETROPERITONEAL LYMPH NODE
DISSECTION
• The rationale for primary RPLND is that, in contrast to most malignancies,
testicular GCT is surgically curable in most patients with low volume
regional metastases.
• The rationale for performing PC-RPLND.
• Salvage PC-RPLND
• Desperation PC-RPLND
• Reoperative RPLND
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Recent advances in the management of
Testicular tumor

23. Fig. 8 Laparoscopic RPLND Port Placement
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Recent advances in the management of
Testicular tumor

24. Fig. 9 Robotic assisted RPLND Port Placement
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Recent advances in the management of
Testicular tumor

25. RADIATION THERAPY
• Indications
– Adjuvant therapy for stages I–II b diseases
– Salvage of loco-regional failure after surgery or chemotherapy
– Palliative treatment to loco-regional or distant metastatic sites
• Techniques
– EBRT to lymph nodes
– High-energy radiation (6 – 18 MV)
• Seminoma is extremely radiosensitive. Radiation therapy is often used for
adjuvant therapy for early-stage seminoma, and its use in non-seminoma
germ cell tumors (GCT) is limited.
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Recent advances in the management of
Testicular tumor

26. • Fig. 10 Paraaortic and ipsilateral
inguinal field for stage II
left testicular seminoms,
with inclusion of the
renal hilus.
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Recent advances in the management of
Testicular tumor

27. Radiation cont..
STAGE DOSE
I
20 Gy in 10# to para-aortic ± pelivic
lymph node by ap-pa field
II 25Gy in 20 # by AP-PA
III
25 Gy in 20 # F/B 10 Gy in 5 #
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Recent advances in the management of
Testicular tumor

28. CHEMOTHERAPY
• Indications
– As an alternative to adjuvant RT for stages I–II seminoma
– Adjuvant therapy for stages II–IV seminoma
• Regimens
– Single-agent carboplatin become an alternative for stage I seminoma
– Regimens including BEP, EP, PVB, and VIP for stages II–IV diseases
Drug/ combination Dose and schedule
Bleomycin 30 IU IV bolus on days 2,9,16
Etoposide 100 mg/m2 IV over 30 mins on
days 1-5
Cisplatin 20 mg/m2 IV over 15-30 mins
on days 1-5
Repeat cycle every 21 days for 3 or 4 cycles
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Recent advances in the management of
Testicular tumor

29. Chemotherapy cont..
EP
Etoposide 100 mg/m2 IV over 30 mins on
days 1-5
Cisplatin 20 mg/m2 IV over 15-30 mins
on days 1-5
Repeat cycle every 21 days for 4 cycles
VeIP
Vinblastine 0.11 mg/kg/d on days 1 and 2
Ifosfamide 1.2 g/m2/d IV on days 1-5
Cisplatin 20 mg/m2/d IV on days 1-5
Mesna 400 mg/m2/d IV bolus prior to
ifosfamide dose, then 1.2 g/m2/d
IV infused continuously for 5 days
Repeat cycle every 21 days for 4 cycles
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Recent advances in the management of
Testicular tumor

30. CONCLUSION
 Most common curable malignancy of young adults.
 Most common- germ cell tumors, Seminoma > nonseminoma
 Nonseminoma occurs a decade earlier.
 Surgery is the main modality of treartment followed by Radiotherapy & or
chemotherapy for seminoma and chemotherapy & RPLND for
nonseminoma.
• New tumor markers –HMGA1/2, OCT ¾, SOX2
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Recent advances in the management of
Testicular tumor