Surgical management

1. TESTICULAR CANCERS
Presented By: Dr Isha Jaiswal
Moderator: Dr Madhup Rastogi
Date:10th September 2014

2. Overview
Cancers of testis are relatively rare cancer accounting for approx. 1 % cancer in
males. However it is important in field of oncology as it represents a highly curable
neoplasm & the incidence is focused on young patients at their peak of
productivity

3. Anatomy
• The testis is the male gonad.
• It is homologous with the ovary in female.
• It lies obliquely within the scrotum suspended by
the spermatic cord
• The left testis is slightly lower than the right
• Shape: Oval
• Size:3.75 cm long, 2.5 cm broad, 1.8 cm thick
• Weight: about 10-15 gm.
• Has 2poles , 2surface, 2 borders

4. Descent of testis
Develops at T10-T12 segments in post abdominal wall from genital
ridge & subsequently descend to reach scrotum
 Begin to descend in 2nd month of intrauterine life
 3rd month reach iliac fossa
 4th -6th month deep inguinal ring
 7th month inguinal canal
 8th month: superficial inguinal ring
 9th month: scrotum
Cryptorchidism: one or both testicles fail to reach scrotum before
birth. Most of time it reached scrotum by 1 year of age. If not
orchidopexy need to be done:

5.  Skin
 DARTOS Muscle
 External Spermatic Fascia
 Cremastric Muscle
 Internal Spermatic Fascia
 Tunica Vaginalis
 Tunica Albuginea
Coverings of testis

6. Structure of testis
• 200-300 lobules
• Each lobule has 2-3 seminiferous tubules
• Each seminiferous tubules lined by cell in
different stages of spermatogenesis
• Among the seminiferous tubules are Sertoli
cells.
• Between the loops of the seminiferous
tubules are interstitial cells, produce
testosterone.
• Seminiferous tubules join to form 20-30
straight tubules.

7. • Rete testis: network of tubules located in the
hilum of the testicle(mediastinum testis) that
carries sperm from the seminiferous
tubules to the efferent ducts
• Rete testis give rise to 12-30 efferent ductules
• Epididymis: tube about 20 feet (6 m) long that
is coiled on the posterior surface of each testis
connect efferent duct to vas deferens
• Ductus deferens :extends from the epididymis
in the scrotum on its own side into the
abdominal cavity through the inguinal canal

8. Blood Supply
Areterial supply
• The testicular artery branch of abdominal aorta .
• The testis has collateral blood supply from
1. the cremasteric artery
2. artery to the ductus deferens
Venous drainage
• The veins emerge from the back of the testis, and receive
tributaries from the epididymis;
• they unite and form convoluted plexus, called the
pampiniform plexus.
• plexus to form a single vein, which opens, on the right side,
into the inferior vena cava ,on the left side into the left
renal vein

9. Lymphatic Drainage
Drain into the retroperitoneal lymph glands between the
levels of T11 and L4, but they are concentrated at the level
of the L1 and L3 vertebrae
Lymph nodes located lateral or anterior to the inferior
vena cava are called paracaval or precaval nodes,
respectively.
Interaortocaval nodes are located between the inferior
vena cava and the aorta.
Nodes anterior or lateral to the aorta are preaortic or para-
aortic nodes, respectively

10.  On the right:
 Interaortocaval region, followed by the paracaval, preaortic, and para-
aortic lymph nodes.
 On the left:
 Preaortic and para-aortic nodes and thence to the interaortocaval
 Metastatic nodal disease to the common iliac, external iliac, or
inguinal lymph nodes is usually secondary to a large volume of
disease with retrograde spread.
 If the patient has undergone a herniorrhaphy, vasectomy, or other
transscrotal procedure, metastasis to the pelvic and inguinal lymph
nodes is more likely
 Through the thoracic duct to lymph nodes in the posterior
mediastinum and supraclavicular fossae and occasionally to the
axillary nodes.
 Contralateral spread is mainly seen with right-sided tumors.
 In 15% to 20%, bilateral nodes are involved

11. Nerve Supply
• Sympathetic nerves arising from segment T10 of the spinal cord.
• Both afferent for testicular sensation and efferent to the blood vessels(vasomotor).

12. Epidemiology of testicular cancer

13. INTRODUCTION
 Comprise a morphologically and clinically diverse group of tumors
 Predominantly affects young males
 1 -2 % of all cancers in USA
 Testicular cancer forms about 1% of all malignancies in males in India.
 Incidence (ASR)– 0.6 per 100000
 Mortality (ASR)– 0.3 per 100000
 95% are Germ Cell Tumours (GCTs)
 90% GCT are in testes,2-10% in extra gonadal (eg retropreitoneum, mediastinal)
 Cure rate increased with introduction of platinum based chemotherapy from 10 to 80%

14. EPIDEMOLOGY OF TESTICULAR CANCER
• Age: for GCT: median age at diagnosis is 34 years, with 50% of incident
cases between 20 and 34 years.
• In a man age: 50 years or older solid testicular mass is usually lymphoma
• Age - 3 peaks
2 – 4 yrs
20 – 40 yrs
above 50 yrs
• Geographic: Highest incidence in Denmark, Norway, and Switzerland
and the lowest in eastern Europe and Asia.
• Race: more common in young white men ,less in African Americans

15. Predisposing Factors
1. Cryptorchidism
2. Klinefelter syndrome
3. Positive family history
4. Positive personal history
5. Intratubular germ cell neoplasia
6. Trauma
7. Viral infection
8. Hormonal factors
9. Exposure to environmental oestrogen

16. Predisposing Factors
1. Cryptorchidism
• For inguinal cryptorchidism odds ratio is
5.3 for seminoma
3 for non seminoma
• This risk is further increased if the testis is intra-abdominal.
• Abdominal testis is more likely to be seminoma, testis brought to scrotum by orchiopexy
is more likely to be NSGCT.
• There is still an increased risk of developing a tumour in the contralateral normally
descended testicle in pt. with cryptorchidism
• GCT develop in 2% of cryptorchids & 5-10% of normally descended testis
• Prepubertal orchidopexy fails to prevent the subsequent development of malignancy

17. KLINEFELTER SYNDROME
• Characterised by:
• testicular atrophy
• absence of spermatogenesis
• eunuchoid habitus
• gynecomastia
Karyotype: 47XXY
Pt. are at increased risk of mediastinal GCT

18. Predisposing Factors
2. Positive family history
Men with first degree relative with testicular cancer
Median age being less by 2-3 yrs
 brother of men with testicular tumor: 8-10 times more risk of
developing TGCT
Relative risk to father and sons: 2-4 times

19. Predisposing Factors
3. Positive personal history
12 folds increased risk of developing GCT in the contralateral testis
Higher risk for contralateral tumor if
• Younger age
• Seminoma

20. Predisposing Factors
4. Intratubular Germ Cell Neoplasia (ITGCN)
• Precursor lesion of all types of germ-cell tumors except spermatocytic seminoma
• Originate from primordial germ cells early during embryogenesis, possibly due to an excess
of estrogens.
 No spermatogenesis
 PLAP positive
 Present in adjacent testicular parenchyma in 80% of pt with GCT
 5-9% in unaffected contralateral testis; increases to 36% in atrophy or
cryptorchidism
 50% risk of GCT in 5 yrs, 70% in 7yrs

21. Pathological classification
3:Classification of Sex-Cord Stromal Tumors of the
Testis 2-3%
 Leydig cell tumor
 Sertoli cell tumor
 Granulosa cell tumor
 Fibroma-thecoma stromal tumor
 Gonadoblastoma
 Sex cord-stromal tumor unclassified type
1:Intra tubular germ-cell neoplasia(IGCN)
2:GERM CELL TUMORS 95%
Seminoma 40%
Classic type
anaplastic
Spermatocytic type
Non seminomatous germ-cell tumors 60%
 Embryonal carcinoma 20-25%
 Teratoma 25-35%
 Yolk sac (endodermal sinus) tumor
 Choriocarcinoma 1%
 Mixed germ-cell tumor
4: others 5%
 lymphoma
 rabdomyosarcoma
 melanoma

22. 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

23. Seminoma
• Serum alpha fetoprotein is normal
• Beta HCG is elevated in 30% of patients with Seminoma
• Classification
a) classical
b) Anaplastic
c) Spermatocytic

24.  Anaplastic
 5% - 10
 Middle age
 Aggressive - lethal
 Greater mitotic activity
 Higher local invasion
 Higher metastatic potential
 Higher rate of β-HCG production
 Typical/ Classical
 82% - 85%
 Middle age
 PLAP – 90%
 Syncytiotrophoblsts – ↑Beta HCG(10%)
 Very slow growth
 Spermatocytic
 2% - 12% of seminomas
 Old age > 50 yr
 Does not arise from ITGC
 PLAP negative
 Extremely low metastatic potential
 Good prognosis

25. Embryonal Carcinoma
 2nd most common germ cell tumor 90% of NSGCT
 Present in majority of mixed germ cell tu mors
 Most men present in their 20s to 30s with a testicular mass
 Highly malignant tumours; may invade the cord stuctures.epidydymis
 High degree of metastasis
 Serum AFP is positive in 33 5, & beta HCG is elevated in 20% of cases

26. Yolk Sac Tumour
 Most common germ cell tumor ( & most common testicular tumor ) in children, where
it occurs in its pure form.
– 60% of GCT in children. First 2 years of life.
– Pure yolk sac tumor <2% of testicular tumors in adults
– 40% of mixed germ-cell tumors.
– Elevated serum levels of alpha-fetoprotein.
– Microscopically, Schiller-Duval bodies are a characteristic feature
 Testicular mass the most usual presentation.

27. 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)

28. Teratoma
 Teratoma in greek means “monster tumor”
 Contain all three germ layers with varying degree of
diffrentiation
 Occurs in its pure form in pediatric age group with a mean age
of diagnosis at 20 months
 In adults, occur as a component of mixed germ cell tumor & is
identified in > 47 % of mixed tumors.
 Normal serum markers.
◦ Mildly elevated AFP levels

29. Interstitial cell tumors
1. Leydig cell tumors
May affect 20-60yrs of age
A masculinising tumor, produces androgens
No association with crytochordism
Presents with painless testicular mass
Precocious puberty
 Prominent external genitalia
 Deep masculinised voice
 Pubic hair
Gynacomastia and decreased libodo due to oestrogen production by
increased peripheral conversion

30. Interstitial cell tumors
2. Sertoli Cell Tumor
 can occur in any age group including infants
 No association with crytochordism
 Excess estrogen production
 Gynacomastia in 1/3rd of cases
 10 % are malignant

31. Interstitial cell tumors
3. Gonadoblastoma
 Mixed germ cell/sex cord/stromal tumor
 Composed of seminoma like germ cells and Sertoli differentiation
 Exclusively in patients with dysgenic gonads and intersex syndromes
 80% are phenotype females with primary amenorrhoea
 20% are males with crytochordism and dysgenic gonads and
hypospadias
 Considered in-situ malignant form of GCT
 Bilateral orchidectomy because of risk of bilateral tumours

32. 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
-Metastases to testis
- rare

33. Spread
1. Direct Spread:
 This spread occurs by invasion.
 Whole of testis in involved and restricted
 Tunica albuginea is rarely penetrated
 May be crossed by “blunder biopsy”
 Scrotal skin involvement
 Fungation on the anterior aspect
 Spread to spermatic cord and epidedymis
may occur : points towards bad prognosis

34. Spread
2. Lymphatic spread:
Seminoma metastasize exclusively through
lymphatics
They drain primarily to para-aortic lymph nodes
From RPLN drain into cysterna chili, thoracic duct
,posterior mediastinum & left supraclavicular
Lymph
 from medial side of testes run along the artery to
the vas to drain to nodes at the bifurcation of
common iliac
No inguinal nodes until scrotal skin involvement

35. Spread
3. Blood Spread
 NSGCT spread through blood route
 Lungs, liver, bones and brain are the usual sites usually involved

36. Clinical Features
1. Due to primary tumor
a) Painless testicular lump
b) Sensation of heaviness if size > than 2-3 times
c) Rarely dragging pain is complained of (1/3rd cases)
d) May mimic epidedymo-orchitis
e) Sudden pain and enlargement due to hemorrhage mimicking torsion
f) History of trauma (co-incidental)

37. DICTUM FOR ANY SOLID SCROTAL SWELLINGS
• All patients with a solid, Firm Intratesticular Mass that
cannot be Trans illuminated should be regarded as
Malignant unless otherwise proved.

38. Clinical Features
2. Due to metastasis
 Abdominal or lumbar pain (lymphatic spread)
 Dyspnoea, hemoptysis and chest pain with lung mets
 Jaundice with liver mets
 Hydronephrosis by para-aortic lymph nodes enlargement
 Pedal oedema by IVC obstruction
 Troiser’s sign

39. Clinical Features
3. Clinical examination:
a) Enlarged testis (except choriocarcinoma)
b) Nodular testis
c) Firm to hard in consistency
d) Loss of testicular sensation
e) Secondary hydrocele
f) Flat and difficult to feel epididymis
g) General examination for metastasis

40. Tumor markers
TWO MAIN CLASSES
• Onco-fetal Substances : AFP & HCG
• AFP - Trophoblastic Cells
HCG - Syncytiotrophoblastic Cells
AFP, BHCG & LDH are included in TNM staging of testicular cancers

41. Human Chorionic
Gonadotropin
Has  and  polypeptide chain
NORMAL VALUE: < 1 ng / ml
HALF LIFE of HCG: 24 to 36 hours
RAISED  HCG -
100 % - Choriocarcinoma
60% - Embryonal carcinoma
55% - Teratocarcinoma
25% - Yolk Cell Tumour
7% - Seminomas
normal value: below 16 ngm / ml
half life of AFP – 5 and 7 days
Raised AFP :
Pure embryonal carcinoma
Teratocarcinoma
Yolk sac Tumor
Combined tumors,
AFP not raised in pure choriocarcinoma & in
pure seminoma
AFP –Alfa feto protein

42. LDH Beta HCG
(mIu/ml)
AFP
(ng/ml)
S1 < 1.5 x N <5000 <1000
S2 1.5-10 x N 5000-50000 1000-10000
S3 >10 x N >50000 >10000
Serum Tumor Markers (S)

43. ROLE OF TUMOUR MARKERS
• Helps in Diagnosis - 80 to 85% of Testicular Tumors have Positive Markers
• Most of Non-Seminomas have raised markers.
• Indicate Histology of Tumor:
If AFP elevated in Seminoma - Means Tumour has Non-Seminomatous elements
• Degree of Marker Elevation Appears to be Directly Proportional to Tumor Burden

44. ROLE OF TUMOUR MARKERS
• may predict the responsiveness of nonseminomas to treatment
• The level of beta-HCG should decrease by 90% or more every 21 days with each successful
treatment cycle of chemotherapy.
• The decline of AFP is less predictable
• Normalization of tumor marker after high inguinal orchidectomy does not ensure complete
disease removal however after Orchiectomy if Markers Elevated means Residual Disease
• Negative Tumor Markers becoming positive on follow up usually indicates -Recurrence of
Tumor
• Markers become Positive earlier than radiological studies

45. Scrotal ultrasound
• Ultrasonography of the scrotum (7.5MHZ) is
a rapid, reliable technique to exclude
• Testicular and other scrotal swelling
• Solid & cystic swelling
• Hydrocele & 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.

46. Staging Work Up
• General
History (document cryptorchidism and previous inguinal or scrotal
surgery)
Physical examination
• Laboratory Studies
CBC, LFT, RFT, LDH
• Serum assays
Alpha fetoprotein (AFP)
Beta human chorionic gonadotropin

47. • 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

48. Large left para aortic nodal mass due to GCT
causing hydronephrosis

49. “I always had the size difference
there, but I didn’t know…I would’ve
still been waiting if it hadn’t started
hurting, it just got so painful I couldn’t
sit on my bike anymore.”
-Lance Armstrong
“I always had the size difference there, but I didn’t
know…I would’ve still been waiting if it hadn’t started
hurting, it just got so painful I couldn’t sit on my bike
anymore.”
-Lance Armstrong
“I always had the size difference there, but I didn’t
know…I would’ve still been waiting if it hadn’t started
hurting, it just got so painful I couldn’t sit on my bike
anymore.”
-Lance Armstrong