Testicular tumorsTesticular tumors

Incidence Incidence

Testicular tumors are rare.Testicular tumors are rare.

1 – 2 % of all malignant tumors. 1 – 2 % of all malignant tumors.

Most common malignancy in men in the 15 to 35 Most common malignancy in men in the 15 to 35 year age group. year age group.

Benign lesions represent a greater percentage Benign lesions represent a greater percentage of cases in children than in adults.of cases in children than in adults.

Age - 3 peaksAge - 3 peaks 2 – 4 yrs2 – 4 yrs 20 – 40 yrs20 – 40 yrs above 60 yrsabove 60 yrs

Testicular cancer is one of the few neoplasms Testicular cancer is one of the few neoplasms associated with accurate serum markers.associated with accurate serum markers.

Most curable solid neoplasms and serves as a Most curable solid neoplasms and serves as a paradigm for the multimodal treatment of paradigm for the multimodal treatment of malignancies. malignancies.

EtiologyEtiology

Cryptorchidism Cryptorchidism

Intersex disorderIntersex disorder

Testicular atrophyTesticular atrophy

Trauma- prompts medical evaluation Trauma- prompts medical evaluation

Chromosomal abnormalities - Chromosomal abnormalities - loss of loss of chromosome 11, 13, 18, abnormal chromosome 12p.chromosome 11, 13, 18, abnormal chromosome 12p.

Sex hormone fluctuations, estrogen Sex hormone fluctuations, estrogen administration during pregnancyadministration during pregnancy

CROSS SECTION OF CROSS SECTION OF TESTISTESTIS

Testis Testis

StromaStroma Seminiferous TubulesSeminiferous Tubules (200 to 350 tubules)(200 to 350 tubules)

Interstitial Cells Supporting Interstitial Cells Supporting Spermatogonia Spermatogonia

LeydigLeydig and and (Androgen)(Androgen) Sertoli Cell Sertoli Cell

CLASSIFICATIONCLASSIFICATION

I.I.Primary Neoplasms of Testis.Primary Neoplasms of Testis.

A.A. Germ Cell Tumor. Germ Cell Tumor.

B.B. Non-Germ Cell Tumor .Non-Germ Cell Tumor .

II.II. Secondary Neoplasms.Secondary Neoplasms.

III.III. Paratesticular Tumors. Paratesticular Tumors.

Germ cell tumorsGerm cell tumors1. Seminomas - 40%1. Seminomas - 40%

(a) Classic Typical Seminoma(a) Classic Typical Seminoma (b) Anaplastic Seminoma(b) Anaplastic Seminoma (c) Spermatocytic Seminoma(c) Spermatocytic Seminoma

2. Embryonal Carcinoma - 20 - 25%2. Embryonal Carcinoma - 20 - 25%

3. Teratoma - 25 - 35%3. Teratoma - 25 - 35% (a) Mature(a) Mature (b) Immature(b) Immature

4. Choriocarcinoma - 1%4. Choriocarcinoma - 1%

5. Yolk Sac Tumour5. Yolk Sac Tumour

Sex cord/ gonadal stromal tumors Sex cord/ gonadal stromal tumors ( 5 to 10% )( 5 to 10% )

1.1. Specialized gonadal stromal tumorSpecialized gonadal stromal tumor(a)(a) Leydig cell tumorLeydig cell tumor(b)(b) sertoli cell tumorsertoli cell tumor

2. Gonadoblastoma2. Gonadoblastoma

3.3. Miscellaneous NeoplasmsMiscellaneous Neoplasms(a)(a) Carcinoid tumorCarcinoid tumor

(b) Tumors of ovarian epithelial sub(b) Tumors of ovarian epithelial sub types types

A.A. AdenomatoidAdenomatoidB.B. Cystadenoma of EpididymisCystadenoma of EpididymisC.C. Desmoplastic small round cell tumorDesmoplastic small round cell tumorD.D. MesotheliomaMesotheliomaE.E. Melanotic neuroectodermalMelanotic neuroectodermal

II. SECONDARY NEOPLASMS OF TESTIS

A. Metastases from any source

III. PARATESTICULAR NEOPLASMS

Carcinoma insitu {CIS}Carcinoma insitu {CIS}

Pre invasive precusor of all GCT, except Pre invasive precusor of all GCT, except spermatocytic seminomaspermatocytic seminoma

Incidence of CIS in the male population is 0.8%.Incidence of CIS in the male population is 0.8%.

Testicular CIS develops from fetal gonocytes & Testicular CIS develops from fetal gonocytes & is characterized histologically by seminiferous is characterized histologically by seminiferous tubules containing only Sertoli cells and tubules containing only Sertoli cells and malignant germ cells. malignant germ cells.

Patients at risk of CISPatients at risk of CIS

History of testicular carcinoma (5% to 6%),History of testicular carcinoma (5% to 6%), Extra gonadalGCT (40%),Extra gonadalGCT (40%), Cryptorchidism (3%), Cryptorchidism (3%), Contralateral testis with unilateral testis cancer Contralateral testis with unilateral testis cancer (5% to 6%), (5% to 6%), Somatosexual ambiguity (25% to 100%)Somatosexual ambiguity (25% to 100%)Atrophic testis 30 %Atrophic testis 30 %Infertility (0.4% to 1.1%) Infertility (0.4% to 1.1%) TESTICULAR BIOPSY gold standard for TESTICULAR BIOPSY gold standard for diagnoses of CISdiagnoses of CIS

Lymphatic drainageLymphatic drainage

The primary drainage of the right testis is The primary drainage of the right testis is within the interaortocaval region.within the interaortocaval region.

Left testis drainage , the para-aortic region Left testis drainage , the para-aortic region in the compartment bounded by the left in the compartment bounded by the left ureter, the left renal vein, the aorta, and ureter, the left renal vein, the aorta, and the origin of the inferior mesenteric artery. the origin of the inferior mesenteric artery.

Cross over from right to left is possible.Cross over from right to left is possible.

Lymphatic drainageLymphatic drainage

Lymphatics of the epididymis drain into the external iliac Lymphatics of the epididymis drain into the external iliac chainchain..

Inguinal node metastasis may result from scrotal Inguinal node metastasis may result from scrotal involvement by the primary tumor, prior inguinal or involvement by the primary tumor, prior inguinal or scrotal surgery, or retrograde lymphatic spread scrotal surgery, or retrograde lymphatic spread secondary to massive retroperitoneal lymph node secondary to massive retroperitoneal lymph node deposits.deposits.

Testicular cancer spreads in a predictable and stepwise Testicular cancer spreads in a predictable and stepwise fashion, except choriocarcinomafashion, except choriocarcinoma. .

..

Clinical featuresClinical features

Painless Swelling of One testisPainless Swelling of One testis

Dull Ache or Heaviness in Lower AbdomenDull Ache or Heaviness in Lower Abdomen

10% - Acute Scrotal Pain10% - Acute Scrotal Pain

10% - Present with Metatstasis10% - Present with Metatstasis

- Neck Mass / Cough / Anorexia / Vomiting / - Neck Mass / Cough / Anorexia / Vomiting /

Back Ache/ Lower limb swellingBack Ache/ Lower limb swelling

5% - Gynecomastia5% - Gynecomastia

Rarely - Infertility Rarely - Infertility

Physical ExaminationPhysical Examination

Examine contralateral normal testis.Examine contralateral normal testis.

Firm to hard fixed area within tunica albugenia is Firm to hard fixed area within tunica albugenia is suspicioussuspicious

Seminoma expand within the testis as a Seminoma expand within the testis as a painless, rubbery enlargement. painless, rubbery enlargement.

Embryonal carcinoma or teratocarcinoma may Embryonal carcinoma or teratocarcinoma may produce an irregular, rather than discrete mass. produce an irregular, rather than discrete mass.

Differential DiagnosisDifferential Diagnosis

Testicular torsionTesticular torsion

Epididymitis, or epididymo-orchitisEpididymitis, or epididymo-orchitis

Hydrocele, Hydrocele,

Hernia, Hernia,

Hematoma, Hematoma,

Spermatocele, Spermatocele,

Syphilitic gumma .Syphilitic gumma .

DICTUM FOR ANY SOLID SCROTAL DICTUM FOR ANY SOLID SCROTAL SWELLINGSSWELLINGS

All patients with a solid, Firm All patients with a solid, Firm Intratesticular Mass that cannot be Intratesticular Mass that cannot be Transilluminated should be regarded Transilluminated should be regarded as Malignant unless otherwise as Malignant unless otherwise proved.proved.

Scrotal ultrasoundScrotal ultrasound

Ultrasonography of the scrotum is a rapid, Ultrasonography of the scrotum is a rapid, reliable technique to exclude hydrocele or reliable technique to exclude hydrocele or epididymitis.epididymitis.

Ultrasonography of the scrotum is basically an Ultrasonography of the scrotum is basically an extension of the physical examination.extension of the physical examination.

Hypoechoic area within the tunica albuginea is Hypoechoic area within the tunica albuginea is markedly suspicious for testicular cancer. markedly suspicious for testicular cancer.

Cystic lesion- epidermoid cystCystic lesion- epidermoid cyst

Tumor markersTumor markers

TWO MAIN CLASSESTWO MAIN CLASSES

Onco-fetal Substances : AFP & HCGOnco-fetal Substances : AFP & HCG

Cellular Enzymes : LDH & PLAPCellular Enzymes : LDH & PLAP

AFP - Trophoblastic Cells AFP - Trophoblastic Cells

HCG - Syncytiotrophoblastic Cells HCG - Syncytiotrophoblastic Cells

( PLAP- placental alkaline phosphatase, & LDH lactic acid ( PLAP- placental alkaline phosphatase, & LDH lactic acid

dehydrogenase)dehydrogenase)

AFP –( Alfafetoprotein)AFP –( Alfafetoprotein)NORMAL VALUE: Below 16 ngm / mlNORMAL VALUE: Below 16 ngm / mlHALF LIFE OF AFP – 5 and 7 daysHALF LIFE OF AFP – 5 and 7 days

Raised AFPRaised AFP : : Pure embryonal carcinomaPure embryonal carcinomaTeratocarcinoma Teratocarcinoma Yolk sac Tumor Yolk sac Tumor Combined tumors,Combined tumors,AFP not raised in pure choriocarcinoma , & in AFP not raised in pure choriocarcinoma , & in pure seminomapure seminoma

HCGHCG – – ( Human Chorionic Gonadotropin)( Human Chorionic Gonadotropin)

Has Has and and polypeptide chain polypeptide chain

NORMAL VALUE: < NORMAL VALUE: < 1 ng / ml 1 ng / ml HALF LIFE of HCG:HALF LIFE of HCG: 24 to 36 hours 24 to 36 hours

RAISED RAISED HCG - HCG - 100 % 100 % - Choriocarcinoma - Choriocarcinoma 60% 60% - Embryonal carcinoma - Embryonal carcinoma 55% 55% - Teratocarcinoma - Teratocarcinoma25% 25% - Yolk Cell Tumour- Yolk Cell Tumour7% 7% - Seminomas- Seminomas

ROLE OF TUMOUR MARKERSROLE OF TUMOUR MARKERS

Helps in Diagnosis - 80 to 85% of Testicular Helps in Diagnosis - 80 to 85% of Testicular

Tumours have Positive Markers Tumours have Positive Markers

Most of Non-Seminomas have raised markersMost of Non-Seminomas have raised markers

Only 10 to 15% Non-Seminomas have normal marker Only 10 to 15% Non-Seminomas have normal marker

level level

After Orchidectomy if Markers Elevated means Residual After Orchidectomy if Markers Elevated means Residual

Disease .Disease .

Elevation of Markers after Lymphadenectomy means a Elevation of Markers after Lymphadenectomy means a

STAGE III DiseaseSTAGE III Disease

ROLE OF TUMOUR MARKERSROLE OF TUMOUR MARKERS

Degree of Marker Elevation Appears to be Directly Degree of Marker Elevation Appears to be Directly Proportional to Tumor BurdenProportional to Tumor Burden

Markers indicate Histology of Tumor:Markers indicate Histology of Tumor: If AFP elevated in Seminoma - Means Tumor has Non-If AFP elevated in Seminoma - Means Tumor has Non-Seminomatous elementsSeminomatous elements

Negative Tumor Markers becoming positive on follow up Negative Tumor Markers becoming positive on follow up usually indicates - Recurrence of Tumorusually indicates - Recurrence of Tumor

Markers become Positive earlier than X-Ray studiesMarkers become Positive earlier than X-Ray studies

Imaging studiesImaging studies

Chest X rayChest X ray

CECT abdomen – retroperitoneal nodesCECT abdomen – retroperitoneal nodes

PET- No apparent advantage over CTPET- No apparent advantage over CT

MRI - No apparent advantage over CTMRI - No apparent advantage over CT

Large left para aortic nodal mass due to Large left para aortic nodal mass due to GST causing hydronephrosisGST causing hydronephrosis

Tumor stagingTumor stagingPrimary Tumor (T)Primary Tumor (T)pTX - Primary tumor cannot be assessed pTX - Primary tumor cannot be assessed (if no radical orchiectomy has been performed, TX is used)(if no radical orchiectomy has been performed, TX is used)pT0 - No evidence of primary tumor (e.g., histologic scar in pT0 - No evidence of primary tumor (e.g., histologic scar in testis)testis)pTis - Intratubular germ cell neoplasia (carcinoma in situ)pTis - Intratubular germ cell neoplasia (carcinoma in situ)pT1 - Tumor limited to the testis and epididymis and no pT1 - Tumor limited to the testis and epididymis and no vascular/lymphatic invasionvascular/lymphatic invasionpT2 - Tumor limited to the testis and epididymis with pT2 - Tumor limited to the testis and epididymis with vascular/lymphatic invasion or tumor extending through the vascular/lymphatic invasion or tumor extending through the tunica albuginea with involvement of tunica vaginalistunica albuginea with involvement of tunica vaginalispT3 - Tumor invades the spermatic cord with or without pT3 - Tumor invades the spermatic cord with or without vascular/lymphatic invasionvascular/lymphatic invasionpT4 - Tumor invades the scrotum with or without pT4 - Tumor invades the scrotum with or without vascular/lymphatic invasionvascular/lymphatic invasion

Regional Lymph NodesRegional Lymph NodesClinical NX - Regional lymph nodes cannot be Clinical NX - Regional lymph nodes cannot be assessedassessedN0 - No regional lymph node metastasisN0 - No regional lymph node metastasisN1 - Lymph node mass 2 cm or less in greatest N1 - Lymph node mass 2 cm or less in greatest dimension or multiple lymph node masses, none dimension or multiple lymph node masses, none more than 2 cm in greatest dimensionmore than 2 cm in greatest dimensionN2 - Lymph node mass, more than 2 cm but not more N2 - Lymph node mass, more than 2 cm but not more than 5 cm in greatest dimension, or multiple lymph than 5 cm in greatest dimension, or multiple lymph node masses, any one mass greater than 2 cm but node masses, any one mass greater than 2 cm but not more than 5 cm in greatest dimensionnot more than 5 cm in greatest dimensionN3 - Lymph node mass more than 5 cm in greatest N3 - Lymph node mass more than 5 cm in greatest dimensiondimension

Pathologic node stagingPathologic node staging

pN0 - No evidence of tumor in lymph nodespN0 - No evidence of tumor in lymph nodes

pN1 - Lymph node mass, 2 cm or less in greatest pN1 - Lymph node mass, 2 cm or less in greatest dimension and ≤6 nodes positive, none >2 cm in dimension and ≤6 nodes positive, none >2 cm in greatest dimensiongreatest dimension

pN2 - Lymph node mass, more than 2 cm but not more pN2 - Lymph node mass, more than 2 cm but not more than 5 cm in greatest dimension; more than 5 nodes than 5 cm in greatest dimension; more than 5 nodes positive, none >5 cm; evidence of extranodal extension positive, none >5 cm; evidence of extranodal extension of tumorof tumor

pN3 - Lymph node mass more than 5 cm in greatest pN3 - Lymph node mass more than 5 cm in greatest dimension.dimension.

Distant metastasisDistant metastasis

M0 - No evidence of distant metastasesM0 - No evidence of distant metastases

M1 - Nonregional nodal or pulmonary M1 - Nonregional nodal or pulmonary metastasesmetastases

M2 - Nonpulmonary visceral massesM2 - Nonpulmonary visceral masses

Serum tumor markersSerum tumor markers

LDHLDH HCGHCG

Miu/mlMiu/ml

AFPAFP

Ng/mlNg/ml

S0S0 _< N_< N <N<N <N<N

S1S1 <1.5 x N<1.5 x N < 5000< 5000 < 1000< 1000

S2S2 1.5-10x N1.5-10x N 5000 to 5000 to 5000050000

1000 to 1000 to 1000010000

S3S3 >10x N>10x N > 50000> 50000 >10000>10000

PRINCIPLES OF TREATMENTPRINCIPLES OF TREATMENT

Treatment should be aimed at one stage above Treatment should be aimed at one stage above

the clinical stage the clinical stage

Seminomas - Radio-Sensitive. Treat with Seminomas - Radio-Sensitive. Treat with

Radiotherapy.Radiotherapy.

Non-Seminomas are Radio-Resistant and best Non-Seminomas are Radio-Resistant and best

treated by Surgerytreated by Surgery

Advanced Disease or Metastasis - Responds Advanced Disease or Metastasis - Responds

well to Chemotherapywell to Chemotherapy

PRINCIPLES OF TREATMENTPRINCIPLES OF TREATMENT

Radical INGUINAL ORCHIDECTOMY is Radical INGUINAL ORCHIDECTOMY is Standard first line of therapyStandard first line of therapy

Lymphatic spread initially goes to Lymphatic spread initially goes to

RETRO-PERITONEAL NODESRETRO-PERITONEAL NODES

Early hematogenous spread RAREEarly hematogenous spread RARE

Bulky Retroperitoneal Tumours or Metastatic Bulky Retroperitoneal Tumours or Metastatic Tumors Initially “DOWN-STAGED” with Tumors Initially “DOWN-STAGED” with CHEMOTHERAPYCHEMOTHERAPY

PRINCIPLES OF TREATMENTPRINCIPLES OF TREATMENT

Transscrotal biopsy is to be condemned. Transscrotal biopsy is to be condemned.

The inguinal approach permits early The inguinal approach permits early control of the vascular and lymphatic control of the vascular and lymphatic supply as well as en-bloc removal of the supply as well as en-bloc removal of the testis with all its tunicae. testis with all its tunicae.

Frozen section in case of dilemma.Frozen section in case of dilemma.

CHEMOTHERAPYCHEMOTHERAPY

ChemotherapyChemotherapy Toxicity Toxicity

BEP -BEP -BleomycinBleomycin Pulmonary fibrosis Pulmonary fibrosis

Etoposide (VP-16) Etoposide (VP-16) Myelosuppression Myelosuppression AlopeciaAlopecia Renal insufficiency (mild)Renal insufficiency (mild) Secondary leukemiaSecondary leukemia

Cis-platinCis-platin Renal insufficiency Renal insufficiency Nausea, vomitingNausea, vomiting NeuropathyNeuropathy

Lymph Nodes Dissection For Right & Lymph Nodes Dissection For Right & Left Sided Testicular TumoursLeft Sided Testicular Tumours

CONCLUSIONCONCLUSION

Improved Overall Survival of Testicular Tumour Improved Overall Survival of Testicular Tumour

due to Better Understanding of the Disease, due to Better Understanding of the Disease,

Tumour Markers and Cis-platinum based Tumour Markers and Cis-platinum based

Chemotherapy.Chemotherapy.

Current Emphasis is on Diminishing overall Current Emphasis is on Diminishing overall

Morbidity of Various Treatment ModalitiesMorbidity of Various Treatment Modalities . .

THANK YOUTHANK YOU