Tumours of the testis

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Introduction

❏ any solid testicular mass in young patient – must rule out malignancy

❏ slightly more common in right testis (corresponds with slightly higher incidence of right-sided cryptorchidism)

❏ 2-3% bilateral (simultaneously or successively)

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Types

• Primary

• Secondary

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Primary testicular tumour• 1% of all malignancies in males• most common solid malignancy in males aged 15-34 years• undescended testicle has increased risk (10-40x) of malignancy• 95 % are germ cell tumours (all are malignant)

• seminoma (35%)• nonseminomatous germ cell tumours (NSGCT)

• embryonal cell carcinoma (20%)• teratoma (5%)• choriocarcinoma (<1%)• yolk sac (<<1%)• mixed cell type (40%)

• 5% are non-germinal cell tumours (usually benign)• Leydig (testosterone, precocious puberty)• Sertoli (gynecomastia, decreased libido)

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7.4 x 5.5-cm seminoma in a radical orchiectomy specimen.

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Seminoma

• Most common form of testicular tumour in the adult• More frequent in the right side• Lymphatic spread

• Macroscopically:– Homogeneous grey- white or pink coloured lobulated cut surface usually devoid of

hemorrhages or necrosis

• Microscopically:– Typical – Anaplastic– Spermatocytic

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Teratoma

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Teratoma

• Derived from totipotential cells• May occur at any age from infancy adult life

• Macroscopically:– Devoid of homogenous appearances of seminoma– Cut surface shows multiple cyst, hemorrhages & varying consistency in different parts

• Microscopically:– Teratoma differentiated– Malignant teratoma intermediate– Malignant teratoma undifferentiated– Malignant teratoma trophoblastic

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Secondary testicular tumour

• male > 50 years of age• usually a lymphoma• metastases (e.g. lung, prostate, GI)

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Etiologic factors

• congenital: cryptorchidism• acquired: trauma, atrophy, sex hormones

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Clinical features

• painless testicular enlargement

• painful if intratesticular hemorrhage or infarction

• firm, non-tender mass

• dull, heavy ache in lower abdomen, anal area or scrotum

• associated hydrocele in 10%

• coincidental trauma in 10%

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Clinical features

• infertility (rarely presenting complaint)

• gynecomastia due to secretory tumour effects

• metastatic disease related back pain

• supraclavicular and inguinal nodes

• abdominal mass (retroperitoneal lymph node metastases)

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Investigations

• testicular ultrasound (hypoechoic area within tunica albuginea = high suspicion of testicular cancer)

• chest x-ray (lung metastases)• markers for staging (ßHCG, AFP, LDH)• CT abdomen/pelvis (retroperitoneal nodes enlarged)• needle aspiration contraindicated

diagnosis is established by inguinal orchiectomy

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Staging

• clinical• Stage I: disease limited to testis, epididymis or spermatic cord• Stage II: disease limited to the retroperitoneal nodes• Stage III: disease metastatic to supradiaphragmatic nodal or visceral sites

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Staging

• pathologic (at orchiectomy)• T1 – tumour confined to testicular body• T2 – tumour extends beyond tunica albuginea• T3 - tumour involves rete testis/epididymis• T4A – tumour invades spermatic cord• T4B – tumour invades scrotal wall

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Staging

• ‘cross-over’ metastases from right to left are fairly common, but they have not been reported from left to right

• right ––> medial, paracaval, anterior and lateral nodes• left ––> left lateral and anterior paraaortic nodes

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Tumour markers

• ßhCG and AFP are positive in 85% of non- seminomatous tumours• pre-orchiectomy elevated marker levels return to normal post-operatively if

no secondaries• ßhCG positive in 7% of seminomas, AFP never elevated with seminoma

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Treatment

• avoid a trans-scrotal approach for biopsy or orchiectomy, due to chance of metastases via lymph drainage

• seminoma• radical inguinal orchiectomy and radiation (90% survival)• adjuvant chemotherapy for metastatic disease

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Treatment

• non-seminoma• radical inguinal orchiectomy and staging• retroperitoneal lymphadenectomy or surveillance• surveillance includes monitoring CXR, ßhCG, and AFP levels• chemotherapy (BEP = Bleomycin, Etopiside, Cisplatin) if evidence of secondary disease

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Prognosis

• 99% cured with Stage I, Stage II• 70-80% complete remission with advanced disease

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