management of testicular carcinoma- Dr vandana,kgmc, kgmu,lucknow, radiotherapy

1. Management of Testicular Tumor
Presented By: Dr. Vandana
Dept. of Radiotherapy, CSMMU, Lucknow

2. Introduction
 Relatively rare. 1-2 % of all male malignancies.
 Malignancy in 20-34 yrs of age.
 Most curable solid neoplasm.
 90-95% of testicular tumors are germ cell tumors, either seminoma or
non-seminoma.
 Improvement in diagnostic techniques, tumor markers, improved surgical
techniques, advanced radiotherapy machines and multidrug chemotherapy ,
decrease the mortality from 50% to <10%.

3. Lymphatic Drainage
 Right testis: along the IVC inter-aortocaval region 
pre-aortic & para-aortic lymph nodes, with possible cross-
over within the retroperitoneum
 Left testis: Preaortic and para-aortic lymph nodes
around the left renal hilum  inter-aortocaval nodes
mostly without cross-over
 Retroperitoneal lymph nodes are located anterior to the
T11 to L4 vertebral bodies concentrated at the L1–L3
level
 Nodal spread to iliac chain is ipsilaterally but
infrequent (~3%)
 Scrotal skin: lymphatics drain into the inguinal and
external iliac nodes.

4. WHO classification
 Germ cell tumors-
 Intratubular germ cell neoplasia ( precursor lesion )
 Seminoma
 Classic
 Spermatocytic
 Anaplastic
 Nonseminoma
 Embryonal carcinoma
 Yolk sac
 Teratoma
 Choriocarcinoma.
 Mixed germ cell tumor.

5. Cont…
 Non Germ Cell Tumor
 Sex cord stromal tumors
2. Leydig cell
3. Sertoli cell
4. Granulosa cell
5. Fibroma Thecoma
6. Gonadoblastoma
 Others:
 Lymphoma, rhabdomyoma, melanoma

6. Royal Marsden staging system
STAGE
I Limited to testis
IIA Nodes <2 cm
IIB Nodes 2–5 cm
IIC Nodes 5–10 cm
IID Nodes >10 cm
III Nodes above and below diaphragm
IV Extralymphatic mets

7. Cont…
Regional lymph nodes (N) clinical
Nx Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis with a lymph node mass ≤2 cm in greatest dimension;
or multiple lymph nodes ≤2 cm in greatest dimension
N2 Metastasis with a lymph node mass > 2 cm but ≤5 cm in greatest
dimension; or multiple lymph nodes, any one mass > 2 cm but
≤5 cm in greatest dimension
N3 Metastasis with a lymph node mass > 5 cm in greatest dimension

8. Nb: indicates the upper limit of normal for the LDH assay

9. STAGE GROUPING
III B

10. Management

11. GENERAL MANAGMENT
 After obtaining serum AFP & B-Hcg levels in suspected case of malignant
germ cell tumour
 Radical inguinal orchietectomy with high ligation of spermatic cord is
done, it is both diagnostic & therapeutic
 Further management depends on, pathology & stage of disease.
Note: - Considering of sperm banking must be discussed with the patients
before undergoing any therapeutic intervention that may compromise
fertility including RT ,Surgery and CT.

12.  Management of testicular tumor is combined modality
treatment.
 Various treatment modalities are:
 Surgery
 Surveillance
 Radiotherapy
 Chemotherapy

13. Surgery

14. Surgery
Radical orchidectomy:
 all patients
 done via an inguinal incision, with cross
clamping of spermatic cord vasculature and
delivery of testis into the surgical field.
 Scrotal violation, increased local/regional
recurrence, but no difference in distant
recurrence rate or overall survival.

15. Retro peritoneal lymph node
dissection(RPLND):
 Indication:
 preferred treatment for low stage NSGCT
 Include the precaval, retrocaval, paracaval,
interaortocaval, retroaortic, preaortic,
para-aortic, and common iliac lymph nodes
bilaterally.
 Disadv.:
 sympathetic nerve fibers are disrupted,
resulting in loss of seminal emission. A
modified RPLND developed that preserves
ejaculation in up to 90%.

16. Surveillance

17. Surveillance
 An option, as potentially 80-85% of patients will not develop
recurrence
 Rationale -With availability of highly effective salvage rt /ct for
relapse disease & low risk of occult disease in nodes in stage 1
pts.
 Indications
 Seminoma Stage I
 NSGCT Stage I
 Disadvantage
 Costly and inconvenient

18. Radiotherapy

19. Radiation therapy
 Indications
 Adjuvant therapy for stages I–IIb 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.

20.  Position and immobilization
 Supine, arms placed by the pt. side and legs straight, with feet stabilized
with a foam wedge underneath the knees.
 Position penis out of field
 Shielding
 Contra-lateral testis is shielded with a lead clamshell device.
Mean dose values to the contralateral testicle.
PA PA + IL iliac
Without shield 1.86 cGy 3.89 cGy
With shield 0.65 cGy 1.48 cGy

21. Stage I:
 Field margins
 Superior: T11–T12 interspace
 Inferior: L5–S1 interspace
 Lateral: transverse process
 For left testis: cover renal hilum
 Dose
 20 Gy in 10# to para-aortic ±
pelivic lymph node by ap-pa field
Elective para-aortic field for stage I
seminoma

22. Stage II
 Superior: T11–T12 interspace
 Inferior: mid-obturator foramen
 Lateral: transverse process down to
L5–S1 interspace then diagonally to the
lateral edge of the acetabulum, then
vertically downward to the median
border of the obturator foramen
 For left testis: cover renal hilum
Paraaortic and ipsilateral inguinal field for
stage II left testicular seminoms, with
inclusion of the rental hilus.

23.  Stage II a-
25Gy in 20 # by AP-PA
 Stage II b & IIc
25 Gy in 20 #
10 Gy in 5 #

24. Chemotherapy

25. 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

27. 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.
 Surveillance generally for patients who are compliant.

28.  Radical inguinal orchiectomy with initial high ligation of the
spermatic cord is the standard procedure for diagnosis and
treatment. Biopsy prior to orchiectomy is usually not
recommended.
 Follow-up is recommended to detect second primary tumors,
local or distant recurrences, and to monitor for potential long-
term side eff ects.

29. Thank You