This document discusses testicular cancer and Wilms tumor. For testicular cancer, it defines the condition, discusses epidemiology such as affecting men aged 15-35 most commonly, and covers anatomy, arterial supply, venous drainage, lymphatic drainage, predisposing factors, types like seminoma, spread patterns, clinical features, diagnostic modalities like blood tests and imaging, clinical staging, and management including surgery and chemotherapy. For Wilms tumor, it defines the condition, discusses epidemiology such as affecting children under 5 most commonly, etiology involving genetic factors, clinical features like abdominal mass, diagnostic evaluation using imaging and labs, staging depending on tumor extent, and multimodal management with surgery, radiation, and

1. Testicular cancer
&
Wilms tumor
Dr. RUTAYISIRE François Xavier
PGY1
Common surgical conditions module
University of Rwanda
Lecturer: Dr. Alexandre NYIRIMODOKA

2. Definition
• Testicular cancer is cancer that develops in the testicles, a part of the
male reproductive system

3. Epidemiology
• Account for 1% of all solid tumors in male.
• Age – most common solid tumor of men between 15-35 years
• Side – Right > Left
• Socio-economic status – high : low = 2:1
• Geographical
• Highest in Scandinavia, Germany, Switzerland
• Intermediate – USA & UK
• Low – Africa and Asia

4. 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
• Weight: about 10-15 gm.

5. Arterial 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

6. Lymphatic Drainage
• Drain into the retroperitoneal lymph nodes
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 paraaortic nodes, respectively

7. Lymphatic Drainage
• On the right:
Interaortocaval region, followed by the
paracaval, preaortic, and paraaortic 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

8. Predisposing Factors
•1. Cryptorchidism
2. 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

10. 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
• Serum alpha fetoprotein is normal
• Beta HCG is elevated in 30% of patients with Seminoma
• Classification
a) classical
b) Anaplastic
c) Spermatocytic

11. Spread
1. 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

12. 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 epididymis may
occur : points towards bad prognosis
blunder
/ˈblʌndə/
noun
noun: blunder; plural noun: blunders
1.a stupid or careless mistake.
verb
2.make a stupid or careless mistake; act or speak
clumsily.
Definitions

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

14. 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) History of trauma (co-
incidental)
e)History of cryptorchidism or
previous testicular cancer
• 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

15. Clinical examination:
a) Enlarged testis (except choriocarcinoma)
b) Nodular irregular 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

16. WAG 2002 UBC Phase IV Urology
Self - Examination
Self – examination should
be taught to young men
They need to be shown
the difference between the
testicle and the epididymis
They need to report any
hard or suspicious lesions
immediately

17. Diagnostic modalities
• 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
• Diagnostic Radiology
– Chest x-ray films, PA and lateral
views
– Computed tomography (CT) scan of
abdomen and pelvis
– CT scan of chest for non seminomas
and stage II seminomas
–Ultrasound of the ipsilateral testes
and of contralateral testis

19. Clinical Staging
(Boden and Gibbs – 1971)
• Stage I (A) – confined to testis with no spread
through capsule or spermatic cord
• Stage II (B) – Clinical or radiological evidence of
spread beyond testis but with in regional L.N.
• B1 -<2cm
• B2 -2-5cm
• B3 - >5cm
• Stage III (C) - Disseminated above diaphragm /
visceral disease

20. Management
• Multimodal approach
Surgery
Chemotherapy
Radiotherapy
• NB: On clinical assessment: any painless solid mass in the testis is
malignant until proven otherwise
• Biopsy is contraindicated

21. Management
• Inguinal Exploration & radical orchiectomy:
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.

22. Wilms Tumor
• Wilms' tumor or nephroblastoma is malignant tumor of the kidneys that
typically occurs in children.
• Dr. Max Wilms, the German surgeon (1867–1918) first described this kind of tumor.

23. Epidemiology
• Wilms tumor is the fifth most common pediatric malignancy (7% of all
childhood tumors).
• Incidence is 1 in 10,000,
• Girls are slightly more affected
• 70% of cases occur before the child is 5 years of age.
• Most commonly unilateral, but in 5% - 10% both kidneys are involved.
• The tumor involves left kidney more than right kidney.
• The majority (75%) occurs in otherwise normal children; a minority
(25%) is associated with other developmental abnormalities.
• It is highly responsive to treatment, with about 90% of patients
surviving at least five years.

24. Etiology
• Unknown,
• But it has been identified that tumor
suppressor gene acts to promote normal
kidney development.
• This gene may be absent or missing in
wilm’s tumor.
• Genetic abnormalities WT1 gene;
dominant oncogene (at chromosome
11p13), WT2 gene (at chromosome
11p15)
• It is believe that tumor begins to grow as a
fetus develops in the womb, with some
cells that are destined to form into the
kidneys malfunctioning and forming a
tumor.
• Wilms tumor has capacity for rapid
growth, usually grows to a large size.

25. Clinical features
• Wilms tumor is diagnosed at a mean age of 3.5 years.
• The most common feature is an upper quadrant abdominal mass (firm,
nontender)
• Abdominal pain occurs in 30%-40% of cases, related to rapid growth of
tumor.
• Urethral obstruction due to compression
• Constipation, vomiting, abdominal ditress, anorexia, weight loss and
dyspnea due to enlargement of tumor.
• Other signs and symptoms of Wilms tumor include hypertension, fever
caused by tumor necrosis, hematuria, and anemia.
• The neoplasm metastasize either by direct extension or by bloodstream.
• They may invade perirenal tissues, lymph nodes, the liver, the diaphragm,
abdominal muscles and the lungs.
• Invasion of bone and brain are less common.

26. Diagnostic evaluation
• Laboratory studies:
• FBC for baseline data
• Platelet count: Coagulation
abnormalities
• Urinalysis for hematuria and urine
culture
• Liver function tests
• Renal function tests
• Blood chemistry; sr. electrolytes,
uric acid
• Imaging Studies
• Ultrasonography
– Initial diagnosis of a renal or abdominal
mass,
– Possible renal vein or inferior vena cava
(IVC)
thrombus (Doppler flow study may be helpful
in the setting of vascular invasion.)
– Information regarding liver and other kidney
CT scanning of the chest and abdomen
– Differential diagnosis of a kidney tumor
versus
adrenal tumor (neuroblastoma)
– Liver metastases
– Status of opposite kidney
– Lymph node assessment
– Status of chest with respect to metastases
• Chest radiography - As a baseline for
pulmonary metastases
• Magnetic resonance imaging

27. MANAGEMENT
• The management of children with
wilm’s tumor include:
• Radiation therapy
• Chemothrapy
• Surgical management
Radiation Therapy
Wilm’s tumor may be bilateral or
large in size , may be inoperable, for
such cases radiation therapy may be
used to reduce the size of tumor, so
that surgery can be performed.
• CHEMOTHERAPY
• The objective of chemotherapy is
to treat any metastatic lesions that
may exist and destroy any cells in
blood stream, before they get
implanted.
• The drugs used for chemotherapy
are •Actinomycin D; 0.06 - 0.12
mg/kg, IV, Doxorubicin (
adriamycin); 1.25 – 1.9 mg/ kg,
Vincristine; 0.125 – 0.05 mg/kg
• SURGICAL MANAGEMENT

28. Staging and treatment
• Staging is determined by
combination of imaging studies
and pathology findings.
• Treatment strategy is
determined by the stage.
• Stage I (43% of patients)-
Tumor limited to kidney and
completely resectable.
• Treatment:
• Nephrectomy +/- 18 weeks of
chemotherapy depending on
age of patient and weight of
tumor.
• EG: less than 2 years old and
less than 550g only requires
Nephrectomy with observation.
• Outcome: 98% 4-year survival

29. Stage II
• Stage II (23% of
patients)- Tumor extend
beyond kidney , into
nearby fatty tissue, but it
is resectable.
Treatment:
• Nephrectomy + abdominal
radiation + 24 weeks of
chemotherapy
• Outcome: 96% 4-year
survival.

30. Stage III
• Stage III (23% of patients) –
Non hematogenous spread in
abdomen, like spread to
lymph nodes in abdomen or
pelvis, but this stage tumor is
not completely resectable.
• Treatment:
• Abdominal radiation + 24 weeks
of chemotherapy + nephrectomy
after tumor shrinkage
• Outcome: 95% 4-year survival

31. • Stage IV (10% of patients)
• Stage IV Wilms' tumor is defined
as the presence of hematogenous
metastases (lung, liver, bone, or
brain), or lymph node metastases
outside the abdominopelvic region.
• Treatment:
• Nephrectomy + abdominal
radiation + 24 weeks of
chemotherapy + radiation of
metastatic site as appropriate.
• Outcome: 90% 4-year survival

32. • Stage V (5% of patients)
• Stage V Wilms’ tumor is defined
as bilateral renal involvement at
the time of initial diagnosis.
• The 4-year survival in 94%
patients with stage I or stage II;
76% for with stage III.
• Treatment: Individualized
therapy based on tumor
burden

33. Thank you