This document provides information about testicular tumors. It discusses that testicular cancer is most common in men aged 15-35 and has three peaks in incidence. The most common types are seminomas and non-seminomas. Risk factors include cryptorchidism, Klinefelter's syndrome, and trauma. Diagnosis involves physical exam, ultrasound, serum tumor markers, and radiology. Treatment depends on the type and stage but generally includes radical orchidectomy followed by chemotherapy, radiation, or surveillance. Prognosis is excellent even for metastatic disease due to chemosensitivity.
2. Introduction
Testicular tumors are rare.
1 – 2 % of all malignant tumors.
Most common malignancy in men in the 15 to 35
year age group.
Benign lesions represent a greater percentage of
cases in children than in adults.
Most curable solid neoplasm
3. Age - 3 peaks
2 – 4 yrs
20 – 40 yrs
above 60 yrs
Testicular cancer is one of the few neoplasms
associated with accurate serum markers.
Most curable solid neoplasms and serves as a
paradigm for the multimodal treatment of
malignancies.
4. AETIOLOGY OF TESTICULAR TUMOUR
Cryptorchidism
Klinefelter’s syndrome
Testicular atrophy
Trauma
Sex hormone fluctuations, estrogen
administration during pregnancy
Race
Carcinoma in situ
Previous testicular cancer
5. CRYPTORCHIDISM & TESTICULAR TUMOUR
Risk of Carcinoma developing
in undescended testis is
14 to 48 times the normal
expected incidence
6. CLASSIFICATION
I.Primary Neoplasms of Testis.
A. Germ Cell Tumor.
B. Non-Germ Cell Tumor .
II. Secondary Neoplasms.
III .Paratesticular Tumors.
9. 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
11. Embryonal carcinoma
25yr – 35yr
3 – 6 % of TT
Small, rounded irregulr mass
Invading tunica vaginalis
Cut surface
Greyish white, fleshy
Areas of necrosis, hemorrhage
Poorly defined capsule
12. 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)
16. Yolk sac tumor
Most common
Infants & children
Adults – in combination
↑ AFP
Pure form
Homogenous yellowish, mucinous
Histology
Embryoid bodies
Resemble 1 to 2 week old embryos (<1 mm)
17. Non Germ Cell Tumors
Sex cord tumors
1. Leydig cell tumors
2. Sertoli cell tumors
Mixed germ cell and stromal cell tumors
1. Gonadoblastoma
Miscellaneous primary non germ cell tumors
1. Epidermoid cyst
2. Adenocarcinoma of rete testis
3. Adrenal rest tumors
18. 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
-biopsy for diagnosis
- no orchidectomy
- testicular irradiation for treatment
Metastases to testis
- rare cases reported (200 cases till now)
19. Clinical features
Painless Swelling of One testis
Dull Ache or Heaviness in Lower Abdomen
10% - Acute Scrotal Pain
10% - Present with Metatstasis
- Neck Mass / Cough / Anorexia / Vomiting / Back
Ache/ Lower limb swelling
5% - Gynecomastia
Rarely - Infertility
20. Physical Examination
Examine contralateral normal testis.
Firm to hard fixed area within tunica albugenia is
suspicious
Seminoma expand within the testis as a painless,
rubbery enlargement.
Embryonal carcinoma or teratocarcinoma may
produce an irregular, rather than discrete mass.
21. Scrotal ultrasound
Ultrasonography of the scrotum is a rapid, reliable
technique to exclude hydrocele or 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.
23. ROLE OF TUMOUR MARKERS
Helps in Diagnosis - 80 to 85% of Testicular Tumours have
Positive Markers
Most of Non-Seminomas have raised markers
Only 10 to 15% Non-Seminomas have normal marker level
After Orchidectomy if Markers Elevated means Residual
Disease or Stage II or III Disease
Elevation of Markers after Lymphadenectomy means a STAGE
III Disease
24. 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
25.
26. Serum tumor markers
LDH HCG
Miu/ml
AFP
Ng/ml
S0 _< N <N <N
S1 <1.5 x N < 5000 < 1000
S2 1.5-10x N 5000 to
50000
1000 to
10000
S3 >10x N > 50000 >10000
27.
28.
29. PRINCIPLES OF TREATMENT
Treatment should be aimed at one stage above the
clinical stage
Seminomas - Radio-Sensitive. Treat with
Radiotherapy.
Non-Seminomas are Radio-Resistant and best
treated by Surgery
Advanced Disease or Metastasis - Responds well to
Chemotherapy
30. PRINCIPLES OF TREATMENT
Radical INGUINAL ORCHIDECTOMY is Standard
first line of therapy
Lymphatic spread initially goes to
RETRO-PERITONEAL NODES
Early hematogenous spread RARE
Bulky Retroperitoneal Tumours or Metastatic
Tumors Initially “DOWN-STAGED” with
CHEMOTHERAPY
31. PRINCIPLES OF TREATMENT
Transscrotal biopsy is to be condemned.
The inguinal approach permits early control of the
vascular and lymphatic supply as well as en-bloc
removal of the testis with all its tunicae.
Frozen section in case of dilemma.
32. Treatment of Seminomas
Stage I, IIA, ?IIB –
Radical Inguinal Orchidectomy followed by
radiotherapy to Ipsilateral Retroperitonium &
Ipsilateral Iliac group Lymph nodes (2500-3500 rads)
Bulky stage II and III Seminomas -
Radical Inguinal Orchidectomy is followed by
Chemotherapy
33. Treatment of Non-Seminoma
Stage I and IIA:
RADICAL ORCHIDECTOMY
followed by RETROPERITONEAL LYMPH NODES
DISSECTION
Stage IIB:
RPLND with possible ADJUVANT CHEMOTHERAPY
Stage IIC and Stage III Disease:
Initial CHEMOTHERAPY followed by SURGERY for Residual Disease
34. STANDARD CHEMOTHERAPY FOR
NON-SEMINOMATOUS GERM CELL TUMOURS
Chemotherapy Toxicity
BEP -
Bleomycin Pulmonary fibrosis
Etoposide (VP-16) Myelosuppression
Alopecia
Renal insufficiency (mild)
Secondary leukemia
Cis-platin Renal insufficiency
Nausea, vomiting
Neuropathy
36. CONCLUSION
Improved Overall Survival of Testicular Tumour due to
Better Understanding of the Disease, Tumour Markers
and Cis-platinum based Chemotherapy
Current Emphasis is on Diminishing overall Morbidity
of Various Treatment Modalities