This document discusses testicular tumors, including their etiology, classification, clinical presentation, diagnosis, staging, and treatment. Some key points: - Testicular cancer is the most common cancer in men ages 15-35 and has a high cure rate with early detection and treatment. - Risk factors include cryptorchidism, prior testicular cancer, infertility, and genetic factors. Carcinoma in situ is a precursor to most germ cell tumors. - Tumors are classified as seminomas or non-seminomas. Staging involves tumor markers, imaging, and pathology to determine extent of disease. - Treatment involves radical orchidectomy followed by radiotherapy for seminomas or chemotherapy for

1. Testicular tumors
Dr Harshita Mehrotra
Resident, General Surgery

2. Importance
• Testicular tumors are rare.
• 1 – 2 % of all malignant tumors.
• Most common malignancy in men in the 15 to 35 year age group.
• Most curable solid neoplasms and serves as a paradigm for the
multimodal treatment of malignancies.
• Seminoma - most common bilateral primary testicular tumour;
Lymphoma - most common bilateral testicular tumour

3. • Dramatic Improvement in Survival:
• Effective diagnostic techniques
• Improved tumor markers
• Multi-modal treatment - Surgical + Radiotherapy/Chemotherapy
• Mortality markedly decreased.

4. Etiology
• Cryptorchidism
• Intersex disorder
• Testicular atrophy
• Chromosomal abnormalities - loss of chromosome 11, 13, 18, abnormal
chromosome 12p.
• Exogenous estrogen administration to mother during pregnancy
• Carcinoma-in-situ
• Previous testicular malignancy

5. Cryptorchidism
• 7 - 10% patients - history of cryptorchidism
• Most common - seminoma
• 5 - 10% tumors - contralateral testis
• Relative risk - Intraabdominal testis (1 in 20) > Intrainguinal
testis (1 in 80)
• Orchidopexy - does not alter malignant potential - facilitates
examination & detection

6. • Malignancy due to
• Abnormal germ cell morphology.
• Elevated temperature - abnormal spermatocyte maturation.
• Endocrinal disturbances.
• Gonadal dysgenesis.

7. Carcinoma in-situ
• Pre malignant precusor of all GCT, except spermatocytic
seminoma.
• Incidence - 0.8%.
• Testicular CIS develops from fetal gonocytes.
• Characterized histologically by seminiferous tubules containing
only Sertoli cells and malignant germ cells.

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

9. Classification
Germ Cell Tumors >90%
Non-Seminomatous TumorsSeminomas
Classical 85%
Spermatocytic 5%
Anaplastic 10%
Embryonal Carcinoma
Yolk Sac Tumor
Choriocarcinoma
Teratoma
Mixed Tumors
Interstitial Cell Tumors
Leydig Cell Tumors
Sertoli Cell Tumors
Other Tumors
Lymphoma
Metastases
Malignant Testicular Tumors
Non-Germ Cell Tumors

11. Seminoma
• Classical: 80 - 85%
• middle age
• PLAP & B-hCG - raised
• slow growing
• good prognosis
• Spermatocytic: 5 - 10%
• age > 50 years
• low metastatic potential
• good prognosis
• Anaplastic: 5 - 10%
• middle age
• aggressive
• higher local & metastatic potential
• high B-hCG production
• Inguinal Orchiectomy + Radiation

12. Non-Seminomatous Germ Cell
Tumors
• Embryonal Carcinoma
• 25 - 35 years
• 3 - 6% testicular tumors
• small, rounded, irregular mass
• invades tunica albuginea
• Yolk Sac Tumor/ Endodermal
Sinus Tumor
• most common testicular tumor in
infants & children
• raised AFP
• histologically - cells demonstrate
vacuolated cytoplasm secondary
to fat and glycogen deposition,
resemble 1 - 2 week old embryos

13. • Teratoma
• raised AFP
• resistant to both chemotherapy &
radiotherapy
• mature teratoma - differentiated
elements from 2-3 embryonic germ cell
layers
• immature teratoma - undifferentiated
primitive tissue
• malignant teratoma - malignant changes
• Chorionic Carcinoma
• pure choriocarcinoma - rare
• second - third decades
• raised PLAP, B-hCG
• high incidence of distant metastases

14. • Leydig Cell Tumors
• most common non-germ cell cell timor of
testis - 1 - 3% testicular tumours
• bimodal age distribution - 5 - 9 years; 25
- 35 years age
• 25% cases - childhood; bilaterally - 5 -
10% cases
• presentation - prepubertal children -
virilization; adults - gynecomastia
• elevated serum & urinary 17-
ketosteroids & estrogens
• Sertoli Cell Tumors
• rare; < 1% testicular tumors
• bimodal age distribution - < 1 year; 20 - 45 years
age
• presentation - testicular mass; virilization in
children; gynecomastia in adults
• Gonadoblastomas
• rare
• seen in patients with gonadal dysgenesis
• age group - 30 years of age
• clinical presentation - gonadal dysgenesis

15. Secondary Tumors of Testis
• Lymphoma
• most common testicular tumour
over age of 50 years
• most common secondary
neoplasm of testis
• presentation - painless
enlargement of testis,
constitutional symptoms in 25%
patients; bilateral - 50% patients
• Leukemic Infiltration of Testis
• relapse of children with acute
lymphocytic leukaemia
• bilateral - 50% cases
• treatment - bilateral testicular
irradiation with 20Gy & reinstitution od
adj chemotherapy
• Metastatic Tumor
• rare
• most common primary - prostate >
lung > gastrointestinal tract >
melanoma > kidney

16. Extragonadal Germ Cell Tumor
• Rare - 3% all germ cell tumors
• Sites - mediastinum > Retroperitoneum > Sacrocoocygeal > Pineal gland
• Presentation - site & volume of disease
• Mediastinal lesions - pulmonary symptoms
• Sacrococcygeal - neonates - palpable mass, bowel/ urinary obstruction
• Pineal - headache, visual/ auditory complaints, hypopituitarism
• Treatment - same as testicular tumors.

17. Lymphatic drainage
• Right Testis - Inter-aortocaval nodes > Precaval > Preaortic > Right common iliac
> Right external iliac
• Left Testis - Left Para-aortic > Preaortic > Left common iliac > Left external iliac
• Cross over from right to left possible.
• Epididymis - external iliac chain.
• Inguinal node metastasis - scrotal involvement by the primary tumor, prior inguinal
or scrotal surgery, or retrograde lymphatic spread secondary to massive
retroperitoneal lymph node deposits.
• Testicular cancer spreads in a predictable and stepwise fashion, except
choriocarcinoma.

18. Metastatic Spread
• Distant metastases - Lung > Liver > Brain > Bone > Kidney >
Adrenal Glands > Gastrointestinal Tract > Spleen
• Germ cell tumors - Lymphatic spread
• Choriocarcinomas - Hematogenous spread - lungs

19. Clinical Presentation
• Painless testicular swelling
• Dull ache/heaviness in Lower Abdomen
• 10% - Acute Scrotal Pain
• 10% - Metatstasis
• Neck Mass /Cough /Anorexia /Vomiting /Back ache/Lower limb
swelling
• 5% - Gynecomastia - Estrogen producing tumors
• Rarely - Infertility

20. Physical Examination
• Firm to hard fixed area within tunica albugenia - suspicious
• Seminoma expand within the testis as a painless, rubbery
enlargement.
• Embryonal carcinoma or teratocarcinoma may produce an irregular,
rather than discrete mass.
• Choriocarcinoma - no testicular enlargement

21. Differential Diagnosis
• Testicular torsion
• Epididymitis, or epididymo-orchitis
• Hydrocele
• Hernia
• Hematoma
• Spermatocele
• Syphilitic gumma

22. Investigations
• All patients with a solid, firm intra-testicular mass that cannot be
transilluminated should be regarded as malignant unless
otherwise proved.
• Scrotal Ultrasound -
• rapid, reliable technique
• hypoechoic area within the tunica albuginea - markedly
suspicious for testicular cancer.

23. Tumor markers
• Onco-fetal Substances: AFP & HCG
• Cellular Enzymes: LDH & PLAP

24. Alfa-fetoprotein
• NORMAL VALUE < 16 ngm/ml
• Raised AFP :
• Pure embryonal carcinoma
• Teratocarcinoma
• Yolk sac Tumor
• Combined tumors
• AFP not raised in pure choriocarcinoma & pure seminoma

25. Human Chorionic Gonadotropin
• NORMAL VALUE < 1 ng/ml
• Raised β hCG -
• 100 % - Choriocarcinoma
• 60% - Embryonal carcinoma
• 55% - Teratocarcinoma
• 25% - Yolk Cell Tumour
• 7% - Seminomas

26. Role of Tumor Markers
• Diagnosis
• 80 - 85% testicular tumors - positive markers
• post orchiectomy elevated markers - stage II/III disease
• post lymphadenectomy residual disease - stage III disease
• histology of timor
• Burden of disease - degree of marker elevation
• Follow-up
• markers becoming positive on follow-up - recurrence
• markers become positive earlier than x-rays

27. Imaging studies
• USG Scrotum
• Chest X ray - Pulmonary Metastasis - 85 - 90% metastases
• CECT abdomen & pelvis – Retroperitoneal nodes

28. Staging of Disease
• Pre-requisites
• history + clinical examination
• tumor markers - hCG, AFP
• Radiology - USG Scrotum, CECT Abd, X-Ray Chest
• Pathology of tumor specimen

30. Prognostic Grouping
Stage T N M S
Stage 0 Tis N0 M0 S0
Stage 1a T1 N0 M0 S0
Stage 1b T2 - T4 N0 M0 S0
Stage 1c any T N0 M0 S1 - S3
Stage IIa any T N1 M0 S0 - S1
Stage IIb any T N2 M0 S0 - S1
Stage IIc any T N3 M0 S0 - S1
Stage IIIa any T any N M1 S0 - S1
Stage IIIb any T any N M0 - M1 S2
Stage IIIc
any T any N M0 - M1a S3
any T any N M1b any S

31. Treatment
• Treatment should be aimed at one stage above clinical stage.
• Seminomas - radio-sensitive - treat with radiotherapy.
• Non-seminomatous - radio-resistant - surgery.
• Advanced diseases/ metastases - chemotherapy.

32. Treatment (Cont.)
• RADICAL INGUINAL ORCHIDECTOMY - first line of therapy
• Bulky Retroperitoneal Tumours/ Metastatic Tumors - Initially
“DOWN-STAGED” with CHEMOTHERAPY
• Transscrotal biopsy - 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.

35. Chemotherapy
Chemotherapy Toxicity
BEP -
• Bleomycin Pulmonary fibrosis
• Etoposide Myelosuppression
Alopecia
Renal insufficiency (mild)
Secondary leukemia
• Cisplatin Renal insufficiency
Nausea, vomiting
Neuropathy

36. Lymph Nodes Dissection For Right &
Left Sided Testicular Tumours

37. Prognosis
Seminoma Non-Seminoma
Stage I 99% 95 - 99%
Stage II 70 - 92% 90%
Stage III 80 - 85% 70 - 80%

38. Conclusion
• Improved Overall Survival of Testicular Tumour due to Better
Understanding of the Disease, Tumour Markers and Cis-platinum
based Chemotherapy.
• Current emphasis - diminishing overall morbidity of various
treatment modalities.

39. Thank You