Testicular Tumors
Mashaal Saad 2016-038
TESTICULAR TUMOR
1% of all Malignant tumor
Affects young adults - 20 to 40 yrs - when Testosterone Fluctuations are
maximum
90% to 95% of all Testicular tumors from germ cells
99% of all Testicular tumors are malignant.
Causes Psychological & Fertility Problems in young
Cryptorchidism increases risk of developing testicular cancer
Classification
Germinal Neoplasms : (90 - 95 %)
1. Seminomas - 40%
(a) Classic Typical Seminoma
(b) Anaplastic Seminoma
(c) Spermatocytic Seminoma
2. Embryonal Carcinoma - 20 - 25%
3. Teratoma - 25 - 35%
(a) Mature
(b) Immature
4. Choriocarcinoma - 1%
5. Yolk Sac tumor
Cont’d…
B. Nongerminal Neoplasms : ( 5 to 10% )
1. Specialized gonadal stromal tumor
(a) Leydig cell tumor
(b) Other gonadal stromal tumor
Case
A 40-year-old male presents with a painless left testicular mass and back
pain. The patient described a 2-month history of progressive scrotal
swelling.
He also noted lower back pain that worsened with heavy lifting. The
patient denied a history of prior scrotal trauma or surgery.
He also noted decreased appetite and an unintentional 20-pound weight
loss over the past 2 months.
O/E:
tachycardia, hypertension
mild gynecomastia,
a palpable mildly tender midline abdominal mass
a firm enlarged non-tender left testicle measuring ~10 cm.
D/D for painless scrotal mass
Hydrocele
Spermatocele
Hernia
Varicocele
Investigations
Aims
Confirm the diagnosis
Detect metastases
Stage the disease
Treat according to stage
Investigations
Haematological – Hb%, Bl. urea/S. creatinine, LFT
Tumour markers – AFP, HCG, LDH
Scrotal Ultrasound – Usually homogenous, hypoechoic, intra testicular mass
X-ray chest
CT / MRI – abdomen
Scrotal Ultrasonography
Clinical Features
History
Solid testicular mass
Gradual
Trauma
Testicular heaviness
Back pain (retroperitoneal)
Cough or dyspnea (pulmonary)
Anorexia, nausea and vomiting (retroduodenal)
Bone pain (skeletal)
Lower extremity swelling (venacaval obstruction)
Clinical Features
Painless, progressively enlarging testicular mass
Para-aortic nodes at the level of L1/2
Along lymphatic chain to thoracic duct to supraclavicular nodes
Poorly differentiated tumors metastasize early
Enlarged abdominal or cervical lymph nodes
Cough, hemoptysis
Tumor Markers
TWO MAIN CLASSES
Onco-fetal Substances : AFP & HCG
Cellular Enzymes : LDH & PLAP
AFP - Trophoblastic Cells
HCG - Syncytiotrophoblastic Cells
Role of Tumor 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
Help determine tumor burden
Surgical Exploration
Orchidectomy
Inguinal incision
Spermatic cord clamped
Testis brought out
Cord divided at internal inguinal ring
Biopsy
TNM Classification
T – primary tumor
N – regional lymph nodes
M – distant metastasis
S – serum tumor markers
TNM Classification
T – primary tumor
TX: cannot be assessed
T0: no evidence of primary tumor
Tis: Intratubular cancer
T1: limited to testis and epididymis, no vascular invasion
T2: invades beyond tunica albuginea or has vascular invasion
T3: invades spermatic cord
T4: invades scrotum
TNM Classification
N – regional lymph nodes
NX: cannot be assessed
N0: no regional lymph node metastases
N1: lymph node metastases =/< 2cm and =/< 5 lymph nodes
N2: metastasis in > 5 nodes, nodal mass > 2 cm and < 5cm
N3: nodal mass > 5 cm
TNM Classification
M – Distant metastasis
MX: cannot be assessed
M0: no distant metastasis
M1: distant metastasis present
M1a: nonregional nodal or pulmonary metastasis
M1b: distant metastasis other than nonregional nodal or lung metastasis
TNM Classification
S – Serum tumor markers
SX: markers not available
S0: Normal level
S1: Lactate dehydrogenase (LDH) level < 1.5 times normal, human chorionic
gonadotropin (HCG) level < 5000 IU/L, alpha-fetoprotein (AFP) level < 1000
ng/mL
S2: LDH 1.5–10 times normal; HCG level, 5000–50,000 IU/L; AFP level, 1000–10,000
ng/mL
S3: LDH >10 times normal; HCG level >50,000 IU/L; AFP level >10,000 ng/mL
Stages of Spread of Testicular Tumors
Stage I
Tumor confined to testis
Stage II
Retroperitoneal lymph node involvement
IIa nodes < 2cm
IIb nodes 2 -5 cm
IIc nodes > 5 cm
Stage III
Metastasis above diaphragm confined to lymph nodes
Stage IV
Extralymphatic metastases (usually lungs and liver)
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
Treatment
1. Removal of the affected testis – usually performed as part of the
diagnostic process
2. No further treatment usually given if stage 1 disease (i.e. no metastases) but
careful surveillance with tumor markers and CT scans required
3. Radiotherapy – local irradiation alone for moderate abdominal lymph
node metastases in seminoma (stages IIa and IIb)
4. Chemotherapy with EP (etoposide and cisplatin) or BEP (bleomycin,
etoposide and cisplatin) – for all cases of metastatic teratoma and
metastatic seminoma beyond stage IIb
5. Debulking surgery for lymph nodes treated by chemotherapy
Management of Seminoma
Stage I disease
Orchidectomy +/- carboplatin based chemotherapy
Stage IIa
Radical radiotherapy to ipsilateral para-aortic and iliac nodes
Stage IIb
Radical radiotherapy or chemotherapy
Etoposide and cisplatin (EP) or cisplatin, etoposide and bleomycin (PEB)
Stages IIc and above
Chemotherapy with etoposide and cisplatin (EP) or cisplatin, etoposide and
bleomycin (PEB)
Management
Relapse within 1 year of orchidectomy without further treatment
No role of curative radiotherapy
Three options
1. Immediate chemotherapy
2. Retroperitoneal lymph node dissection
3. Surveillance and treatment
