Testicular tumors

PROF DR PANNA LAL SAHA PROFESSOR OF SURGERY & HOD

BGC TRUST MEDICAL COLLEGE CHITTAGONG

Incidence

Testicular tumors are rare. 1 2 % of all malignant tumors.

Incidence
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.

Etiology
Cryptorchidism Intersex disorder Testicular atrophy Trauma- prompts medical evaluation Chromosomal abnormalities - loss of
chromosome 11, 13, 18, abnormal chromosome 12p.

Sex hormone fluctuations, estrogen administration during pregnancy

CLASSIFICATION
I. Primary Neoplasms of Testis. A. Germ Cell Tumor. B. Non-Germ Cell Tumor . II. Secondary Neoplasms.

III.

Paratesticular Tumors.

Germ cell tumors

1. 2. 3. 2. 5. 6. Seminomas - 40% Teratoma - 32% Combined Seminoma & Teratoma 14% Interstitial tumours (1.5%); Lymphoma (7%); Other Tumours

Lymphatic drainage
The primary drainage of the right testis is within the inter aorto caval region. Left testis drainage , the para-aortic region in the compartment bounded by the left ureter, the left renal vein, the aorta, and the origin of the inferior mesenteric artery. Cross over from right to left is possible.

Lymphatic drainage
Lymphatics of the epididymis drain into the external iliac chain.
Inguinal node metastasis may result from 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.
.

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

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.

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

DICTUM FOR ANY SOLID SCROTAL SWELLINGS

All patients with a solid, firm intra testicular mass that cannot be trans illuminated should be regarded as Malignant unless otherwise proved.

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.

Tumor markers
TWO MAIN CLASSES
Onco-fetal Substances : AFP & HCG

Cellular Enzymes : LDH & PLAP

AFP - Trophoblastic Cells

HCG - Syncytiotrophoblastic Cells

( PLAP- placental alkaline phosphatase, & LDH lactic acid dehydrogenase)

AFP ( Alfafetoprotein)
NORMAL VALUE: Below 16 ngm / ml HALF LIFE OF AFP 5 and 7 days Raised AFP : Pure embryonal carcinoma Teratocarcinoma Yolk sac Tumor Combined tumors, AFP not raised in pure choriocarcinoma , & in pure seminoma

HCG ( Human Chorionic Gonadotropin)

Has and polypeptide chain
NORMAL VALUE: < 1 ng / ml HALF LIFE of HCG: 24 to 36 hours RAISED HCG 100 % - Choriocarcinoma 60% - Embryonal carcinoma 55% - Teratocarcinoma 25% - Yolk Cell Tumour 7% - Seminomas

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 level

have normal marker

After Orchidectomy if Markers Elevated means Residual Disease . Elevation of Markers after Lymphadenectomy means a STAGE III Disease

ROLE OF TUMOUR MARKERS

Degree of Marker Elevation Appears to be Directly Proportional to Tumor Burden
Markers indicate Histology of Tumor: If AFP elevated in Seminoma - Means Tumor has NonSeminomatous elements Negative Tumor Markers becoming positive on follow up usually indicates - Recurrence of Tumor Markers become Positive earlier than X-Ray studies

Imaging studies
Chest X ray
CT Scan PET (Positron Emission Tomography)- No apparent advantage over CT MRI - No apparent advantage over CT

Large left para aortic nodal mass due to GST causing hydronephrosis

Staging of testicular tumours

The stages are: stage 1: testis lesion only no spread; stage 2: nodes below the diaphragm only; stage 3: nodes above the diaphragm; stage 4: pulmonary or hepatic metastases.

Serum tumor markers

LDH S0 S1 _< N <1.5 x N HCG Miu/ml <N < 5000 AFP Ng/ml <N < 1000

S2
S3

1.5-10x N
>10x N

5000 to 50000 > 50000

1000 to 10000 >10000

PRINCIPLES OF TREATMENT
Treatment should be aimed at one stage above the clinical stage
Seminomas Radiotherapy. Radio-Sensitive. Treat with

Non-Seminomas are Radio-Resistant and best treated by Surgery Advanced Disease or Metastasis - Responds well to Chemotherapy

PRINCIPLES OF TREATMENT
Radical INGUINAL ORCHIDECTOMY Standard first line of therapy
Lymphatic spread initially goes to

is

RETRO-PERITONEAL NODES
Early hematogenous spread RARE Bulky Retroperitoneal Tumours or Metastatic Tumors Initially DOWN-STAGED with CHEMOTHERAPY

PRINCIPLES OF TREATMENT
Trans scrotal 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.

CHEMOTHERAPY

Chemotherapy
BEP Bleomycin Etoposide (VP-16)

Toxicity
Pulmonary fibrosis Myelosuppression Alopecia Renal insufficiency (mild) Secondary leukemia Renal insufficiency Nausea, vomiting Neuropathy

Cis-platin

Lymph Nodes Dissection For Right & Left Sided Testicular Tumours

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 .

THANK YOU