DR. ASHOK PRADHAN MBBS,MS

1. Testicular Tumor
(Pure-Seminoma)
DR. ASHOK PRADHAN
2ND YR SURGERY JR
UCMS,TH

2. INTRODUCTION
• Germ cell tumors (GCTs)-95% of malignant
tumors
• Only 2% of all human malignancies
• Bimodal age group
• Several risk factors - Positive family history,
cryptorchidism, testicular dysgenesis,
Klinefelter syndrome

3. Classification
i.Primary Neoplasma of Testis
A. Germ Cell Tumour
– Seminoma
– Non seminoma
B. Non-Germ Cell Tumour
Leydig cell tumor
Sertoli cell tumor
Gonadoblastoma
II. Secondary Neoplasms.
III. Paratesticular Tumours.

4. Cont.
SECONDARY NEOPLASMS OF TESTIS
A. Lymphoma
B. Reticuloendothelial Neoplasms
C. B. Metastases
PARATESTICULAR
A. Adenomatoid
B. Cystadenoma of Epididymis
C. Mesenchymal Neoplasms
D. Mesothelioma
E. Metastases

5. Normal spermatocyte
Totipotential germ cell Seminoma
Embryonal carcinoma
Extraembryonic
differentiation
Choriocarcinoma
Tropoblastic pathway
Yolk sac tumor
Yolksac pathway
Tretatoma( Intraembryonic
differentiation)
Tumerogenic model for germ cell tumors of testis

6. Germinal Neoplasms
1. Seminomas - 40%
– Classic Typical Seminoma
– Anaplastic Seminoma
– Spermatocytic Seminoma
2.Non seminoma
Yolk sac tumor 20%
Teratoma – 5%
– Mature
– Immature
Choriocarcinoma - 1%

7. Seminoma
Classical – 85%,
most common in 4th decades
Grossly- coalesing gray nodules
microscopically – monotonous
sheet of large cells with clear
cytoplasm & densely staining
nuclei
Syncytotrophoblastic elements
seen – so, hCG prodution
Spread through lymphatics,
PLAP +ve

8. Anaplastic seminoma
• Anaplastic – 5-10%
• Greater mitotic activity, 3 or
more mitoses/ HPF
• Higher local invasion &
metastatic potential
• Higher rate of β-HCG
production
• Prognosis is good, PLAP +ve

9. Spermatocytic seminoma
• Spermatocytic – 5-10%
• Microscopically cells vary
in size and characterised
by densely staining
cytoplasm and rounded
nuclei with condensed
chromatin
• > 50 years
• PLAP negative
• Extremely low metastatic
potential & good
prognosis

10. Yolk Sac Tumour( endodermal sinus
tumor)
• 2nd most common germ cell
• 60% of GCT in children,
mainly in first 2 years of
life.
• Pure yolk sac tumor <2% of
testicular tumors in adults,
most commonly mixed
variety
• Elevated serum levels of
alpha-fetoprotein (90%)
• Microscopically, Schiller-
Duval bodies are a
characteristic feature

11. Teratoma
• Children and adults
• Arises from rete testis
• As small as peanuts or as large as
coconut
• Even large, tumor is moulded by tunica
albugenia
• Contain all three germ layers
• Immature teratoma - undifferentiated primitive tissue
• Mature teratoma - terminally differentiated tissues such as
cartilage, skeletal muscle, or nerve tissue, and frequently
forms cystic structures

12. Choriocarcinoma
• A rare and aggressive
tumour (<1%)
• Lesion tends to be small
within testis
• Gross inspection- central
hemorrhage
• Hematogenous spread &
metastasis to lungs and
brain
• Microscopically- syncytio
and cytotropoblasts seen
• Typically elevated hCG

13. Patters of metastatic spreads
• Lymph nodes of testis extend
from T11 to L4 but contracted at
the level of renal hilum
• Primary landing site for right
testis interaortocaval area at
the Rt Renal hilum  precaval 
preaortic  paracaval Rt
common iliac and Rt external
iliac lymph nodes
• Left testis para-aortic area at
the level of Lt renal hilum 
preaortic  left common iliac
and left external iliac lymph
nodes

15. Clinical Features
• Most commonly as a painless testicular lump
Pain - 30 %
• Sensation of heaviness if size > than 2-3 times
• May mimic epidedymo-orchitis
• Sudden pain and enlargement due to
hemorrhage mimicking torsion
• History of trauma (co-incidental)

16. Due to metastasis
• Abdominal ( retrodudodenal mets ) pain
• Lumbar pain (due to involvement of psoas muscle)
• Dyspnoea, hemoptysis and chest pain with lung
metastases
• Jaundice with liver metastases
• Hydronephrosis by para-aortic lymph nodes
enlargement
• Pedal oedema by IVC obstruction – u/l or b/l •
• Troiser’s sign
• Bone pain ( skeletal mets )

17. Investigation
USG
• Mass is truly
intratesticular
• Distinguish the tumor
from epididymal
pathology
• Facilitate testicular
examination in the
presence of a hydrocele.

18. CT scan of Abdomen & Pelvis
• To identify metastatic
involvement above and
below the diaphragm
• Sensitivity-40%,
• Specificity-95%

19. MRI
• Equivalent to CT in
determining the size
and location of
retroperitoneal
adenopathy.
• Sensitivity of 100% and
• Specificity of 95-100%

20. PET SCAN
• Indication - detection of residual
viable seminoma in patients with
masses greater than 3 cm in
diameter after chemotherapy
• Higher sensitivity (70%) and
specificity (up to 100%)
• Unable to detect lesions <5 mm
in size or teratomas of any size
due to their very low metabolic
activity.

21. Serum Marker
AFP –( Alfafetoprotein)
• Normal value : Below 16 ngm / ml
• Half life – 5 and 7 days
HCG – ( Human Chorionic Gonadotropin)
• Normal value: < 1 ng / ml
• Half life of hCG: 24 to 36 hours
others
• LDH(Lactate Dehydrogenase): Has low specificity.
• PLAP(Placental Alkaline phosphatase): Raised in 40% of
patients with advanced disease.
• CD30: possible marker for embryonal carcinoma.

22. Clinical staging
Stage A Lesion Confined to testis
Stage B Regional lymph node
spreads
Stage C Spread beyond the
retorperitoneal lymph
node

23. Clinical staging for seminoma
Stage i Lesion confined to testis
Stage ii Retroperitoneal nodal involvement
IIA - Nodes <2 cm in size or ≤ 5
Positive Nodes
IIB - 2 to 5 cm in size or > 5 Positive
Nodes
IIC - Large, Bulky, abdominal mass
usually > 5 to 10 cm
Stage iii Supradiaphragmatic nodal
involvement
Visceral involvement

24. TNM classification
T- Primary tumor
TX: cannot be evaluated.
T0: no evidence of a primary
tumor
Tis: carcinoma in situ (CIS)
T1: Tumor limited to testis or
epididymis, no
vascular invasion
T2 Invades beyond tunica
albuginea and into tunica
vagainalis or has vascular invasion
T3: Tumor invades the spermatic
cord
T4: Tumor invades the scrotum

25. Cont.
Distant metastases
MX : Cannot be assesed
M0 : No distant metastasis
M1 : Distant metastasis
M1a : Nonregional nodal or
pulmonary metastasis
M1b : Distant metastasis other than
to nonregional lymph nodes and lung
Tumor marker
Sx: Marker not available
S0: Markers level within normal
limits
S1: LDH < 1.5* N, hCG <5000mIU/ml
and AFP < 1000 ng/ml
S2: LDH 1.5-10*N, hCG 5000-
50000mIU/ml and AFP 1000- 10,000
ng/ml
S3: LDH> 10*N, hCG >50000mIU/ml
and AFP > 10,000 ng/ml

26. Differential diagnosis
• Torsion
• Epididymitis
• Epididimo-orchitis
• Hydrocele
• Hernia

27. Approaching patient with testicular
mass( NCCN)
Work up with
Serum tumor marker
b- hCG
LDH
AFP
PLAP
Testicular Ultrasound
Then primary treatment
with radical inguinal
orchiectomy & send for
HPE
Consider inguinal biopsy
of contralateral testis if:
Suspicious ultrasound for
intratesticular mass
Cryptorchid testis
Marked atrophy

28. Pure seminoma GCT AFP –ve & elevated
beta hCG
Post diagnostic work up
Abdominal/pelvic CT
Repeat b-hCG, LDH, AFP
Staging
Stage IA, IB
Stage IS
Stage IIA, IIB, IIC
Stage IIIA, IIIB, IIIC

29. Primary Treatment for Pure Seminoma
Stages IA and IB
The standard treatment options after initial
orchiectomy include
• Surveillance
• Radiotherapy, or
• Chemotherapy with 1 or 2 cycles of
carboplatin.
• The disease-specific survival for stage I disease
is 99%

30. Follow-Up After Primary Treatment for
Pure Seminoma Stages IA and IB
Surveillance
serum tumor markers (AFP, β-HCG, and LDH)
performed every 3 to 4 months for 1 to 2 years
every 6 to 12 months for years 3 to 4 and
annually thereafter
Abdominal/pelvic CT
every 6 mo for years 1-2
every 6-12 mo for year 3, then
annually for years 4-5
chest x-ray as clinically indicated for years 1-5

31. Follow up after Carboplastin Stage IA, IB
AFP, beta-HCG, LDH
Every 3month for years 1
Every 4 mo for year 2,
Every 6 months for year 3,then annually
Abdominal/pelvic CT annually for years 1-3;
Chest x-ray as clinically indicated

32. Follow Up RT Stage IA & IB
AFP, beta-HCG, LDH
Every 4 mo for years 1-2, then
annually for years 3-10
Abdominal/pelvic CT annually for 3 years (for
patients status post only para-aortic RT)
Chest x-ray as clinically indicated

33. Pure Seminoma Stage IS
Primary Treatment for Pure Seminoma Stage IS
Radiation to an infradiaphragmatic area,
including para-aortic lymph nodes with or
without radiation to the ipsilateral ilioinguinal
nodes
Follow-Up
Similar to those for patients with stages IA and
IB treated with adjuvant radiation therapy.

34. Pure Seminoma Stages IIA and IIB
• Radiotherapy to include para-aortic and
ipsilateral iliac lymph nodes
• Consider primary chemotherapy for selected
stage IIB patients: EP for 4 cycle or BEP for 3
cycles
• Follow up
EP- Etoposide/cisplastin
BEP- Bleomycin/etoposide/cisplastin

35. Pure Seminoma Stage IIC & III
GOOD RISK
Primary chemotherapy
EP for 4 cycle
BEP for 3 cycle
INTERMIDATE RISK
Primary chemotherapy
BEP for 4 cycles
EP- Etoposide/cisplastin
BEP- Bleomycin/etoposide/cisplastin

37. Postchemotherapy Management of Pure
Seminoma Stages IIB, IIC, and III
A.No residual mass or residual mass <3 cm and normal
markerssurveillanceFU
B.Residual mass and normal markerPET scan
– If –ve surveillance FU
– If +ve RPLND/ 2nd line chemotherapy/ RT FU
• If during FU recurrance occur then 2nd line
chemotherpay
C.Progressive Disease and raised tumor marker2nd line
chemotherapy

38. Second line chemotherapy
Cisplatin-based combination chemotherapy
– 4 cycles of TIP (paclitaxel, ifosfamide, cisplatin) or
– 4 cycles of VeIP (vinblastine, ifosfamide, cisplatin

39. THANK YOU