from gmc hospital sukkur.sindh.

1. Testicular
Tumor
May 13

2. ANATOMY
2
Anatomy of the testis

3.  Skin
DARTOS Muscle
External Spermatic Fascia
Cremastric Muscle
Internal Spermatic Fascia
Tunica Vaginalis
Tunica Albuginea
Coverings of testis

4. Structure of testis
• 200-300 lobules
• Each lobule has 2-3 seminiferous tubules
• Each seminiferous tubules lined by cell in
different stages of spermatogenesis
• Among the seminiferous tubules are Sertoli
cells.
• Between the loops of the seminiferous
tubules are interstitial cells, produce
testosterone.

5. BLOOD SUPPLY VENOUS DRAINAGE
5
Fig 6. Blood supply of testis

6. Lymphatic Drainage
Drain into the retroperitoneal lymph glands between the
levels of T11 and L4, but they are concentrated at the level
of the L1 and L3 vertebrae

7. Testicular Tumor
INTRODUCTION
Testicular cancer forms about 1 -1.5% of all malignancies in males
 Incidence – 0.6 per 100000
Mortality – 0.3 per 100000
Cure rate increased with introduction of platinum based chemotherapy from 10 to 80%

8. EPIDEMOLOGY OF TESTICULAR CANCER
• Age: for GCT: median age at diagnosis is 34 years.
• Age - 3 peaks
2 – 4 yrs
20 – 40 yrs
above 50 yrs
In a man age: 50 years or older solid testicular mass is usually
lymphoma
• Race: more common in young white men ,less in African .

9. Testicular Descent
December 16 9Recent advances in the management of Testicular tumor

10. Predisposing Factors
1. Cryptorchidism
2. Klinefelter syndrome
3. Positive family history
4. Contralateral germ cell tumor
5. Trauma
6. Viral infection
7. Hormonal factors
8. Exposure to environmental oestrogen

11. Predisposing Factors
1. Cryptorchidism
• This risk is further increased if the testis is intra-abdominal.
• Abdominal testis is more likely to be seminoma, testis brought to
scrotum by orchiopexy is more likely to be NSGCT.
• There is still an increased risk of developing a tumour in the
contralateral normally descended testicle in pt. with cryptorchidism
• Prepubertal orchidopexy fails to prevent the subsequent development
of malignancy

12. KLINEFELTER SYNDROME
• Characterised by:
• testicular atrophy
• absence of spermatogenesis
• gynecomastia
Karyotype: 47XXY

13. Pathological classification
2:Interstitial cell tumor of Testis 2-3%
Leydig cell tumor
Sertoli cell tumor
1:GERM CELL TUMORS 95%
Seminoma 40%
Non seminomatous germ-cell tumors 60%
 Embryonal carcinoma 20-25%
 Teratoma 25-35%
 Yolk sac (endodermal sinus) tumor
 Choriocarcinoma 1%
 Mixed germ-cell tumor
4: others 5%
 lymphoma

14. Seminoma
 The commonest variety of testicular tumour
 Adults are the usual target (4th and 5th decade); never seen in infancy
 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

15. Seminoma
• Serum alpha fetoprotein is normal
• Beta HCG is elevated in 30% of patients with Seminoma
• Classification
a) classical
b) Anaplastic
c) Spermatocytic

16. Gross appearance of seminoma. The tumor in A is very small,
whereas that in B has replaced most of the testis

17. Embryonal Carcinoma
 2nd most common germ cell tumor 90% of NSGCT
 Most men present in their 20s to 30s with a testicular mass
 Highly malignant tumours; may invade the cord stuctures.epidydymis
 High degree of metastasis
 Serum AFP is positive in 33%, & beta HCG is elevated in 20% of cases

18. EMBRYONAL CARCINOMA
• MACROSCOPIC
:
1. Fleshy gray white
tumor with
prominent
necrosis &
hemorrhage

19. Yolk Sac Tumour
 Most common germ cell tumor ( & most common testicular tumor ) in children,
• 60% of GCT in children. First 2 years of life.
• #<2% of testicular tumors in adults
• Elevated serum levels of alpha-fetoprotein.
• Microscopically, Schiller-Duval bodies are a characteristic feature
 Testicular mass the most usual presentation.

20. YOLK SAC TUMOR
• MACROSCOPIC :
white to tan masses,
with myxoid & cystic
changes

21. pediatric yolk sac tumor appears as a solid, yellow, myxoid nodule

22. The cut surface of this adult yolk sac tumor shows areas of hemorrhage and cystic change.

23. Choriocarcinoma
 A rare and aggressive tumour (5yrs survival is 5%)
 Typically elevated hCG
 Primary is very small and often exhibit NO TESTICULAR
ENLARGEMENT
 Small palpable nodule may be present
 Presents with disseminated disease.
 Prone to hemorrhage.

24. Choriocarcinoma

25. Teratoma
 Teratoma in greek means “monster tumor”
 Contain all three germ layers with varying degree of
diffrentiation
 Occurs in its pure form in pediatric age group.
 In adults, occur as a component of mixed germ cell tumor.
 Normal serum marker
◦ Mildly elevated AFP levels

26. Interstitial cell tumors
1. Leydig cell tumors
Presents with painless testicular mass
A masculinising tumor, produces androgens
Precocious puberty
 Prominent external genitalia
 Deep masculinised voice
 Pubic hair
Gynacomastia and decreased libodo due to oestrogen production by
increased peripheral conversion

27. LEYDIG CELL TUMOR
• MACROSCOPIC :
1. Leydig cells impart a
golden brown colour.
tumor is solid &
lobulated
2. Necrosis can be seen in
malignant tumors

28. Interstitial cell tumors
2. Sertoli Cell Tumor
 can occur in any age group including infants
 It is a faminising tumor
 Excess estrogen production
 Gynacomastia in 1/3rd of cases
 10 % are malignant

29. Interstitial cell tumors
3. Gonadoblastoma
 Mixed germ cell.
 Composed of seminoma like germ cells and Sertoli cells.
 Exclusively in patients with dysgenic gonads and intersex syndromes
 80% are phenotype females with primary amenorrhoea
 20% are males with crytochordism and dysgenic gonads and hypospadias
 Bilateral orchidectomy because of risk of bilateral tumours.

30. LYMPHOMA
• CLINICAL :
1. Lymphoma most often result of secondary spread; occasionally ,
primary lymphoma may occur
2. Most men are in their 60s
3. Involvement is bilateral in 20 % of all cases

31. LYMPHOMA
MACROSCOPIC : white to tan
fleshy tumor

32. Spread
1. Direct spread
2. Lymphatic spread
They drain primarily to para-aortic lymph nodes
No inguinal nodes until scrotal skin involvement
Seminoma metastasize exclusively through
lymphatics
3. Blood Spread
 NSGCT spread through blood route
 Lungs, liver, bones and brain are the usual sites usually involved

33. CLINICAL FEATURES
Painless Swelling of Testes
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
December 16 33Recent advances in the management of Testicular tumor

34. Clinical Features
2. Due to metastasis
 Abdominal or lumbar pain (lymphatic spread)
 Dyspnoea, hemoptysis and chest pain with lung mets
 Jaundice with liver mets
 Hydronephrosis by para-aortic lymph nodes enlargement
 Pedal oedema by IVC obstruction

35. Clinical Features
3. Clinical examination:
a) Enlarged testis (except choriocarcinoma)
b) Nodular testis
c) Firm to hard in consistency
d) Loss of testicular sensation
e) Secondary hydrocele

36. INVESTIGATIONS
1. Scrotal Ultrasound
2. CT Scan Abdomen & Pelvis
3. CT Thorax / Chest X-Ray - PA and lateral views
4. Tumour Markers
- AFP
-  HCG
5. MRI/PET Scan
December 16 36Recent advances in the management of Testicular tumor

37.  Human Chorionic
Gonadotropin
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
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
AFP –Alfa feto protein

38. ROLE OF TUMOUR MARKERS
• Helps in Diagnosis - 80 to 85% of Testicular Tumors have Positive Markers
• Most of Non-Seminomas have raised markers.
• Degree of Marker Elevation Appears to be Directly Proportional to Tumor Burden
• Normalization of tumor marker after high inguinal orchidectomy does not
ensure complete disease removal however after Orchidectomy if Markers
Elevated means Residual Disease
• Negative Tumor Markers becoming positive on follow up usually indicates -
Recurrence of Tumor
• Markers become Positive earlier than radiological studies

39. T3

41. SURGICAL TREATMENT
Scrotal Exploration and orchidectomy for suspected
testicular tumor
• Radical orchiectomy
• Diagnostic and Therapeutic treatment of choice.
• Complete removal of ipsilateral epididymis and spermatic cord to the level
of the internal inguinal ring.
• Partial orchiectomy
• Considered in patient with polar tumor measuring 2 cm or less.
• Adjuvant radiotherapy is given postoperatively.
41

42. CHEMOTHERAPY
• Indications
• As an alternative to adjuvant RT for stages I–II seminoma
• Adjuvant therapy for stages II–IV seminoma
• Regimens
• Regimens including BEP, EP, PVB, and VIP for stages II–IV diseases
Drug/ combination Dose and schedule
Bleomycin 30 IU IV bolus on days 2,9,16
Etoposide 100 mg/m2 IV over 30 mins on
days 1-5
Cisplatin 20 mg/m2 IV over 15-30 mins
on days 1-5
Repeat cycle every 21 days for 3 or 4 cycles
December 16 42Recent advances in the management of Testicular tumor

43. RETROPERITONEAL LYMPH NODE DISSECTION
• The rationale for primary RPLND is that, in contrast to most malignancies, testicular GCT is
surgically curable in most patients with low volume regional metastases.
43

44. Fig. 8 Laparoscopic RPLND Port Placement
December 16 44Recent advances in the management of Testicular tumor

45. Fig. 9 Robotic assisted RPLND Port Placement
December 16 45Recent advances in the management of Testicular tumor

46. RADIATION THERAPY
• Seminoma is extremely radiosensitive. Radiation therapy is often used for adjuvant therapy for
early-stage seminoma, and its use in non-seminoma germ cell tumors (GCT) is limited.
December 16 46Recent advances in the management of Testicular tumor

47. • Fig. 10 Paraaortic and ipsilateral
inguinal field for stage II
left testicular seminoms,
with inclusion of the
renal hilus.
December 16 47Recent advances in the management of Testicular tumor

48. Thank you