imaging of Testicular malignancies

1. IMAGING IN TESTICULAR MALIGNANCIES
DR.M.VINOTHKUMAR
APOLLO SPECIALITY HOSPITAL

2. normal anatomy of testis

3. TESTICULAR TUMOURS
 1 per cent of all cancers in men.
Risk factors
 Cryptorchidism
 Testicular atrophy (e.g. mumps),
 HIV.
 Testicular microlithiasis,
 Klinefelter’s syndrome,
 Down syndrome and
 Maternal use of diethyl stilbesterol.
 previous history of contralateral testicular tumour
 Family history
 Radiation

4. CLINICAL PRESENTATION
 Painless mass.
 Vague discomfort in scrotum.
Role of ultrasound
 Help distinguish intratesticular from extratesticular lesions.
 The majority of extratesticular masses are benign and
intratesticular masses are more likely to be malignant.
 100 percent sensitive for detection of testicular tumors.
Differential diagnosis
 hematoma, orchitis, abscess, infarction, and granuloma
that mimic testicular malignancy

5. Classification

6. Germ Cell Tumors
 90 to 95 percent of testicular cancer.
 Serum tumor markers are important in diagnosis, staging and follow-up.
 LDH (lactose dehydrogenase), AFP (alpha-fetoprotein) and hCG (human
chorionic gonadotrophin)
o LDH may increase in any type of tumor and it correlates well with the
extent of the disease.
o The αlpha-fetoprotein level is never elevated in patients with pure
seminoma.
o hCG is elevated in all patients of choriocarcinoma, majority of NSGCT
and only in few patients with seminomas.

7. Seminomas
 Most common type, approximately 50 percent of all germ cell
tumors.
 Aged – 40 yrs and almost never in infants.
 best prognosis of the germ cell tumors because of their high
sensitivity to radiation and chemotherapy .
Types of seminomas
 Typical.
 Anaplastic.
 Spermatocytic.
 men aged in their 60s and 70s and are associated
with an excellent prognosis

8. Seminomas
Ultrasound
 homogeneous intratesticular mass of low echogenicity compared to
normal testicular tissue.
 oval and well-defined in the absence of local invasion.
 internal blood flow is seen on colour Dopper imaging.
 cystic regions and calcifications are less common than in non-
seminomatous germ cell tumours.
 larger seminomas can have a heterogeneous appearance.
seminomas can can arise outside of the testicle
most often within the anterior mediastinum,
e.g. anterior mediastinal germ cell tumours.

10. CT
 Abdominal and pelvic CT are important in visualising metastases both as a part of
primary staging seminoma but also in primary diagnosis when a testicular mass is
unknown.
 Metastases to the para-aortic lymph nodes at the level of the renal vessels are the
typical first site of spread owing to the lymphatic drainage of the testicles relating to
embryological testicular descent. The nodal metastases are often bulky, of homogenous
density and tend to encase surrounding vessels.
 Inguinal or iliac lymph node metastases suggest lymphatic spread via the scrotum and
therefore local tumour extension beyond the tunica vaginalis.
 Hematogenous metastases to lung, brain, or both are evident
in about 25 percent of patients at the time of presentation.
Seminomas

11. • large para-aortic mass which in places
encases the aorta.
• left-sided ureteric obstruction and
hydronephrosis.
Seminomas

12. Non-seminomatous germ cell tumours
 Embryonal cell carcinoma: rare
 Choriocarcinoma: rare (carries worst prognosis)
 Yolk sac tumour
 Teratoma: accounts for 5-10% of germ cell tumours
 mature
 immature
 teratoma with malignant transformation
 Mixed germ cell tumour
 is the most common type of NSGCT
 accounts for 40% of all germ cell tumours
 the most common combination is teratoma and embryonal cell
carcinoma

13. Clinical presentation
 They tend to be more aggressive than seminomas, and frequently
metastasise.
Serological markers
 Alpha-fetoprotein (AFP): typically elevated in yolk sac tumour
 Beta-human chorionic gonadotropin (B-hCG): typically elevated
in choriocarcinoma
 Lactate dehydrogenase (LDH)
Non-seminomatous germ cell tumours

14.  Teratomas are composed of all three germ cell layers—endoderm,
mesoderm, and ectoderm.
 can occur in any age group.
 second most common testicular tumor in prepubertal boys.
 Mature teratoma in children is often benign, but teratoma in adults,
regardless of age, should be treated as
malignant.
 Echogenic foci represent calcification, cartilage, immature bone, and
fibrosis.
Testicular teratoma
Teratoma of testis. Note small cystic
areas and foci of calcification within
the lesion

15.  Highly malignant testicular tumor.
 Microscopic vascular invasion is common, which explains the
tendency of this tumor for early hematogenous metastasis,
especially to the lungs, when the primary tumor is relatively small.
 Many choriocarcinomas showextensive hemorrhagic necrosis in
the central portion of the tumor; at US, this
appears as mixed cystic and solid components.
Choriocarcinoma

16.  Occurs most often in men aged in their 30s
 More aggressive than seminomas.
 3 % pure embryonal carcinomas however, 45 percent of tumors of mixed
histologic characteristics contain embryonal components.
 Unlike seminomas, a pure embryonal carcinoma is often small and
does not cause enlargement of the scrotum.
 At US, embryonal carcinomas are predominantly hypoechoic lesions with
poorly defined margins and an inhomogeneous echotexture.
 Echogenic foci commonly appear and represent hemorrhage,
calcification, or fibrosis.
 Tumor invasion of the tunica albuginea is common and may distort the
contour of the testis.
Embryonal carcinoma

17. Staging
TNM staging
T: tumour
Primary tumour staging is from histological assessment
following orchidectomy
Tx:
primary tumour cannot be assessed (orchidectomy not
performed)
T0: no evidence of primary tumour
Tis: intratubular germ cell neoplasia (carcinoma in situ).
T1:
tumour limited to testis and epididymis may invade tunica
albuginea may NOT invade tunica vaginalis no vascular or
lymphatic invasion
T2:
tumour limited to testis and epididymis involvement of
tunica vaginalis vascular or lymphatic invasion
T3: invasion of spermatic cord
T4: invasion of scrotum

18. N: nodes
Abdominal retroperitoneal nodes are considered regional lymph nodes. A CT
short axis measurement threshold of 7-8 mm has 70% sensitivity and specificity
for malignant involvement or retroperitoneal nodes 4. The largest dimension of a
lymph node is used to differentiate between N1-N3.
Nx: nodes cannot be assessed
N0: no evidence of nodal involvement
N1: one or more lymph nodes involved but all <2 cm in greatest dimension
N2: one or more lymph nodes involved 2-5 cm in greatest dimension
N3: one or more lymph nodes involved >5 cm in greatest dimension
M: metastases
Mx: presence of metastases cannot be assessed
M0: no evidence of metastases
M1: distant metastases present
M1a: non-regional lymph node OR pulmonary metastases
M1b: distant metastases not fulfilling M1a

19. S: serum tumour markers
Most men with nonseminomatous germ cell tumour have elevated serum beta hcg
and alpha fetoprotein (AFP). For men with seminomas, beta hCG is elevated only
in a minority and AFP level are almost always normal 5.
Sx: no serum tumour markers available
S0: within normal limits
S1:
AFP: <1000 ng/ml
beta hCG: <5000 IU/L
LDH: <1.5x upper limit of normal
S2:
AFP: 1,000-10,000 ng/ml
beta hCG: 5,000-50,000 IU/L
LDH: 1.5-10x upper limit of normal
S3:
AFP: >10,000 ng/ml
beta hCG: >50,000 IU/L
LDH: >10x upper limit of normal

20. Stage groupings
stage I: T1–4, N0, M0, SX
stage II: any pT/Tx, N1–3, M0, SX
IIa: any pT/Tx, N1, M0, S0 OR any pT/Tx, N1, M0, S1
IIb: any pT/Tx, N2, M0, S0 OR any pT/Tx, N2, M0, S1
IIc: any pT/Tx, N3, M0, S0 OR any pT/Tx, N3, M0, S1
stage III: any pT/Tx, any N, M1, SX
IIIa: any pT/Tx, any N, M1a, S0 OR any pT/Tx, any N, M1a, S1
IIIb: any pT/Tx, N1–3, M0, S2 OR any pT/Tx, any N, M1a, S2
IIIc: any pT/Tx, N1–3, M0, S3 OR any pT/Tx, any N, M1a, S3
OR any pT/Tx, any N, M1b, any S

21. THANK YOU