Testicular Cancer

Plan

• Defining the subject and its Epidemiology• The Classification and Investigations

• The Treatment

What is it?• Primary Germ Cell Tumors of testis arising by malignant

transformation of primordial germ cells constitute 95% oftesticular neoplasms.

• If GCTs arise from an extra-gonadal site: The mediastinum,retro peritoneum, and very rarely, the pineal gland.

• It is Notable for:- 1) young age of afflicted patients.

- 2) Totipotent capacity for differentiation of the tumor cells- 3) its curability.

• Approximately, 95% of newly diagnosed patients are cured• Experience in the management of GCTs leads to improved

outcome.

Epidemiology

• In 2010,8480 new cases of testicular GCT were

diagnosed, and only 350 men were died in USAges 20-40 years old

Testicular mass > 50 years old regarded aslymphoma untill proven otherwise

GCT is 4-5 times more common in whites than inafrican blacks in US.

• Testicular cancer- Most common malignancy in men in the 15-35year age group and evokes special interest

- One of most curable solid neoplasm• Serves as a paradigm for multimodal treatment- Dramatic improvement in survival:

• Effective diagnostic techniques• Tumour markers

• Effective multidrug chemotherapeutic regimens• Modification of surgical technique

Classification of Testicular Tumours

• Germ Cell Tumours- Seminoma

• Classic• Atypical

• Spermatocytic- Nonseminomatous• Embryonal carcinoma

• Teratoma• Mature• Immature

• Choriocarcinoma• Yolk sac tumor

CLASSIFICATION

I. Primary Neoplasms of Testis.A. Germ Cell Tumor.

B. Non-Germ Cell Tumor .

II. Secondary Neoplasms.

III. Paratesticular Tumors.

Germ cell tumors1. 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 Tumour

Sex cord/ gonadal stromal tumors ( 5 to10% )

1. Specialized gonadal stromal tumor(a) Leydig cell tumor(b) sertoli cell tumor

2. Gonadoblastoma

3. Miscellaneous Neoplasms(a) Carcinoid tumor

(b) Tumors of ovarian epithelial subtypes

II. SECONDARY NEOPLASMS OF TESTIS

A. Reticuloendothelial NeoplasmsB. Metastases

III. PARATESTICULAR NEOPLASMS

A. AdenomatoidB. Cystadenoma of EpididymisC. Desmoplastic small round cell tumorD. MesotheliomaE. Melanotic neuroectodermal

• Testicular cancer has become one of the mostcurable cancers in US because of advances in

medical and surgical therapy• Cisplatin-based chemotherapy regimens haveimproved the response rates for testis cancer

Examination• Detailed evaluation of neck, chest and abdominalcontents.- Testicular tumors often have a palpable parenchymal testismass

• Can be better appreciated if compared with contralateral normaltesticle.

- Needs to differentiate between• intraparenchymal testis masses often malignant• extraparenchymal testicular masses often benign.

- Scrotal ultrasound can distinguish intrinsic from extrinsictesticular lesions with a high degree of accuracy and can

detect intratesticular lesions as small as 1 to 2 mm indiameter.

Examination:

• High-resolution CT scan of the abdomen,pelvis and chest x-ray.• Regional metases first appear in theretroperitoneal lymph nodes

• CT to evaluate retroperitoneum, negativeresults, as evidenced by a retroperitonealrelapse rate of 20% to 25% in men, withclinical stage I disease who do not undergo

retroperitoneal lymph node dissection RPLND

Labs

• Serum marker alpha fetoprotein• Sb subunit of human chorionic gonadotropin(Beta-HCG)

• Lactate dehydrogenase• The differences between them:- LDH is elevated in 80% to 85% of men withnonseminomatous GCTs.

- In contrast, serum B-HCG is elevated in fewer than20% of testicular seminomas

- AFP is not elevated in pure seminomas.

• Neither serum B-HCG nor AFP alone or incombination is sufficiently sensitive or specificto establish the diagnosis of testicular cancerin the absence of histologic confirmation.• Serum LDH concentrations are elevated in30% to 80% of men with pure seminoma andIn 60% of those with nonseminomatous

tumors.

• LDH is a less sensitive and less specific tumormarker than B-HCG or AFP for men with

nonseminomatous GCTs- But it may be the only marker that is elevated inseminomas.

• Significantly elevated serum LDH hasindependent prognostic value in men withadvanced seminoma.

• Radical inguinal orchiectomy with high ligation ofthe spermatic cord near the internal inguinal ring

is performed to permit histologic evaluation of:- primary tumor and provision of local tumor control.- Note: Scrotal violation through scrotal incision or anattempt to biopsy the testicle must be avoidedbecause of concern for changing the lymphaticchannels available to the testis tumor and potential

poorer outcome.

• Serum half-lives of HCG and AFP are 18-36 hours and 5-7 days.- Testicular cancer produces any of these serum markers

- Following progressive change after radical orchiectomy is an importantconsideration in determining the adequacy of therapy.• Determination of histologic subtype of the testis cancer

• Several parameters may identify patients at high risk for metastasisto the retroperitoneum

- Despite absence of lymphadenopathy on the staging CT scan- Nonseminomatous germ cell tumours, those factors include the

following:1- Vascular lymph invasion

2- Primary tumor (T) Stage T2-T33- Embryonal carcinoma component greater than 40% of total tumor volume

Treatment• Patients with these risk factors who have no bulkyretroperitoneal lymphadenopathy- Have normal tumor markers after radical orchiectomymaybe candidates for RPLND.

• Principles underlying modern surgical treatment oftesticular GCT- based on stepwise predictable metastatic pattern of thesetumours

- Notable exception of choriocarcinoma- RPLND is only reliable method to identify nodalmicrometases

- It is gold standard for providing accurate pathologic stagingof retroperitoneum

• Both the number and size of involvedretroperitoneal lymph nodes have prognostic

importance• Surgical therapy for metastatic testicularcancer has evolved- The full bilateral RPLND used in the past evolvedfirst to a template-type Dissection- Then to a nerve-sparing modification with aunilateral template

RPLN

Surgical template for modified, left-sided (A)and right-sided (B) retroperitoneal lymphnode dissection