Recent advances in the management of testicular tumor

Recent advances in the management of Testicular tumor

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RECENT ADVANCES IN THE MANAGEMENT OF TESTICULAR TUMOR

PRESENTER: Dr.Manharsinh Rajput

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Testicular Descent

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ANATOMY

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Fig 5. Anatomy of the testis


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BLOOD SUPPLY

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Fig 6. Blood supply of testis


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LYMPHATIC DRAINAGE

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Fig. 7 Lymphatic drainage


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INTRODUCTION

• Testicular cancer accounts for only about 1% of all human neoplasms.

• Testicular cancer although rare, is the most common malignancy in men in 15-35 years age group and accounts for approximately 23% of all cancers in this group.

• Risk factors

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WHO CLASSIFICATIONGerm cell tumors:Precursor lesions- Intratubular malignant germ cell tumor (carcinoma in situ)Tumors of one histologic type (pure forms) Seminoma variant- seminoma with syncitiotrophoblastic cells Spermatocytic seminoma variant- spermatocytic seminoma with sarcoma Embryonal carcinoma Yolk sac tumor Polyembryoma

Trophoblastic tumors- choriocarcinoma

Teratoma Mature teratoma Dermoid cyst Immature teratoma Teratoma with malignant areasMixed tumors

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CLASSIFICATION CONT..Sex cord/ Gonadal Stromal Tumors:Pure forms Leydig’s cell tumor Sertoli’s cell tumor large cell calcifying lipid rich cellGranulosa cell tumor Adult type granulosa cell tumor Juvenile type granulosa cell tumorTumors of thecoma / fibroma group

Incompletely differentiated sex cord/ gonadal stromal tumors

Mixed forms

Unclassified forms

Tumors containing both germ cell and sex cord/gonadal stromal elements -Gonadoblastoma -Mixed germ cell- sex cord/ gonadal stromal tumors, unclassifiedMiscellaneous tumors -Carcinoid tumors -Tumors of ovarian epithelial types

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CLASSIFICATION CONT..Lymphoid and hematopoietic tumors: -Lymphoma - Plasmacytoma - LeukemiaTumors of collecting duct and rete: -Adenoma -CarcinomaTumors of tunica, epididymis, spermatic cord, supporting structures, and appendices: Adenomatoid tumor Mesothelioma Adenoma Carcinoma Melanotic neuroectodermal tumor. Soft tissue tumors

Unclassified tumors

Secondary tumors

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SEMINOMA

Age of presentation 3rd and 4th decade Presentation present with uniform testicular swelling Serum markers are rarely elevated. AFP never rises. Lymphatic spread Good prognosis

NON SEMINOMA

2nd and 3rd decade

present with multinodular testicular swelling.

Serum markers are commonly elevated.

Lymphatic as well as hematogenous.

Worse prognosis

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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

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• Physical Examination

• Careful examination of the affected and the normal contralateral testis

• Examine for any evidence of palpable abdominal mass, inguinal

lymphadenopathy, supraclavicular lymphadenopathy.

• Chest examination for intrathoracic disease.

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INVESTIGATIONS

1. Scrotal Ultrasound 2. CT Thorax / Chest X-Ray - PA and lateral views3. CT Scan Abdomen & Pelvis4. Tumour Markers

- AFP- HCG- LDH- PLAP

5. MRI/PET Scan

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ROLE OF FNAC & BIOPSY

• In patients with an atrophic testis, history of cryptorchidism, or age

younger than 40 years, the prevalence of ITGCN in the contralateral testis

has been reported to be 36%.

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CLINICAL STAGINGStage I - Tumour confined to testis.

Stage II - Spread to Regional nodes.

Stage III - Spread beyond retroperitoneal Nodes or Above Diaphragm or visceral disease

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TNM STAGINGT0 = No evidence of TumourT1s = Intratubular, pre invasiveT1 = Confined to TestisT2 = Invades beyond Tunica Albuginea or into EpididymisT3 = Invades Spermatic CordT4 = Invades Scrotum

N1 = Single < 2 cmN2 = Multiple < 5 cm / Single 2-5 cmN3 = Any node > 5 cm

Mo = No distant metastasisM1 = Distant metastasis(M1a = Nonregional or pulmonary , M1b = sites other than m1a)

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TREATMENT

After obtaining serum AFP & B-HCG levels in suspected case of malignant germ cell tumor.

Radical inguinal orchiectomy with high ligation of spermatic cord is done, it is both diagnostic & therapeutic.

Further management depends on, pathology & stage of disease.

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SEMINOMA

Stage I,IIA Stage IIB,IIC,III

Retroperitoneal irradiation

BEP / EP

1.Non responder or discrete residual mass>3 cm– Excision2.35% residual mass harbours active disease—salvage chemotherapy

Responder

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NSGCT

Stage I,IIA Stage IIB,IIC,III

RPLND BEP / EP

1.Partial response RPLND/Excision of lung nodule2.Residual disease with raised tumor marker Salvage chemotherapy

Complete ResponseSurveillance

Follow up

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SURGERY

• 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 & abnormal

or absent c/l testis.• Adjuvant radiotherapy is given postoperatively.

• Delayed orchiectomy• Advanced NSGCT based on biopsy of metastatic site without primary

orchiectomy.

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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.

• The rationale for performing PC-RPLND.

• Salvage PC-RPLND

• Desperation PC-RPLND

• Reoperative RPLND

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Fig. 8 Laparoscopic RPLND Port Placement

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Fig. 9 Robotic assisted RPLND Port Placement

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RADIATION THERAPY• Indications

– Adjuvant therapy for stages I–II b diseases– Salvage of loco-regional failure after surgery or chemotherapy– Palliative treatment to loco-regional or distant metastatic sites

• Techniques– EBRT to lymph nodes– High-energy radiation (6 – 18 MV)

• 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.

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• Fig. 10 Paraaortic and ipsilateral inguinal field for stage II left testicular seminoms, with inclusion of the renal hilus.

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Radiation cont..STAGE DOSE

I 20 Gy in 10# to para-aortic ± pelivic lymph node by ap-pa field

II 25Gy in 20 # by AP-PA

III 25 Gy in 20 # F/B 10 Gy in 5 #

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CHEMOTHERAPY• Indications

– As an alternative to adjuvant RT for stages I–II seminoma– Adjuvant therapy for stages II–IV seminoma

• Regimens – Single-agent carboplatin become an alternative for stage I seminoma– Regimens including BEP, EP, PVB, and VIP for stages II–IV diseases

Drug/ combination Dose and scheduleBleomycin 30 IU IV bolus on days 2,9,16Etoposide 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

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Chemotherapy cont..EP

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 4 cycles

VeIPVinblastine 0.11 mg/kg/d on days 1 and 2

Ifosfamide 1.2 g/m2/d IV on days 1-5

Cisplatin 20 mg/m2/d IV on days 1-5

Mesna 400 mg/m2/d IV bolus prior to ifosfamide dose, then 1.2 g/m2/d IV infused continuously for 5 days

Repeat cycle every 21 days for 4 cycles

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CONCLUSION

Most common curable malignancy of young adults.

Most common- germ cell tumors, Seminoma > nonseminoma

Nonseminoma occurs a decade earlier.

Surgery is the main modality of treartment followed by Radiotherapy & or

chemotherapy for seminoma and chemotherapy & RPLND for

nonseminoma.• New tumor markers –HMGA1/2, OCT ¾, SOX2

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Recent advances in the management of testicular tumor

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