Testicular tumorsDr Harshita Mehrotra

Resident, General Surgery

Importance

• Testicular tumors are rare.

• 1 – 2 % of all malignant tumors.

• Most common malignancy in men in the 15 to 35 year age group.

• Most curable solid neoplasms and serves as a paradigm for the

multimodal treatment of malignancies.

• Seminoma - most common bilateral primary testicular tumour;

Lymphoma - most common bilateral testicular tumour

• Dramatic Improvement in Survival:

• Effective diagnostic techniques

• Improved tumor markers

• Multi-modal treatment - Surgical + Radiotherapy/Chemotherapy

• Mortality markedly decreased.

Etiology

• Cryptorchidism

• Intersex disorder

• Testicular atrophy

• Chromosomal abnormalities - loss of chromosome 11, 13, 18, abnormal

chromosome 12p.

• Exogenous estrogen administration to mother during pregnancy

• Carcinoma-in-situ

• Previous testicular malignancy

Cryptorchidism

• 7 - 10% patients - history of cryptorchidism

• Most common - seminoma

• 5 - 10% tumors - contralateral testis

• Relative risk - Intraabdominal testis (1 in 20) > Intrainguinal

testis (1 in 80)

• Orchidopexy - does not alter malignant potential - facilitates

examination & detection

• Malignancy due to

• Abnormal germ cell morphology.

• Elevated temperature - abnormal spermatocyte maturation.

• Endocrinal disturbances.

• Gonadal dysgenesis.

Carcinoma in-situ

• Pre malignant precusor of all GCT, except spermatocytic

seminoma.

• Incidence - 0.8%.

• Testicular CIS develops from fetal gonocytes.

• Characterized histologically by seminiferous tubules containing

only Sertoli cells and malignant germ cells.

• Risk Factors for CIS:

• History of testicular carcinoma (5% to 6%),

• Extra gonadalGCT (40%),

• Cryptorchidism (3%),

• Contralateral testis with unilateral testis cancer (5% to 6%),

• Somatosexual ambiguity (25% to 100%)

• Atrophic testis 30 %

• Infertility (0.4% to 1.1%)

• TESTICULAR BIOPSY gold standard for diagnoses of CIS

Classification

Germ Cell Tumors >90%

Non-Seminomatous TumorsSeminomas

Classical 85%

Spermatocytic 5%

Anaplastic 10%

Embryonal Carcinoma

Yolk Sac Tumor

Choriocarcinoma

Teratoma

Mixed Tumors

Interstitial Cell Tumors

Leydig Cell Tumors

Sertoli Cell Tumors

Other Tumors

Lymphoma

Metastases

Malignant Testicular Tumors

Non-Germ Cell Tumors

Seminoma

• Classical: 80 - 85%

• middle age

• PLAP & B-hCG - raised

• slow growing

• good prognosis

• Spermatocytic: 5 - 10%

• age > 50 years

• low metastatic potential

• good prognosis

• Anaplastic: 5 - 10%

• middle age

• aggressive

• higher local & metastatic potential

• high B-hCG production

• Inguinal Orchiectomy + Radiation

Non-Seminomatous Germ Cell

Tumors

• Embryonal Carcinoma

• 25 - 35 years

• 3 - 6% testicular tumors

• small, rounded, irregular mass

• invades tunica albuginea

• Yolk Sac Tumor/ Endodermal

Sinus Tumor

• most common testicular tumor in

infants & children

• raised AFP

• histologically - cells demonstrate

vacuolated cytoplasm secondary

to fat and glycogen deposition,

resemble 1 - 2 week old embryos

• Teratoma

• raised AFP

• resistant to both chemotherapy &

radiotherapy

• mature teratoma - differentiated

elements from 2-3 embryonic germ cell

layers

• immature teratoma - undifferentiated

primitive tissue

• malignant teratoma - malignant changes

• Chorionic Carcinoma

• pure choriocarcinoma - rare

• second - third decades

• raised PLAP, B-hCG

• high incidence of distant metastases

• Leydig Cell Tumors

• most common non-germ cell cell timor of

testis - 1 - 3% testicular tumours

• bimodal age distribution - 5 - 9 years; 25

- 35 years age

• 25% cases - childhood; bilaterally - 5 -

10% cases

• presentation - prepubertal children -

virilization; adults - gynecomastia

• elevated serum & urinary 17-

ketosteroids & estrogens

• Sertoli Cell Tumors

• rare; < 1% testicular tumors

• bimodal age distribution - < 1 year; 20 - 45 years

age

• presentation - testicular mass; virilization in

children; gynecomastia in adults

• Gonadoblastomas

• rare

• seen in patients with gonadal dysgenesis

• age group - 30 years of age

• clinical presentation - gonadal dysgenesis

Secondary Tumors of Testis

• Lymphoma

• most common testicular tumour

over age of 50 years

• most common secondary

neoplasm of testis

• presentation - painless

enlargement of testis,

constitutional symptoms in 25%

patients; bilateral - 50% patients

• Leukemic Infiltration of Testis

• relapse of children with acute

lymphocytic leukaemia

• bilateral - 50% cases

• treatment - bilateral testicular

irradiation with 20Gy & reinstitution od

adj chemotherapy

• Metastatic Tumor

• rare

• most common primary - prostate >

lung > gastrointestinal tract >

melanoma > kidney

Extragonadal Germ Cell Tumor

• Rare - 3% all germ cell tumors

• Sites - mediastinum > Retroperitoneum > Sacrocoocygeal > Pineal gland

• Presentation - site & volume of disease

• Mediastinal lesions - pulmonary symptoms

• Sacrococcygeal - neonates - palpable mass, bowel/ urinary obstruction

• Pineal - headache, visual/ auditory complaints, hypopituitarism

• Treatment - same as testicular tumors.

Lymphatic drainage

• Right Testis - Inter-aortocaval nodes > Precaval > Preaortic > Right common iliac

> Right external iliac

• Left Testis - Left Para-aortic > Preaortic > Left common iliac > Left external iliac

• Cross over from right to left possible.

• Epididymis - external iliac chain.

• Inguinal node metastasis - scrotal involvement by the primary tumor, prior inguinal

or scrotal surgery, or retrograde lymphatic spread secondary to massive

retroperitoneal lymph node deposits.

• Testicular cancer spreads in a predictable and stepwise fashion, except

choriocarcinoma.

Metastatic Spread

• Distant metastases - Lung > Liver > Brain > Bone > Kidney >

Adrenal Glands > Gastrointestinal Tract > Spleen

• Germ cell tumors - Lymphatic spread

• Choriocarcinomas - Hematogenous spread - lungs

Clinical Presentation

• Painless testicular swelling

• Dull ache/heaviness in Lower Abdomen

• 10% - Acute Scrotal Pain

• 10% - Metatstasis

• Neck Mass /Cough /Anorexia /Vomiting /Back ache/Lower limb

swelling

• 5% - Gynecomastia - Estrogen producing tumors

• Rarely - Infertility

Physical Examination

• Firm to hard fixed area within tunica albugenia - suspicious

• Seminoma expand within the testis as a painless, rubbery

enlargement.

• Embryonal carcinoma or teratocarcinoma may produce an irregular,

rather than discrete mass.

• Choriocarcinoma - no testicular enlargement

Differential Diagnosis

• Testicular torsion

• Epididymitis, or epididymo-orchitis

• Hydrocele

• Hernia

• Hematoma

• Spermatocele

• Syphilitic gumma

Investigations

• All patients with a solid, firm intra-testicular mass that cannot be

transilluminated should be regarded as malignant unless

otherwise proved.

• Scrotal Ultrasound -

• rapid, reliable technique

• hypoechoic area within the tunica albuginea - markedly

suspicious for testicular cancer.

Tumor markers

• Onco-fetal Substances: AFP & HCG

• Cellular Enzymes: LDH & PLAP

Alfa-fetoprotein

• NORMAL VALUE < 16 ngm/ml

• Raised AFP :

• Pure embryonal carcinoma

• Teratocarcinoma

• Yolk sac Tumor

• Combined tumors

• AFP not raised in pure choriocarcinoma & pure seminoma

Human Chorionic Gonadotropin

• NORMAL VALUE < 1 ng/ml

• Raised β hCG -

• 100 % - Choriocarcinoma

• 60% - Embryonal carcinoma

• 55% - Teratocarcinoma

• 25% - Yolk Cell Tumour

• 7% - Seminomas

Role of Tumor Markers

• Diagnosis

• 80 - 85% testicular tumors - positive markers

• post orchiectomy elevated markers - stage II/III disease

• post lymphadenectomy residual disease - stage III disease

• histology of timor

• Burden of disease - degree of marker elevation

• Follow-up

• markers becoming positive on follow-up - recurrence

• markers become positive earlier than x-rays

Imaging studies

• USG Scrotum

• Chest X ray - Pulmonary Metastasis - 85 - 90% metastases

• CECT abdomen & pelvis – Retroperitoneal nodes

Staging of Disease

• Pre-requisites

• history + clinical examination

• tumor markers - hCG, AFP

• Radiology - USG Scrotum, CECT Abd, X-Ray Chest

• Pathology of tumor specimen

Prognostic Grouping

Stage T N M S

Stage 0 Tis N0 M0 S0

Stage 1a T1 N0 M0 S0

Stage 1b T2 - T4 N0 M0 S0

Stage 1c any T N0 M0 S1 - S3

Stage IIa any T N1 M0 S0 - S1

Stage IIb any T N2 M0 S0 - S1

Stage IIc any T N3 M0 S0 - S1

Stage IIIa any T any N M1 S0 - S1

Stage IIIb any T any N M0 - M1 S2

Stage IIIcany T any N M0 - M1a S3

any T any N M1b any S

Treatment

• Treatment should be aimed at one stage above clinical stage.

• Seminomas - radio-sensitive - treat with radiotherapy.

• Non-seminomatous - radio-resistant - surgery.

• Advanced diseases/ metastases - chemotherapy.

Treatment (Cont.)

• RADICAL INGUINAL ORCHIDECTOMY - first line of therapy

• Bulky Retroperitoneal Tumours/ Metastatic Tumors - Initially

“DOWN-STAGED” with CHEMOTHERAPY

• Transscrotal biopsy - CONDEMNED.

• The inguinal approach permits early control of the vascular and

lymphatic supply as well as en-bloc removal of the testis with all its

tunicae.

Chemotherapy

Chemotherapy Toxicity

BEP -

• Bleomycin Pulmonary fibrosis

• Etoposide Myelosuppression

Alopecia

Renal insufficiency (mild)

Secondary leukemia

• Cisplatin Renal insufficiency

Nausea, vomiting

Neuropathy

Lymph Nodes Dissection For Right &

Left Sided Testicular Tumours

Prognosis

Seminoma Non-Seminoma

Stage I 99% 95 - 99%

Stage II 70 - 92% 90%

Stage III 80 - 85% 70 - 80%

Conclusion

• Improved Overall Survival of Testicular Tumour due to Better

Understanding of the Disease, Tumour Markers and Cis-platinum

based Chemotherapy.

• Current emphasis - diminishing overall morbidity of various

treatment modalities.

Thank You