Testicular Tumoلبيrs

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Testicular tumors Testicular tumors Dr.Jihad Anad, Dr.Jihad Anad, . .

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Transcript of Testicular Tumoلبيrs

  • Testicular tumorsDr.Jihad Anad,.

  • Incidence Testicular tumors are rare.

    1 2 % of all malignant tumors.

    Most common malignancy in men in the 15 to 35 year age group. and the second most common solid tumor in men 35-40 yearsBenign lesions represent a greater percentage of cases in children than in adults.

  • Age - 3 peaks 2 4 yrs 20 40 yrs above 60 yrs

    Testicular cancer is one of the few neoplasms associated with accurate serum markers.

    Most curable solid neoplasms and serves as a paradigm for the multimodal treatment of malignancies.

  • EtiologyCryptorchidism 3 - 14XMetachronous testis cancer 2 - 4XPositive family history 5XDiethylstilbestrol exposure 2.5 - 5XGonadal dysgenesis 50XAndrogen insensitivity syndrome 15X

  • Several reasons are postulated to explain why tumorigenesis might occur in cryptorchid patients. These reasons include: abnormal germ cell morphology, increasedtemperature exposure, interference with the testicularblood supply, endocrine dysfunction andgonadal dysgenesis

  • Hormonal imbalances may play a causative role in cancer development particularly inpatients with testicular atrophy. Patients might experience decreased feedback inhibition for gonadotropin secretion, which could be the driving force for malignant transformation of an already damaged germinal epithelium.

  • CROSS SECTION OF TESTISTestis

    StromaSeminiferous Tubules (200 to 350 tubules)

    Interstitial Cells Supporting Spermatogonia Leydig or (Androgen) Sertoli Cell

  • 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

  • Classification of germcell tumor (GCT)GCTs arise from pluripotential cells, so a variety of elements may habitate in primary tumor

    More than half of GCTs contain more than one cell type and are therefore known as mixed GCTs

  • Sex cord/ gonadal stromal tumors ( 5 to 10% )

    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 sub types

  • A.AdenomatoidB.Cystadenoma of EpididymisC.Desmoplastic small round cell tumorD.MesotheliomaE.Melanotic neuroectodermalII. SECONDARY NEOPLASMS OF TESTISA.Reticuloendothelial NeoplasmsB.MetastasesIII.PARATESTICULAR NEOPLASMS

  • Carcinoma insitu {CIS}Pre invasive precusor of all GCT, except spermatocytic seminoma the pediatric testicular tumors (yolk-sac andmature teratoma).Incidence of CIS in the male population is 0.8%. Testicular CIS develops from fetal gonocytes & is characterized histologically by seminiferous tubules containing only Sertoli cells and malignant germ cells. 50%of patients with CIS found on testicular biopsy developed invasive tumors within five years of diagnosis if left untreated

  • Patients at risk of CISHistory 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

  • Testicular microlithiasis was not felt to be associated with invasive testicular germ cell tumors in asymptomatic populations with no risk factors for CIS or testicular cancer. Patients at risk for testicular CIS and potentially for invasive germ cell tumors should be offered either careful surveillance, or testicular biopsy following a discussion of the potential risks and benefits of diagnosis and therapy.

  • Classic SeminomaSeminomas comprise the most common type of germ cell tumor (approximately 45%)classic seminoma accounts for 80%-85%of seminomatous germ cell tumors.

  • Seminoma With High Mitotic IndexThe tumors have a higher rate of local invasion, an increased rate of metastatic spread, and a higher rate of bHCG production.

  • Spermatocytic SeminomaSpermatocytic seminomas account for less than 5% of all seminomasThey occur most commonly in men over the age of 40 years and approximately 5% of patients have bilateral disease.Unlike other germ cell tumors that can involve the ovary, retroperitoneum, or mediastinum, spermatocytic seminomas only involve the testicle.

  • Only rarely are spermatocytic seminomas associated with sarcomas. The sarcomas are typically undifferentiated, although on occasion there may be differentiated forms such as rhabdomyosarcoma. The sarcoma elements metastasize extensively.

  • Embryonal CarcinomaPure embryonal cell carcinoma comprises only 3%- 4%variable amounts in up to 40%of tumors with mixed histologic typesAre most common during the third decade of lifePure embryonal cell carcinomas may be associated with elevated levels of serum AFP

  • Syncytiotrophoblastic cells are scattered throughout the tumor and are responsible for bHCG elevation in patients with embryonal histologies.Lymphovascular invasion and involvement of epididymal and paratesticular structures are common. These findings are of prognostic importance.

  • Yolk SacTumorThe yolk sac tumor is the predominant tumor in infants and childrenIn adults, pure yolk sac tumors account for a very small percentage of testicular neoplasms (2%)Yolk sac elements are present in up to 40% of mixed germ cell testicular neoplasms and are responsible for the production of AFP.

  • Lymphatic drainageThe primary drainage of the right testis is within the interaortocaval region.

    Left testis drainage , the para-aortic region in the compartment bounded by the left ureter, the left renal vein, the aorta, and the origin of the inferior mesenteric artery.

    Cross over from right to left is possible.

  • ChoriocarcinomaPure choriocarcinomas account for less than 1% of germ cell neoplasms.Clinically, the primary tumors are often very small and may not be palpable. Patients typically present with symptoms due to extensive metastatic diseasesyncytiotrophoblasts and cytotrophoblasts.produce bHCG

  • TeratomaTeratomas constitute approximately 35% of germ cell tumors in infants and children. In adults, teratomas are found in only 2%-7%of testis tumors in pure form, but 45%-50% of mixed germ cell tumors contain teratomathese tumors contain more than one germ cell layer in different stages of maturation

  • Mature elements look like benign tissues derived from normal endoderm, ectoderm, and mesoderm.Immature elements consist of undifferentiated primitive tissues from the three germ cell layersLack chromosomal imbalances and do not show gains of isochromosome (12p)

  • Mixed Germ Cell TumorsApproximately 60%of germ cell tumors contain more than one histologic pattern59% contain seminoma, 41% contain yolk sac tumor, and 47%contain embryonal carcinoma and teratoma.

  • Lymphatic drainageLymphatics of the epididymis drain into the external iliac chain.

    Inguinal node metastasis may result from 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. .

  • Clinical featuresPainless Swelling of One testisDull Ache or Heaviness in Lower Abdomen10% - Acute Scrotal Pain10% - Present with Metatstasis- Neck Mass / Cough / Anorexia / Vomiting / Back Ache/ Lower limb swelling5% - GynecomastiaRarely - Infertility

  • Physical Examination Examine contralateral normal testis.

    Firm to hard fixed area within tunica albugenia is suspicious

    Seminoma expand within the testis as a painless, rubbery enlargement.

    Embryonal carcinoma or teratocarcinoma may produce an irregular, rather than discrete mass.

  • Differential Diagnosis Testicular torsionEpididymitis, or epididymo-orchitisHydrocele, Hernia, Hematoma, Spermatocele, Syphilitic gumma .

  • DICTUM FOR ANY SOLID SCROTAL SWELLINGSAll patients with a solid, Firm Intratesticular Mass that cannot be Transilluminated should be regarded as Malignant unless other wise proved.

  • Scrotal ultrasoundUltrasonography of the scrotum is a rapid, reliable technique to exclude hydrocele or epididymitis. Ultrasonography of the scrotum is basically an extension of the physical examination.

    Hypoechoic area within the tunica albuginea is markedly suspicious for testicular cancer.

  • Cystic lesion- epidermoid cyst

  • Tumor markersTWO MAIN CLASSESOnco-fetal Substances : AFP & HCGCellular Enzymes : LDH & PLAP AFP - Trophoblastic Cells HCG - Syncytiotrophoblastic Cells ( PLAP- placental alkaline phosphatase, & LDH lactic acid dehydrogenase)

  • AFP ( Alfafetoprotein)NORMAL VALUE: Below 16 ngm / mlHALF LIFE OF AFP 5 and 7 days

    Raised AFP : Pure embryonal carcinomaTeratocarcinoma Yolk sac Tumor Combined tumors,AFP not raised in pure choriocarcinoma , & in pure seminoma

  • HCG ( Human Chorionic Gonadotropin)Has and polypeptide chain

    NORMAL VALUE: < 1 ng / ml HALF LIFE of HCG: 24 to 36 hours

    RAISED HCG - 100 % - Choriocarcinoma 60% - Embryonal carcinoma 55% - Teratocarcinoma25% - Yolk Cell Tumour7% - Seminomas

  • ROLE OF TUMOUR MARKERSHelps in Diagnosis - 80 to 85% of Testicular Tumours have Positive Markers Most of Non-Seminomas have raised markersOnly 10 to 15% Non-Seminomas have normal marker level After Orchidectomy if Markers Elevated means Residual Disease .Elevation of Markers after Lymphadenectomy means a STAGE III Disease

  • ROLE OF TUMOUR MARKERSDegree of Marker Elevation Appears to be Directly Proportional to Tumor Burden

    Markers indicate Histology of Tumor: If AFP elevated in Seminoma - Means Tumor has Non-Seminomatous elements

    Negative Tumor Markers becoming positive on follow up usually indicates - Recurrence of Tumor

    Markers become Positive earlier than X-Ray studies

  • Imaging studiesChest X ray

    CT scan abdomen retroperitoneal nodes

    PET- No apparent advantage over CT

    MRI - No apparent advantage over CT

  • Large left para aortic nodal mass due to GST causing hydronephrosis

  • Tumor stagingPrimary Tumor (T)pTX - Primary tumor cannot be assessed (if no radical orchiectomy has been performed, TX is used)pT0 - No evidence of primary tumor (e.g., histologic scar in testis)pTis - Intratubular germ cell neoplasia (carcinoma in situ)pT1 - Tumor limited to the testis and epididymis and no vascular/lymphatic invasionpT2 - Tumor limited to the testis and epididymis with vascular/lymphatic invasion or tumor extending through the tunica albuginea with involvement of tunica vaginalispT3 - Tumor invades the spermatic cord with or without vascular/lymphatic invasionpT4 - Tumor invades the scrotum with or without vascular/lymphatic invasion

  • Regional Lymph NodesClinical NX - Regional lymph nodes cannot be assessedN0 - No regional lymph node metastasisN1 - Lymph node mass 2 cm or less in greatest dimension or multiple lymph node masses, none more than 2 cm in greatest dimensionN2 - Lymph node mass, more than 2 cm but not more than 5 cm in greatest dimension, or multiple lymph node masses, any one mass greater than 2 cm but not more than 5 cm in greatest dimensionN3 - Lymph node mass more than 5 cm in greatest dimension

  • Pathologic node stagingpN0 - No evidence of tumor in lymph nodes

    pN1 - Lymph node mass, 2 cm or less in greatest dimension and 6 nodes positive, none >2 cm in greatest dimension

    pN2 - Lymph node mass, more than 2 cm but not more than 5 cm in greatest dimension; more than 5 nodes positive, none >5 cm; evidence of extranodal extension of tumor

    pN3 - Lymph node mass more than 5 cm in greatest dimension.

  • Distant metastasisM0 - No evidence of distant metastases

    M1 - Nonregional nodal or pulmonary metastases

    M2 - Nonpulmonary visceral masses

  • Serum tumor markers

    LDHHCGMiu/mlAFPNg/mlS0 _< N 10000

  • PRINCIPLES OF TREATMENTTreatment should be aimed at one stage above the clinical stage Seminomas - Radio-Sensitive. Treat with Radiotherapy.Non-Seminomas are Radio-Resistant and best treated by Surgery (RPLND)Advanced Disease or Metastasis - Responds well to Chemotherapy

  • PRINCIPLES OF TREATMENTRadical INGUINAL ORCHIDECTOMY is Standard first line of therapy (sine qua non)Lymphatic spread initially goes to RETRO-PERITONEAL NODESEarly hematogenous spread RAREBulky Retroperitoneal Tumours or Metastatic Tumors Initially DOWN-STAGED with CHEMOTHERAPY

  • PRINCIPLES OF TREATMENTTransscrotal biopsy is to be 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.

    Frozen section in case of dilemma.

  • Chemotherapy side effects

  • Lymph Nodes Dissection For Right & Left Sided Testicular Tumours

  • Retroperitoneal lymph node dissection (RPLND)Prophylactic node dissection in patients with NSGCT confined to the testis Resection of (low-volume) retroperitoneal nodes in NSGCT as part of the initial therapyResection of post-chemotherapy or post-RPLND-I/RPLND-II masses

  • CONCLUSIONImproved Overall Survival of Testicular Tumour due to Better Understanding of the Disease, Tumour Markers and Cis-platinum based Chemotherapy.

    Current Emphasis is on Diminishing overall Morbidity of Various Treatment Modalities .

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