Testicular Tumour

Click here to load reader

  • date post

    17-May-2017
  • Category

    Documents

  • view

    224
  • download

    3

Embed Size (px)

Transcript of Testicular Tumour

  • Testicular tumors

    PROF DR PANNA LAL SAHAPROFESSOR OF SURGERY & HODBGC TRUST MEDICAL COLLEGECHITTAGONG

  • Incidence

    Testicular tumors are rare.

    1 2 % of all malignant tumors.

  • Age - 3 peaks

    2 4 yrs 20 40 yrs above 60 yrsTesticular cancer is one of the few neoplasms associated with accurate serum markers.

    Most curable solid neoplasms.

    Incidence

  • EtiologyCryptorchidism Intersex disorderTesticular atrophyTrauma- prompts medical evaluation Chromosomal abnormalities - loss of chromosome 11, 13, 18, abnormal chromosome 12p.Sex hormone fluctuations, estrogen administration during pregnancy

  • CLASSIFICATION I.Primary Neoplasms of Testis.A.Germ Cell Tumor. B.Non-Germ Cell Tumor .

    II.Secondary Neoplasms.

    III. Paratesticular Tumors.

  • Germ cell tumors

    1. Seminomas - 40% Teratoma - 32%

    Combined Seminoma & Teratoma 14%

    Interstitial tumours (1.5%);

    5. Lymphoma (7%);

    6. Other Tumours

  • Lymphatic drainageThe primary drainage of the right testis is within the inter aorto caval 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.

  • 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 intra testicular mass that cannot be trans illuminated should be regarded as Malignant unless otherwise 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.

  • 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

    PET (Positron Emission Tomography)- No apparent advantage over CT

    MRI - No apparent advantage over CT

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

  • Staging of testicular tumours

    The stages are: stage 1: testis lesion only no spread; stage 2: nodes below the diaphragm only; stage 3: nodes above the diaphragm; stage 4: pulmonary or hepatic metastases.

  • 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 SurgeryAdvanced Disease or Metastasis - Responds well to Chemotherapy

  • PRINCIPLES OF TREATMENTRadical INGUINAL ORCHIDECTOMY is Standard first line of therapyLymphatic spread initially goes to

    RETRO-PERITONEAL NODESEarly hematogenous spread RAREBulky Retroperitoneal Tumours or Metastatic Tumors Initially DOWN-STAGED with CHEMOTHERAPY

  • PRINCIPLES OF TREATMENTTrans scrotal 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.

  • CHEMOTHERAPYChemotherapy Toxicity

    BEP -Bleomycin Pulmonary fibrosis

    Etoposide (VP-16) Myelosuppression Alopecia Renal insufficiency (mild) Secondary leukemia

    Cis-platin Renal insufficiency Nausea, vomiting Neuropathy

  • Lymph Nodes Dissection For Right & Left Sided Testicular Tumours

  • 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 .

  • THANK YOU