Testicular tumoursUrology2012

Case presentationHistory25C/o hemoptysis, abdominal discomfort; History of UDT, right side-operatedNo child*

On exam:Generally wellScar R groinNodes palpable, inguinalBig R testis, normal L testisWhat next?

OutcomesClinical presentation age, MetastasisClassificationDiagnosisDifferential diagnosisManagement

Epidemiology

Incidence2-3/100 000 in whites L 2-3% bilateral95% Germ cellAge16-35 yrs

AetiologyGonadal dysgenesisHereditary not clearEnvironmental factorsChemical carcinogens Infections7-10% in undescended testis- Dysgenesis, temp, Abn blood supply, endocrine dysf(x)

Risk Factors

Previous history of testicular tumor UDTInfertility Atrophic testis CIS

Anatomy

ClassificationGerm cellSeminomaNon seminomaEmbryonalChoriocarcinomaTeratocarcinomaYolk sac tumourMixed variantNon Germ cellLeydig cellSertoli cellSarcoma leukaemiaLymphomametastasis

Frequency

Seminoma -30%Embryonal Carcinoma- 30%Teratoma- 10%Teratocarcinoma- 25%Choriocarcinoma -1%Combined- 15%o

Tumour markersAFPB-HCGLDH

Metastatic patternLocal Lymphatichematogenous

Clinical presentetion50% have metastasis on diagnosis10% present with this as first sxNeck mass, respiratory, GIT, bone pain, neurological, lower extremities LocalHeavy feeling or painless swelling10% acute testicular pain

5% Gynecomastia

ExaminationLocal examContra lateral vs. ipsilateral testis, EpydidimisSpermatic cordAbdominalGeneral

Differential diagnosisTesticular torsion Epidydimo-orchitisHydrocoeleInguinoscrotal hernia paratesticular tumours

InvestigationsLaboratory

Serum tumour markersFBC, U&E,LFT`s

Radiological

SonarCXRCT scan abdomenRole of MRI?

Sonar

CT Scan

MRI

stagingClinical and surgicalTumor type degree of infiltrationVascular invasionLymph metastasisDistant metastasisSerum tumor markers

StagingA- confined to testisB -Retroperitoneal spreadB1-3C- Metastatic disease Or TNMS staging

Prognosis Mortality 50% in 1970Cure rate of > 95 % now!MorbidityTumour related Treatment relatedFertility?,QOL

PrognosisSeminoma overall cure rate is > 90%Age older patientsSperm cryopreservation?B HCG positive in 5-10% very radio & chemosensitive

Non seminomaChoriocarcinoma- Can present with extensive metastasiss with paradoxically small primaryTeratoma- mature and immature elementsYolk sac tumour- In infants and young children

treatmentNB Multimodal

Radical orchidectomyRadiotherapy ChemotherapyRetroperitoneal lymph node dissectionFollow up

General comments Misdiagnosis common No transscrotal biopsies Good work-upQuick referralFollow up !

OtherExtragonadal germ cell tumoursLeydig cell 10% malignant, present in children with virilising and in adults feminising.Sertoli cell- any age.10% malignantGonadoblastoma- In dysgenetic gonads

Secondary tumoursLymphomaLeukaemic infiltrationMetastasis- prostate, Breast, kidney

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