Testicular tumours

Urology2012

Case presentation

• HistoryHistory• 2525• C/o hemoptysis, abdominal discomfort; C/o hemoptysis, abdominal discomfort; • History of UDT, right side-operatedHistory of UDT, right side-operated• No childNo child

2

o On exam:On exam:o Generally wellGenerally wello Scar R groinScar R groino Nodes palpable, inguinalNodes palpable, inguinalo Big R testis, normal L testisBig R testis, normal L testiso What next?What next?

Outcomes

• Clinical presentation –age, Metastasis

• Classification• Diagnosis• Differential diagnosis• Management

Epidemiology

• Incidence• 2-3/100 000 in whites• <1/100 000 in blacks• R > L 2-3% bilateral• 95% Germ cell

• Age• 16-35 yrs

Aetiology

• Gonadal dysgenesis• Hereditary not clear• Environmental factors• Chemical carcinogens• Infections• 7-10% in undescended testis- Dysgenesis,

temp, Abn blood supply, endocrine dysf(x)

Risk Factors

• Previous history of testicular tumor

• UDT• Infertility• Atrophic testis • CIS

Anatomy

Classification

• Germ cell– Seminoma– Non seminoma

– Embryonal– Choriocarcinoma– Teratocarcinoma– Yolk sac tumour– Mixed variant

• Non Germ cell– Leydig cell– Sertoli cell– Sarcoma– leukaemia– Lymphoma– metastasis

Frequency

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

Tumour markers

• AFP• B-HCG• LDH

Metastatic pattern

• Local • Lymphatic• hematogenous

Clinical presentetion

• 50% have metastasis on diagnosis• 10% present with this as first sx• Neck mass, respiratory, GIT, bone pain, neurological,

lower extremities

• Local• Heavy feeling or painless swelling• 10% acute testicular pain

• 5% Gynecomastia

Examination

• Local exam• Contra lateral vs.

ipsilateral testis , • Epydidimis• Spermatic cord

• Abdominal• General

Differential diagnosis

• Testicular torsion • Epidydimo-orchitis• Hydrocoele• Inguinoscrotal hernia• paratesticular tumours

Investigations

• Laboratory

• Serum tumour markers• FBC, U&E,LFT`s

• Radiological

– Sonar– CXR– CT scan abdomen– Role of MRI?

Sonar

CT Scan

MRI

staging

– Clinical and surgical– Tumor type– degree of infiltration– Vascular invasion– Lymph metastasis– Distant metastasis– Serum tumor markers

Staging

• A- confined to testis• B -Retroperitoneal spread

– B1-3• C- Metastatic disease • Or TNMS staging

Prognosis

• Mortality • 50% in 1970• Cure rate of > 95 % now!

• Morbidity– Tumour related – Treatment related– Fertility?,QOL

Prognosis

• Seminoma –overall cure rate is > 90%• Age – older patients• Sperm cryopreservation?• B HCG positive in 5-10%• very radio & chemosensitive

Non seminoma

• Choriocarcinoma- Can present with extensive metastasiss with paradoxically small primary

• Teratoma- mature and immature elements• Yolk sac tumour- In infants and young children

treatment

• NB Multimodal

• Radical orchidectomy• Radiotherapy• Chemotherapy• Retroperitoneal lymph

node dissection• Follow up

General comments

• Misdiagnosis common• No transscrotal

biopsies • Good work-up• Quick referral• Follow up !

Other

• Extragonadal germ cell tumours• Leydig cell – 10% malignant, present in

children with virilising and in adults feminising.

• Sertoli cell- any age.10% malignant• Gonadoblastoma- In dysgenetic gonads

Secondary tumours

• Lymphoma• Leukaemic infiltration• Metastasis- prostate, Breast, kidney

Thank you