Download - .Testicular Tumour

Transcript

Testicular tumors

PROF DR PANNA LAL SAHAPROFESSOR OF SURGERY & HOD

BGC 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 yrs• Testicular cancer is one of the few neoplasms

associated with accurate serum markers.

• Most curable solid neoplasms.

Incidence

Etiology

• Cryptorchidism • Intersex disorder• Testicular atrophy• Trauma- 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%

2. Teratoma - 32%

3. Combined Seminoma & Teratoma 14%

2. Interstitial tumours (1.5%);

5. Lymphoma (7%);

6. Other Tumours

Lymphatic drainage

• The 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 drainage• Lymphatics 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 features

• Painless Swelling of One testis• Dull Ache or Heaviness in Lower Abdomen• 10% - Acute Scrotal Pain• 10% - Present with Metatstasis

- Neck Mass / Cough / Anorexia / Vomiting / Back Ache/ Lower limb swelling

• 5% - Gynecomastia• Rarely - 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 torsion• Epididymitis, or epididymo-orchitis• Hydrocele, • Hernia, • Hematoma, • Spermatocele, • Syphilitic gumma .

DICTUM FOR ANY SOLID SCROTAL SWELLINGS

• All patients with a solid, firm intra testicular mass that cannot be trans illuminated should be regarded as Malignant unless otherwise proved.

Scrotal ultrasound

• Ultrasonography 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 markers

TWO MAIN CLASSES• Onco-fetal Substances : AFP & HCG• Cellular 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 carcinoma• Teratocarcinoma • 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 MARKERS

• Helps in Diagnosis - 80 to 85% of Testicular Tumours have Positive Markers

• Most of Non-Seminomas have raised markers• Only 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 MARKERS

• Degree 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 studies

• Chest 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 markersLDH HCG

Miu/mlAFPNg/ml

S0 _< N <N <N

S1 <1.5 x N < 5000 < 1000

S2 1.5-10x N 5000 to 50000

1000 to 10000

S3 >10x N > 50000 >10000

PRINCIPLES OF TREATMENT

• Treatment 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

• Advanced Disease or Metastasis - Responds well to Chemotherapy

PRINCIPLES OF TREATMENT

• Radical INGUINAL ORCHIDECTOMY is Standard first line of therapy

• Lymphatic spread initially goes to RETRO-PERITONEAL NODES

• Early hematogenous spread RARE• Bulky Retroperitoneal Tumours or Metastatic

Tumors Initially “DOWN-STAGED” with CHEMOTHERAPY

PRINCIPLES OF TREATMENT

• Trans 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.

CHEMOTHERAPY

Chemotherapy ToxicityBEP -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

CONCLUSION

• Improved 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