1. Testicular Cancer and Retroperitoneal Lymph Node Dissection
Dr Manish Patel
Urological Cancer Surgeon, Westmead Hospital
Senior Lecturer, University of Sydney

2. Normal Testicle

3. Testicular Tumors-WHO Classification
Lymphoid and Haematopoietic tumors
Lymphoma, plasmacytoma, leukaemia
Paratesticular Tumors
Adenomatoid tumor
Mesothelioma
Adenoma
Carcinoma
Desmoplastic small round cell tumors
Soft tissue tumors
Secondary tumors
Tumor like lesions
Germ Cell Tumors
CIS
Seminoma
Classic, Anaplastic , spermatocytic
NSGCT
Embryonal
Yolk Sac
Choriocarcinoma
Teratoma
Sex Cord/gonadal stromal tumors

4. Carcinoma in-situ
High Risk: Cryptorchidism (3%), Infertile men (1%), Extragonadal GCT (40%).
Thought to be the precursor of GCT.
Found in most testis with GCT.
Found in 5% of contralateral testis.
Will all eventually develop GCT.

5. Germ Cell tumors-Seminoma
35-70% of GCT
Aged y.o
Can contain synsytiotrophoblasts
No AFP elevation,
15% have HCG elevation.

6. Germ Cell Tumors- Non Seminoma
Approx 40% GCT
Combination of :
Embryonal
Yolk Sac
Chriocarcinoma
Teratoma-benign, malignant transformation. T

7. Gonadal Stromal Tumors
Leydig Cell Tumor
From the stromal cells of the testis.
Approx 10% metastasise.
Leydig Cell Tumors
3% of testicular tumors.
Adults 30% feminisation.
Sertoli Cell Tumors
2% of adult tumors
More benign.
Sertoli Cell Tumor

8. Testis cancer-Epidemiology
Most frequent malignancy of white males aged
Rare in Asian and African populations.
Frequency Increasing. ?Why
Encourage testicular self exam- no evidence of clear benefit.

9. Predisposing Conditions
Family History
Brothers increase risk much more than fathers or other 1st degree relatives
Undescended Testicles
Other causes of testicular atrophy
Maternal Estrogen exposure?

10. Testis Cancer Presentation
Painless swelling of the testis.
Painful testis (10%)
Tender breasts.
Back pain, abdominal mass
Cough, haemoptysis, SOB
Neck mass
Often Delayed Presentation Because of Embarrassment.

11. Testicular Tumor-Investigation and Diagnosis.
Clinical suspicion.
Tumor markers
AFP
HCG
LDH
Ultrasound
Orchidectomy

12. Radical (Inguinal) orchidectomy

13. NSGCT-Stage I Tumour confined to Testicle
35-75% chance of micrometastatic disease in RP
Assess risk by pathology
Embryonal, lymphovascular invasion.
Options
Surveillance
Chemotherapy (X2 cycles)
RPLND

14. NSGCT- Stage II Disease in RP

15. NSGCT- Stage II Disease in RP
Options
Chemotherapy
RPLND

16. NSGCT- Stage III Disease in chest or other viscera
85% survival
Treatment :
Chemotherapy

17. Seminoma- Stage I Confined to the Testicle
20% chance of micrometastasis to RP
Options:
XRT to RP
Surveillance
Chemotherapy (single cycle)

18. Seminoma-Stage II Disease in the RP
Options for treatment
Chemotherapy
XRT if mass <5cm

19. Seminoma- Stage III Disease in chest or other viscera
Options
Chemotherapy

20. Which Chemotherapy? IGCCCG classification. Good Risk
Tesicular or RP primary, nomets other then lungs, low tumour markers.
GET BEPx3 or EPx4
Intermediate and Poor Risk
BEP X4

21. Chemotherapy Complications
Bleomycin
Lung and Vessel fibrosis.
Etoposide
Late secondary malignancies
Cisplatin
Renal toxicity
Neuro toxicity
All
Haemopoetic

22. Fertility Reduced fertility even before orchidectomy.
Orchidectomy will possibly reduce sperm count a little.
Chemotherapy:
Reduced fertility for approx 2 years
XRT (dogleg) will reduce fertility.
Solution:
Sperm banking

23. The Residual Mass after Chemotherapy
Can occur in: RP
LUNGs
Liver
Other sites.

24. What is it made off? NSGCT
Necrosis/ fibrosis= 50%
Teratoma = 45%
Viable cancer = 5%
Can you predict?
Degree of shrinkage
Teratoma in primary
Size of the mass

25. What is it made of? Seminoma
Depends on size.
<3cm only 2/74 had viable cancer
>3cm 25% had viable cancer
PET scan is useful for seminoma masses.

26. Retroperitoneal Lymphnode Dissection (RPLND)
What is it done for?
Removal of all retroperitoneal nodes after chemo (including and mass).
Removal of retroperitoneal tumour when still growing and have run out of chemotherapy
Occasional for other cancer types eg. Renal cancer or TCC of the bladder.

27. Boundries of RPLND

28. A Severe Case.
Duodenum
Mass
Aorta
IVC
Kidney

29. Lumber Sympathetic Nerves Control Ejaculation
Sympathetic chain
Lumber Sympathetic
Nerves
Hypogastric plexus

30. Nerve sparing: Dissection of individual sympathetic nerves
Left Sympathetic nerves
Aorta
IVC
Right Sympathetic nerves

31. Post-op course
Ileus
Respiratory
Pain
Fluid shifts
Warm legs

32. Complications Short term Long-term Prolonged ileus Bowel obstruction
Respiratory failure PE
Ascites (chylous)
Long-term
Anejaculation
Adhesive bowel obstruction

33. Follow-up Depends on cancer stage and presense of residual disease.
Generally don’t need abdo CTs
Tumour Markers
Chest XR