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Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

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Presentation on theme: "Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell."— Presentation transcript:

1 Tumors of the testis S. Vahidi M.D

2 Tumors of the testis Introduction: 1-8 new cases/ male/year 1-8 new cases/ male/year 90-95% germ cell tumors 90-95% germ cell tumors Survival of patients has improved dramatically Survival of patients has improved dramatically Higher socioeconomic/lower classes 2/1 Higher socioeconomic/lower classes 2/1 R>L R>L 1-2%: Bilateral. Seminoma-lymphoma 1-2%: Bilateral. Seminoma-lymphoma 7-10% of T-tumors develop in cryptorchidism 7-10% of T-tumors develop in cryptorchidism Orchiopexy does not alter the malignant potential Orchiopexy does not alter the malignant potential Exogenous estrogen Adm. To the mother during pregnancy Exogenous estrogen Adm. To the mother during pregnancy

3 Tumors of the testis Classification: Primary Benigne Primary Benigne Secondary Malignant Secondary Malignant Germ cell Germ cell Non germ cell Non germ cell Germ cell tumors: Germ cell tumors:Seminoma Nonseminomatous: Embryonal Teratoma Teratoma Choriocarcimoma Choriocarcimoma Mixed tumors Mixed tumors

4 Tumors of the testis Tumorigenic hypothesis: Normal spermatocyte Totipotential germ cell Embryonal carcinoma (totipotential tumor cell) Seminoma Choriocarcimoma Yolk sac tumor Teratoma ? Extra embryonic differentiation Trophoblastic pathways Yolk sac pathways Intra embryonic differentiation

5 Tumors of the testis Pathology A. Seminoma (35%) Classic (85%) Classic (85%) Anaplastic (5-10%) Anaplastic (5-10%) Spermatocytic (5-10%) Spermatocytic (5-10%) B. Embryonal cell carcimoma (20%) Adult type Adult type Infantile type (yolk sac tumor) Infantile type (yolk sac tumor) C. Teratoma (5%) D. Choriocarcinoma (<1%) E. Mixed cell type (40%) Teratocarcinoma Teratocarcinoma F. Carcimoma in situ (CIS)

6 Tumors of the testis Patterns of metastatic spread Step wise lymphatic fashion. (T1-T4) Step wise lymphatic fashion. (T1-T4) RT testis: intra aortocaval at RT K.hilum RT testis: intra aortocaval at RT K.hilum Precaval-preaortic-Paracaval-RT common Iliac- RT ext Iliac nodes LT testis: paraaortic area at LT K. Hilum LT testis: paraaortic area at LT K. Hilum Pre aortic- LT common Iliac- LT ext. Iliac nodes RT to LT crossover metastasis: common RT to LT crossover metastasis: common LT to RT crossover metastasis: No LT to RT crossover metastasis: No Visceral metastases: lung – liver-brain – bone- kidney-adrenal. GI. Spleen Visceral metastases: lung – liver-brain – bone- kidney-adrenal. GI. Spleen Hematogenous : choriocarcinoma Hematogenous : choriocarcinoma

7 Tumors of the testis Clinical staging T-primary tumors Cannot be assessed No evidence of primary tumor Intratubular cancer (CIS) Limited to testis and epididymis, no vascular invasion Invades beyond tunica albuginea or has vascular invasion Invades spermatic cord Invades scrotum TX:T0:Tis:T1:T2:T3:T4: N-Regional lymph nodes Cannot be assessed No regional lymph node metastasis Lymph node metastasis 2cm, or multiple nodes, none more than 2 cm. and<6 nodes positive Nodal mass>2cm and 5cm. Or 6 nodes positive Nodal mass> 5 cm NX:N1:N2:N3: M-Distant metastasis Cannot be assessed No distant metastasis Distant metastasis present in nonregional lymph nodes or lungs Nonpulmonary visceral metastases MX:M0:M1:M2: S-Serum tumor markers Markers not available Marker levels within normalimits Lactic acid dehydrogenase (LDH)<1.5xnormal and HCG<500 mlU/ml and AFP<1000ng/ml LDH xnormal or hCG mIU/ml or AFP ng/ml LDH>10xnormal or hCG>50000 mIU/ml or AFP>10000 ng/ml SX:S0:S1:S2:S3:

8 Tumors of the testis Clinical findings A-symptoms: Painless enlargment of testis Painless enlargment of testis Acute testicalor pain (10%) Acute testicalor pain (10%) Symptoms related to metastasis (10%): back pain- cough-dyspnea anorexia-nausea- bone pain- lower ext. edema Symptoms related to metastasis (10%): back pain- cough-dyspnea anorexia-nausea- bone pain- lower ext. edema Asymptomatic (10%) Asymptomatic (10%)

9 Tumors of the testis Clinical findings B: signs: Testicular mass or diffuse enlargment Testicular mass or diffuse enlargment Node palpation Node palpation Gynecomastia Gynecomastia Hemoptysis Hemoptysis

10 Tumors of the testis Laboratory findings and tumor markers: Anemia- liver function tests- creatinin Anemia- liver function tests- creatinin Tumor markers: Tumor markers: αFP αFP βHCG βHCG LDH LDH PLAP-GGT PLAP-GGT AFP(%)hCG(%) SeminomaTeratomaTeratocarcinomaEmbryonalchoriocarcinoma

11 Tumors of the testis Imaging Ultrasonography Ultrasonography CXR CXR CT-Scan CT-Scan Pedal LAG Pedal LAG For staging

12 Differential diagnosis Epdidymitis & Epididymoorchitis Epdidymitis & Epididymoorchitis Hydrocele Hydrocele Spermatocele Spermatocele Hematocele Hematocele Granulomatous orchitis Granulomatous orchitis Varicocele Varicocele Epidermoid cyst Epidermoid cyst Tumors of the testis

13 Treatment Inguinal Exploration & radical orchiectomy A. A. Low stage seminoma: retroperitoneal irradiation 95% care A. high stage seminoma: primary chemotherapy 95% complete response Tumors of the testis

14 Treament C: low stage NSGCT: R.O +RPLND (N2 2cycles chemotherapy) Surveillncc: 1)NSGCT confined within tunica albuginea 2)No vascular invasion 3)normalize tumor markers 4)no evidence of disease in radiographic imaging 5)the patient is considered reliable Modified RPLND: Nodal tissue dissection ipsilateral to the tumor below the level of the inferior mesenteric artery Clinical stage I+ vascular invasion: 2 cycles of chemotherapy Tumors of the testis

15 Treatment High stage NSGCT: primary chemotherapy (+RPLND?) Normal tumor marker+retroperitoneal mass mass resection tumor marker salvage chemotherapy tumor marker salvage chemotherapy (upto 70% care) (upto 70% care) High risk patients: mediastinal primary tumor non pulmonary visceval metastasis S3 marker levels Tumors of the testis

16 Follow up: careful exam of remaining testis, abdomen, lymph node area lab (AFP, BHCG-LDH) CXR every 3 month/ first 2 years every 6 month/ until 5 years and then yearly Surveillance follow up: tumor marker at each visit. CXR & CT every 3-4 month Visit: monthly/ first 2 years bimonthly/ third year bimonthly/ third year Tumors of the testis

17 Prognosis Seminoma: R.O+radiotherapy: stage I: 98% 5 years survival rate stage II: 92-94% 5 years survival rate stage III (chemotherapy): 35-75% NSGCT: stage I: % low, volume stage II: 90% low, volume stage II: 90% stage III: 55-80% stage III: 55-80% Tumors of the testis

18 Non-Germ cell tumors 5-6% of all testis tumor leydig cell tumors most common 5-9 & years old no association with UDT clinical finding: virilization (prepubertal) asymptomatic (adults). 10% malignant Treatment : radical orchiectomy- RPLND Sertoli cell tumors exceedingly rare 10% malignant radical orchiecty+RPLND Gonadoblastoma in gonadal dysgenesis(80% female fenotype) radical orchiectomy + contralateral gonadectomy Tumors of the testis

19 Secondary tumors of the testis 1. lymphoma most common t.t. in>50 years old 2. leukemiat.Biopsy is choice 3. metastatic tumor: prostate- lung – GI-melanoma-kidney Tumors of the testis

20 Extragonadal germ cell tumors 3% of all germ cell tumors the most common sites: mediastinum- retroperitoneum, sacrococcygeal – pineal gland Tumors of the testis

21 Tumors of the epididymis, paratesticular tissue & spermatic cord T. Of epididym: commonly benign: adenomatoidleiomyomacystadenoma T. of spermatic cord: lipomaRabdomyosarcoma leiomyosarcoma. Fibrosarcoma liposarcoma Tumors of the testis


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