Presentation is loading. Please wait.

Presentation is loading. Please wait.

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

Similar presentations


Presentation on theme: "Testicular Cancer and Retroperitoneal Lymph Node Dissection Dr Manish Patel Urological Cancer Surgeon, Westmead Hospital Senior Lecturer, University of."— Presentation transcript:

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 Germ Cell Tumors CIS Seminoma Classic, Anaplastic, spermatocytic NSGCT Embryonal Yolk Sac Choriocarcinoma Teratoma Sex Cord/gonadal stromal tumors 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

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

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

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

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

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

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

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

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

12 Radical (Inguinal) orchidectomy

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

14 NSGCT- Stage II Disease in RP

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

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

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

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

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

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

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

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

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

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

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

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

27 Boundries of RPLND

28 A Severe Case. Kidney Mass IVC Duodenum Aorta

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

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

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

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

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


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

Similar presentations


Ads by Google