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Epidemiology Are rare, lifetime probability 0.2%

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Presentation on theme: "Epidemiology Are rare, lifetime probability 0.2%"— Presentation transcript:

1 Epidemiology Are rare, lifetime probability 0.2%
90-95% are germ cell tumor More common in whites (4 fold) More in high socioeconomic class (2 fold) More common on right side Geographical difference noted

2 Bilateral tumors 1-2% are bilateral 50% in men with history of UDT
Synchronously or asynchronously Seminoma is the most common germ cell tumor in primary type Malignant lymphoma is the most common bilateral tumor of testis

3 Risk factors Cryptorchidism, most important
7-10% in men with Hx of UDT Seminoma is the most common form Risk is higher in intra-abdominal testis Orchiopexy do not alter the risk Exogenous estrogen to pregnant mother Truma Infection related atrophy

4 Classification Seminoma Embryonal Teratoma Nonseminoma Choriocarcinoma
Mixed tumors

5 Seminoma (35%) Has 3 histologic type Classic seminoma 85%
More common in 4th decade of life Syncytiotrophoblastic elements in 10-15% Anaplastic seminoma 5-10% of all seminoma More than 3 mitosis and high pleomorphism Present at higher stage than classical type Spermatocytic seminoma 5-10% More than 50% are over the 50 years

6 Normal testis

7 Seminoma

8 Embryonal cell carcinoma(20%)
Adult type and infantile type(Yolk sac tumor) Extensive hemorrhage and necrosis Marked pleomorphism and mitosis Yolk sac tumor is most common germ cell tumor of infants and children Embryoid body commonly seen and resemble 1-2 week embryo

9 Embryonal

10 Teratoma (5%) Seen in adult and children
Contain more than one germ cell layer Mature teratoma may have elements resembling benign structures derived from ectoderm ,mesoderm and edoderm

11 Choriocarcinoma(<1%)
Are rare tumors Lesion are small with central hemorrhage Syncytio-and cytotrophoblasts must be seen Are aggressive tumors with early hematogenous spread

12 Mixed cell type(40%) Most are teratocarcinoma ( 25%)
Treatment is like nonseminomatous germ cell tumor Carcinoma in situ : 5% in contralateral testis Contralateral atrophy or microlithiasis may be a sign of CIS and needs BX CIS usually treated by radiotherapy

13 Metastasis Spread in a stepwise lymphatic fashion
Lymph nodes of testis extend from T1-L4 Primary site for right testis is interaortocaval area Primary site for left testis is para-aortic area Right to left crossover metastasis are common Visceral metastasis may be seen in advance disease Lung,Liver,Brain,Bone,Kidney,Adrenal,GI ,Spleen Choriocarcinoma is the exception with early hematogenous spread especially to lung

14 Staging Stage A: confined to testis
Stage B: regional lymph node spread Stage C: Beyond retroperitoneal lymph node Stage I: confined to testis Stage II: retroperitoneal lymph node involvement:IIA<2cm, IIB>2cm Stage III: supradiphragmatic node involvement or visceral involvement

15 TNM staging

16 Symptoms Painless enlargement of testis Acute testicular pain (10%)
Symptoms related to metastatic disease (10%) Back pain, cough, bone pain Asymptomatic (10%)

17 Signs Testis mass or diffuse enlargement Mass is firm and non tender
Hydrocele Gynecomastia (5% all, 30-50%sertoli and leydig cell tumors) Hemoptysis

18 Lab findings Anemia Renal function tests Liver function tests
Placental Alkaline phosphatase (PLAP) Gamma-glutamyl tranpeptidase (GGT)

19 Alfa- fetoprotein (AFP)
Glycoprotein, half life : 4-6 days High level in fetal serum Trace amount after 1 y/o Never found in seminoma present in many NSGCT

20 Human chorionic gonadotropin
Glycoprotein, half life: 24 hrs Has 2 subunit: alpha, beta Normal men has not significant level of HCG Elevated in all NSGCT and in 7% of seminoma

21 Lactic acid dehydrogenase
A cellular enzyme, has 5 isoenzyme Normally found in muscle, liver, kidney and brain Elevated level of total and isoenzyme I in NSGCT May be elevated in seminoma

22 Tumor markers in different tumor

23 Differential diagnosis
Incorrect initial diagnosis in 25% Epididymitis and epididymo-orchitis Hydrocele Hematocele, spermatocele Varicocele Epidermoid cyst

24 Imaging Scrotal sonography CT scan
Chest radiography (85-90% of lung metastasis) Pedal lymphangiography

25 Sonography

26 Figure 13a. Testicular germ cell tumor.
Figure 13a.  Testicular germ cell tumor. (a) US image shows an enlarged testis (arrows) with heterogeneous parenchyma and multiple cystic areas. (b) On a color Doppler US image, the mass (arrowheads) is hypervascular with cystic areas. Chavhan G B et al. Radiographics 2008;28: ©2008 by Radiological Society of North America

27 Sonography

28 CT scan in testis tumor

29 CT scan in testis tumor

30 Treatment (seminoma) Low stage:
Radical orchiectomy+ retroperitoneal irradiation 95% of stage I are cured Low-volume retroperitoneal disease can be treated by radiation No prophylactic mediastinal radiation Chemotherapy as salvage therapy


32 Treatment (seminoma) High stage (bulky seminoma ) Primary chemotherapy
Cisplatin, Bleomycin, Etoposide PEB for 3 cycle or PE for 4 cycles 90% complete response Residual mass are 90% fibrosis If well circumscribed and >3 cm consider excision

33 Treatment(NSGCT) Low stage Orchiectomy and: Survveillance
RPLND or modified RPLND Primary chemotherapy (PEB)

34 Surveillance (NSGCT) Tumor is NSGCT, confined to tunica albuginea
No vascular invasion Tumor markers normalize after orchiectomy No evidence of disease in imaging(CXR, CT) Patient is reliable

35 RPLND (classic)

36 RPLND (modified)

37 Treatment(NSGCT) High stage NSGCT:(>3cm node or >3 node)
Primary platinum based chemotherapy Resection of residual mass if tumor markers will normalize 20%residual cancer usually embryonal cell If markers not normalized salvage chemotherapy (BEP+Ifosfamide) 70% cure rate

38 Non-Germ cell tumors 5-6% of all testis tumors Leydig cell tumors
Sertoli cell tumors Gonadoblastoma

39 Leydig cell tumors Most common Non-germ cell tumor
1-3% of all testis tumor 25% in childhood Peak incidence 5-9 y/o and y/o Bilateral in 5-10% No association with UDT No necrosis and hemorrhage Reinke crystals are pathognomic

40 Leydig cell tumors Virilization and benign in prepubertal
Asymptomatic and 10% malignant in adults Gynecomastia in 20-25% Elevated level of 17 ketosteroid and estrogen 10-30 elevation of 17 keto steroid is typical of malignancy Radical orchiectomy RPLND for malignant lesions Prognosis is excellent for benign lesion and poor for metastatic disease

41 Sertoli cell tumor Rare, < 1% of all testis tumor
Peak incidence <1 y/o and y/o 10% malignant Testicular mass, Virilization in children, Gynecomastia in 30% adults Radical orchiectomy RPLND in metastatic disease

42 Gonadoblastoma 0.5% of all testis tumor
Almost exclusively in gonadal dysgenesis Peak incidence in <30 years 4/5 patients are female phenotypically Male patients have UDT or Hypospadiasis Radical orchiectomy If gonadal dysgenesis contralateral gonadectomy because 50% bilateral Prognosis is excellent

43 Secondary tumors of testis
Are rare Lymphoma Leukemia Metastatic

44 Lymphoma Most common testis tumor in >50 yrs
Most common secondary neoplasm of testis 5% of all testis tumor Hemorrhage and necrosis are common Late presentation of widespread lymphoma Initial presentation of occult disease Primary extragonadal disease

45 Lymphoma Painless enlargement of testis
Bilateral testis involvement in 50% Constitutional symptoms in 25% Fine needle aspiration Radical orchiectomy Adjuvant chemotherapy for primary testicular lymphoma

46 Other secondary tumors
A common site of relapse in ALL Bilateral involvement in 50% Testis biopsy for diagnosis Bilateral testis radiation+ adjuvant chemotherapy Metastatic tumor is rare Prostate is the most common primary site

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