1. Testicular tumours Urology 2012

2. Case presentation HistoryHistory 2525 C/o hemoptysis, abdominal discomfort;C/o hemoptysis, abdominal discomfort; History of UDT, right side-operatedHistory of UDT, right side-operated No childNo child 2

3. o On exam: o Generally well o Scar R groin o Nodes palpable, inguinal o Big R testis, normal L testis o What next?

4. Outcomes Clinical presentation – age, Metastasis Classification Diagnosis Differential diagnosis Management

5. Epidemiology Incidence 2-3/100 000 in whites <1/100 000 in blacks R > L 2-3% bilateral 95% Germ cell Age 16-35 yrs

6. Aetiology Gonadal dysgenesis Hereditary not clear Environmental factors Chemical carcinogens Infections 7-10% in undescended testis- Dysgenesis, temp, Abn blood supply, endocrine dysf(x)

7. Risk Factors Previous history of testicular tumor UDT Infertility Atrophic testis CIS

8. Anatomy

9. Classification Germ cell – Seminoma – Non seminoma – Embryonal – Choriocarcinoma – Teratocarcinoma – Yolk sac tumour – Mixed variant Non Germ cell – Leydig cell – Sertoli cell – Sarcoma – leukaemia – Lymphoma – metastasis

10. Frequency Seminoma -30% Embryonal Carcinoma- 30% Teratoma- 10% Teratocarcinoma- 25% Choriocarcinoma -1% Combined- 15%o

11. Tumour markers AFP B-HCG LDH

12. Metastatic pattern Local Lymphatic hematogenous

13. Clinical presentetion 50% have metastasis on diagnosis 10% present with this as first sx Neck mass, respiratory, GIT, bone pain, neurological, lower extremities Local Heavy feeling or painless swelling 10% acute testicular pain 5% Gynecomastia

14. Examination Local exam Contra lateral vs. ipsilateral testis, Epydidimis Spermatic cord Abdominal General

15. Differential diagnosis Testicular torsion Epidydimo-orchitis Hydrocoele Inguinoscrotal hernia paratesticular tumours

16. Investigations Laboratory Serum tumour markers FBC, U&E,LFT`s Radiological – Sonar – CXR – CT scan abdomen – Role of MRI?

17. Sonar

18. CT Scan

19. MRI

20. staging – Clinical and surgical – Tumor type – degree of infiltration – Vascular invasion – Lymph metastasis – Distant metastasis – Serum tumor markers

21. Staging A- confined to testis B -Retroperitoneal spread – B1-3 C- Metastatic disease Or TNMS staging

22. Prognosis Mortality 50% in 1970 Cure rate of > 95 % now! Morbidity – Tumour related – Treatment related – Fertility?,QOL

23. Prognosis Seminoma –overall cure rate is > 90% Age – older patients Sperm cryopreservation? B HCG positive in 5-10% very radio & chemosensitive

24. Non seminoma Choriocarcinoma- Can present with extensive metastasiss with paradoxically small primary Teratoma- mature and immature elements Yolk sac tumour- In infants and young children

25. treatment NB Multimodal Radical orchidectomy Radiotherapy Chemotherapy Retroperitoneal lymph node dissection Follow up

26. General comments Misdiagnosis common No transscrotal biopsies Good work-up Quick referral Follow up !

27. Other Extragonadal germ cell tumours Leydig cell – 10% malignant, present in children with virilising and in adults feminising. Sertoli cell- any age.10% malignant Gonadoblastoma- In dysgenetic gonads

28. Secondary tumours Lymphoma Leukaemic infiltration Metastasis- prostate, Breast, kidney

29. Thank you