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

Normal Testicle

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

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.

Germ Cell tumors-Seminoma 35-70% of GCT Aged 30-40 y.o Can contain synsytiotrophoblasts No AFP elevation, 15% have HCG elevation.

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

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

Testis cancer-Epidemiology Most frequent malignancy of white males aged 20-34. Rare in Asian and African populations. Frequency Increasing. ?Why Encourage testicular self exam- no evidence of clear benefit.

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?

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.

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

Radical (Inguinal) orchidectomy

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

NSGCT- Stage II Disease in RP

NSGCT- Stage II Disease in RP Options Chemotherapy RPLND

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

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

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

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

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

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

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

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

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

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.

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.

Boundries of RPLND

A Severe Case. Duodenum Mass Aorta IVC Kidney

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

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

Post-op course Ileus Respiratory Pain Fluid shifts Warm legs

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

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