1. Testicular tumors

2. Incidence Testicular tumors are rare. 1 – 2 % of all malignant tumors.
Most common malignancy in men in the 15 to 35 year age group.
Benign lesions represent a greater percentage of cases in children than in adults.

3. Age peaks
2 – 4 yrs
20 – 40 yrs
above 60 yrs
Testicular cancer is one of the few neoplasms associated with accurate serum markers.
Most curable solid neoplasms and serves as a paradigm for the multimodal treatment of malignancies.

4. Etiology Cryptorchidism Intersex disorder Testicular atrophy
Trauma- prompts medical evaluation
Chromosomal abnormalities - loss of chromosome 11, 13, 18, abnormal chromosome 12p.
Sex hormone fluctuations, estrogen administration during pregnancy

5. CROSS SECTION OF TESTIS
Stroma Seminiferous Tubules
(200 to 350 tubules)
Interstitial Cells Supporting Spermatogonia
Leydig and
(Androgen) Sertoli Cell

6. CLASSIFICATION I. Primary Neoplasms of Testis. A. Germ Cell Tumor.
B. Non-Germ Cell Tumor .
II. Secondary Neoplasms.
III. Paratesticular Tumors.

7. Germ cell tumors 1. Seminomas - 40% (a) Classic Typical Seminoma
(b) Anaplastic Seminoma
(c) Spermatocytic Seminoma
2. Embryonal Carcinoma %
3. Teratoma %
(a) Mature
(b) Immature
4. Choriocarcinoma - 1%
5. Yolk Sac Tumour

8. Sex cord/ gonadal stromal tumors ( 5 to 10% )
1. Specialized gonadal stromal tumor
(a) Leydig cell tumor
(b) sertoli cell tumor
2. Gonadoblastoma
3. Miscellaneous Neoplasms
(a) Carcinoid tumor
(b) Tumors of ovarian epithelial sub
types

9. A. Metastases from any source
II. SECONDARY NEOPLASMS OF TESTIS
A. Metastases from any source
III. PARATESTICULAR NEOPLASMS
A. Adenomatoid
B. Cystadenoma of Epididymis
C. Desmoplastic small round cell tumor
D. Mesothelioma
E. Melanotic neuroectodermal

10. Carcinoma insitu {CIS}
Pre invasive precusor of all GCT, except spermatocytic seminoma
Incidence of CIS in the male population is 0.8%.
Testicular CIS develops from fetal gonocytes & is characterized histologically by seminiferous tubules containing only Sertoli cells and malignant germ cells.

11. Patients at risk of CIS History of testicular carcinoma (5% to 6%),
Extra gonadalGCT (40%),
Cryptorchidism (3%),
Contralateral testis with unilateral testis cancer (5% to 6%),
Somatosexual ambiguity (25% to 100%)
Atrophic testis 30 %
Infertility (0.4% to 1.1%)
TESTICULAR BIOPSY gold standard for diagnoses of CIS

12. Lymphatic drainage
The primary drainage of the right testis is within the interaortocaval region.
Left testis drainage , the para-aortic region in the compartment bounded by the left ureter, the left renal vein, the aorta, and the origin of the inferior mesenteric artery.
Cross over from right to left is possible.

13. Lymphatic drainage
Lymphatics of the epididymis drain into the external iliac chain.
Inguinal node metastasis may result from scrotal involvement by the primary tumor, prior inguinal or scrotal surgery, or retrograde lymphatic spread secondary to massive retroperitoneal lymph node deposits.
Testicular cancer spreads in a predictable and stepwise fashion, except choriocarcinoma. .

14. Clinical features Painless Swelling of One testis
Dull Ache or Heaviness in Lower Abdomen
10% - Acute Scrotal Pain
10% - Present with Metatstasis
- Neck Mass / Cough / Anorexia / Vomiting / Back Ache/ Lower limb swelling
5% - Gynecomastia
Rarely - Infertility

15. Physical Examination Examine contralateral normal testis.
Firm to hard fixed area within tunica albugenia is suspicious
Seminoma expand within the testis as a painless, rubbery enlargement.
Embryonal carcinoma or teratocarcinoma may produce an irregular, rather than discrete mass.

16. Differential Diagnosis
Testicular torsion
Epididymitis, or epididymo-orchitis
Hydrocele,
Hernia,
Hematoma,
Spermatocele,
Syphilitic gumma .

17. DICTUM FOR ANY SOLID SCROTAL SWELLINGS
All patients with a solid, Firm Intratesticular Mass that cannot be Transilluminated should be regarded as Malignant unless otherwise proved.

18. Scrotal ultrasound
Ultrasonography of the scrotum is a rapid, reliable technique to exclude hydrocele or epididymitis.
Ultrasonography of the scrotum is basically an extension of the physical examination.
Hypoechoic area within the tunica albuginea is markedly suspicious for testicular cancer.

19. Cystic lesion- epidermoid cyst

20. Tumor markers TWO MAIN CLASSES Onco-fetal Substances : AFP & HCG
Cellular Enzymes : LDH & PLAP
AFP - Trophoblastic Cells
HCG - Syncytiotrophoblastic Cells
( PLAP- placental alkaline phosphatase, & LDH lactic acid dehydrogenase)

21. AFP –( Alfafetoprotein)
NORMAL VALUE: Below 16 ngm / ml
HALF LIFE OF AFP – 5 and 7 days
Raised AFP :
Pure embryonal carcinoma
Teratocarcinoma
Yolk sac Tumor
Combined tumors,
AFP not raised in pure choriocarcinoma , & in pure seminoma

22. HCG – ( Human Chorionic Gonadotropin)
Has  and  polypeptide chain
NORMAL VALUE: < 1 ng / ml
HALF LIFE of HCG: 24 to 36 hours
RAISED  HCG -
100 % - Choriocarcinoma
60% - Embryonal carcinoma
55% Teratocarcinoma
25% - Yolk Cell Tumour
7% - Seminomas

23. ROLE OF TUMOUR MARKERS
Helps in Diagnosis to 85% of Testicular Tumours have Positive Markers
Most of Non-Seminomas have raised markers
Only 10 to 15% Non-Seminomas have normal marker level
After Orchidectomy if Markers Elevated means Residual Disease .
Elevation of Markers after Lymphadenectomy means a STAGE III Disease

24. ROLE OF TUMOUR MARKERS
Degree of Marker Elevation Appears to be Directly Proportional to Tumor Burden
Markers indicate Histology of Tumor:
If AFP elevated in Seminoma - Means Tumor has Non-Seminomatous elements
Negative Tumor Markers becoming positive on follow up usually indicates - Recurrence of Tumor
Markers become Positive earlier than X-Ray studies

25. Imaging studies Chest X ray CECT abdomen – retroperitoneal nodes
PET- No apparent advantage over CT
MRI - No apparent advantage over CT

26. Large left para aortic nodal mass due to GST causing hydronephrosis

27. Tumor staging
Primary Tumor (T)pTX - Primary tumor cannot be assessed (if no radical orchiectomy has been performed, TX is used)
pT0 - No evidence of primary tumor (e.g., histologic scar in testis)
pTis - Intratubular germ cell neoplasia (carcinoma in situ)
pT1 - Tumor limited to the testis and epididymis and no vascular/lymphatic invasion
pT2 - Tumor limited to the testis and epididymis with vascular/lymphatic invasion or tumor extending through the tunica albuginea with involvement of tunica vaginalis
pT3 - Tumor invades the spermatic cord with or without vascular/lymphatic invasion
pT4 - Tumor invades the scrotum with or without vascular/lymphatic invasion

28. Regional Lymph Nodes
Clinical NX - Regional lymph nodes cannot be assessed
N0 - No regional lymph node metastasis
N1 - Lymph node mass 2 cm or less in greatest dimension or multiple lymph node masses, none more than 2 cm in greatest dimension
N2 - Lymph node mass, more than 2 cm but not more than 5 cm in greatest dimension, or multiple lymph node masses, any one mass greater than 2 cm but not more than 5 cm in greatest dimension
N3 - Lymph node mass more than 5 cm in greatest dimension

29. Pathologic node staging
pN0 - No evidence of tumor in lymph nodes
pN1 - Lymph node mass, 2 cm or less in greatest dimension and ≤6 nodes positive, none >2 cm in greatest dimension
pN2 - Lymph node mass, more than 2 cm but not more than 5 cm in greatest dimension; more than 5 nodes positive, none >5 cm; evidence of extranodal extension of tumor
pN3 - Lymph node mass more than 5 cm in greatest dimension.

30. Distant metastasis M0 - No evidence of distant metastases
M1 - Nonregional nodal or pulmonary metastases
M2 - Nonpulmonary visceral masses

31. Serum tumor markers LDH HCG Miu/ml AFP Ng/ml S0 _< N <N S1
<1.5 x N
< 5000
< 1000 S2
1.5-10x N
5000 to
1000 to 10000 S3
>10x N
> 50000
>10000

32. PRINCIPLES OF TREATMENT
Treatment should be aimed at one stage above the clinical stage
Seminomas - Radio-Sensitive. Treat with Radiotherapy.
Non-Seminomas are Radio-Resistant and best treated by Surgery
Advanced Disease or Metastasis - Responds well to Chemotherapy

33. PRINCIPLES OF TREATMENT
Radical INGUINAL ORCHIDECTOMY is Standard first line of therapy
Lymphatic spread initially goes to
RETRO-PERITONEAL NODES
Early hematogenous spread RARE
Bulky Retroperitoneal Tumours or Metastatic Tumors Initially “DOWN-STAGED” with CHEMOTHERAPY

34. PRINCIPLES OF TREATMENT
Transscrotal biopsy is to be condemned.
The inguinal approach permits early control of the vascular and lymphatic supply as well as en-bloc removal of the testis with all its tunicae.
Frozen section in case of dilemma.

35. Chemotherapy Toxicity
BEP -
Bleomycin Pulmonary fibrosis
Etoposide (VP-16) Myelosuppression
Alopecia
Renal insufficiency (mild)
Secondary leukemia
Cis-platin Renal insufficiency
Nausea, vomiting
Neuropathy

36. Lymph Nodes Dissection For Right & Left Sided Testicular Tumours

37. CONCLUSION
Improved Overall Survival of Testicular Tumour due to Better Understanding of the Disease, Tumour Markers and Cis-platinum based Chemotherapy.
Current Emphasis is on Diminishing overall Morbidity of Various Treatment Modalities .

38. THANK YOU