Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Urology 10 Testicular Tumors PPT-Powerpoint Presentations and lecture notes
Testicular tumors
Department of Urology
T
E S T I
C
U L AR TUMORS:
? Testicular cancer accounts for
? Testicular cancer although
only about 1% of all human
rare, is the most common
neoplasms.
malignancy in men in 15-35
years age group and
accounts for approximately
23% of all cancers in this
group.
WHO CLASSIFICATION OF TESTICULAR
TUMORS:
Germ cell tumors:
Precursor lesions- intratubular malignant germ cell tumor (carcinoma
in situ)
Tumors of one histologic type (pure forms)
Seminoma
variant- seminoma with syncitiotrophoblastic cells
Spermatocytic seminoma
variant- spermatocytic seminoma with sarcoma
Embryonal carcinoma
Yolk sac tumor
Polyembryoma
Trophoblastic tumors- choriocarcinoma
Teratoma
Mature teratoma
Dermoid cyst
Immature teratoma
Teratoma with malignant areas
Mixed tumors
CLASSIFICATION (CONT...)
Sex cord/ Gonadal Stromal Tumors:
-Pure forms
Leydig's cell tumor
Sertoli's cell tumor
large cell calcifying
lipid rich cell
-Granulosa cell tumor
Adult type granulosa cell tumor
Juvenile type granulosa cell tumor
-Tumors of thecoma/ fibroma group
-Incompletely diffrentiated sex cord/ gonadal stromal tumors
-Mixed forms.
CLASSIFICATION (CONT...)
-Unclassified forms
-Tumors containing both germ cell and sex cord/ gonadal stromal
elements
-Gonadoblastoma
-Mixed germ cell- sex cord/ gonadal stromal tumors,
unclassified
-Miscellaneous tumors
-Carcinoid tumors
-Tumors of ovarian epithelial types.
CLASSIFICATION (CONT...)
-Lymphoid and hematopoietic tumors:
-Lymphoma
- Plasmacytoma
- Leukemia
-Tumors of collecting duct and rete:
-Adenoma
-Carcinoma
-Tumors of tunica, epididymis, spermatic cord, supporting
structures, and appendices:
-Adenomatoid tumor
- Mesothelioma
- Adenoma
-Carcinoma
-Melanotic neuroectodermal tumor.
CLASSIFICATION (CONT...)
-Soft tissue tumors,
-Unclassified tumors, and
-Secondary tumors.
GERM CELL TUMORS- EPIDEMIOLOGY
Low in
Life time
probability of
Africa
developing
and Asia.
testicular
cancer is 0.2%.
The average annual age
adjusted rate is highest in
Denmark, Norway,
Switzerland Germany and
Intermediate
New Zealand.
in U.S and
U.K.
GERM CELL TUMORS- EPIDEMIOLOGY
AGE:
RACIAL FACTORS:
?These neoplasms
?More common in
are the most
white population
common
solid
than in blacks.
tumors of men
age 20 ? 40 years
and second most
common of men
age 15 ? 19
years.
GERM CELL TUMOR- EPIDEMIOLOGY
The evidence for a
predominantly genetic
influence is not
overwhelming.
GENETIC FACTORS:-
The 2 ? 3% incidence of
bilateral tumors may
suggest the potential
importance of genetic and
(or) congenital factors.
GERM CELL TUMORS- ETIOLOGY
CRYPTORCHIDISM:
7-10% of patients with testicular tumors have prior
history of cryptorchidism.
The relative risk of developing a testicular cancer in
maldescent testis is 3 to 14 times the normal expected
incidence.
5-10% of patients with a history of cryptorchidism develop
malignancy in the contralateral normally descended testes.
25% of patients with bilateral cryptorcidism and a history of
tetsis cancer develop second GCT.
GERM CELL TUMORS- ETIOLOGY
TRAUMA:
ATROPHY:
? There is little to
? Causative role of
suggest a cause and
atrophy remains
effect relationship in
speculative.
humans.
? nonspecific or mumps
associated atrophy of
? Infact trauma in an
the testis has been
enlarged testes is an
suggested as a potential
event that prompts
causative factor in
medical evaluation.
testicular cancer.
GERM CELL TUMORS- ETIOLOGY
Offspring of
women exposed to
Exogenous
diethylstilbestrol
estrogen
or oral
administration has
HORMONES:
contraceptives has
also been linked to
relative risk rate of the induction of
developing
leydig's cell
testicular cancer
tumors.
of 2.8 - 5.3%.
GERM CELL TUMOR- CLINICAL MANIFESTATIONS:
The usual presentation of a testicular tumor is
a nodule or painless swelling in one gonad.
30-40% may complain of a
On rare occasions,
dull ache or heavy
infertility is the presenting
sensation in the lower
complaint.
abdomen, anal area, or
scrotum.
In 10%, acute pain is the
presenting complain.
GERM CELL TUMORS- CLINICAL MANIFESTATIONS
In 10% of patients, the presenting manifestation may be due to metastasis:-
A neck mass
? Supraclavicular lymph node metastasis.
Gastrointestinal disturbances
? Retroduodenal metastasis
Lumbar back pain
? Involving psoas muscle or nerve roots
Bone pain
? Skeletal metastasis
Central and peripheral nervous system manifestations
? Cerebral, spinal cord, or peripheral root involvement
Unilateral or bilateral lower extremity
? Iliac or caval obstruction.
GERM CELL TUMORS- PHYSICAL EXAMINATION
BIMANUAL EXAMINATION:
Beginning with the normal contralateral testis.
Any firm, hard, or fixed area should be considered
suspicious.
Testicular tumors tend to remain ovoid, being limited
by the tough investing tunica albuginea.
A hydrocele may be present and increases the
difficulty of palpation.
GERM CELL TUMOR-
Scrotal Sonography:
USGof the scrotum is basically an extension of the physical
examination.
Any hypoechoic area within the tunica albuginea is
markedly suspicious for testicular cancer.
In patients with a diagnosis of EGCT, ultrasound of the
testis is mandatory to be certain that one is not dealing
with a primary GCT.
GERM CELL TUMORS- IMAGING STUDIES
Chest Radiography:
?Postero-anterior and lateral chest
radiographs: Metastatic workup
Chest CT:
?Indicated in patients with
abnormal X-ray scans.
GERM CELL TUMORS- IMAGING
Abdominal CT:
Most effective means to identify
retroperitoneal lymph node involvement.
Excellent for visualization of kidney, ureters,
retro-crural space in the para-aortic region.
However cannot sufficiently distinguish
between fibrosis, teratoma, and malignancy
by size criteria alone.
MRI:
Testicular tumors are hypointense on T2
weighted images, and show brisk and early
enhancement after I.V Gadolinium.
PET:
To detect radiographic abnormalities after
chemotherapy.
Neither PET nor CT has the ability to detect
microscopic nodal disease.
Applied to body fluid and tissue sections.
Oncofetal substances: associated with
embryonic development (AFP, HCG),
Cellular enzymes: LDH, PLAP.
Capable of detecting small tumor burdens
(105 cells) that are not detectable by
currently available imaging techniques.
AFP:
Not produced by pure choriocarcinoma or
pure seminoma.
HCG:
Choriocarcinoma (all patients),
Embryonal carcinoma (40-60%),
Pure seminoma (5-10%).
LDH:
Has low specificity.
There is a direct relationship between tumor
burden and LDH levels.
PLAP:
Raised in 40% of patients with advanced disease.
GGTP:
Raised in one third of patients with active
seminoma.
CD30:
? possible marker for embryonal carcinoma.
RADICAL INGUINAL ORCHIDECTOMY(HIGH
TYPE)
TESTIS SPARING SURGERY- Highly
controversial
GERM CELL TUMORS : STAGING
The American Joint Committee on Cancer staging for GCTs:
Primary Tumor (T):
pTx: primary tumor cannot be assessed.
pT0: no evidence of primary tumor
pTis: intratubular germ cell neoplasia.
pT1: tumor limited to the testis and epididymis and no vascular or lymphatic invasion.
pT2: tumor limited to the testis and epididymis with vascular or 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.
GERM CELL TUMORS : STAGING
N2:
N1:
lymph
lymph
node mass
node
more than
mass
2cm but
2cm or
not more
less in
than 5 cm
in
N3:
greatest
lymph
Region
Nx:
N0:
greatest
no
dimensio
dimension,
node
al
regional
lymph
regional
n or
or
mass
lymph
nodes
lymph
multiple
multiple
more
nodes
lymph
cannot
node
lymph
than
metastas
node
node
5cm in
(N)
be
masses,
assessed.
is.
masses,
greatest
none
anyone
dimensio
more
mass
greater
n.
than
than 2 cm
2cm in
but not
greatest
more than
dimensio
5 cm in
n.
greatest
dimension.
GERM CELL TUMOR STAGING:
Distant
M0: no
metastasis
evidence of
(M)
distant
metastasis.
M1: non
M2:
regional nodal
nonpulmonary
or pulmonary
visceral
metastasis.
metastasis.
GERM CELL TUMOR STAGING:
Serum tumor markers (S)
LDH
hCG (mIU/ml)
AFP (ng/ml)
S0
N
N
N
S1
<1.5 x N
< 5000
< 1000
S2
1.5-10 N
5000 ? 50000
1000-10,000
S3
> 10 N
>50,000
> 10,000
PROGNOSIS
SEMINOMA
Good Prognosis:
Intermediate prognosis:
? Any primary site
? Any primary site
? No pulmonary or visceral
? Nonpulmonary visceral
metastasis
metastasis
? AFP: Normal;
? AFP: Normal;
Poor prognosis:
? hCG: Any value
? hCG: Any value
No patients classified as
? LDH: Any value
? LDH: Any value
poor prognosis
PROGNOSIS
NONSEMINOMA
Good Prognosis:
Intermediate prognosis:
Poor prognosis:
? Testis or retroperitoneal
? Testis or retroperitoneal
Any of the following
primary
primary,
criteria:
? No pulmonary or visceral
? No nonpulmonary
? Mediastinal primary
metastasis
visceral metastasis
? Nonpulmonary visceral
? AFP<1000ng/ml;
? Any of: AFP1000-
metastasis
hCG<5000IU/L;
10,000ng/ml; hCG5000-
? AFP>10,000ng/ml;
LDH<1.5times upper
50,000IU/L; LDH1.5-10
hCG>50,000IU/L;
limit.
times upper limit
LDH>10 times upper
limit.
TREATMENT
Stage 1 T1-
3N0M0S0
Spematocytic
seminoma:
age >65yrs;
Typical and
exclude
anaplastic
sarcoma,
seminoma
benign tumor
Risk factors
No adjuvant
primary tumor
tratment
>6cm; vascular
or lymphatic
invasion
No risk factors
Risk factors
present
Radiation- low
Chemotherapy
surveillance
dose, abdominal
single agent-
and pelvic
carboplatin
Radiation therapy:
Today most centers administer 25Gy to para-
aortic nodes only.
This has a 5 year survival in excess of 95%.
Primary Chemotherapy:
Single agent carboplatin compare favorably
with adjuvant radiation therapy.
2 courses of carboplatin were associated with
no relapse and favorable toxicity profile.
Surveillance:
Appropriate for patients with:
1. tumors smaller than 6 cm,
2. absence of vascular invasion, and
3. normal hCG levels.
in motivated and reliable patients.
GERM CELL TUMORS
SEMINOMA: STAGE I A AND I B
Radiation-
abdominal and
Stage IIA and
pelvic
IIB seminoma
Chemotherapy-
if lymph nodes
close to kidney
GERM CELL TUMORS
SEMINOMA: STAGE I A AND I B
Radiation therapy:
N1 disease receive 30 Gy, and N2 disease receive 35 Gy.
Patients with stage II seminoma have 5 year survival rates
of 70% to 92%.
Chemotherapy:
Irradiation to kidney is avoided- parenchyma is sensitive.
So, chemotherapy is preferred in this region.
GERM CELL TUMORS
Stage IIC and III seminoma
Chemotherapy- cisplatin based
Residual retroperitoneal mass following chemotherapy
Diffuse desmoplastic
reaction- observation
Descrete well deliniated mass>3cm
Surgical resection
Histology-
Histology- germ cell
necrosis/fibrosis
tumor
observation
Salvage chemotherapy
GERM CELL TUMORS
Cisplatin based chemotherapy:
>90% of patients achieve a complete response.
Residual masses are resected if on CT scan:
-if they are well delineated,
-distinct from surrounding structures, and
-diameter is larger than 3 cm.
NON-SEMINOMATOUS GERM CELL TUMORS
STAGE 1: TREATMENT PRINCIPLES.
Stage 1
Risk factors: T2 or higher, embryonal>40%,
vascular/lymphatic invasion.
Stage 1S
Risk factors
Chemotherapy
absent
Risk factors present
BEP 3 cycles
Primary
surveillance
Modified RPLND
chemotherapy
BEP 3 cycles
Stage N0
Stage N1
Stage N2
Adjuvant
observation
observation
chemotherapy
BEP 2 cycles
NONSEMINOMATOUS GERM CELL TUMORS
STAGE 1: TREATMENT PRINCIPLES
Retro-peritoneal lymph node dissection:
? Capable of eradicating resectable disease in the majority
of N1-N2 tumors.
? 5 year survival for stage 1 is 95%.
? 5-10% experience relapse: high cure rates with
chemotherapy.
Modified (template) RPLND:
? Complete dissection in the most likely area, and
modification in less likely area.
? Ejaculation is preserved in 100%, and fertility noted in
75% of patients.
NONSEMINOMATOUS GERM CELL TUMORS
STAGE 1: TREATMENT PRINCIPLES
Primary radiation therapy:
? 5 year survival for stage 1: 80-95% when chemotherapy is
used to treat relapses.
? Relapse rate after radiation therapy: 24%.
The main objections to radiation therapy:
? Inaccuracy of clinical staging,
? Lack of survival data,
? Prior radiation makes it difficult for future surgical or
pharmacological intervention, and
? Risk of second malignancy: 18% in 25 years.
NONSEMINOMATOUS GERM CELL TUMORS
STAGE 1: TREATMENT PRINCIPLES
Prognostic factors for clinical stage 1 tumors:
? Invasion of testicular veins,
? Invasion of lymphatics,
? Absence of yolk sac elements,
? presence of embryonal cell carcinoma, and
? Angiogenesis: factor VIII stain positive.
NONSEMINOMATOUS GERM CELL TUMORS
STAGE 1: TREATMENT PRINCIPLES
Surveillance:
Surveillance is indicated in stage 1 disease:-
? without any risk factors for relapse,
? in motivated patients, and
? who fully understands the risk of failure to comply.
NONSEMINOMATOUS GERM CELL
TUMORS
STAGE 1: TREATMENT PRINCIPLES
Surveillance protocol:
Physical examination, chest radiographs, and
tumor markers: monthly for 1st year, every 2
months for second year, and every 3-6
months thereafter.
CT abd: every 2-3 months for the first 2
years, and every 6 months thereafter.
Finally, surveillance is necessary for
minimum of 5 years, possibly 10 years after
orchiectomy.
NONSEMINOMATOUS GERM CELL TUMORS
STAGE 1: TREATMENT PRINCIPLES
Primary chemotherapy:
2 cycles of bleomycin, cisplatin, and etoposide are used.
5 year survival: 95%-100%.
Added advantage of treating metastatic disease outside
the retroperitoneum.
Suitable for centers where expertise for RPLND are not
available.
NONSEMINOMATOUS GERM CELL TUMORS
STAGE I A AND I B: TREATMENT PRINCIPLES
Stage IIA and
IIB
RPLND-
Primary
bilateral
chemotherapy
BEP- 3 cycles
Minimal nodal
Nodal
involvement
involvement
<2cm
>2cm
Adjuvant
surveillance
chemotherapy
BEP- 2 cycles
NONSEMINOMATOUS GERM CELL TUMORS
STAGE I A AND I B: TREATMENT PRINCIPLES
RPLND:
A complete bilateral lymphadenectomy is recommended.
? Patients with minimal retroperitoneal disease on RPLND:
careful follow-up.
? Patients with more extensive disease on RPLND: two
cycles of adjuvant chemotherapy.
NONSEMINOMATOUS GERM CELL TUMORS
STAGE I A AND I B: TREATMENT PRINCIPLES
Primary chemotherapy:
? If nodes are larger than 3 cm on CT.
? Avoids ejaculatory failure.
Disadvantages: azoospermia, secondary malignancy.
17% of stage IIa patients and 39% of stage IIb patients
require RPLND after chemotherapy for relapse.
NONSEMINOMATOUS GERM CELL TUMORS
Stage IIC and Stage III
Good risk disease
Poor risk
disease
Chemotherapy
Chemotherapy BEP- 3 cycles
ifosfamide
substitutes
etoposide
Response to
Resolution of disease
Residual retroperitoneal mass-
Persistent elevation
chemotherapy
bilateral RPLND with tumorectomy
of tumor markers
poor, or elevated
tumor markers-
Exclude false
observation
Histology- necrosis,
Germ cell
Salvagee
fibrosis, teratoma
tumor
positive-
chemotherapy
chemotherapy
Recurrent disease
observation
Salvage
Inadequate
chemotherapy
response
Salvage chemotherapy
Desperation
surgery
Complete
No response;
response
elevated tumor
markers
observation
Desperation
surgery
NONSEMINOMATOUS GERM CELL TUMORS
STAGE I C AND I I: TREATMENT PRINCIPLES
Contraindication to adjunctive surgery in patients after
chemotherapy: The presence of elevated levels of tumor
markers.
Salvage Chemotherapy:
? residual cancer that has been resected after
chemotherapy,
? who do not respond to traditional courses of induction
therapy.
NONSEMINOMATOUS GERM CELL TUMORS
STAGE I C AND I I: TREATMENT PRINCIPLES
Patients who failed initial chemotherapy regimens:
Ifosfamide in combination with vinblastine and cisplatin.
Patients who failed 1st and 2nd line therapy:
Autologous bone marrow transplant or stem cell support
with high dose chemotherapy regimens.
THANKS
This post was last modified on 08 April 2022