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Tumors of the testis

Tumors of the testis. S. Vahidi M.D. Tumors of the testis. Introduction: 1-8 new cases/ 100000 male/year 90-95% germ cell tumors Survival of patients has improved dramatically Higher socioeconomic/lower classes 2/1 R>L 1-2%: Bilateral. Seminoma -lymphoma

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Tumors of the testis

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  1. Tumors of the testis S. Vahidi M.D

  2. Tumors of the testis Introduction: • 1-8 new cases/ 100000 male/year • 90-95% germ cell tumors • Survival of patients has improved dramatically • Higher socioeconomic/lower classes 2/1 • R>L • 1-2%: Bilateral. Seminoma-lymphoma • 7-10% of T-tumors develop in cryptorchidism • Orchiopexy does not alter the malignant potential • Exogenous estrogen Adm. To the mother during pregnancy

  3. Tumors of the testis Classification:  Primary  Benigne  Secondary  Malignant  Germ cell  Non germ cell  Germ cell tumors: Seminoma Nonseminomatous: Embryonal Teratoma Choriocarcimoma Mixed tumors

  4. Tumors of the testis Tumorigenic hypothesis: Normal spermatocyte Totipotential germ cell Seminoma ? Embryonal carcinoma (totipotential tumor cell) Extra embryonic differentiation Intra embryonic differentiation Trophoblastic pathways Yolk sac pathways Teratoma Choriocarcimoma Yolk sac tumor

  5. Tumors of the testis Pathology A.Seminoma (35%) • Classic (85%) • Anaplastic (5-10%) • Spermatocytic (5-10%) B.Embryonal cell carcimoma (20%) • Adult type • Infantile type (yolk sac tumor) C.Teratoma (5%) D.Choriocarcinoma (<1%) E.Mixed cell type (40%) • Teratocarcinoma F.Carcimoma in situ (CIS)

  6. Tumors of the testis Patterns of metastatic spread • Step wise lymphatic fashion. (T1-T4) • RT testis:intra aortocaval at RT K.hilum Precaval-preaortic-Paracaval-RT common Iliac- RT ext Iliac nodes • LT testis:paraaortic area at LT K. Hilum Pre aortic- LT common Iliac- LT ext. Iliac nodes • RT to LT crossover metastasis: common • LT to RT crossover metastasis: No • Visceral metastases: lung – liver-brain – bone- kidney-adrenal . GI. Spleen • Hematogenous : choriocarcinoma

  7. Tumors of the testis Clinical staging

  8. Tumors of the testis Clinical findings A-symptoms: • Painless enlargment of testis • Acute testicalor pain (10%) • Symptoms related to metastasis (10%): back pain-cough-dyspnea anorexia-nausea- bone pain- lower ext. edema • Asymptomatic (10%)

  9. Tumors of the testis Clinical findings B: signs: • Testicular mass or diffuse enlargment • Node palpation • Gynecomastia • Hemoptysis

  10. Tumors of the testis Laboratory findings and tumor markers: • Anemia-liver function tests- creatinin • Tumor markers: • αFP • βHCG • LDH • PLAP-GGT

  11. Tumors of the testis Imaging • Ultrasonography • CXR • CT-Scan • Pedal LAG For staging

  12. Tumors of the testis Differential diagnosis • Epdidymitis & Epididymoorchitis • Hydrocele • Spermatocele • Hematocele • Granulomatous orchitis • Varicocele • Epidermoid cyst

  13. Tumors of the testis Treatment Inguinal Exploration & radical orchiectomy • Low stage seminoma: retroperitoneal irradiation 95% care • high stage seminoma: primary chemotherapy 95% complete response

  14. Tumors of the testis Treament C: low stage NSGCT: R.O +RPLND (N22cycles chemotherapy) Surveillncc:1)NSGCT confined within tunica albuginea 2)No vascular invasion 3)normalize tumor markers 4)no evidence of disease in radiographic imaging 5)the patient is considered reliable Modified RPLND: Nodal tissue dissection ipsilateral to the tumor below the level of the inferior mesenteric artery Clinical stage I+ vascular invasion: 2 cycles of chemotherapy

  15. Tumors of the testis Treatment High stage NSGCT: primary chemotherapy (+RPLND?) Normal tumor marker+retroperitoneal massmass resection tumor markersalvage chemotherapy (upto 70% care) High risk patients: mediastinal primary tumor non pulmonary visceval metastasis S3 marker levels

  16. Tumors of the testis Follow up: careful exam of remaining testis, abdomen, lymph node area lab (AFP, BHCG-LDH) CXR every 3 month/ first 2 years every 6 month/ until 5 years and then yearly Surveillance follow up: tumor marker at each visit. CXR & CT every 3-4 month Visit: monthly/ first 2 years bimonthly/ third year

  17. Tumors of the testis Prognosis Seminoma: R.O+radiotherapy: stage I: 98% 5 years survival rate stage II: 92-94% 5 years survival rate stage III (chemotherapy): 35-75% NSGCT: stage I: 96-100% low, volume stage II: 90% stage III: 55-80%

  18. Tumors of the testis Non-Germ cell tumors 5-6% of all testis tumor leydig cell tumors most common 5-9 & 25-35 years old no association with UDT clinical finding: virilization (prepubertal) asymptomatic (adults). 10% malignant Treatment : radical orchiectomy- RPLND Sertoli cell tumors exceedingly rare 10% malignant radical orchiecty+RPLND Gonadoblastoma in gonadaldysgenesis(80% female fenotype) radical orchiectomy + contralateralgonadectomy

  19. Tumors of the testis Secondary tumors of the testis 1. lymphoma most common t.t. in>50 years old 2. leukemia t.Biopsy is choice 3. metastatic tumor: prostate- lung –GI-melanoma-kidney

  20. Tumors of the testis Extragonadal germ cell tumors 3% of all germ cell tumors the most common sites: mediastinum-retroperitoneum, sacrococcygeal – pineal gland

  21. Tumors of the testis Tumors of the epididymis, paratesticular tissue & spermatic cord T. Of epididym: commonly benign: adenomatoid leiomyoma cystadenoma T. of spermatic cord: lipoma Rabdomyosarcoma leiomyosarcoma. Fibrosarcoma liposarcoma

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