Testicular-tumors - Testicular tumors Testicular B.Vijay...

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Unformatted text preview: Testicular tumors Testicular B.Vijay Anand, SRMC, Chennai. SRMC, Incidence Testicular tumors are rare. Testicular 1 – 2 % of all malignant tumors. of 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. of Age - 3 peaks Age 2 – 4 yrs yrs 20 – 40 yrs 20 above 60 yrs above Testicular cancer is one of the few neoplasms Testicular associated with accurate serum markers. associated Most curable solid neoplasms and serves as a Most paradigm for the multimodal treatment of malignancies. Etiology Etiology Cryptorchidism Cryptorchidism Intersex disorder Intersex Testicular atrophy Trauma- prompts medical evaluation TraumaChromosomal abnormalities - loss of chromosome 11, 13, 18, abnormal chromosome 12p. chromosome Sex hormone fluctuations, estrogen Sex administration during pregnancy administration CROSS SECTION OF TESTIS TESTIS Testis Testis Stroma Stroma Interstitial Cells Interstitial Seminiferous Tubules (200 to 350 tubules) (200 Supporting Leydig Leydig (Androgen) (Androgen) Spermatogonia or Sertoli Cell CLASSIFICATION CLASSIFICATION I. Primary Neoplasms of Testis. I. A. Germ Cell Tumor. Germ B. Non-Germ Cell Tumor . B. II. Secondary Neoplasms. III. Paratesticular Tumors. Germ cell tumors Germ 1. Seminomas - 40% (a) Classic Typical Seminoma (a) (b) Anaplastic Seminoma (b) (c) Spermatocytic Seminoma (c) 2. Embryonal Carcinoma - 20 - 25% 3. Teratoma - 25 - 35% (a) Mature (a) (b) Immature (b) 4. Choriocarcinoma - 1% 5. Yolk Sac Tumour Classification of germcell tumor (GCT) (GCT) GCTs arise from pluripotential cells, so a variety of elements may habitate in primary tumor primary More than half of GCTs contain more than one cell type and are therefore known as mixed GCTs Sex cord/ gonadal stromal tumors ( 5 to 10% ) to 1. Specialized gonadal stromal tumor (a) Leydig cell tumor (b) sertoli cell tumor 2. Gonadoblastoma 2. 3. Miscellaneous Neoplasms (a) Carcinoid tumor (b) Tumors of ovarian epithelial sub (b) types II. SECONDARY NEOPLASMS OF TESTIS A. B. Reticuloendothelial Neoplasms Metastases III. PARATESTICULAR NEOPLASMS A. A. B. C. D. E. Adenomatoid Cystadenoma of Epididymis Desmoplastic small round cell tumor Mesothelioma Melanotic neuroectodermal Carcinoma insitu {CIS} Carcinoma Pre invasive precusor of all GCT, except Pre spermatocytic seminoma spermatocytic 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. Patients at risk of CIS Patients History of testicular carcinoma (5% to 6%), Extra gonadalGCT (40%), Extra Cryptorchidism (3%), Contralateral testis with unilateral testis cancer (5% to 6%), Somatosexual ambiguity (25% to 100%) Somatosexual Atrophic testis 30 % Infertility (0.4% to 1.1%) Infertility TESTICULAR BIOPSY gold standard for diagnoses of CIS diagnoses Lymphatic drainage Lymphatic The primary drainage of the right testis is The within the interaortocaval region. within Left testis drainage , the para-aortic region Left 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. Cross Lymphatic drainage Lymphatic Lymphatics of the epididymis drain into the external iliac Lymphatics chain. chain Inguinal node metastasis may result from scrotal Inguinal involvement by the primary tumor, prior inguinal or scrotal surgery, or retrograde lymphatic spread secondary to massive retroperitoneal lymph node deposits. deposits. Testicular cancer spreads in a predictable and stepwise Testicular fashion, except choriocarcinoma. fashion, . Clinical features Clinical 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 / Neck Back Ache/ Lower limb swelling Back 5% - Gynecomastia Rarely - Infertility Rarely Physical Examination Physical Examine contralateral normal testis. Examine Firm to hard fixed area within tunica albugenia is Firm suspicious suspicious Seminoma expand within the testis as a Seminoma painless, rubbery enlargement. Embryonal carcinoma or teratocarcinoma may produce an irregular, rather than discrete mass. Differential Diagnosis Differential Testicular torsion Testicular Epididymitis, or epididymo-orchitis Hydrocele, Hydrocele, Hernia, Hematoma, Spermatocele, Syphilitic gumma . Syphilitic DICTUM FOR ANY SOLID SCROTAL SWELLINGS SWELLINGS All patients with a solid, Firm All Intratesticular Mass that cannot be Transilluminated should be regarded as Malignant unless otherwise proved. proved. Scrotal ultrasound Scrotal Ultrasonography of the scrotum is a rapid, Ultrasonography reliable technique to exclude hydrocele or epididymitis. epididymitis. Ultrasonography of the scrotum is basically an extension of the physical examination. extension Hypoechoic area within the tunica albuginea is Hypoechoic markedly suspicious for testicular cancer. Cystic lesion- epidermoid cyst Cystic Tumor markers Tumor 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) dehydrogenase) AFP –( Alfafetoprotein) AFP NORMAL VALUE: Below 16 ngm / ml HALF LIFE OF AFP – 5 and 7 days Raised AFP : Pure embryonal carcinoma Pure Teratocarcinoma Teratocarcinoma Yolk sac Tumor Combined tumors, Combined AFP not raised in pure choriocarcinoma , & in AFP pure seminoma pure HCG – ( Human Chorionic Gonadotropin) HCG Human Has α and β polypeptide chain Has NORMAL VALUE: < 1 ng / ml HALF LIFE of HCG: 24 to 36 hours HALF RAISED β HCG RAISED 100 % - Choriocarcinoma 60% - Embryonal carcinoma 55% - Teratocarcinoma 25% - Yolk Cell Tumour 25% Yolk 7% - Seminomas 7% Seminomas ROLE OF TUMOUR MARKERS ROLE Helps in Diagnosis - 80 to 85% of Testicular Helps Tumours have Positive Markers Most of Non-Seminomas have raised markers Most Only 10 to 15% Non-Seminomas have normal marker Only level After Orchidectomy if Markers Elevated means Residual Disease . Disease Elevation of Markers after Lymphadenectomy means a Elevation STAGE III Disease STAGE ROLE OF TUMOUR MARKERS ROLE Degree of Marker Elevation Appears to be Directly Degree Proportional to Tumor Burden Proportional Markers indicate Histology of Tumor: If AFP elevated in Seminoma - Means Tumor has NonIf Seminomatous elements Negative Tumor Markers becoming positive on follow up Negative usually indicates - Recurrence of Tumor usually Markers become Positive earlier than X-Ray studies Imaging studies Imaging Chest X ray CECT abdomen – retroperitoneal nodes PET- No apparent advantage over CT MRI - No apparent advantage over CT Large left para aortic nodal mass due to GST causing hydronephrosis GST Tumor staging Tumor Primary Tumor (T)pTX - Primary tumor cannot be pTX assessed (if no radical orchiectomy has been performed, TX is used) TX pT0 - No evidence of primary tumor (e.g., histologic scar pT0 in testis) in pTis - Intratubular germ cell neoplasia (carcinoma in situ) pT1 - Tumor limited to the testis and epididymis and no pT1 vascular/lymphatic invasion vascular/lymphatic pT2 - Tumor limited to the testis and epididymis with pT2 vascular/lymphatic invasion or tumor extending through the tunica albuginea with involvement of tunica vaginalis the pT3 - Tumor invades the spermatic cord with or without pT3 vascular/lymphatic invasion vascular/lymphatic pT4 - Tumor invades the scrotum with or without pT4 vascular/lymphatic invasion vascular/lymphatic Regional Lymph Nodes Regional Clinical NX - Regional lymph nodes cannot be Clinical assessed assessed N0 - No regional lymph node metastasis N1 - Lymph node mass 2 cm or less in greatest N1 dimension or multiple lymph node masses, none more than 2 cm in greatest dimension more N2 - Lymph node mass, more than 2 cm but not N2 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 greatest N3 - Lymph node mass more than 5 cm in N3 Pathologic node staging Pathologic pN0 - No evidence of tumor in lymph nodes pN1 - Lymph node mass, 2 cm or less in greatest pN1 dimension and ≤6 nodes positive, none >2 cm in greatest dimension greatest pN2 - Lymph node mass, more than 2 cm but not more pN2 than 5 cm in greatest dimension; more than 5 nodes positive, none >5 cm; evidence of extranodal extension of tumor of pN3 - Lymph node mass more than 5 cm in greatest pN3 dimension. dimension. Distant metastasis Distant M0 - No evidence of distant metastases M1 - Nonregional nodal or pulmonary M1 metastases metastases M2 - Nonpulmonary visceral masses Serum tumor markers Serum LDH HCG Miu/ml AFP Ng/ml <N <N <N <N S0 _< N _< S1 <1.5 x N < 5000 < 1000 S2 1.5-10x N S3 >10x N 5000 to 5000 50000 50000 > 50000 1000 to 1000 10000 10000 >10000 >10000 PRINCIPLES OF TREATMENT PRINCIPLES Treatment should be aimed at one stage above Treatment the clinical stage Seminomas Radiotherapy. Radiotherapy. Radio-Sensitive. Treat with Non-Seminomas are Radio-Resistant and best Non-Seminomas treated by Surgery treated Advanced Disease or Metastasis - Responds Advanced well to Chemotherapy well PRINCIPLES OF TREATMENT PRINCIPLES Radical INGUINAL ORCHIDECTOMY is Radical Standard first line of therapy Standard Lymphatic spread initially goes to Lymphatic RETRO-PERITONEAL NODES RETRO-PERITONEAL Early hematogenous spread RARE Bulky Retroperitoneal Tumours or Metastatic Bulky Tumors Initially “DOWN-STAGED” with CHEMOTHERAPY CHEMOTHERAPY PRINCIPLES OF TREATMENT PRINCIPLES Transscrotal biopsy is to be condemned. Transscrotal 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. Frozen CHEMOTHERAPY CHEMOTHERAPY Chemotherapy BEP Bleomycin Toxicity Pulmonary fibrosis Etoposide (VP-16) Etoposide Myelosuppression Alopecia Alopecia Renal insufficiency (mild) Renal Secondary leukemia Secondary Cis-platin Renal insufficiency Nausea, vomiting Nausea, Neuropathy Neuropathy Lymph Nodes Dissection For Right & Left Sided Testicular Tumours Left CONCLUSION CONCLUSION Improved Overall Survival of Testicular Tumour Improved due to Better Understanding of the Disease, Tumour Markers and Cis-platinum based Chemotherapy. Chemotherapy. Current Emphasis is on Diminishing overall Current Morbidity of Various Treatment Modalities . Morbidity THANK YOU THANK ...
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This note was uploaded on 12/27/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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