Tumors of the testis

Tumors of the Tumors of the testistestis

S. Vahidi M.DS. Vahidi M.D

Tumors of the testisTumors of the testisIntroduction:Introduction:

1-8 new cases/ 100000 male/year1-8 new cases/ 100000 male/year 90-95% germ cell tumors90-95% germ cell tumors Survival of patients has improved dramaticallySurvival of patients has improved dramatically Higher socioeconomic/lower classes 2/1Higher socioeconomic/lower classes 2/1 R>LR>L 1-2%: Bilateral. Seminoma-lymphoma1-2%: Bilateral. Seminoma-lymphoma 7-10% of T-tumors develop in cryptorchidism7-10% of T-tumors develop in cryptorchidism Orchiopexy does not alter the malignant Orchiopexy does not alter the malignant

potentialpotential Exogenous estrogen Adm. To the mother Exogenous estrogen Adm. To the mother

during pregnancy during pregnancy

Tumors of the testisTumors of the testis Classification:Classification:

PrimaryPrimary Benigne Benigne SecondarySecondary Malignant Malignant

Germ cellGerm cell Non germ cellNon germ cell

Germ cell tumors:Germ cell tumors:SeminomaSeminomaNonseminomatous: EmbryonalNonseminomatous: Embryonal TeratomaTeratoma ChoriocarcimomaChoriocarcimoma Mixed tumorsMixed tumors

Tumors of the testisTumors of the testisTumorigenic hypothesis: Tumorigenic hypothesis:

Normal spermatocyteNormal spermatocyte

Totipotential germ cellTotipotential germ cell

Embryonal carcinomaEmbryonal carcinoma((totipotential tumor celltotipotential tumor cell ) )

SeminomaSeminoma

ChoriocarcimomaChoriocarcimoma Yolk sac tumorYolk sac tumor TeratomaTeratoma

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Extra embryonic differentiation

Trophoblastic pathways

Yolk sac pathways

Intra embryonic differentiation

Tumors of the testisTumors of the testis Pathology Pathology

A.A. SeminomaSeminoma (35%) (35%) Classic (85%)Classic (85%) Anaplastic (5-10%)Anaplastic (5-10%) Spermatocytic (5-10%)Spermatocytic (5-10%)

B.B. Embryonal cell carcimomaEmbryonal cell carcimoma (20%) (20%) Adult typeAdult type Infantile type (yolk sac tumor)Infantile type (yolk sac tumor)

C.C. TeratomaTeratoma (5%) (5%)D.D. ChoriocarcinomaChoriocarcinoma (<1%) (<1%)E.E. Mixed cell typeMixed cell type (40%) (40%)

TeratocarcinomaTeratocarcinomaF.F. Carcimoma in situCarcimoma in situ (CIS) (CIS)

Tumors of the testis Tumors of the testis Patterns of metastatic spreadPatterns of metastatic spread

Step wise lymphatic fashion. (T1-T4)Step wise lymphatic fashion. (T1-T4) RT testis:RT testis: intra aortocaval at RT K.hilumintra aortocaval at RT K.hilum

Precaval-preaortic-Paracaval-RT common Iliac- Precaval-preaortic-Paracaval-RT common Iliac- RT ext Iliac nodesRT ext Iliac nodes

LT testis:LT testis: paraaortic area at LT K. Hilumparaaortic area at LT K. HilumPre aortic- LT common Iliac- LT ext. Iliac nodesPre aortic- LT common Iliac- LT ext. Iliac nodes

RT to LT crossover metastasis: commonRT to LT crossover metastasis: common LT to RT crossover metastasis: NoLT to RT crossover metastasis: No Visceral metastases: lung Visceral metastases: lung –– liver-brain liver-brain –– bone- bone-

kidney-adrenal . GI. Spleenkidney-adrenal . GI. Spleen Hematogenous : choriocarcinomaHematogenous : choriocarcinoma

Tumors of the testisTumors of the testisClinical Clinical

staging staging T-primary tumorsT-primary tumors

TX:TX:T0:T0:Tis:Tis:T1:T1:T2:T2:T3:T3:T4:T4:

Cannot be assessedCannot be assessedNo evidence of primary tumorNo evidence of primary tumorIntratubular cancer (CIS)Intratubular cancer (CIS)Limited to testis and epididymis, no vascular invasionLimited to testis and epididymis, no vascular invasionInvades beyond tunica albuginea or has vascular invasionInvades beyond tunica albuginea or has vascular invasionInvades spermatic cordInvades spermatic cordInvades scrotumInvades scrotum

N-Regional lymph nodesN-Regional lymph nodes

NX:NX:N1:N1:N2:N2:N3:N3:

Cannot be assessedCannot be assessedNo regional lymph node metastasisNo regional lymph node metastasisLymph node metastasis≤ 2cm, or multiple nodes, none more than 2 cm. and<6 nodes Lymph node metastasis≤ 2cm, or multiple nodes, none more than 2 cm. and<6 nodes positivepositiveNodal mass>2cm and ≤5cm. Or ≥6 nodes positiveNodal mass>2cm and ≤5cm. Or ≥6 nodes positiveNodal mass> 5 cmNodal mass> 5 cm

M-Distant metastasisM-Distant metastasis

MX:MX:M0:M0:M1:M1:M2:M2:

Cannot be assessedCannot be assessedNo distant metastasisNo distant metastasisDistant metastasis present in nonregional lymph nodes or lungsDistant metastasis present in nonregional lymph nodes or lungsNonpulmonary visceral metastasesNonpulmonary visceral metastases

S-Serum tumor markersS-Serum tumor markers

SX:SX:S0:S0:S1:S1:S2:S2:S3:S3:

Markers not availableMarkers not availableMarker levels within normalimits Marker levels within normalimits Lactic acid dehydrogenase (LDH)<1.5xnormal and HCG<500 mlU/ml and Lactic acid dehydrogenase (LDH)<1.5xnormal and HCG<500 mlU/ml and AFP<1000ng/mlAFP<1000ng/mlLDH 1.5-10xnormal or hCG 5000-50000mIU/ml or AFP 1000-10000 ng/mlLDH 1.5-10xnormal or hCG 5000-50000mIU/ml or AFP 1000-10000 ng/mlLDH>10xnormal or hCG>50000 mIU/ml or AFP>10000 ng/mlLDH>10xnormal or hCG>50000 mIU/ml or AFP>10000 ng/ml

Tumors of the testisTumors of the testis

Clinical findingsClinical findingsA-symptoms:A-symptoms:

Painless enlargment of testisPainless enlargment of testis Acute testicalor pain (10%)Acute testicalor pain (10%) Symptoms related to metastasis (10%): Symptoms related to metastasis (10%):

back pain-cough-dyspnea anorexia-back pain-cough-dyspnea anorexia-nausea- bone pain- lower ext. edemanausea- bone pain- lower ext. edema

Asymptomatic (10%)Asymptomatic (10%)

Tumors of the testisTumors of the testisClinical findingsClinical findingsB: signs:B: signs:

Testicular mass or diffuse enlargmentTesticular mass or diffuse enlargment Node palpationNode palpation GynecomastiaGynecomastia HemoptysisHemoptysis

Tumors of the testisTumors of the testisLaboratory findings and tumor Laboratory findings and tumor

markers:markers:

Anemia-Anemia-liver function tests- liver function tests- creatinincreatinin

Tumor markers: Tumor markers: ααFPFP ββHCGHCG LDHLDH PLAP-GGTPLAP-GGT

hCG(%)hCG(%)AFP(AFP(%)%)

SeminomaSeminomaTeratomaTeratomaTeratocarcinTeratocarcinomaomaEmbryonalEmbryonalchoriocarcinchoriocarcinomaoma

77252557576060100100

0038386464707000

Tumors of the testisTumors of the testisImagingImaging

UltrasonographyUltrasonography CXRCXR CT-ScanCT-Scan Pedal LAGPedal LAG

For staging

Differential diagnosisDifferential diagnosis Epdidymitis & EpididymoorchitisEpdidymitis & Epididymoorchitis HydroceleHydrocele SpermatoceleSpermatocele HematoceleHematocele Granulomatous orchitisGranulomatous orchitis VaricoceleVaricocele Epidermoid cystEpidermoid cyst

Tumors of the testisTumors of the testis

TreatmentTreatmentInguinal Exploration & radical orchiectomy

A. Low stage seminoma: retroperitoneal irradiation 95% care

A.A. high stage seminoma: primary chemotherapyhigh stage seminoma: primary chemotherapy95% complete response 95% complete response

Tumors of the testisTumors of the testis

Treament C: low stage NSGCT: R.O +RPLND (N22cycles

chemotherapy)Surveillncc: 1)NSGCT confined within tunica albuginea

2)No vascular invasion3)normalize tumor markers4)no evidence of disease in radiographic imaging5)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

Tumors of the testisTumors of the testis

TreatmentTreatmentHigh stage NSGCT:High stage NSGCT: primary chemotherapy primary chemotherapy

(+RPLND?)(+RPLND?)Normal tumor marker+retroperitoneal massNormal tumor marker+retroperitoneal massmass mass resection resection tumor markertumor markersalvage chemotherapy salvage chemotherapy (upto 70% care)(upto 70% care)

High risk patients:High risk patients:mediastinal primary tumormediastinal primary tumornon pulmonary visceval metastasisnon pulmonary visceval metastasisS3 marker levelsS3 marker levels

Tumors of the testisTumors of the testis

Follow up:Follow up:careful exam of remaining testis, abdomen, lymph node areacareful exam of remaining testis, abdomen, lymph node arealab (AFP, BHCG-LDH)lab (AFP, BHCG-LDH)CXRCXRevery 3 month/ first 2 yearsevery 3 month/ first 2 yearsevery 6 month/ until 5 yearsevery 6 month/ until 5 yearsand then yearly and then yearly

Surveillance follow up:Surveillance follow up:tumor marker at each visit.tumor marker at each visit.CXR & CT every 3-4 monthCXR & CT every 3-4 monthVisit:Visit: monthly/ first 2 yearsmonthly/ first 2 years bimonthly/ third year bimonthly/ third year

Tumors of the testisTumors of the testis

Prognosis Prognosis Seminoma: R.O+radiotherapy:Seminoma: R.O+radiotherapy:stage I: stage I: 98% 5 years survival rate98% 5 years survival ratestage II: stage II: 92-94% 5 years survival rate92-94% 5 years survival ratestage III stage III (chemotherapy): 35-75%(chemotherapy): 35-75%NSGCT: NSGCT: stage I:stage I: 96-100% 96-100% low, volume stage II:low, volume stage II: 90% 90% stage III:stage III: 55-80% 55-80%

Tumors of the testisTumors of the testis

Non-Germ cell tumors 5-6% of all testis tumorNon-Germ cell tumors 5-6% of all testis tumorleydig cell tumorsleydig cell tumors most common most common5-9 & 25-35 years old5-9 & 25-35 years oldno association with UDTno association with UDTclinical finding: virilization (prepubertal)clinical finding: virilization (prepubertal)asymptomatic (adults). 10% malignantasymptomatic (adults). 10% malignantTreatment : radical orchiectomy- RPLNDTreatment : radical orchiectomy- RPLND

Sertoli cell tumorsSertoli cell tumors exceedingly rareexceedingly rare10% malignant10% malignantradical orchiecty+RPLNDradical orchiecty+RPLND

GonadoblastomaGonadoblastomain gonadal dysgenesis(80% female fenotype)in gonadal dysgenesis(80% female fenotype)radical orchiectomy + contralateral gonadectomyradical orchiectomy + contralateral gonadectomy

Tumors of the testisTumors of the testis

Secondary tumors of the testisSecondary tumors of the testis1. lymphoma1. lymphoma most common t.t. in>50 most common t.t. in>50 years oldyears old2. leukemia2. leukemia t.Biopsy is choicet.Biopsy is choice3. metastatic tumor:3. metastatic tumor: prostate- lung prostate- lung ––GI-GI-melanoma-kidneymelanoma-kidney

Tumors of the testisTumors of the testis

Extragonadal germ cell tumorsExtragonadal germ cell tumors3% of all germ cell tumors3% of all germ cell tumorsthe most common sites: the most common sites: mediastinum-retroperitoneum, mediastinum-retroperitoneum, sacrococcygeal sacrococcygeal –– pineal gland pineal gland

Tumors of the testisTumors of the testis

Tumors of the epididymis, paratesticular tissue & Tumors of the epididymis, paratesticular tissue & spermatic cordspermatic cordT. Of epididym:T. Of epididym: commonly benign: commonly benign:adenomatoidadenomatoidleiomyomaleiomyomacystadenomacystadenomaT. of spermatic cord:T. of spermatic cord: lipomalipomaRabdomyosarcomaRabdomyosarcomaleiomyosarcoma. Fibrosarcomaleiomyosarcoma. Fibrosarcomaliposarcomaliposarcoma

Tumors of the testisTumors of the testis