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Tumors of the Tumors of the testis testis S. Vahidi M.D S. Vahidi M.D
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Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

Mar 29, 2015

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Page 1: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

Tumors of the Tumors of the testistestis

S. Vahidi M.DS. Vahidi M.D

Page 2: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

Tumors of the testisTumors of the testis

Introduction: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

Page 3: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

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

Page 4: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

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

??

Extra embryonic differentiation

Trophoblastic pathways

Yolk sac pathways

Intra embryonic differentiation

Page 5: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

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)

Page 6: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

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

Page 7: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

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 assessed

No evidence of primary tumorNo evidence of primary tumor

Intratubular cancer (CIS)Intratubular cancer (CIS)

Limited to testis and epididymis, no vascular invasionLimited to testis and epididymis, no vascular invasion

Invades beyond tunica albuginea or has vascular invasionInvades beyond tunica albuginea or has vascular invasion

Invades spermatic cordInvades spermatic cord

Invades scrotumInvades scrotum

N-Regional lymph nodesN-Regional lymph nodes

NX:NX:

N1:N1:

N2:N2:

N3:N3:

Cannot be assessedCannot be assessed

No regional lymph node metastasisNo regional lymph node metastasis

Lymph 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 positivepositive

Nodal mass>2cm and ≤5cm. Or ≥6 nodes positiveNodal mass>2cm and ≤5cm. Or ≥6 nodes positive

Nodal mass> 5 cmNodal mass> 5 cm

M-Distant metastasisM-Distant metastasis

MX:MX:

M0:M0:

M1:M1:

M2:M2:

Cannot be assessedCannot be assessed

No distant metastasisNo distant metastasis

Distant metastasis present in nonregional lymph nodes or lungsDistant metastasis present in nonregional lymph nodes or lungs

Nonpulmonary 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 available

Marker 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/ml

LDH 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/ml

LDH>10xnormal or hCG>50000 mIU/ml or AFP>10000 ng/mlLDH>10xnormal or hCG>50000 mIU/ml or AFP>10000 ng/ml

Page 8: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

Tumors of the testisTumors of the testis

Clinical findingsClinical findings

A-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%)

Page 9: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

Tumors of the testisTumors of the testis

Clinical findingsClinical findings

B: signs:B: signs: Testicular mass or diffuse enlargmentTesticular mass or diffuse enlargment Node palpationNode palpation GynecomastiaGynecomastia HemoptysisHemoptysis

Page 10: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

Tumors of the testisTumors of the testis

Laboratory 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(%)%)

SeminomaSeminoma

TeratomaTeratoma

TeratocarcinTeratocarcinomaoma

EmbryonalEmbryonal

choriocarcinchoriocarcinomaoma

77

2525

5757

6060

100100

00

3838

6464

7070

00

Page 11: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

Tumors of the testisTumors of the testis

ImagingImaging UltrasonographyUltrasonography CXRCXR CT-ScanCT-Scan Pedal LAGPedal LAG

For staging

Page 12: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

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

Tumors of the testisTumors of the testis

Page 13: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

TreatmentTreatmentInguinal Exploration & radical orchiectomy

A. Low stage seminoma: retroperitoneal irradiation

95% care

A.A. high stage seminoma: primary chemotherapyhigh stage seminoma: primary chemotherapy

95% complete response 95% complete response

Tumors of the testisTumors of the testis

Page 14: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

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

Page 15: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

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

Page 16: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

Follow up:Follow up:careful exam of remaining testis, abdomen, lymph node careful exam of remaining testis, abdomen, lymph node areaarealab (AFP, BHCG-LDH)lab (AFP, BHCG-LDH)CXRCXR

every 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

Page 17: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

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 92-94% 5 years survival

rateratestage 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

Page 18: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

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

Page 19: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

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 old

2. leukemia2. leukemia t.Biopsy is choicet.Biopsy is choice

3. metastatic tumor:3. metastatic tumor: prostate- lung prostate- lung ––GI-GI-melanoma-kidneymelanoma-kidney

Tumors of the testisTumors of the testis

Page 20: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

Extragonadal germ cell tumorsExtragonadal germ cell tumors

3% of all germ cell tumors3% of all germ cell tumors

the most common sites: the most common sites: mediastinum-retroperitoneum, mediastinum-retroperitoneum, sacrococcygeal sacrococcygeal –– pineal gland pineal gland

Tumors of the testisTumors of the testis

Page 21: Tumors of the testis S. Vahidi M.D. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year 1-8 new cases/ 100000 male/year 90-95% germ cell.

Tumors of the epididymis, paratesticular tissue & Tumors of the epididymis, paratesticular tissue & spermatic cordspermatic cord

T. Of epididym:T. Of epididym: commonly benign: commonly benign:adenomatoidadenomatoidleiomyomaleiomyomacystadenomacystadenoma

T. of spermatic cord:T. of spermatic cord: lipomalipomaRabdomyosarcomaRabdomyosarcomaleiomyosarcoma. Fibrosarcomaleiomyosarcoma. Fibrosarcomaliposarcomaliposarcoma

Tumors of the testisTumors of the testis