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    Testicular Tumours - Mashaal Saad

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    shahryar shaukat
    The document summarizes testicular tumors, including that they affect young adults, are mostly malignant germ cell tumors, and can cause psychological and fertility problems. It describes tumor classifications, clinical features, investigations including tumor markers and imaging, staging, and principles of treatment including surgery, radiotherapy, and chemotherapy depending on tumor type and stage.

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    Testicular Tumours - Mashaal Saad

    Uploaded by

    shahryar shaukat
    59 views26 pages
    The document summarizes testicular tumors, including that they affect young adults, are mostly malignant germ cell tumors, and can cause psychological and fertility problems. It describes tumor classifications, clinical features, investigations including tumor markers and imaging, staging, and principles of treatment including surgery, radiotherapy, and chemotherapy depending on tumor type and stage.

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    Treatment and diagnosis of testicular tumors

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    The document summarizes testicular tumors, including that they affect young adults, are mostly malignant germ cell tumors, and can cause psychological and fertility problems. It describes tumor classifications, clinical features, investigations including tumor markers and imaging, staging, and principles of treatment including surgery, radiotherapy, and chemotherapy depending on tumor type and stage.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    59 views26 pages

    Testicular Tumours - Mashaal Saad

    Uploaded by

    shahryar shaukat
    The document summarizes testicular tumors, including that they affect young adults, are mostly malignant germ cell tumors, and can cause psychological and fertility problems. It describes tumor classifications, clinical features, investigations including tumor markers and imaging, staging, and principles of treatment including surgery, radiotherapy, and chemotherapy depending on tumor type and stage.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 26

    Testicular Tumors

    Mashaal Saad 2016-038


    TESTICULAR TUMOR

     1% of all Malignant tumor


     Affects young adults - 20 to 40 yrs - when Testosterone Fluctuations are
    maximum
     90% to 95% of all Testicular tumors from germ cells
     99% of all Testicular tumors are malignant.
     Causes Psychological & Fertility Problems in young
     Cryptorchidism increases risk of developing testicular cancer
    Classification

     Germinal Neoplasms : (90 - 95 %)


    1. Seminomas - 40%
    (a) Classic Typical Seminoma
    (b) Anaplastic Seminoma
    (c) Spermatocytic Seminoma
    2. Embryonal Carcinoma - 20 - 25%
    3. Teratoma - 25 - 35%
    (a) Mature
    (b) Immature
    4. Choriocarcinoma - 1%
    5. Yolk Sac tumor
    Cont’d…

     B. Nongerminal Neoplasms : ( 5 to 10% )


    1. Specialized gonadal stromal tumor
    (a) Leydig cell tumor
    (b) Other gonadal stromal tumor
    Case

     A 40-year-old male presents with a painless left testicular mass and back
    pain. The patient described a 2-month history of progressive scrotal
    swelling.
     He also noted lower back pain that worsened with heavy lifting. The
    patient denied a history of prior scrotal trauma or surgery.
     He also noted decreased appetite and an unintentional 20-pound weight
    loss over the past 2 months.
     O/E:
     tachycardia, hypertension
     mild gynecomastia,
     a palpable mildly tender midline abdominal mass
     a firm enlarged non-tender left testicle measuring ~10 cm.
    D/D for painless scrotal mass

     Hydrocele
     Spermatocele
     Hernia
     Varicocele
    Investigations

     Aims
     Confirm the diagnosis
     Detect metastases
     Stage the disease

     Treat according to stage


    Investigations

     Haematological – Hb%, Bl. urea/S. creatinine, LFT


     Tumour markers – AFP, HCG, LDH
     Scrotal Ultrasound – Usually homogenous, hypoechoic, intra testicular mass
     X-ray chest
     CT / MRI – abdomen
    Scrotal Ultrasonography
    Clinical Features

     History
     Solid testicular mass
     Gradual
     Trauma
     Testicular heaviness
     Back pain (retroperitoneal)
     Cough or dyspnea (pulmonary)
     Anorexia, nausea and vomiting (retroduodenal)
     Bone pain (skeletal)
     Lower extremity swelling (venacaval obstruction)
    Clinical Features

     Painless, progressively enlarging testicular mass


     Para-aortic nodes at the level of L1/2
     Along lymphatic chain to thoracic duct to supraclavicular nodes

     Poorly differentiated tumors metastasize early


     Enlarged abdominal or cervical lymph nodes

     Cough, hemoptysis
    Tumor Markers

    TWO MAIN CLASSES


     Onco-fetal Substances : AFP & HCG
     Cellular Enzymes : LDH & PLAP
     AFP - Trophoblastic Cells

     HCG - Syncytiotrophoblastic Cells


    Role of Tumor Markers

     Helps in Diagnosis - 80 to 85% of Testicular Tumours have Positive Markers


     Most of Non-Seminomas have raised markers
     Only 10 to 15% Non-Seminomas have normal marker level
     After Orchidectomy if Markers Elevated means Residual Disease or Stage II
    or III Disease
     Elevation of Markers after lymphadenectomy means a STAGE III Disease
     Help determine tumor burden
    Surgical Exploration

     Orchidectomy
     Inguinal incision
     Spermatic cord clamped
     Testis brought out
     Cord divided at internal inguinal ring
     Biopsy
    TNM Classification

     T – primary tumor
     N – regional lymph nodes
     M – distant metastasis
     S – serum tumor markers
    TNM Classification

     T – primary tumor
     TX: cannot be assessed
     T0: no evidence of primary tumor
     Tis: Intratubular cancer
     T1: limited to testis and epididymis, no vascular invasion
     T2: invades beyond tunica albuginea or has vascular invasion
     T3: invades spermatic cord
     T4: invades scrotum
    TNM Classification

     N – regional lymph nodes


     NX: cannot be assessed
     N0: no regional lymph node metastases
     N1: lymph node metastases =/< 2cm and =/< 5 lymph nodes
     N2: metastasis in > 5 nodes, nodal mass > 2 cm and < 5cm
     N3: nodal mass > 5 cm
    TNM Classification

     M – Distant metastasis
     MX: cannot be assessed
     M0: no distant metastasis
     M1: distant metastasis present
     M1a: nonregional nodal or pulmonary metastasis
     M1b: distant metastasis other than nonregional nodal or lung metastasis
    TNM Classification

     S – Serum tumor markers


     SX: markers not available
     S0: Normal level
     S1: Lactate dehydrogenase (LDH) level < 1.5 times normal, human chorionic
    gonadotropin (HCG) level < 5000 IU/L, alpha-fetoprotein (AFP) level < 1000
    ng/mL
     S2: LDH 1.5–10 times normal; HCG level, 5000–50,000 IU/L; AFP level, 1000–10,000
    ng/mL
     S3: LDH >10 times normal; HCG level >50,000 IU/L; AFP level >10,000 ng/mL
    Stages of Spread of Testicular Tumors

     Stage I
     Tumor confined to testis
     Stage II
     Retroperitoneal lymph node involvement
     IIa nodes < 2cm
     IIb nodes 2 -5 cm
     IIc nodes > 5 cm
     Stage III
     Metastasis above diaphragm confined to lymph nodes
     Stage IV
     Extralymphatic metastases (usually lungs and liver)
    Principles of Treatment

     Treatment should be aimed at one stage above the clinical stage


     Seminomas - Radio-Sensitive. Treat with Radiotherapy.
     Non-Seminomas are Radio-Resistant and best treated by Surgery
     Advanced Disease or Metastasis - Responds well to Chemotherapy
    Treatment

    1. Removal of the affected testis – usually performed as part of the


    diagnostic process
    2. No further treatment usually given if stage 1 disease (i.e. no metastases) but
    careful surveillance with tumor markers and CT scans required
    3. Radiotherapy – local irradiation alone for moderate abdominal lymph
    node metastases in seminoma (stages IIa and IIb)
    4. Chemotherapy with EP (etoposide and cisplatin) or BEP (bleomycin,
    etoposide and cisplatin) – for all cases of metastatic teratoma and
    metastatic seminoma beyond stage IIb
    5. Debulking surgery for lymph nodes treated by chemotherapy
    Management of Seminoma

     Stage I disease
     Orchidectomy +/- carboplatin based chemotherapy
     Stage IIa
     Radical radiotherapy to ipsilateral para-aortic and iliac nodes
     Stage IIb
     Radical radiotherapy or chemotherapy
     Etoposide and cisplatin (EP) or cisplatin, etoposide and bleomycin (PEB)
     Stages IIc and above
     Chemotherapy with etoposide and cisplatin (EP) or cisplatin, etoposide and
    bleomycin (PEB)
    Management

     Relapse within 1 year of orchidectomy without further treatment


     No role of curative radiotherapy

     Three options
    1. Immediate chemotherapy
    2. Retroperitoneal lymph node dissection
    3. Surveillance and treatment

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