Testicular tumors are rare.
1 – 2 % of all malignant tumors.
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.
Most curable solid neoplasm
2. Introduction
Testicular tumors are rare.
1 – 2 % of all malignant tumors.
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.
Most curable solid neoplasm
3. • Age - 3 peaks
2 – 4 yrs
20 – 40 yrs
above 60 yrs
• Testicular cancer is one of the few neoplasms
associated with accurate serum markers.
• Most curable solid neoplasms and serves as a
paradigm for the multimodal treatment of
malignancies.
10. Age wise incidence of
testicular tumour
Tumour Type Age group (years)
1. Seminoma 35-40
2. Pure Teratoma Pediatric age group
3. Embryonal CA 25-30
4. Chorio CA 25-35
5. Yolk sac Tumour infancy & child hood
6. Mixed terato CA 25-30
7. Lymphoma > 50
11. Germ cell tumors
Favourable outcome - GCT
Sensitive to both
Radiotherapy
Chemotherapy
Differentiation
Rapid rate of growth
Young – no co-morbid
Extra Gonadal Germ Cell Tumors (EGCT)
Prognosis is ½ GCT
12. Seminoma
The commonest variety of testicular tumour
Adults are the usual target (4th and 5th decade);
never seen in infancy
Right > Left Testis
Starts in the mediastinum: compresses the
surrounding structure.
Patients present with painless testicular mass
30 % have metastases at presentation, but only
3% have symptoms related to metastases
13. • Serum alpha fetoprotein is normal
• Beta HCG is elevated in 30% of patients with
Seminoma
• Classification
a) Typical
b) Anaplastic
c) Spermatocytic
14. Anaplastic
5% - 10
Middle age
Aggressive - lethal
Greater mitotic activity
Higher local invasion
Higher metastatic potential
Higher rate of β
-HCG production
Inguinal orchidectomy +
Radiation
Spermatocytic
2% - 12% of seminomas
Old age > 50 yr
Extremely low metastatic potential
Good prognosis
Typical/ Classical
82% - 85%
Middle age
PLAP – 90%
Syncytiotrophoblsts – ↑Beta HCG (10%)
Very slow growth
Inguinal orchidectomy + Radiation
15. Macroscopically:
Characterized by a
circumscribed lobular
gray white fleshy
tumor that have areas
of necrosis &
hemorrhage
Cut surface in
homogenous and
greyish white or
pinkish in colour
16. • Microscopically:
Typical seminoma Cells have
round to oval nuclei with
one to several nucleoli &
clear to eosinophillic
cytoplasm.
Cell borders are well defined
arranged in solid nests
separated by fibrous septa.
Active lymphocytic
infiltration in 80% cases.
Strongly positive for
placental Alkaline
phosphatase (PLAP)
17. Embryonal Carcinoma
2nd most common germ cell tumor
Present in majority of mixed germ cell tumors
Most men present in their 20s to 30s with a
testicular mass
Highly malignant tumours; may invade the cord
stuctures
High degree of metastasis
Serum AFP is normal , & beta HCG is elevated in
60 % of cases
18. Macroscopically:
Tan to yellow neoplasms
(fleshy tumor) that
exhibit large areas of
hemorrhage and
necrosis.
• Most undifferentiated;
capacity to differentiate
to other NSGCT within
primary or mets
20. Choriocarcinoma
A rare and aggressive tumour (5yrs survival is 5%)
Typically elevated hCG
Presents with disseminated disease
Metastasis to lungs and brain
Primary is very small and often exhibit NO TESTICULAR
ENLARGEMENT
Small palpable nodule may be present.
Prone to hemorrhage, sometimes spontaneous (lungs
and brain)
Catastrophic hemorrhage immediately after
chemotherapy;
21. Macroscopically:
Primary lesion may be a
hemorrhagic or a clotted
mass in which bits of grey
tumor can be seen
Presents as nodules
• Microscopically:
Consists of both
syncitiotrophoblast and
cytotrophoblast
Prominent areas of
hemorrhage and necrosis.
22. Yolk Sac Tumour
Most common germ cell tumor ( & most
common testicular tumor ) in children, where
it occurs in its pure form.
In adults, it is unusual in pure form, but is
found approx. 50 % of mixed germ cell
tumors.
Testicular mass the most usual presentation.
Always produce AFP, never hCG
Easily detectable, lower relapse
23. Macroscopically:
White to tan masses, with myxoid & cystic
changes
• Microscopically:
Reticular network of medium sized cuboidal
cellswith cytoplasmic and extracytoplasmic
eosinophil, hyaline like goblets (84%)
Glandular, papillary or microcystic pattern
Schiller-Duval bodies are characteristic
24. TERATOMA
Teratoma in greek means “monster tumor”
Occurs in its pure form with a mean age of
diagnosis at 20 months
In adults, occur as a component of mixed
germ cell tumor & is identified in > 47 % of
mixed tumors.
Pure teratomas are uncommon.
Normal serum markers.
◦ Mildly elevated AFP levels
25. Macroscopically:
Largely depends on elements within it with solid & cystic areas
Microscopically:
Contain more than one germ cell layers(ectoderm, endodermand
mesoderm).
Range from “mature” with well differentiated tissue to
“immature” with undifferentiated primitive tisuue.
Composed of somatic type of tissues that include enteric type
glands, respiratory epithelium, cartilage, muscles, hair etc.
Immature Teratomas contain immature neuroepithelium,
blastema or cellular stroma.
Can give rise to carcinoma, such as adenocarcinoma , or
sarcoma, such as rhabdomyosarcoma.
26. • Growing Teratoma Syndrome:
May grow uncontrollably, invade the surrunding
tissueand become unresectable
• Teratoma with malignant transformation
Rarely teratoma may transform into a somatic
malignancy such as rhabdomyosarcoma,
adenocarnoma or primitive neuroectodermal
tumour
29. Secondary Tumors of Testis
• Lymphoma – most common secondary tumor
- most common testicular tumor in patients
above 50 years
- most common variety is histiocytic
• Leukamic Infilteration of testis
-primary site of relapse after ALL remission
-occurs mainly in the interstitial space
-biopsy for diagnosis
- no orchidectomy
- testicular irradiation for treatment
• Metastases to testis
- rare cases reported
30. Tumors of adnexa / Paratesticular
tissue
• Adenomatoid tumor
-most common paratesticular tumor
-benign in nature
• Mesothelioma
-metastatic in 15% cases to inguinal lymph nodes
• Cystadenoma
- bilateral cases are associated with Von Hippel Lindau
syndrome
• Rhabdomyosarcoma
- most commonly seen in second decade of life
31. Intratubular Germ Cell Neoplasia
(ITGCN)
Adjacent to germ cell tumor: 98%
•Cryptorchidism: 2-8%
•Prior germ cell tumor (contralateral testis): 5%
•50% risk of developing GCT in 5y
•Treat with observation, XRT (20 Gy) or orchiectomy
•Chemo reduces risk but still 25% - 45% risk of GCT at 10y
(Christensen et al. Ann. Oncol. 1998)
•Can be precursor to all types of GCT except
spermatocytic seminoma
32. Metastasis
1. Direct Spread:
This spread occurs by invasion.
Whole of testis in involved and restricted
Tunica albuginea is rarely penetrated
May be crossed by “blunder biopsy”
Scrotal skin involvement
Fungation on the anterior aspect
Spread to spermatic cord and epidedymis may
occur : points towards bad prognosis
33. 2. Lymphatic spread:
Seminoma metastasize exclusively
through lymphatics
They drain primarily to para-aortic
lymph nodes in the region of origin
of tetsticular arteries
Left supraclavicular fossa through
the thoracic duct
Lymph from medial side of testes
run along the artery to the vas to
drain to nodes at the bifurcation of
common iliac
No inguinal nodes until scrotal skin
involvement
34. 3. Blood Spread
NSGCT spread through blood route
Lungs, liver, bones and brain are the usual sites
usually involved
35. Chemo and radiation sensitive
Capacity to differentiate
Consistent pattern of metastasis
Ability to produce marker substances (AFP/HCG)
NSGCT: unique potential for teratomatous differentiation
High growth rates 10-30 days
Retroperitoneum is usually the first and only site of metastatic
disease
Landing zones for right-sided tumors: Interaortocaval, precaval
lymph nodes
Landing zones for left-sided tumors: Para-aortic, left hilar
lymph nodes
Right to Left Crossover extremely common
GCT – Unique Features
36. Clinical Features / Presentaion
1. Due to primary tumor
a) Painless testicular lump
b) Sensation of heaviness if size > than 2-3 times
c) Rarely dragging pain is complained of (1/3rd
cases)
d) May mimic epidedymo-orchitis
e) Sudden pain and enlargement due to
hemorrhage mimicking torsion
f) History of trauma (co-incidental
37. 2. Due to metastasis
Abdominal or lumbar pain (lymphatic spread)
Mass in epigastrium
Dyspnoea, hemoptysis and chest pain with lung mets
Jaundice with liver mets
Hydronephrosis by para-aortic lymph nodes
enlargement
Pedal oedema by IVC obstruction
Troiser’s sign
43. Embryonal cell cancers
• Embryonal cell cancers are
heterogeneous.
• The borders of the tumor are
less distinct.
• More aggressive in behavior.
• The tunica albuginea may be
invaded
44. Yolk Sac Tumor
• Imaging findings are
nonspecific,especially in
children, in whom the only
finding may be testicular
enlargement without a defined
mass.
45. Teratoma
• Well-circumscribed complex
masses. a common feature
and may be a
• Cysts are anechoic or complex,
depending on the cyst
contents (ie, serous, mucoid,
or keratinous fluid)
46. • Choriocarcinomas are often
heterogeneous with multiple
internal calcifications present.
47. • Leydig and Sertoli
cell, are generally
well defined and
hypoechoic.
• Calcifications are
frequently
described.
49. “Burned-out" Germ Cell Tumor
• The patient may present with
widespread metastases even though the
primary tumor has involuted.
• These tumors are clinically occult, with
the testis being normal to small upon
palpation.
• These primary tumors have a variable
appearance. They are generally small
and can be hypoechoic, hyperechoic, or
merely an area of focal calcification.
50. Clinical Staging TNMS
• Findings at Inguinal Orchiectomy Histology, size,
extent of invasion, LVI
• •Imaging Chest and Retroperitoneum
• CT scan with IV contrast
• PET CT more accurate for seminoma rather than
NSCGT
• •Serum Tumor Markers AFP, bHCG , LDH
52. AFP –( Alfafetoprotein)
NORMAL VALUE: Below 16 ngm / ml
HALF LIFE OF AFP – 5 and 7 days
Raised AFP :
• Pure embryonal carcinoma
• Teratocarcinoma
• Yolk sac Tumor
• Combined tumors,
• AFP not raised in pure choriocarcinoma , & in
pure seminoma
53. HCG – ( Human Chorionic
Gonadotropin)
Has and polypeptide chain
NORMAL VALUE: < 1 ng / ml
HALF LIFE of HCG: 24 to 36 hours
RAISED HCG -
100 % - Choriocarcinoma
60% - Embryonal carcinoma
55% - Teratocarcinoma
25% - Yolk Cell Tumour
7% - Seminomas
54. ROLE OF TUMOUR 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
55. • Degree of Marker Elevation Appears to be Directly
Proportional to Tumour Burden
• Markers indicate Histology of Tumour:
If AFP elevated in Seminoma - Means Tumour has Non-
Seminomatous elements
• Negative Tumour Markers becoming positive on follow up
usually indicates -
Recurrence of Tumour
• Markers become Positive earlier than X-Ray studies
56.
57. LDH HCG
Miu/ml
AFP
Ng/ml
S0 _< N <N <N
S1 <1.5 x N < 5000 < 1000
S2 1.5-10x N 5000 to
50000
1000 to
10000
S3 >10x N > 50000 >10000
58.
59. 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
60. • Transscrotal biopsy is to be condemned.
• 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
61. Treatment of Seminomas
Stage I, IIA, ?IIB –
Radical Inguinal Orchidectomy followed by radiotherapy to
Ipsilateral Retroperitonium & Ipsilateral Iliac group Lymph
nodes (2500-3500 rads)
Bulky stage II and III Seminomas -
Radical Inguinal Orchidectomy is followed by Chemotherapy
62. Testes sparing surgery
•Controversial
•Mass <2cm
•Simultaneous bilateral tumors
•Solitary testicle with normal
testosterone
•Biopsy adjacent parenchyma (80%
ITGCN)
•Can treat remaining testicle with
20Gy of XRT
63. Scrotal violation
• Local recurrence higher (2.9% vs 0.4%)
(Capelouto et al. J. Urol. 1995)
• •Seminoma – extend radiation portal to
include groin and scrotum area
• •NSCGT – excise scar and cord remnant
• •Extensive groin resection or
hemiscrotectomy not required especially after
chemo
64. Treatment of Non-Seminoma
Stage I and IIA:
RADICAL ORCHIDECTOMY
followed by RETROPERITONEAL LYMPH NODES DISSECTION
Stage IIB:
RPLND with possible ADJUVANT CHEMOTHERAPY
Stage IIC and Stage III Disease:
Initial CHEMOTHERAPY followed by SURGERY for Residual
Disease
68. Lymphatic drainage
• The primary drainage of the right testis is
within the interaortocaval region.
• Left testis drainage , the para-aortic region 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.
69. Retroperitoneal lymph node dissection
Rationale for RPLND:
The retroperitoneum is the most common site of occult
metastasis
15-25% of retroperitoneal teratoma, resistant to cheotherapy
Low risk of Abdomino-pelvic recurrence no need for long term
surveillance after bilateral RPLND
Offers high cure rates
The long term survival approaches 100% with RPLND +
adjuvant chemotherapy
Disadvantage:
Experienced surgeon
Major surgical procedure
70. STANDARD CHEMOTHERAPY FOR
NON-SEMINOMATOUS GERM CELL
TUMOURS
Chemotherapy Toxicity
BEP -
Bleomycin Pulmonary fibrosis
Etoposide (VP-16) Myelosuppression
Alopecia
Renal insufficiency (mild)
Secondary leukemia
Cis-platin Renal insufficiency
Nausea, vomiting
Neuropathy
72. Surveillance
Rationale for surveillance:
70-80% patients of stage I are cured by orchidectomy
alone
No need of chemotherapy in majority of the patients
The disadvantages being:
Higher risk of relapse
Need for long term surveillance (>5yrs)
Potential for secondary malignancies by surveillance
CT
More intensive therapy required in cases of relapse
than primary chemotherapy
73. “I always had the size difference there, but
I didn’t know…I would’ve still been waiting
if it hadn’t started hurting, it just got so
painful I couldn’t sit on my bike anymore.”
-Lance Armstrong
Yuvraj Singh –extra gonadal
seminoma