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Testicular Tumours
-Dr. Shubham Lavania
21/10/2016
Introduction
 Testicular tumors are rare.
 1 – 2 % of all malignant tumors.
 Most common malignancy in men in the 15 to...
• Age - 3 peaks
2 – 4 yrs
20 – 40 yrs
above 60 yrs
• Testicular cancer is one of the few neoplasms
associated with accurat...
Improvement in Survival
 Effective diagnostic techniques
 Improved tumor markers
 Multi-model treatment
 Surgical
 Ra...
AETIOLOGY OF TESTICULAR TUMOUR
• Cryptorchidism
• Intersex disorder – Klinefelter’s syndrome
• Testicular atrophy
• Trauma...
1. Seminomas - 40%
(a) Classic Typical Seminoma
(b) Anaplastic Seminoma
(c) Spermatocytic Seminoma
2. Embryonal Carcinoma ...
Non Germ Cell Tumors
1. Specialized gonadal stromal tumor
(a) Leydig cell tumor
(b) sertoli cell tumor
2. Gonadoblastoma
3...
Age wise incidence of
testicular tumour
Tumour Type Age group (years)
1. Seminoma 35-40
2. Pure Teratoma Pediatric age gro...
Germ cell tumors
 Favourable outcome - GCT
 Sensitive to both
 Radiotherapy
 Chemotherapy
 Differentiation
 Rapid ra...
Seminoma
 The commonest variety of testicular tumour
 Adults are the usual target (4th and 5th decade);
never seen in in...
• Serum alpha fetoprotein is normal
• Beta HCG is elevated in 30% of patients with
Seminoma
• Classification
a) Typical
b)...
 Anaplastic
 5% - 10
 Middle age
 Aggressive - lethal
 Greater mitotic activity
 Higher local invasion
 Higher meta...
 Macroscopically:
Characterized by a
circumscribed lobular
gray white fleshy
tumor that have areas
of necrosis &
hemorrh...
• Microscopically:
Typical seminoma Cells have
round to oval nuclei with
one to several nucleoli &
clear to eosinophillic...
Embryonal Carcinoma
 2nd most common germ cell tumor
 Present in majority of mixed germ cell tumors
 Most men present i...
 Macroscopically:
Tan to yellow neoplasms
(fleshy tumor) that
exhibit large areas of
hemorrhage and
necrosis.
• Most und...
 Microscopically:
Undifferentiated malignant cells
with crowded pleomorphic
nuclei
Solid sheets,
Papillary
Glandular
...
Choriocarcinoma
 A rare and aggressive tumour (5yrs survival is 5%)
 Typically elevated hCG
 Presents with disseminated...
 Macroscopically:
Primary lesion may be a
hemorrhagic or a clotted
mass in which bits of grey
tumor can be seen
Present...
Yolk Sac Tumour
Most common germ cell tumor ( & most
common testicular tumor ) in children, where
it occurs in its pure f...
Macroscopically:
White to tan masses, with myxoid & cystic
changes
• Microscopically:
Reticular network of medium sized...
TERATOMA
Teratoma in greek means “monster tumor”
Occurs in its pure form with a mean age of
diagnosis at 20 months
In a...
 Macroscopically:
Largely depends on elements within it with solid & cystic areas
 Microscopically:
Contain more than ...
• Growing Teratoma Syndrome:
May grow uncontrollably, invade the surrunding
tissueand become unresectable
• Teratoma with...
Cut surface
Variably sized cysts
Gelatinous, mucinous,
hyalinized material
Intersposed solid islands –
cartilage/ bone...
Secondary Tumors of Testis
• Lymphoma – most common secondary tumor
- most common testicular tumor in patients
above 50 ye...
Tumors of adnexa / Paratesticular
tissue
• Adenomatoid tumor
-most common paratesticular tumor
-benign in nature
• Mesothe...
Intratubular Germ Cell Neoplasia
(ITGCN)
Adjacent to germ cell tumor: 98%
•Cryptorchidism: 2-8%
•Prior germ cell tumor (co...
Metastasis
1. Direct Spread:
 This spread occurs by invasion.
 Whole of testis in involved and restricted
 Tunica albug...
2. Lymphatic spread:
Seminoma metastasize exclusively
through lymphatics
They drain primarily to para-aortic
lymph nodes...
3. Blood Spread
 NSGCT spread through blood route
 Lungs, liver, bones and brain are the usual sites
usually involved
Chemo and radiation sensitive
Capacity to differentiate
Consistent pattern of metastasis
Ability to produce marker substan...
Clinical Features / Presentaion
1. Due to primary tumor
a) Painless testicular lump
b) Sensation of heaviness if size > th...
2. Due to metastasis
 Abdominal or lumbar pain (lymphatic spread)
 Mass in epigastrium
 Dyspnoea, hemoptysis and chest ...
Differential Diagnosis
• Testicular torsion
• Epididymitis, or epididymo-orchitis
• Hydrocele,
• Hernia,
• Hematoma,
• Spe...
Investigations
1. USG testes: gold standard
2. Tumor markers/ hormones
a) AFP
b) Beta hCG
3. Chest radiography
4. USG abdo...
Radiological work up
Plain X-Ray
chest:
Metastasis
USG :
Hypoechoic
relative to the
surrounding
parenchyma
Seminoma
• Seminomas are well defined within the tunica
albuginea and homogeneously hypoechoic
Embryonal cell cancers
• Embryonal cell cancers are
heterogeneous.
• The borders of the tumor are
less distinct.
• More ag...
Yolk Sac Tumor
• Imaging findings are
nonspecific,especially in
children, in whom the only
finding may be testicular
enlar...
Teratoma
• Well-circumscribed complex
masses. a common feature
and may be a
• Cysts are anechoic or complex,
depending on ...
• Choriocarcinomas are often
heterogeneous with multiple
internal calcifications present.
• Leydig and Sertoli
cell, are generally
well defined and
hypoechoic.
• Calcifications are
frequently
described.
Testicular lymphoma
generally appears as
discrete hypoechoic
lesions, which may
completely infiltrate
the testicle &
epidi...
“Burned-out" Germ Cell Tumor
• The patient may present with
widespread metastases even though the
primary tumor has involu...
Clinical Staging TNMS
• Findings at Inguinal Orchiectomy Histology, size,
extent of invasion, LVI
• •Imaging Chest and Ret...
Serum Markers
TWO MAIN CLASSES
• Onco-fetal Substances : AFP & HCG
• Cellular Enzymes : LDH & PLAP
AFP - Trophoblastic Cel...
AFP –( Alfafetoprotein)
NORMAL VALUE: Below 16 ngm / ml
HALF LIFE OF AFP – 5 and 7 days
Raised AFP :
• Pure embryonal carc...
HCG – ( Human Chorionic
Gonadotropin)
Has  and  polypeptide chain
NORMAL VALUE: < 1 ng / ml
HALF LIFE of HCG: 24 to 36 h...
ROLE OF TUMOUR MARKERS
• Helps in Diagnosis - 80 to 85% of Testicular Tumours have Positive
Markers
• Most of Non-Seminoma...
• Degree of Marker Elevation Appears to be Directly
Proportional to Tumour Burden
• Markers indicate Histology of Tumour:
...
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 > 5000...
PRINCIPLES OF TREATMENT
• Treatment should be aimed at one stage
above the clinical stage
• Seminomas - Radio-Sensitive. T...
• Transscrotal biopsy is to be condemned.
• The inguinal approach permits early control of
the vascular and lymphatic supp...
Treatment of Seminomas
Stage I, IIA, ?IIB –
Radical Inguinal Orchidectomy followed by radiotherapy to
Ipsilateral Retroper...
Testes sparing surgery
•Controversial
•Mass <2cm
•Simultaneous bilateral tumors
•Solitary testicle with normal
testosteron...
Scrotal violation
• Local recurrence higher (2.9% vs 0.4%)
(Capelouto et al. J. Urol. 1995)
• •Seminoma – extend radiation...
Treatment of Non-Seminoma
Stage I and IIA:
RADICAL ORCHIDECTOMY
followed by RETROPERITONEAL LYMPH NODES DISSECTION
Stage I...
Lymph Nodes Dissection For Right & Left Sided Testicular
Tumours
Lymphatic drainage
• The primary drainage of the right testis is
within the interaortocaval region.
• Left testis drainage...
Retroperitoneal lymph node dissection
Rationale for RPLND:
The retroperitoneum is the most common site of occult
metasta...
STANDARD CHEMOTHERAPY FOR
NON-SEMINOMATOUS GERM CELL
TUMOURS
Chemotherapy Toxicity
BEP -
Bleomycin Pulmonary fibrosis
Etop...
PROGNOSIS
Seminoma Nonseminoma
Stage I 99% 95% to 99%
Stage II 70% to 92% 90%
Stage III 80% to 85% 70% to 80%
Surveillance
 Rationale for surveillance:
70-80% patients of stage I are cured by orchidectomy
alone
No need of chemoth...
“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 ...
Testicular tumours
Testicular tumours
Testicular tumours
Testicular tumours
Testicular tumours
Testicular tumours
Testicular tumours
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Testicular tumours

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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

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Testicular tumours

  1. 1. Testicular Tumours -Dr. Shubham Lavania 21/10/2016
  2. 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. 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.
  4. 4. Improvement in Survival  Effective diagnostic techniques  Improved tumor markers  Multi-model treatment  Surgical  Radiotherapy  Multi-drug chemotherapy regimens  Mortality  before 1970 – 50 %  1997 – 5 %
  5. 5. AETIOLOGY OF TESTICULAR TUMOUR • Cryptorchidism • Intersex disorder – Klinefelter’s syndrome • Testicular atrophy • Trauma- prompts medical evaluation • Chromosomal abnormalities - loss of chromosome 11, 13, 18, abnormal chromosome 12p. • Sex hormone fluctuations, estrogen administration during pregnancy • Race • Carcinoma in situ • Previous testicular cancer
  6. 6. 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 Tumour Germ cell tumors
  7. 7. Non Germ Cell Tumors 1. Specialized gonadal stromal tumor (a) Leydig cell tumor (b) sertoli cell tumor 2. Gonadoblastoma 3. Miscellaneous Neoplasms (a) Carcinoid tumor (b) Tumors of ovarian epithelial sub types
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. • Serum alpha fetoprotein is normal • Beta HCG is elevated in 30% of patients with Seminoma • Classification a) Typical b) Anaplastic c) Spermatocytic
  12. 12.  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
  13. 13.  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
  14. 14. • 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)
  15. 15. 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
  16. 16.  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
  17. 17.  Microscopically: Undifferentiated malignant cells with crowded pleomorphic nuclei Solid sheets, Papillary Glandular Tubular arrangement of cells
  18. 18. 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;
  19. 19.  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.
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23.  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.
  24. 24. • 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
  25. 25. Cut surface Variably sized cysts Gelatinous, mucinous, hyalinized material Intersposed solid islands – cartilage/ bone/pancreatic/ liver/ intesttinal/ muscle/ neural/ connective tissue
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 3. Blood Spread  NSGCT spread through blood route  Lungs, liver, bones and brain are the usual sites usually involved
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. Differential Diagnosis • Testicular torsion • Epididymitis, or epididymo-orchitis • Hydrocele, • Hernia, • Hematoma, • Spermatocele, • Syphilitic gumma .
  36. 36. Investigations 1. USG testes: gold standard 2. Tumor markers/ hormones a) AFP b) Beta hCG 3. Chest radiography 4. USG abdomen 5. CT abdomen 6. MRI: intra-abdominal and intra-thoracic secondaries 7. IVP and RFT : obstruction on ureters
  37. 37. Radiological work up Plain X-Ray chest: Metastasis
  38. 38. USG : Hypoechoic relative to the surrounding parenchyma
  39. 39. Seminoma • Seminomas are well defined within the tunica albuginea and homogeneously hypoechoic
  40. 40. 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
  41. 41. Yolk Sac Tumor • Imaging findings are nonspecific,especially in children, in whom the only finding may be testicular enlargement without a defined mass.
  42. 42. 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)
  43. 43. • Choriocarcinomas are often heterogeneous with multiple internal calcifications present.
  44. 44. • Leydig and Sertoli cell, are generally well defined and hypoechoic. • Calcifications are frequently described.
  45. 45. Testicular lymphoma generally appears as discrete hypoechoic lesions, which may completely infiltrate the testicle & epididymis
  46. 46. “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.
  47. 47. 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
  48. 48. Serum Markers 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)
  49. 49. 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
  50. 50. 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
  51. 51. 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
  52. 52. • 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
  53. 53. 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
  54. 54. 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
  55. 55. • 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
  56. 56. 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
  57. 57. 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
  58. 58. 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
  59. 59. 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
  60. 60. Lymph Nodes Dissection For Right & Left Sided Testicular Tumours
  61. 61. 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.
  62. 62. 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
  63. 63. 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
  64. 64. PROGNOSIS Seminoma Nonseminoma Stage I 99% 95% to 99% Stage II 70% to 92% 90% Stage III 80% to 85% 70% to 80%
  65. 65. 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
  66. 66. “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
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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

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