Testicular Tumours Part 1 Vinod Jain 02.09.2014

Testicular Tumours Classification Incidence Etiology Spread of tumour Clinical Staging Clinical features Differential Diagnosis Investigations Treatment Follow up schedule

Classification Primary Tumour Secondary Tumour Para testicular neoplasm Lymphona Leukaemia Metastatic Germ Cell tumour Non Germ Cell tumour Seminoma (SGCT) Non Semimomatous (NSGCT) Leydig cell Tm Sertoli Cell Tm Gonadoblastoma Adeno CA of rete tests Terratoma Embryonal CA Chorio CA Yolk sac Tumour Mixed Tumour

Metastatic testicular Tumour In decreasing order Prostate Lung Gut Melanoma Kidney

Incidence Age – most common solid tumor of men between 20-30 years Race – White : Black = 4:1 in U.S. Side – Right > Left Socio-economic status – high : low = 2:1 Geographical Highest in Scandinavia, Germany, Switzerland Intermediate – USA & UK Low – Africa and Asia

Age wise incidence of testicular tumour Tumour Type Age group (years) Seminoma 35-40 Pure Terratoma Pediatric age group Embryonal CA 25-30 Chorio CA 25-35 Yolk sac Tumour infancy & child hood Mixed terrato CA 25-30 Lymphoma > 50

Etiology Congenital – 3-14 times common in undescended testes Abnormal germ cell morphology Elevated temperature Interference with blood supply Gonadal dysgenesis Endocrine dysfunction Acquired Trauma – co incidence Endocrine – sex hormone fluctuation Infection – Mumps induced atrophy/ non-specific infections

(Cross metastasis more common in right side tumour) Spread of Tumour Local Lymphatic – Right inter aortocaval at L2  precaval  preaortic  Right common iliac  Right ext. iliac Left  Paraortic at renal hilium  preaortic  common iliac  Left ext. iliac (Cross metastasis more common in right side tumour)

Spread of Tumour Blood (Distant metastases in decreasing order Lung Liver Brain Bone Kidney Adrenal GIT Spleen

Clinical Staging (Boden and Gibbs – 1971) Stage I (A) – confined to testis with no spread through capsule or spermatic cord Stage II (B) – Clinical or radiological evidence of spread beyond testis but with in regional L.N. B1 -<2cm B2 -2-5cm B3 - >5cm Stage III (C) - Disseminated above diaphragm / visceral disease

Clinical features A. Presentations Gradually increasing lump / hardness in testis Abnormal sensitivity – numbness / heaviness / Pain Loss of sexual activity Dull ache in lower abdomen / groin Haemospermia General weakness Metastatic presentations (Contd.)

Clinical features (Contd.) - Metastatic presentations Cough and Dyspnoea Anorexia Nausea / Vomiting (retro duodenal LN) Neck mass Swelling lower extremity (IVC obstruction) Back pain (retroperitoneal L. N.) Gynaecomastia Bone pains Unilateral limb swelling (L.N metastasis) B. Signs Local Systemic

Differential Diagnosis Epidedymo-orchitis Testicular haematoma Spermatocele Hydrocele Testicular Torsion

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

Tumour markers NSGCT SGCT AFP  N HCG   LDH   (Advanced) (Advanced)

Let us revise Classification Incidence Etiology Spread of tumour Clinical Staging Clinical features Differential Diagnosis Investigations ---------------------------------------------------------------------------------- Treatment Follow up schedule