Tumours of the testis 1
Introduction ❏ any solid testicular mass in young patient – must rule out malignancy ❏ slightly more common in right testis (corresponds with slightly higher incidence of right-sided cryptorchidism) ❏ 2-3% bilateral (simultaneously or successively) 2
Types Primary Secondary 3
Primary testicular tumour 1% of all malignancies in males most common solid malignancy in males aged years undescended testicle has increased risk (10-40x) of malignancy 95 % are germ cell tumours (all are malignant) seminoma (35%) nonseminomatous germ cell tumours (NSGCT) embryonal cell carcinoma (20%) teratoma (5%) choriocarcinoma (<1%) yolk sac (<<1%) mixed cell type (40%) 5% are non-germinal cell tumours (usually benign) Leydig (testosterone, precocious puberty) Sertoli (gynecomastia, decreased libido) 4
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7.4 x 5.5-cm seminoma in a radical orchiectomy specimen. 7
Seminoma Most common form of testicular tumour in the adult More frequent in the right side Lymphatic spread Macroscopically: – Homogeneous grey- white or pink coloured lobulated cut surface usually devoid of hemorrhages or necrosis Microscopically: – Typical – Anaplastic – Spermatocytic 8
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Teratoma 10
Teratoma Derived from totipotential cells May occur at any age from infancy adult life Macroscopically: – Devoid of homogenous appearances of seminoma – Cut surface shows multiple cyst, hemorrhages & varying consistency in different parts Microscopically: – Teratoma differentiated – Malignant teratoma intermediate – Malignant teratoma undifferentiated – Malignant teratoma trophoblastic 11
Secondary testicular tumour male > 50 years of age usually a lymphoma metastases (e.g. lung, prostate, GI) 12
Etiologic factors congenital: cryptorchidism acquired: trauma, atrophy, sex hormones 13
Clinical features painless testicular enlargement painful if intratesticular hemorrhage or infarction firm, non-tender mass dull, heavy ache in lower abdomen, anal area or scrotum associated hydrocele in 10% coincidental trauma in 10% 14
Clinical features infertility (rarely presenting complaint) gynecomastia due to secretory tumour effects metastatic disease related back pain supraclavicular and inguinal nodes abdominal mass (retroperitoneal lymph node metastases) 15
Investigations testicular ultrasound (hypoechoic area within tunica albuginea = high suspicion of testicular cancer) chest x-ray (lung metastases) markers for staging (ßHCG, AFP, LDH) CT abdomen/pelvis (retroperitoneal nodes enlarged) needle aspiration contraindicated diagnosis is established by inguinal orchiectomy 16
Staging clinical Stage I: disease limited to testis, epididymis or spermatic cord Stage II: disease limited to the retroperitoneal nodes Stage III: disease metastatic to supradiaphragmatic nodal or visceral sites 17
Staging pathologic (at orchiectomy) T1 – tumour confined to testicular body T2 – tumour extends beyond tunica albuginea T3 - tumour involves rete testis/epididymis T4A – tumour invades spermatic cord T4B – tumour invades scrotal wall 18
Staging ‘cross-over’ metastases from right to left are fairly common, but they have not been reported from left to right right ––> medial, paracaval, anterior and lateral nodes left ––> left lateral and anterior paraaortic nodes 19
Tumour markers ßhCG and AFP are positive in 85% of non- seminomatous tumours pre-orchiectomy elevated marker levels return to normal post-operatively if no secondaries ßhCG positive in 7% of seminomas, AFP never elevated with seminoma 20
Treatment avoid a trans-scrotal approach for biopsy or orchiectomy, due to chance of metastases via lymph drainage seminoma radical inguinal orchiectomy and radiation (90% survival) adjuvant chemotherapy for metastatic disease 21
Treatment non-seminoma radical inguinal orchiectomy and staging retroperitoneal lymphadenectomy or surveillance surveillance includes monitoring CXR, ßhCG, and AFP levels chemotherapy (BEP = Bleomycin, Etopiside, Cisplatin) if evidence of secondary disease 22
Prognosis 99% cured with Stage I, Stage II 70-80% complete remission with advanced disease 23