1. Testicular Cancer

2. Plan Defining the subject and its Epidemiology The Classification and Investigations The Treatment

3. What is it? Primary Germ Cell Tumors of testis arising by malignant transformation of primordial germ cells constitute 95% of testicular neoplasms. If GCTs arise from an extra-gonadal site: The mediastinum, retro peritoneum, and very rarely, the pineal gland. It is Notable for: - 1) young age of afflicted patients. - 2) Totipotent capacity for differentiation of the tumor cells - 3) its curability. Approximately, 95% of newly diagnosed patients are cured Experience in the management of GCTs leads to improved outcome.

4. Epidemiology In 2010, 8480 new cases of testicular GCT were diagnosed, and only 350 men were died in US Ages 20-40 years old Testicular mass > 50 years old regarded as lymphoma untill proven otherwise GCT is 4-5 times more common in whites than in african blacks in US.

5. Testicular cancer - Most common malignancy in men in the 15-35 year age group and evokes special interest - One of most curable solid neoplasm Serves as a paradigm for multimodal treatment - Dramatic improvement in survival: Effective diagnostic techniques Tumour markers Effective multidrug chemotherapeutic regimens Modification of surgical technique

6. Classification of Testicular Tumours Germ Cell Tumours - Seminoma Classic Atypical Spermatocytic - Nonseminomatous Embryonal carcinoma Teratoma Mature Immature Choriocarcinoma Yolk sac tumor

7. CLASSIFICATION I. Primary Neoplasms of Testis. A. Germ Cell Tumor. B.Non-Germ Cell Tumor. II.Secondary Neoplasms. III.Paratesticular Tumors.

8. Germ cell tumors 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

9. Sex cord/ gonadal stromal tumors( 5 to 10% ) 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

10. II. SECONDARY NEOPLASMS OF TESTIS A.Reticuloendothelial Neoplasms B.Metastases III.PARATESTICULAR NEOPLASMS A.Adenomatoid B.Cystadenoma of Epididymis C.Desmoplastic small round cell tumor D.Mesothelioma E.Melanotic neuroectodermal

11. Testicular cancer has become one of the most curable cancers in US because of advances in medical and surgical therapy Cisplatin-based chemotherapy regimens have improved the response rates for testis cancer

13. Examination Detailed evaluation of neck, chest and abdominal contents. - Testicular tumors often have a palpable parenchymal testis mass Can be better appreciated if compared with contralateral normal testicle. - Needs to differentiate between intraparenchymal testis masses often malignant extraparenchymal testicular masses often benign. - Scrotal ultrasound can distinguish intrinsic from extrinsic testicular lesions with a high degree of accuracy and can detect intratesticular lesions as small as 1 to 2 mm in diameter.

14. Examination: High-resolution CT scan of the abdomen, pelvis and chest x-ray. Regional metases first appear in the retroperitoneal lymph nodes CT to evaluate retroperitoneum, negative results, as evidenced by a retroperitoneal relapse rate of 20% to 25% in men, with clinical stage I disease who do not undergo retroperitoneal lymph node dissection RPLND

15. Labs Serum marker alpha fetoprotein Sb subunit of human chorionic gonadotropin (Beta-HCG) Lactate dehydrogenase The differences between them: - LDH is elevated in 80% to 85% of men with nonseminomatous GCTs. - In contrast, serum B-HCG is elevated in fewer than 20% of testicular seminomas - AFP is not elevated in pure seminomas.

16. Neither serum B-HCG nor AFP alone or in combination is sufficiently sensitive or specific to establish the diagnosis of testicular cancer in the absence of histologic confirmation. Serum LDH concentrations are elevated in 30% to 80% of men with pure seminoma and In 60% of those with nonseminomatous tumors.

17. LDH is a less sensitive and less specific tumor marker than B-HCG or AFP for men with nonseminomatous GCTs - But it may be the only marker that is elevated in seminomas. Significantly elevated serum LDH has independent prognostic value in men with advanced seminoma.

18. Radical inguinal orchiectomy with high ligation of the spermatic cord near the internal inguinal ring is performed to permit histologic evaluation of: - primary tumor and provision of local tumor control. - Note: Scrotal violation through scrotal incision or an attempt to biopsy the testicle must be avoided because of concern for changing the lymphatic channels available to the testis tumor and potential poorer outcome.

19. Serum half-lives of HCG and AFP are 18-36 hours and 5-7 days. - Testicular cancer produces any of these serum markers - Following progressive change after radical orchiectomy is an important consideration in determining the adequacy of therapy. Determination of histologic subtype of the testis cancer Several parameters may identify patients at high risk for metastasis to the retroperitoneum - Despite absence of lymphadenopathy on the staging CT scan - Nonseminomatous germ cell tumours, those factors include the following: 1- Vascular lymph invasion 2- Primary tumor (T) Stage T2-T3 3- Embryonal carcinoma component greater than 40% of total tumor volume

21. Treatment Patients with these risk factors who have no bulky retroperitoneal lymphadenopathy - Have normal tumor markers after radical orchiectomy maybe candidates for RPLND. Principles underlying modern surgical treatment of testicular GCT - based on stepwise predictable metastatic pattern of these tumours - Notable exception of choriocarcinoma - RPLND is only reliable method to identify nodal micrometases - It is gold standard for providing accurate pathologic staging of retroperitoneum

22. Both the number and size of involved retroperitoneal lymph nodes have prognostic importance Surgical therapy for metastatic testicular cancer has evolved - The full bilateral RPLND used in the past evolved first to a template-type Dissection - Then to a nerve-sparing modification with a unilateral template

23. RPLN Surgical template for modified, left-sided (A) and right-sided (B) retroperitoneal lymph node dissection