1. GÖZDE AKAN BERFİN GİZEM USLU
Testıcular cancer
GÖZDE AKAN
BERFİN GİZEM USLU

2. ANATOMY Paired, ovoid male reproductive organ 4 x 3 x 2.5cm
approximately 25 ml
lobules
Lies obliquely within the scrotum suspended by the spermatic cord

3. FUNCTIONS
Produce sperms and male hormones, primarily testosterone

5. LYMPHATIC DRAINAGE On the right :
along the IVC  - interaortacaval region - preartic and paraaortic lymph nodes ,with possible cross- over within the retroperitoneum 
On the left :
preaortic and paraaortic nodes around the left renal hilum - interaortacaval nodes mostly without cross-over

6. EPIDEMIOLOGY
Uncommon malignancy, accounting for 1–2% of all tumours in men
However, it is important because its incidence is increasing worldwide
Most common malignancy in young men (aged 15–34 years) in many populations worldwide
The peak age of men with seminomas is 30–40 years, compared with 20–30 years for nonseminomatous GCT
Contrary to the trends in incidence, the testicular cancer mortality rate has been decreasing in most European countries, largely attributable to the advent of platinum- based chemotherapy regimens and multidisciplinary approach to testicular cancer management 

7. Cryptorchidism -four to eight times greater risk
RISK FACTORS
Cryptorchidism -four to eight times greater risk 
Prior Testicular Cancer- 500-fold higher rate than in the general population
Genetics- Klinefelter syndrome (47XXY)
Down syndrome
Androgen insensitivity syndrome
Family history
Infertility

8. 6.Environmental exposure
7.Scrotal trauma
8.Inguinal hernia
9.Smoking
10.Race-more common among Caucasian males
Highest rates in Scandinavia,
Germany and New Zealand
HIV

9. CLINICAL FEATURES Due to metastasis; Due to primary tumor;
Painless testicular lump
Sensation of heaviness
Rarely pain (1/3rd cases)
May mimic epidedymoorchitis
Gynaecomastia appears in 7% of cases
Due to metastasis;
Abdominal or lumbar pain (lymphatic spread)
Dyspnea, hemoptysis and chest pain with lung metastasis
Jaundice with liver metastasis
Hydronephrosis by para-aortic lymph nodes enlargement
Pedal edema by IVC obstruction

10. PHYSICAL EXAMINATION:
Enlarged testis (except choriocarcinoma)
Nodular testis
Loss of testicular sensation
Flat and difficult to feel epididymis
General examination for metastasis

12. CLASSIFICATION OF TESTICULAR TUMORS
Germ Cell Tumors (%90)
Seminomas (%60)
Classical
Spermatocystic
Anaplastic
Non-Seminomatous Tumors (%40)
Embryonal Carcinoma
Yolk Sac Tumor
Choriocarcinoma
Teratoma
Mixed Tumors
Non-Germ Cell Tumors
Sex-Cord Stromal Tumors (%2)
Leydig Cell Tumor
Sertoli Cell Tumor
Granulosa Cell Tumor
Mixed Type
Unclassified
Mixed Germ Cell and Stromal Tumor
Adnexal and Paratesticular Tumors
Miscellaneous Tumors (%5)
(Metastatic tumors, Carcinoid,Lymphoma)

13. GERM CELL TUMORS 1) Seminoma testicular cancer
The commonest variety of testicular tumour
Adults are the usual target (4th and 5th decade); never seen in infancy
Patients present with painless testicular mass
30 % have metastases at presentation, but
only 3% have symptoms related to metastases
Serum alpha fetoprotein is normal
Beta HCG↑30% of patients
with Seminoma
Highly sensitive to radiotherapy
among testis tumors

14. SEMINOMA CLASSICAL (%85) Middle age (30-50) ↑BetaHCG(10%)
Very slow growth
Spermatocytic(2% - 12% )
Old age (> 50 yr)
Most common GCT in men > 65 yrs
Extremely low metastatic potential
Good prognosis
ANAPLASTIC (5% - 10)
Middle age
Aggressive - lethal
Greater mitotic activity
Higher local invasion
Higher metastatic potential
Higher rate of β-HCG production

15. 2)NON-SEMİNOMATOUS GERM CELL TUMORS
2. a) Embryonal Carcinoma:
2nd most common germ cell tumor
90% of NSGCT
Present in majority of mixed germ cell tumours
Most men present in their 20s to 30s with a testicular mass
Highly malignant tumours; may invade the cord structures epididymis
High degree of metastasis
Serum AFP is positive in 30%, beta HCG is elevated in 20% of cases

16. 2)NON-SEMİNOMATOUS GERM CELL TUMORS
2.b) Choriocarcinoma:
A rare and aggressive tumour (5years survival is 5%)
Typically elevated B-Hcg > 99%
Usually present with distant mets – lung and /or brain
Primary is very small and often exhibit NO TESTICULAR ENLARGEMENT, small palpable nodule may be present.
Hematogenous mets most common

17. 2)NON-SEMİNOMATOUS GERM CELL TUMORS
2.c) Yolk sac tumor:
Most common prepubertal GCT in children.
Pure yolk sac tumor <2% of testicular tumors in adults
40% of mixed germ-cell tumors.
AFP ↑ >90% of pts
Testicular mass the most usual presentation
Respond very well to chemotherapy, even if they have spread
Microscopically, Schiller-Duval bodies are
a characteristic feature

18. 2)NON-SEMİNOMATOUS GERM CELL TUMORS
2.d) Teratoma:
Teratoma in greek means “monster tumor”
Contain all three germ layers with varying degree of diffrentiation
Occurs in its pure form in pediatric age group with a mean age of diagnosis at 20 months
In adults, occur as a component of mixed germ cell tumor
Normal serum markers.
Mildly elevated AFP levels

19. 3)SEX CORD STROMAL TUMORS
Sertoli cell:
-Excess estrogen production
-Gynecomastia in 1/3rd of cases
-10 % are malignant
 -Androgen insensitivity syndrome
-Peutz-Jeghers syndrome
Leydig cell:
-Produces androgens
-Reinke crystals
 -Klinefelter’s syndrome 
Granulosa cell
Mixed types

20. METASTATIC TUMORS OF TESTIS
Lymphoma
-most common secondary tumor
-most common testicular tumor in patients above 50 years 
Leukemia
Prostate cancer

21. SPREAD Direct Spread: This spread occurs by invasion.
Tunica albuginea is rarely penetrated
Scrotal skin involvement
Spread to spermatic cord and epidedymis may occur :
points towards bad prognosis
Lymphatic spread:
Seminoma metastasize exclusively through lymphatics
They drain primarily to para-aortic lymph nodes
Blood Spread
NSGCT spread through blood route
Lungs, liver, bones and brain are the usual sites usually involved

22. TUMOR MARKERS AFP (alpha-fetoprotein): Trophoblastic Cells
-upper limit of normal serum AFP<10-15 microg/L
-serum AFP concentrations >10,000 microg/L are found almost
exclusively in patients with (NSGCTs) or hepatocellular carcinoma
B-HCG: Syncytiotrophoblastic Cells
-most commonly elevated tumor marker in testicular cancer
-normal value in men is less than 5 to 10 IU/L
-Increased levels of beta-HCG can be found in seminoma or nonseminoma

23. TUMOR MARKERS Lactate Dehydrogenase (LDH):
-elevated in 40 to 60 percent of men with testicular germ cell tumors
-less sensitive and less specific tumor marker than (beta-hCG) or (AFP) for men with NSGCTs
- increased levels reflect tumor burden, growth rate, and cellular proliferation
AFP, BHCG & LDH are included in TNM staging of testicular cancers

24. DIAGNOSIS
Painless swelling or a nodule in one testicle is the most common presenting sign
In any man with a solid, firm mass within the testis, testicular cancer must be the considered diagnosis until proven otherwise
Physical examination
Scrotal USG
Blood test: CBC + AFP , B-HCG , LDH
CT Scan, MRI, PET Scan
Radical inguinal orchiectomy
Contralateral testicular biopsy
Retroperitoneal lymph node dissection

26. DDx Epididymo-orchitis Hematoma Torsion Paratesticular neoplasm
(most commonly benign)
Hernia
Varicocele-spermatocele
Tuberculosis and other
testicular infections

27. STAGING(for all patients)
Serum tumour markers
-AFP
-hCG
-LDH
Abdominopelvic CT
Chest X-ray/ CT
Testis ultrasound (bilateral)

28. TNM STAGING
Testicular cancer is staged using the TNM system created by the American Joint Committee on Cancer (AJCC).
T refers to how much the main (primary) tumor has spread to tissues next to the testicle.
N describes how much the cancer has spread to regional (nearby) lymph nodes.
M indicates whether the cancer has metastasized (spread to distant lymph nodes or other organs of the body).
S indicates the serum (blood) levels of tumor markers that are made by some testicular cancers.

29. ROYAL MARSDEN CLASSIFICATION
Stage I: Cancer is found only in the testicle.
Stage II: Cancer has spread to the retroperitoneal lymph nodes in the belly.
-IIA: <2 cm in size or < 6 positive nodes
-IIB: 2-5 cm in size or > 6 positive nodes
-IIC: large and bulky abdominal mass, usually > cm
Stage III: Cancer has spread beyond the lymph nodes in the belly. There may be cancer in parts of the body far away from the testicles such as the lungs, brain, bones and liver.
Stage IV: Hematogenous spread

31. GENERAL MANAGEMENT
After obtaining serum AFP & B-Hcg levels in suspected case of malignant germ cell tumour
Radical inguinal orchietectomy with high ligation of spermatic cord is done, it is both diagnostic & therapeutic
Further management depends on, pathology & stage of disease.

32. Radical inguinal orchietectomy
Testicular tumors are diagnosed, staged and locally controlled by inguinal orchiectomy.
Scrotal biopsy is irrelevant and contraindicated.

33. TREATMENT Radical Inguinal Orchiectomy Surveillance
Retro Peritoneal Lymph Node Dissection(RPLND)
Radiotherapy
Chemotherapy

34. SEMINOMAS TX 1. Early Stage Radiation therapy (gold standard)
Surveillance (selected cases)
2. Advanced Stage
Chemotherapy

35. NONSEMINOMAS TX Early Stage (Stage I)
Retroperitoneal Lymph Node Dissection
Open / Laparoscopic
Surveillance (low-risk patients)
Chemotherapy (2 courses) (high-risk patients*)
* angio-lymphatic invasion
>%50 presence of embryonal cell carcinoma
Absence of yolk sac component
Advanced Stage (>IIB)
Chemotherapy (BEP : Bleomycin/etoposide Cisplatin)

36. PROGNOSIS High-risk prognostic features include any of the following:
Mediastinal primary tumor
Nonpulmonary visceral metastases
AFP > 10,000 ng/mL
hCG > 50,000 IU/L
LDH > 10 times the upper limit

37. A good prognosis can typically be expected in patients with the following:
Testicular or retroperitoneal primary tumor
No nonpulmonary visceral metastases
Alpha-fetoprotein < 1000 ng/mL
Human chorionic gonadotropin < 5000 IU/L
Lactate dehydrogenase (LDH) < 1.5 times the upper limit

39. FOLLOW-UP At least 5 years with: -periodic x-rays -CT scans
-blood tests for tumor markers
Also, since there is an increased risk (about 2%) of a second tumor, it is important to continue monthly testicular self-exams.

40. REFERENCES
"What Is Testicular Cancer?" American Cancer Society. N.p., n.d. Web. 01 Apr < cancer.html>.
"Testicular Cancer." Background, Pathophysiology, Epidemiology. N.p., 13 Mar Web. 01 Apr < overview>.
"Testes and Epididymis Anatomy." Overview, Gross Anatomy, Microscopic Anatomy. N.p., 28 Oct Web. 01 Apr <