1. Tumors of the testis
S. Vahidi M.D

2. Tumors of the testis Introduction: 1-8 new cases/ 100000 male/year
90-95% germ cell tumors
Survival of patients has improved dramatically
Higher socioeconomic/lower classes 2/1
R>L
1-2%: Bilateral. Seminoma-lymphoma
7-10% of T-tumors develop in cryptorchidism
Orchiopexy does not alter the malignant potential
Exogenous estrogen Adm. To the mother during pregnancy

3. Tumors of the testis Classification:  Primary  Benigne
 Secondary  Malignant
 Germ cell
 Non germ cell
 Germ cell tumors:
Seminoma
Nonseminomatous: Embryonal
Teratoma
Choriocarcimoma
Mixed tumors

4. Totipotential germ cell (totipotential tumor cell)
Tumors of the testis
Tumorigenic hypothesis:
Normal spermatocyte
Totipotential germ cell
Seminoma ?
Embryonal carcinoma
(totipotential tumor cell)
Extra embryonic differentiation
Intra embryonic differentiation
Trophoblastic pathways
Yolk sac pathways
Choriocarcimoma
Yolk sac tumor
Teratoma

5. Tumors of the testis Pathology A. Seminoma (35%)
Classic (85%)
Anaplastic (5-10%)
Spermatocytic (5-10%)
B. Embryonal cell carcimoma (20%)
Adult type
Infantile type (yolk sac tumor)
C. Teratoma (5%)
D. Choriocarcinoma (<1%)
E. Mixed cell type (40%)
Teratocarcinoma
F. Carcimoma in situ (CIS)

6. Tumors of the testis Patterns of metastatic spread
Step wise lymphatic fashion. (T1-T4)
RT testis: intra aortocaval at RT K.hilum
Precaval-preaortic-Paracaval-RT common Iliac- RT ext Iliac nodes
LT testis: paraaortic area at LT K. Hilum
Pre aortic- LT common Iliac- LT ext. Iliac nodes
RT to LT crossover metastasis: common
LT to RT crossover metastasis: No
Visceral metastases: lung – liver-brain – bone- kidney-adrenal . GI. Spleen
Hematogenous : choriocarcinoma

7. Tumors of the testis Clinical staging T-primary tumors
Cannot be assessed
No evidence of primary tumor
Intratubular cancer (CIS)
Limited to testis and epididymis, no vascular invasion
Invades beyond tunica albuginea or has vascular invasion
Invades spermatic cord
Invades scrotum
TX:
T0:
Tis:
T1:
T2:
T3:
T4:
N-Regional lymph nodes
No regional lymph node metastasis
Lymph node metastasis≤ 2cm, or multiple nodes, none more than 2 cm. and<6 nodes positive
Nodal mass>2cm and ≤5cm. Or ≥6 nodes positive
Nodal mass> 5 cm
NX:
N1:
N2:
N3:
M-Distant metastasis
No distant metastasis
Distant metastasis present in nonregional lymph nodes or lungs
Nonpulmonary visceral metastases
MX:
M0:
M1:
M2:
S-Serum tumor markers
Markers not available
Marker levels within normalimits
Lactic acid dehydrogenase (LDH)<1.5xnormal and HCG<500 mlU/ml and AFP<1000ng/ml
LDH xnormal or hCG mIU/ml or AFP ng/ml
LDH>10xnormal or hCG>50000 mIU/ml or AFP>10000 ng/ml
SX:
S0:
S1:
S2:
S3:

8. Tumors of the testis Clinical findings A-symptoms:
Painless enlargment of testis
Acute testicalor pain (10%)
Symptoms related to metastasis (10%): back pain-cough-dyspnea anorexia-nausea- bone pain- lower ext. edema
Asymptomatic (10%)

9. Tumors of the testis Clinical findings B: signs:
Testicular mass or diffuse enlargment
Node palpation
Gynecomastia
Hemoptysis

10. Tumors of the testis Laboratory findings and tumor markers:
Anemia-liver function tests- creatinin
Tumor markers:
αFP
βHCG
LDH
PLAP-GGT
AFP(%)
hCG(%) 38 64 70 7 25 57 60
100
Seminoma
Teratoma
Teratocarcinoma
Embryonal
choriocarcinoma

11. Tumors of the testis Imaging Ultrasonography CXR CT-Scan Pedal LAG
For staging

12. Tumors of the testis Differential diagnosis
Epdidymitis & Epididymoorchitis
Hydrocele
Spermatocele
Hematocele
Granulomatous orchitis
Varicocele
Epidermoid cyst

13. Tumors of the testis Treatment
Inguinal Exploration & radical orchiectomy
Low stage seminoma: retroperitoneal irradiation
95% care
high stage seminoma: primary chemotherapy
95% complete response

14. Tumors of the testis Treament
C: low stage NSGCT: R.O +RPLND (N22cycles chemotherapy)
Surveillncc: 1)NSGCT confined within tunica albuginea
2)No vascular invasion
3)normalize tumor markers
4)no evidence of disease in radiographic imaging
5)the patient is considered reliable
Modified RPLND: Nodal tissue dissection ipsilateral to the tumor below the level of the inferior mesenteric artery
Clinical stage I+ vascular invasion: 2 cycles of chemotherapy

15. Tumors of the testis Treatment
High stage NSGCT: primary chemotherapy (+RPLND?)
Normal tumor marker+retroperitoneal massmass resection
tumor markersalvage chemotherapy
(upto 70% care)
High risk patients:
mediastinal primary tumor
non pulmonary visceval metastasis
S3 marker levels

16. Tumors of the testis Follow up:
careful exam of remaining testis, abdomen, lymph node area
lab (AFP, BHCG-LDH)
CXR
every 3 month/ first 2 years
every 6 month/ until 5 years
and then yearly
Surveillance follow up:
tumor marker at each visit.
CXR & CT every 3-4 month
Visit:
monthly/ first 2 years
bimonthly/ third year

17. Tumors of the testis Prognosis Seminoma: R.O+radiotherapy:
stage I: 98% 5 years survival rate
stage II: 92-94% 5 years survival rate
stage III (chemotherapy): 35-75%
NSGCT: stage I: %
low, volume stage II: 90%
stage III: 55-80%

18. Tumors of the testis Non-Germ cell tumors 5-6% of all testis tumor
leydig cell tumors most common
5-9 & years old
no association with UDT
clinical finding: virilization (prepubertal)
asymptomatic (adults). 10% malignant
Treatment : radical orchiectomy- RPLND
Sertoli cell tumors
exceedingly rare
10% malignant
radical orchiecty+RPLND
Gonadoblastoma
in gonadal dysgenesis(80% female fenotype)
radical orchiectomy + contralateral gonadectomy

19. Tumors of the testis Secondary tumors of the testis
1. lymphoma most common t.t. in>50 years old
2. leukemia t.Biopsy is choice
3. metastatic tumor: prostate- lung –GI-melanoma-kidney

20. Tumors of the testis Extragonadal germ cell tumors
3% of all germ cell tumors
the most common sites: mediastinum-retroperitoneum, sacrococcygeal – pineal gland

21. Tumors of the testis T. Of epididym: commonly benign: adenomatoid
Tumors of the epididymis, paratesticular tissue & spermatic cord
T. Of epididym: commonly benign:
adenomatoid
leiomyoma
cystadenoma
T. of spermatic cord:
lipoma
Rabdomyosarcoma
leiomyosarcoma. Fibrosarcoma
liposarcoma