1. Epidemiology Are rare, lifetime probability 0.2%
90-95% are germ cell tumor
More common in whites (4 fold)
More in high socioeconomic class (2 fold)
More common on right side
Geographical difference noted

2. Bilateral tumors 1-2% are bilateral 50% in men with history of UDT
Synchronously or asynchronously
Seminoma is the most common germ cell tumor in primary type
Malignant lymphoma is the most common bilateral tumor of testis

3. Risk factors Cryptorchidism, most important
7-10% in men with Hx of UDT
Seminoma is the most common form
Risk is higher in intra-abdominal testis
Orchiopexy do not alter the risk
Exogenous estrogen to pregnant mother
Truma
Infection related atrophy

4. Classification Seminoma Embryonal Teratoma Nonseminoma Choriocarcinoma
Mixed tumors

5. Seminoma (35%) Has 3 histologic type Classic seminoma 85%
More common in 4th decade of life
Syncytiotrophoblastic elements in 10-15%
Anaplastic seminoma 5-10% of all seminoma
More than 3 mitosis and high pleomorphism
Present at higher stage than classical type
Spermatocytic seminoma 5-10%
More than 50% are over the 50 years

6. Normal testis

7. Seminoma

8. Embryonal cell carcinoma(20%)
Adult type and infantile type(Yolk sac tumor)
Extensive hemorrhage and necrosis
Marked pleomorphism and mitosis
Yolk sac tumor is most common germ cell tumor of infants and children
Embryoid body commonly seen and resemble 1-2 week embryo

9. Embryonal

10. Teratoma (5%) Seen in adult and children
Contain more than one germ cell layer
Mature teratoma may have elements resembling benign structures derived from ectoderm ,mesoderm and edoderm

11. Choriocarcinoma(<1%)
Are rare tumors
Lesion are small with central hemorrhage
Syncytio-and cytotrophoblasts must be seen
Are aggressive tumors with early hematogenous spread

12. Mixed cell type(40%) Most are teratocarcinoma ( 25%)
Treatment is like nonseminomatous germ cell tumor
Carcinoma in situ : 5% in contralateral testis
Contralateral atrophy or microlithiasis may be a sign of CIS and needs BX
CIS usually treated by radiotherapy

13. Metastasis Spread in a stepwise lymphatic fashion
Lymph nodes of testis extend from T1-L4
Primary site for right testis is interaortocaval area
Primary site for left testis is para-aortic area
Right to left crossover metastasis are common
Visceral metastasis may be seen in advance disease
Lung,Liver,Brain,Bone,Kidney,Adrenal,GI ,Spleen
Choriocarcinoma is the exception with early hematogenous spread especially to lung

14. Staging Stage A: confined to testis
Stage B: regional lymph node spread
Stage C: Beyond retroperitoneal lymph node
Stage I: confined to testis
Stage II: retroperitoneal lymph node involvement:IIA<2cm, IIB>2cm
Stage III: supradiphragmatic node involvement or visceral involvement

15. TNM staging

16. Symptoms Painless enlargement of testis Acute testicular pain (10%)
Symptoms related to metastatic disease (10%)
Back pain, cough, bone pain
Asymptomatic (10%)

17. Signs Testis mass or diffuse enlargement Mass is firm and non tender
Hydrocele
Gynecomastia (5% all, 30-50%sertoli and leydig cell tumors)
Hemoptysis

18. Lab findings Anemia Renal function tests Liver function tests
Placental Alkaline phosphatase (PLAP)
Gamma-glutamyl tranpeptidase (GGT)

19. Alfa- fetoprotein (AFP)
Glycoprotein, half life : 4-6 days
High level in fetal serum
Trace amount after 1 y/o
Never found in seminoma
present in many NSGCT

20. Human chorionic gonadotropin
Glycoprotein, half life: 24 hrs
Has 2 subunit: alpha, beta
Normal men has not significant level of HCG
Elevated in all NSGCT and in 7% of seminoma

21. Lactic acid dehydrogenase
A cellular enzyme, has 5 isoenzyme
Normally found in muscle, liver, kidney and brain
Elevated level of total and isoenzyme I in NSGCT
May be elevated in seminoma

22. Tumor markers in different tumor

23. Differential diagnosis
Incorrect initial diagnosis in 25%
Epididymitis and epididymo-orchitis
Hydrocele
Hematocele, spermatocele
Varicocele
Epidermoid cyst

24. Imaging Scrotal sonography CT scan
Chest radiography (85-90% of lung metastasis)
Pedal lymphangiography

25. Sonography

26. Figure 13a. Testicular germ cell tumor.
Figure 13a.  Testicular germ cell tumor. (a) US image shows an enlarged testis (arrows) with heterogeneous parenchyma and multiple cystic areas. (b) On a color Doppler US image, the mass (arrowheads) is hypervascular with cystic areas.
Chavhan G B et al. Radiographics 2008;28:
©2008 by Radiological Society of North America

27. Sonography

28. CT scan in testis tumor

29. CT scan in testis tumor

30. Treatment (seminoma) Low stage:
Radical orchiectomy+ retroperitoneal irradiation
95% of stage I are cured
Low-volume retroperitoneal disease can be treated by radiation
No prophylactic mediastinal radiation
Chemotherapy as salvage therapy

32. Treatment (seminoma) High stage (bulky seminoma ) Primary chemotherapy
Cisplatin, Bleomycin, Etoposide
PEB for 3 cycle or PE for 4 cycles
90% complete response
Residual mass are 90% fibrosis
If well circumscribed and >3 cm consider excision

33. Treatment(NSGCT) Low stage Orchiectomy and: Survveillance
RPLND or modified RPLND
Primary chemotherapy (PEB)

34. Surveillance (NSGCT) Tumor is NSGCT, confined to tunica albuginea
No vascular invasion
Tumor markers normalize after orchiectomy
No evidence of disease in imaging(CXR, CT)
Patient is reliable

35. RPLND (classic)

36. RPLND (modified)

37. Treatment(NSGCT) High stage NSGCT:(>3cm node or >3 node)
Primary platinum based chemotherapy
Resection of residual mass if tumor markers will normalize
20%residual cancer usually embryonal cell
If markers not normalized salvage chemotherapy (BEP+Ifosfamide)
70% cure rate

38. Non-Germ cell tumors 5-6% of all testis tumors Leydig cell tumors
Sertoli cell tumors
Gonadoblastoma

39. Leydig cell tumors Most common Non-germ cell tumor
1-3% of all testis tumor
25% in childhood
Peak incidence 5-9 y/o and y/o
Bilateral in 5-10%
No association with UDT
No necrosis and hemorrhage
Reinke crystals are pathognomic

40. Leydig cell tumors Virilization and benign in prepubertal
Asymptomatic and 10% malignant in adults
Gynecomastia in 20-25%
Elevated level of 17 ketosteroid and estrogen
10-30 elevation of 17 keto steroid is typical of malignancy
Radical orchiectomy
RPLND for malignant lesions
Prognosis is excellent for benign lesion and poor for metastatic disease

41. Sertoli cell tumor Rare, < 1% of all testis tumor
Peak incidence <1 y/o and y/o
10% malignant
Testicular mass, Virilization in children, Gynecomastia in 30% adults
Radical orchiectomy
RPLND in metastatic disease

42. Gonadoblastoma 0.5% of all testis tumor
Almost exclusively in gonadal dysgenesis
Peak incidence in <30 years
4/5 patients are female phenotypically
Male patients have UDT or Hypospadiasis
Radical orchiectomy
If gonadal dysgenesis contralateral gonadectomy because 50% bilateral
Prognosis is excellent

43. Secondary tumors of testis
Are rare
Lymphoma
Leukemia
Metastatic

44. Lymphoma Most common testis tumor in >50 yrs
Most common secondary neoplasm of testis
5% of all testis tumor
Hemorrhage and necrosis are common
Late presentation of widespread lymphoma
Initial presentation of occult disease
Primary extragonadal disease

45. Lymphoma Painless enlargement of testis
Bilateral testis involvement in 50%
Constitutional symptoms in 25%
Fine needle aspiration
Radical orchiectomy
Adjuvant chemotherapy for primary testicular lymphoma

46. Other secondary tumors
A common site of relapse in ALL
Bilateral involvement in 50%
Testis biopsy for diagnosis
Bilateral testis radiation+ adjuvant chemotherapy
Metastatic tumor is rare
Prostate is the most common primary site