ROLE OF SURGERY IN TESTICULAR CANCER

Dr.A.Joseph Stalin

Testicular cancervs

Squamous cell carcinoma/ Adenocarcinoma

Biology of Testicular malignancy

• Primordial germ cells

• Over expression of stem cell genes

• Rapidly dividing cells

• Highly responsive to Chemo & Radiotherapy.

Testicular cancer Vs SCC/Adeno ca

• Radiotherapy dose : 20-30 Gy.

• Chemotherapy dose : Cisplatin -20 mg/m2 Bleomycin -30 units weekly

Surgery has limited and selective role in management of Testicular

cancer

Role of Surgery

• 1.Radical High Inguinal Orchidectomy

- PRIMARY TREATMENT of testicular malignancy - STAGING - PROGNOSTICATION - MANAGEMENT PROTOCOL based on surgery.

8

PRINCIPLES OF ORCHIDECTOMY

– Early ligation of cord at deep ring level

– Stump should be pushed into retro peritoneum ( future removal with RPLND)

CHEVASSU MANEUVER

2. Hemi Scrotectomy with Radical orchidectomy

• In patients who have undergone trans scrotal procedures.

• Risk of Inguinal and pelvic lymphatic spread.

Chemotherapy should never be started without doing Radical

High Inguinal orchidectomy & Post orchidectomy tumour markers.

3.RPLND

• In Pure Seminoma , RPLND has NO ROLE except for ,

- Post chemo residual mass (>3 cm) with normal tumour markers and PET positive cases.

RPLND

• In Non Seminomatous GCT, role can be

- Prophylactic RPLND - Therapeutic RPLND - Post chemo RPLND - Desperate RPLND

Prophylactic RPLND

• Indication : NSGCT Stage: IA,IB

• Rationale: 30 % of stage I harbour occult mets.

• Advantage: Defnitive patholoigcal nodal staging Disadvantage : Surgical morbidity/over treatment.

Therapeutic RPLND

• Indication : NSGCTStage II (Low burden, markers negative)

• Advantage: Complete removal of viable GCT, Chemo resistant teratoma.

Post Chemo - RPLND

-Post Chemo - RPLND is indicated in the setting of normalized

tumor markers with radiographic evidence of a residual

retroperitoneal mass (≥ 1 cm) after induction chemotherapy

• Done at 6 weeks following chemotherapy.

HISTOLOGY in retroperitoneal specimen

after induction chemotherapy

• Necrosis/fibrosis – 45%

• Teratoma-40%

• Viable GCT-15%

AFTER SECOND LINE CHEMOTHERAPY

• Viable GCT- 50%

• Teratoma - 40%

• Necrosis / Fibrosis -10%

Role of Chemo after Post Chemo - RPLND

• Two additional cycles of chemotherapy following complete resection

of viable GCT (> 10% of the specimen)after first chemotherapy

remains a common standard of care with a cure rate of 70%

• When necrosis or teratoma is present, no additional chemotherapy

is required

Why is it important to remove teratoma?

• Teratoma though benign is biologically unpredictable

• Left un-resected, possesses the potential to invade adjacent organs (growing teratoma syndrome)

• Undergo malignant transformation

• Increases the risk of late relapse

GROWING TERATOMA SYNDROME

• Tumor growth with declining tumor markers

occurring during chemotherapy

• Needs early surgical intervention and

completion of chemotherapy after surgery

DESPERATION RPLND

• Persistently elevated or increasing tumor markers after

primary induction chemotherapy, failed salvage

chemotherapy

• Completely resectable retroperitoneal masses

• Technically difficult

• 20% to 55% - 5-year survival rate

ANATOMY

1. Lymphatics of the testis drain into the

retroperitoneal lymphnode chain extending from

T11 to L5,concentrated in the renal hilum

2. Common embryologic origin with kidney

3. Surgical mapping studies by Donohue et al divides

the retro-peritoneum into specific anatomic

regions

• The sympathetic fibers that mediate

seminal emission originate primarily

from the T12 to L3 thoraco lumbar

spinal cord.

• After leaving the sympathetic trunk,

the fibers converge towards the

midline and form the hypogastric

plexus near the takeoff of the inferior

mesenteric artery (IMA) just above

the aortic bifurcation.

TYPES OF RPLND

EXTENT OF DISSECTION

Bilateral supra hilar/extended template

Bilateral infra hilar / Standard template

Nerve Sparing Unilateral modified template

Nerve dissecting bilateral template

Suprahilar

• Supra-hilar metastasis rare in low stage NSGCT

• Reserved for residual hilar or suprahilar masses following chemotherapy

• Higher complication rates

• Chylous ascites

Complications

• Retrograde Ejaculation• Infertility• Prolonged ileus• Hemorrhage• Ureteral injury• Injury to major viscera

• Mortality <1%

• Lymphocele• Wound infection• Atelectasis• Pulmonary embolism• Bowel obstruction• Wound dehiscence

Role of surgery

• EXTRA GONADAL Germ cell tumour : Sacro coccyxeal region, mediastinum

• NON GERM CELL TUMOUR : Surgery is the main modality of treatment

CONCLUSION

• Role of Surgery :

• High Inguinal Orchidectomy is the primary treatment.

• Other surgical options include : Hemi scrotectomy. RPLND Metastectomy/Wide local excision.

Thank You