Testicular TumoursPart 1

Vinod Jain

02.09.2014

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Testicular Tumours • Classification • Incidence • Etiology • Spread of tumour • Clinical Staging • Clinical features • Differential Diagnosis • Investigations• Treatment • Follow up schedule

Classification

Secondary Tumour

Para testicularneoplasm

Germ Celltumour

Non GermCell tumour

Lymphona Leukaemia Metastatic

Seminoma(SGCT)

Non Semimomatous(NSGCT)

Leydig cell Tm Sertoli Cell Tm

Gonadoblastoma Adeno CA of rete tests

Terratoma Embryonal CA Chorio CA Yolk sac

Tumour

Mixed Tumour

Primary Tumour

Metastatic testicular Tumour

In decreasing order Prostate Lung Gut Melanoma Kidney

Incidence • Age – most common solid tumor of men

between 20-30 years • Race – White : Black = 4:1 in U.S.• Side – Right > Left • Socio-economic status – high : low = 2:1• Geographical

•Highest in Scandinavia, Germany, Switzerland •Intermediate – USA & UK •Low – Africa and Asia

Age wise incidence of testicular tumour

Tumour Type Age group (years)1. Seminoma 35-402. Pure Terratoma Pediatric age group3. Embryonal CA 25-304. Chorio CA 25-355. Yolk sac Tumour infancy & child hood6. Mixed terrato CA 25-30 7. Lymphoma > 50

Etiology • Congenital – 3-14 times common in undescended

testes • Abnormal germ cell morphology • Elevated temperature • Interference with blood supply• Gonadal dysgenesis• Endocrine dysfunction• Acquired

•Trauma – co incidence •Endocrine – sex hormone fluctuation •Infection – Mumps induced atrophy/ non-specific infections

Spread of Tumour • Local • Lymphatic –

– Right inter aortocaval at L2 precaval preaortic Right common iliac Right ext. iliac

– Left Paraortic at renal hilium preaortic common iliac Left ext. iliac

(Cross metastasis more common in right side tumour)

Spread of Tumour

• Blood (Distant metastases in decreasing order Lung Liver BrainBone Kidney Adrenal GITSpleen

Clinical Staging (Boden and Gibbs – 1971)

• Stage I (A) – confined to testis with no spread through capsule or spermatic cord

• Stage II (B) – Clinical or radiological evidence of spread beyond testis but with in regional L.N.

•B1 -<2cm •B2 -2-5cm •B3 - >5cm

• Stage III (C) - Disseminated above diaphragm / visceral disease

Clinical features

A. Presentations• Gradually increasing lump / hardness in testis• Abnormal sensitivity – numbness / heaviness /

Pain • Loss of sexual activity • Dull ache in lower abdomen / groin • Haemospermia • General weakness • Metastatic presentations (Contd.)

Clinical features (Contd.)

- Metastatic presentations •Cough and Dyspnoea •Anorexia •Nausea / Vomiting (retro duodenal LN) •Neck mass•Swelling lower extremity (IVC obstruction) •Back pain (retroperitoneal L. N.)•Gynaecomastia •Bone pains •Unilateral limb swelling (L.N metastasis)

B. Signs •Local •Systemic

Differential Diagnosis

• Epidedymo-orchitis • Testicular haematoma • Spermatocele• Hydrocele• Testicular Torsion

Investigations

• Haematological – Hb%, Bl. urea/S. creatinine, LFT

• Tumour markers – AFP, HCG, LDH• Scrotal Ultrasound – Usually homogenous,

hypoechoic, intra testicular mass• X-ray chest • CT / MRI – abdomen

Tumour markers

NSGCT SGCT • AFP N• HCG • LDH

(Advanced) (Advanced)

Let us revise• Classification • Incidence • Etiology • Spread of tumour • Clinical Staging • Clinical features • Differential Diagnosis • Investigations----------------------------------------------------------------------------------• Treatment • Follow up schedule