tetis2.ppt

8/10/2019 tetis2.ppt

1/39

Management of

Testicular Tumours

Dr.Sunil Shroff, MS, FRCS (UK ), D.Urol (Lond.)

Prof & HOD SriRamachandra Medical College & Research Institution,Chennai


2/39


3/39

Survival in Testicular Tumours

Improved overall survival in last 15 to 20

years due to -

Better understanding of Natural History

and Pathogenesis of disease

Reliable Tumour Markers

Cis-platinum based chemotherapy


4/39

CROSS SECTION OF TESTI S

Testis

Stroma Seminiferous Tubules

(200 to 350 tubules)

Interstitial Cells SupportingSpermatogonia

Leydig or

(Androgen) Sertoli Cell


5/39

EPIDEMIOLOGY

Incidence : 1.2 per 100,000 (Bombay)

3.7 per 100,000 (USA)

Age : 3 Peaks- 20-40 yrs. Maximum

- 0 - 10 yrs.

- After - 60 yrs.

Bilaterality : 2 to 3% Testicular Tumour


6/39

CLASSIFICATION

I. Primary Neoplasma of Testis.

A. Germ Cell Tumour

B. Non-Germ Cell Tumour

II. Secondary Neoplasms.

III. Paratesticular Tumours.


7/39

I . PRIMARY NEOPLASMS OF TESTI S

A. Germinal Neoplasms : (90 - 95 %)1. Seminomas - 40%

(a) Classic Typical Seminoma

(b) Anaplastic Seminoma

(c) Spermatocytic Seminoma

2. Embryonal Carcinoma - 20 - 25%

3. Teratoma - 25 - 35%

(a) Mature(b) Immature

4. Choriocarcinoma - 1%

5. Yolk Sac Tumour


8/39

I . PRIMARY NEOPLASMS OF TESTIS

B. Nongerminal Neoplasms : ( 5 to 10% )

1. Specialized gonadal stromal tumor

(a) Leydig cell tumor

(b) Other gonadal stromal tumor

2. Gonadoblastoma

3. Miscellaneous Neoplasms

(a) Adenocarcinoma of the rete testis

(b) Mesenchymal neoplasms

(c) Carcinoid

(d) Adrenal rest tumor


9/39

A. Adenomatoid

B. Cystadenoma of EpididymisC. Mesenchymal Neoplasms

D. Mesothelioma

E. Metastases

II. SECONDARY NEOPLASMS OF TESTIS

A. Reticuloendothelial Neoplasms

B. Metastases

III. PARATESTICULAR NEOPLASMS


10/39

AETIOLOGY OF TESTICULAR TUMOUR

1. Cryptorchidism

2. Carcinoma in situ

3. Trauma

4. Atrophy


11/39

CRYPTORCHIDI SM & TESTICULAR TUMOUR

Risk of Carcinoma

developing inundescended testis is

14 to 48 times thenormal expected

incidence


12/39

CRYPTORCHIDI SM & TESTICULAR TUMOUR

The cause for malignancy are as follows:

Abnormal Germ Cell MorphologyElevated temperature in abdomen &

Inguinal region as opposed to scrotum

Endocrinal disturbances

Gonadal dysgenesis


13/39

Testicular Tumour & Molecular Biology

Molecular & Genetic Research may

help Future patient with TesticularTumours:

Earlier diagnosis

Identify Susceptible Individuals

(Recent Advances)


14/39


Seminoma &

Embryonal - N-myc expressionCarcinoma

Seminoma - c-Ki-ras expression

ImmatureTeratomas - c-erb B-1 expression

PROTO-ONCOGENES in Germ Cell Tumours (Shuin et al)


15/39


(Recent Advances)

Testicular germ cell tumour show

consistent expression of both:

Parental alleles of H19

IGF-2 genes.


16/39

Clinical Staging of Testicular Tumour

Staging A or I - Tumour confined to testis.

Staging B or II - Spread to Regional nodes.

IIA - Nodes 6 Positive Nodes

IIC - Large, Bulky, abd.mass usually > 5 to 10 cm

Staging C or III - Spread beyond retroperitonealNodes or Above Diaphragm or visceral disease


17/39

To properly Stage Testicular Tumours following

are pre-requisites:

(a) Pathology of Tumour Specimen(b) History

(c) Clinical Examination

(d) Radiological procedure - USG / CT /MRI / Bone Scan

(e) Tumour Markers - HCG, AFP

Requi rements for staging


18/39

TNM Staging of Testicular Tumour

T0 = No evidence of TumourT1s = Intratubular, pre invasive

T1 = Confined to Testis

T2 = Invades beyond Tunica Albuginea

or into EpididymisT3 = Invades Spermatic Cord

T4 = Invades Scrotum

N1 = Single < 2 cmN2 = Multiple < 5 cm / Single 2-5 cm

N3 = Any node > 5 cm

Epididymis or Scrotal skin

Lymph drainage to Inguinal Nodes


19/39

Pathogenesis & Natural H istory of

Testicular Tumour

Course of Spread of Germ Cell Tumours are

predictible once Histology of Tumour cofirmed

Lymphatic Spread has a set pattern

depending on side of Tumour

Seminoma may have non-seminomatous

metastasisHigh Grade Tumours spread by both

Vascular invasion & via Lymphatics


20/39

I nvestigation

1. Ultrasound - Hypoechoic area

2. Chest X-Ray - PA and lateral views

3. CT Scan4. Tumour Markers

- AFP

- HCG

- LDH

- PLAP


21/39

CLINICAL FEATURES

Painless Swelling of One Gonad

Dull Ache or Heaviness in Lower Abdomen

10% - Acute Scrotal Pain

10% - Present with Metatstasis

- Neck Mass / Cough / Anorexia / Vomiting /

Back Ache/ Lower limb swelling

5% - Gynecomastia

Rarely - Infertility


22/39

DICTUM FOR ANY SOLID SCROTAL SWELLINGS

All patients with a solid, Firm

Intratesticular Mass that cannotbe Transilluminated should beregarded as Malignant unless

otherwise proved


23/39

Tumour Markers

TWO MAIN CLASSES

Onco-fetal Substances : AFP & HCGCellular Enzymes : LDH & PLAP

( AFP - Trophoblastic Cells

HCG - Syncytiotrophoblastic Cells )


24/39

AFP( Alfafetoprotein )

NORMAL VALUE: Below 16 ngm / ml

HALF LIFE OF AFP 5 and 7 days

Raised AFP :

Pure embryonal carcinoma

Teratocarcinoma

Yolk sac TumourCombined Tumour

REMEMBER: AFP Not raised is Pure Choriocarcinoma or Pure Seminoma


25/39

HCG( Human Chorionic Gonadotropin )

Has and polypeptide chain

NORMAL VALUE: < 1 ng / ml

HALF LIFE of HCG:24 to 36 hours

RAISED HCG -

100 % - Choriocarcinoma

60% - Embryonal carcinoma

55% - Teratocarcinoma\

25% - Yolk Cell Tumour

7% - Seminomas


26/39

ROLE OF TUMOUR MARKERSHelps in Diagnosis - 80 to 85% of Testicular

Tumours have Positive Markers

Most of Non-Seminomas have raised markersOnly 10 to 15% Non-Seminomas have normal

marker level

After Orchidectomy if Markers Elevated means

Residual Disease or Stage II or III Disease

Elevation of Markers after Lymphadenectomy means

a STAGE III Disease


27/39

ROLE OF TUMOUR MARKERS cont...

Degree of Marker Elevation Appears to be DirectlyProportional to Tumour Burden

Markers indicate Histology of Tumour:

If AFP elevated in Seminoma - Means Tumour hasNon-Seminomatous elements

Negative Tumour Markers becoming positive on followup usually indicates -

Recurrence of TumourMarkers become Positive earlier than X-Ray studies


28/39

PRINCIPLES OF TREATMENT

Treatment should be aimed at one stage above

the clinical stage

Seminomas - Radio-Sensitive. Treat withRadiotherapy.

Non-Seminomas are Radio-Resistant and best

treated by SurgeryAdvanced Disease or Metastasis - Responds well

to Chemotherapy


29/39

PRINCIPLES OF TREATMENT

Radical INGUINAL ORCHIDECTOMY is

Standard first line of therapy

Lymphatic spread initially goes toRETRO-PERITONEAL NODES

Early hematogenous spread RARE

Bulky Retroperitoneal Tumours or MetastaticTumors Initially DOWN-STAGED with

CHEMOTHERAPY


30/39

Treatment of SeminomasStage I, IIA, ?IIB

Radical Inguinal Orichidectomy followed by

radiotherapy to Ipsilateral Retroperitonium &Ipsilateral Iliac group Lymph nodes (2500-3500 rads)

Bulky stage II and III Seminomas -Radical Inguinal Orchidectomy is followed byChemotherapy


31/39

Treatment of Non-SeminomaStage I and IIA:RADICAL ORCHIDECTOMY

followed by RETROPERITONEAL LYMPH NODES

DISSECTION

Stage IIB:

RPLND with possible ADJUVANT CHEMOTHERAPY

Stage IIC and Stage III Disease:

Initial CHEMOTHERAPY followed by SURGERY forResidual Disease


32/39

Chemotherapy Toxicity

BEP -Bleomycin Pulmonary fibrosis

Etoposide (VP-16) MyelosuppressionAlopeciaRenal insufficiency (mild)

Secondary leukemia

Cis-platin Renal insufficiencyNausea, vomitingNeuropathy

STANDARD CHEMOTHERAPY FOR

NON-SEM INOMATOUS GERM CELL TUMOURS


33/39

Left Right

Axial CT Section demonstarating - Left H ydronephrosis, due

to large Para-Aortic Nodal Mass from a Germ cell tumour


34/39

Limits of Lymph Nodes Dissection For Right &

Left Sided Testicular Tumours


35/39

THERAPY OF PATIENT WITH SEM INOMA

Stage I, IIA, ? IIB Stage IIB, IIC, III

B - Bleomycin

Abdominal Radiotherapy E - Etoposide (VP-16)

4 cycles

P - cis-platin

Follow Up Stable/Regress Relapse/Growth

F/U ? RPLND? Chemotherapy

? XRT


36/39

Therapy of Nonseminomatous Germ Cell Testicular Tumours

Radical Inguinal Orchidectomy

Stage I, II (minimum)

RPLND

Stage I, II B1 Stage II B2

Observe BEP 2 cycles

Bleomycin

Etoposide

Cis-platin


37/39

Radical Inguinal Orchidectomy

Stage II C (advanced) / III

BEP

4 cyclesComplete Response Partial Response Progress

Observe RPLND VIP or AutologousBone marrowTransplant

Cancer Teratoma / Fibrosis

V-VinblastineI-Ifosfamide OBSERVEP-cis-platin

Therapy of Nonseminomatous Germ Cell Testicular Tumours


38/39

PROGNOSIS

Seminoma Nonseminoma

Stage I 99% 95% to 99%

Stage II 70% to 92% 90%

Stage III 80% to 85% 70% to 80%


39/39

CONCLUSION

Improved Overall Survival of Testicular

Tumour due to Better Understanding of

the Disease, Tumour Markers and Cis-

platinum based Chemotherapy

Current Emphasis is on Diminishingoverall Morbidity of Various Treatment

Modalities

tetis2.ppt

Documents