TESTICULAR TUMOURS PROF. DR. METE KÄ°LCÄ°LER - PowerPoint Presentation

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TESTICULAR TUMOURS

PROF. DR. METE KİLCİLER DEPARTMENT OF UROLOGY, SCHOOL OF MEDICINE, BAHÇEŞEHİR UNIVERSITY

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Tumo

u

rs

of the testis

Introduction:

I

ntratesticular

-

malignant

90-95

% germ cell tumors

1-2% Bilateral

-

lymphoma

7-10

% of

testis

tumors

develop in cryptorchidism

Orchiopexy

does not alter the malignant potential

Exogenous estrogen

t

o

the mother during pregnancy

Survival of patients has improved dramatically

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Tumo

u

rs

of the testis

Classification:

ï‚¡

Primary

ï‚¡

Benign

ï‚¡

Secondary

ï‚¡

Malignant

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Germ cell

ï‚¡

Non germ cell

ï‚¡

Germ cell tumors:

Seminoma

Non

-

seminomatous

: Embryonal

Teratoma

Choriocarcimoma

Mixed tumors

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Primary Testicular Cancer

GERM CELLSeminoma 35%Classic (85%)Anaplastic (5-10%)Spermatocytic

(5-10%)

Embryonal 4%Adult typeInfantile type (yolk sac tumor)Teratoma 10%Choriocarcinoma 1%Mixed cell type 40%TeratocarcinomaNONGERM CELLLeydig 1-3%

Sertoli

<1%

Gonadoblastoma

0.5%

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Seminoma

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Embriyonal carcinoma

Grossly, the tumors are large, often hemorrhagic and necrotic producing at cut surface.

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Pathologic features of yolk sac tumor

Gross: The cut surface is gray-white and may be cystic.

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Choriocarcinoma: large, hemorrhagic, necrotic tumor.

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Tumors of the testis

Clinical findings

A-symptoms:

Painless

enlargment

of testis

Acute

testic

u

l

a

r

pain (10%)

Symptoms related to metastasis (10%): back pain-cough-dyspnea anorexia-nausea- bone pain- lower ext. edema

Asymptomatic (10%)

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Tumors of the testis

Clinical findings

B: signs:

Testicular mass or diffuse

enlargment

Node palpation

Gynecomastia

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Tumors of the testis

Laboratory findings and tumor markers:

Anemia-

increased

l

iver

function tests-

increased

creatinin

Tumor markers:

A

FP

Î’

-

HCG

LDH

hCG(%)

AFP

(%)

Seminoma

Teratoma

Teratocarcinoma

Embryonal

choriocarcinoma

7

25

57

60

100

0

38

64

70

0

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Alpha Feto

ProteinExpressed by the early embryo (also liver and GI tract)Half-life: 5-7 daysProduced by pure embryonal, teratocarcinoma

, yolk sac, mixed tumors (NOT pure

choriocarcinoma or seminoma)Falsely elevated in liver dysfunction, viral hepatitis

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Beta Human

Chorionic GonadotrophinSecretory product of the placentaHalf-life: 24-36 hoursProduced by syncytiotrophoblastic tissueAll choriocarcinomas, 60

% embryonal,

10% seminomaFalsely elevated in hypogonadism and marijuana use

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Presents normally in smooth, cardiac and skeletal muscle, liver and brainMost useful in advanced seminoma or tumors where other markers are not elevated

Many false positivesLactic Acid Dehydrogenase

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Tumors of the testis

Imaging

Ultrasonography

CT-Scan

MR

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Risk Factors

Cryptorchidism: 7-10% of patients with testicular cancer have a history of cryptorchidismAbnormal germ cell morphologyElevated temperature5-10% of patients with testicular cancer and a history of cryptorchidism develop cancer in the contralateral testisOrchidopexy does not prevent development of cancer

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Gonadal Dysgenesis 20-30% develop cancer (gonadoblastoma

) Trauma HormonesEstrogen in the pregnencyAtrophy (nonspecific vs. mumps orchitis)Speculative

Risk Factors

II

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Differential diagnosis

Epdidymitis & Epididymoorchitis

Hydrocele

Spermatocele

Hematocele

Granulomatous orchitis

Varicocele

Epidermoid cyst

Tumors of the testis

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Radical Orchiectomy

Inguinal approach best way for the surgeryAvoid seeding the scrotum and disrupting lymphatics

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Treatment

Inguinal Exploration & radical orchiectomy

Low stage seminoma: retroperitoneal irradiation

95% care

high stage seminoma: primary chemotherapy

95% complete response

Tumors of the testis

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Treament

C: low stage NSGCT:

Radical

orchiectomy

1)

C

onfined

within tunica

albuginea

?

2)

V

ascular

invasion

?

3)tumor

markers? 4)radiographic imaging? Tumors of the testis

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Treatment

of h

igh

stage NSGCT:

primary

chemotherapy

+RPLND

Tumors of the testis

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Follow up:

every 3 month/ first 2 years

every 6 month/ until 5 years

and then yearly

C

areful

exam of remaining testis, abdomen, lymph node area

tumor marker at each visit.

CT

every 3-4 month

Tumors of the testis

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Prognosis

Seminoma:

R.O+radiotherapy

:

stage I: 98% 5 years survival rate

stage II:

92%

5 years survival rate

stage III (chemotherapy): 35-75%

NSGCT: stage I: 96-100%

low, volume stage II: 90%

stage III: 55-80%

Tumors of the testis

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Secondary tumors of the testis

1. lymphoma

: M

ost

common

t

estis

t

umour

in>50 years old

2.

leukemia

:

Testis b

iopsy

is choice

3. metastatic tumor:

prostate- lung –GI-melanoma-kidneyTumors of the testis

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Extragonadal

germ cell tumors

3% of all germ cell tumors

the most common sites: mediastinum-

retroperitoneum

,

sacrococcygeal

–

pineal gland

Tumors of the testis

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Tumors of the epididymis,

paratesticular

tissue & spermatic cord

T

umor

o

f

epididym

: commonly benign:

adenomatoid

leiomyoma

cystadenoma

T

umor

of spermatic cord:

lipoma

Rabdomyosarcoma

leiomyosarcoma

. Fibrosarcoma liposarcoma

Tumors of the testis

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Sex cord-stromal tumors of the testis

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Leydig cell tumor key facts:

Can develop at any age from infancy to old ageMost are benign, some are malignMost tumors are hormonally active, but some are inactiveMay secrete androgens or estrogens-Androgen excess: Premature puberty & macrogenitosomia

-Estrogen excess: Gynecomastia in adult males

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Sertoli cell tumor

These tumors are more rare than Leydig cell tumors. They elaborate androgens or estrogens. Occasionally, they cause gynecomastia but sexual precocity is infrequent.

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Thank

You