Uro-oncology TESTICULAR TUMORSSssss.pptx

Uro-oncology

1. TESTICULAR TUMORS Dr Hemanta Pun 2 nd Year Resident Surgery

2. Embryology ..Develops from Urogenital ridges Consists of : Sex cords : Seminiferous tubules, Retetestis Primordial sex cells : Spermatogonia Sex cord cells : Sertoli cells Mesenchyma : Tunica albuginea , Interstitial cells The retetestis becomes canalized and joins the mesonephric tubules ----- Formation of efferent ductules Mesonephric duts : Epididymis , Vas defernes , seminal vesicle and ejaculatory duct.

3. Descent of the testis ..Develops high up in the post. abd wall Descent occurs- 3 rd - 9 th month of IUL, reaches the scrotum just before birth After reaching the scrotum, processus vaginalis becomes obliterated and persists only in the scrotum as Tunica vaginalis

4. Anatomy Firm, Ovoid and mobile organ Wt. : 15-25 gms ..Coverings : Tunica Vaginalis Tunica Albuginea Tunica vasculosa Structures :

5. Arterial Supply : ..Testicular arteries Rich collateral arterial blood supply from : internal iliac artery via the artery of the ductus deferens inferior epigastric artery via the cremasteric artery femoral artery via the external pudendal artery… Venous Drainage Pamipiniform plx . → Testicular Vein Rt testicular vein → Inferior venacava Lt testicular vein → Lt Renal vein.. Lymphatic supply : .. Para-aortic (or Lumbar) LN

6. TESTICULAR TUMORS Epidemiology Uncommon malignant neoplasm ( 1% of all malignant tumors in males) >99 % : malignant ..Prevalence as per predominant cell type: Germ cell tumor : 90-95% Non germinal : 5-10% ..Laterality : Right > Left (Bilateral in 1-2%) Age : 20-40 yrs ( seminoma in 40-50yrs)

7. Risk Factors .. Cryptorchidism 7-10% risk Highest in Intraabdominal testis (1 in 20) and lowest in Inguinal testis (1 in 80). ..Exogenous estrogen admin to the mother during pregnancy Trauma Infection

8. Classification Germ cell tumor (GCT) Seminoma NS GCT - Spermatocytic - Teratoma -Typical - Emb cell ca - Anaplastic - Chorioca -Yolk sac tumor Sex cord stromal tumors: Sertoli cell tumor Leydig cell tumor Granular cell tumor Mixed types Mixed Germ cell & Stromal elements : Gonadoblastoma Miscellaneous : Carcinoid Lymphoma Testicular metastasis

9. Genesis of tumors

10. Pathology Seminoma : ..3 histological subtypes (Classic, Anaplastic, Spermatocytic ) Derived from : Seminiferous tubules (cells resembles spermatocyte) Spread via Lymphatics . ..Age : 40-50yrs

11. NSGCT : Embryonal cell ca : highly malignant tumors Yolk sac tumor : secrete AFP Choriocarcinoma : highly malignant tumor secrete beta- hcg . spread via blood and lymph. d) Teratoma : Arises from totipotent cells in the retetestis Contains a variety of cell types Pulmonary mets ---- in Teratoma

12. Interstitial cell tumors : Arise from Leydig or Sertoli cell Prepubertal tumours : Usu arise from Leydig cells (Produce androgens) Cause sexual precocity including prominent external genitalia, suprapubic hair growth and a deep masculinised voice. Regression of the symptoms after orchidectomy may be incomplete... Post pubertal tumors Usu arise from Sertoli cells (produce feminising hormones) Causes gynaecomastia , erectile dysfunction, loss of libido and azoospermia . As a rule, the tumor is benign and orchidectomy cures.

13. Clinical Features Symptoms : Painless enlargement of testis Testicular lump Sensation of testicular heaviness Pain (10%) ..Asymptomatic (10%) Symptoms r/t mets (10%) Retroperitoneal mets (inv Nv roots) – Back pain Pulmonary mets Retroduodenal mets Skeletal mets IVC mets

14. Signs : Testes : enlarged, firm, non-tender Loss of testicular sensation .. Associated hydrocele .. Signs of Metastasis : Enlarged supraclavicular LN Abdominal mets : Abdominal mass, Hepatomegaly Pulmonary mets

15. Pattern of metastatic spread .. GCT spreads via Lymphatics (except Chorioca ) (Lymph nodes of the testis extend from T1 to L4..) The primary landing site Right testis : Interaortocaval area at the level of the right renal hilum (.. precaval , preaortic , paracaval , right common iliac, and right external iliac lymph nodes) Left testis : Para-aortic area at the level of the left renal hilum (.. preaortic , left common iliac, and left external iliac lymph nodes) Right-to-left crossover metastases are common

16. Factors altering the primary drainage Invasion of the epididymis or spermatic cord.. Scrotal violation or invasion of the tunica albuginea ---Hence FNAC absolutely C/I Retroperitoneum : most commonly involved site In advanced disease : Visceral mets seen (lung, liver, brain, bone, kidney, adrenal, gastrointestinal tract, and spleen) .. Chorio ca : Early hematogenous spread, (lung and Spleen.)

17. Differential diagnosis Epididymo-orchitis Hydrocele Spermatocele Hematocele Granulomatous orchitis

18. Investigations Lab findings : Anemia Deranged LFT and RFT ...Biochemical markers AFP (T 1/2 :4-6 days) hcg (T1/2 : 24hrs) LDH

19. Imaging ..Scrotal USG Rapid and accurate assessment Determine whether the mass is truly intratesticular v/s Epididymal pathology Facilitate the testicular examination in the presence of hydrocele .. CXR CT abdomen/pelvis

20. Approach to testicular tumor Investigation ( Scrotal USG/Tumor markers) Radical inguinal orchidectomy Clinical Staging (Tumor pathology/ LN and metastatic Imaging/ Tumor markers) Second Line treatment (Surveillance/Radiation/RPLND/Chemo /Multimodal) History and Examination

21. Treatment of Low-stage Seminoma (Stage 1A and 1B) Orchidectomy Tumor Size<6cms Absence of vascular invasion Normal β HCG Regular Surveillance Radiotherapy Chemotherapy Treatment results-5 year survival rate -95%

22. Surveillance Duration : upto 10 yrs History and Physical exam Tumor markers : every 3–4 months for years 1–3 every 6 months for years 4–7 then annually up to 10 years. Imaging while on Imaging : CT Abdominal / pelvis at each visit CXR at alternate visits.

23. Treatment of Low-stage Seminoma (Stage 2A and 2B) Radiotherapy of retroperitoneal LN ( Ipsilateral ext. iliac nodes , B/L common iliac nodes, Paracaval , Paraaortic , cisterna chyli ) Dose : 150 Gy /day X 5 days a week for 3 cycles 2. If involved lymph nodes, close to kidney  Chemotherapy to prevent radiation damage to renal parenchyma Treatment results-5 year survival rate-80%(70-92%)

24. Treatment of High-stage Seminoma (Stage 2C and 3) Chemotherapy Good Risk Patients 4 cycles of EP or, 3 cycles of PEB ( Etoposide / Cisplatin / Bleomycin ) Intermediate risk 4 cycles of PEB

25. Cisplatin based chemotherapy Radiographic complete post chemo retroperitoneal response masses detected by CT  PET resected if diam >3cm No further t/t HPE: GCT Fibrosis Salvage Chemo Vinblastine Ifosfamide Cisplatin 90% patients achieve complete response with chemotherapy.

26. Low-stage NSGCTs (Stage 1) Orchidectomy Risk factors T2 or higher Vascular invasion Abnormal tumor markers Disease on imaging Surveillance Modified RPLND Chemo (3cycles of BEP) N0 N1 Adjuvant chemo No chemo Observe N2

27. Surveillance (for NSGCTs) Regular F/U : every 1–2 months for the first 2 years every 3 months in year 3 every 4 months in year 4 and every 6 months in year 5. Tumor markers and CXR are obtained at each visit CT scans are obtained every 2–3 months in year 1 Every 3–4 months in year 2 every 4 months in year 3 every 6 months in year 4 once a year in year 5.

28. Stage IS Persistent tumor marker elevation- no radiologic evidence of ds  chemotherapy with BEP- 3 cycles Stage IIA , IIB RPLND- b/l Iº chemotherapy BEP- 3 cycles Minimal nodal Nodal inv, Inv, <2 cm >2 cm Adj chemo- no Adj chemo- yes BEP- 2 cycles

29. High stage ds (IIC, III) Good risk ds Poor risk ds Chemo with etoposide high dose & ABMT Response to chemo- poor or elevated tumor markers- salvage chemo Inadequate response desperation surgery

30. Good risk ds Chemo, BEP- 3 cycles Resolution of ds Residual RP Residual visc, brain Persisitent ↑ mass-b/l RPLND mets- excision tumor markers Observation with tumorectomy Recurrent ds histo-necrosis, GCT fibrosis,teratoma Salvage chemo± high dose chemo with ABMT observation salvage chemo exclude exclude with VIP -↑HCG mets brain -↑AFP c/l testis Complete response no response ↑ tumor markers Observation “desperation sx”- salvage chemo excision of all rec tissue VIP

31. Other testicular tumors: Leydig cell tumors: 10%- malignant May involve RPLN, lung and bone Precocious puberty- prominent ext genitalia, mature masculine voice and pubic hair growth In some- symptoms of feminization+ T/t: - Radical inguinal orchidectomy & staging CT of RPLN followed by RPLND ( in tumors which appears histologically malignant) - Radio resistant Prognosis- Good

32. Sertoli cell tumors Any age group including infancy 10%- malignant Testicular mass Pain ± Gynaecomastia ± T/t: - Radical inguinal orchidectomy- curative in 90% of benign cases - 10% malignant cases- RPLND

33. Gonadoblastomas : Very rare tumors Occurs- Infancy to beyond 70 yrs 4/5 th of patients- phenotypic females with small breasts, hypoplastic internal genitalia and streak gonads 1/5 th patients- phenotypic males with gynaecomastia , hypospadias & some female int genitalia T/t: B/l radical orchidectomy

34. Other tumors: Epidermoid cyst Adenocarcinoma of rete testis Mesothelioma Carcinoid Secondary tumors: Lymphoma Leukemic infiltration of the testis Metastatic tumors- prostate, lung, GIT, melanoma & kidney

35. THANK YOU