This document provides information about testicular tumors. It discusses that testicular cancer is most common in men aged 15-35 and has three peaks in incidence. The most common types are seminomas and non-seminomas. Risk factors include cryptorchidism, Klinefelter's syndrome, and trauma. Diagnosis involves physical exam, ultrasound, serum tumor markers, and radiology. Treatment depends on the type and stage but generally includes radical orchidectomy followed by chemotherapy, radiation, or surveillance. Prognosis is excellent even for metastatic disease due to chemosensitivity.

1. Dr.Haleemullah
H.O

2. Introduction
 Testicular tumors are rare.
 1 – 2 % of all malignant tumors.
 Most common malignancy in men in the 15 to 35
year age group.
 Benign lesions represent a greater percentage of
cases in children than in adults.
 Most curable solid neoplasm

3.  Age - 3 peaks
2 – 4 yrs
20 – 40 yrs
above 60 yrs
 Testicular cancer is one of the few neoplasms
associated with accurate serum markers.
 Most curable solid neoplasms and serves as a
paradigm for the multimodal treatment of
malignancies.

4. AETIOLOGY OF TESTICULAR TUMOUR
 Cryptorchidism
 Klinefelter’s syndrome
 Testicular atrophy
 Trauma
 Sex hormone fluctuations, estrogen
administration during pregnancy
 Race
 Carcinoma in situ
 Previous testicular cancer

5. CRYPTORCHIDISM & TESTICULAR TUMOUR
Risk of Carcinoma developing
in undescended testis is
14 to 48 times the normal
expected incidence

6. CLASSIFICATION
 I.Primary Neoplasms of Testis.
A. Germ Cell Tumor.
B. Non-Germ Cell Tumor .
 II. Secondary Neoplasms.
 III .Paratesticular Tumors.

7. Germ cell tumors
 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. Non Germ Cell Tumors
1. Specialized gonadal stromal tumor
(a) Leydig cell tumor
(b) sertoli cell tumor
2. Gonadoblastoma
3. Miscellaneous Neoplasms
(a) Carcinoid tumor
(b) Tumors of ovarian epithelial sub
types

9. Seminoma
 The commonest variety of testicular tumour
 Adults are the usual target (4th and 5th decade); never seen in infancy
 Right > Left Testis
 Starts in the mediastinum: compresses the surrounding structure.
 Patients present with painless testicular mass
 30 % have metastases at presentation, but only 3% have symptoms related to
metastases

10.  Cut potato appearance

11.  Embryonal carcinoma
 25yr – 35yr
 3 – 6 % of TT
 Small, rounded irregulr mass
 Invading tunica vaginalis
 Cut surface
 Greyish white, fleshy
 Areas of necrosis, hemorrhage
 Poorly defined capsule

12. Choriocarcinoma
 A rare and aggressive tumour (5yrs survival is 5%)
 Typically elevated hCG
 Presents with disseminated disease
 Metastasis to lungs and brain
 Primary is very small and often exhibit NO TESTICULAR
ENLARGEMENT
 Small palpable nodule may be present.
 Prone to hemorrhage, sometimes spontaneous (lungs and brain)

13. Teratoma
 Children – 38% - benign
 Adults – 3% - metastatic potential
 AFP - ↑ 20% – 25%
 Metastasis
 Resistent both Chemo, Radiation
 Mature Teratoma
 Differentiated elements form 2 or more embryonic germ cell layers
 ectoderm, endoderm & mesoderm
 Immature Teratoma
 Undifferentiated primitive tissues
 Malignant Teratoma
 Malignant changes

14.  Teratoma
 More than one germ cell layer in various stages of maturation &
differentiation
 Large, lobulated, non-homogenous
 Cut surface
 Variably sized cysts
 Gelatinous, mucinous, hyalinized material
 Intersposed solid islands – cartilage/ bone/pancreatic/ liver/
intesttinal/ muscle/ neural/ connective tissue

15.  Immature Teratoma
 Areas of fibrosis & hemorrhage
 Mature Teratoma

16.  Yolk sac tumor
 Most common
 Infants & children
 Adults – in combination
 ↑ AFP
 Pure form
 Homogenous yellowish, mucinous
 Histology
 Embryoid bodies
 Resemble 1 to 2 week old embryos (<1 mm)

17. Non Germ Cell Tumors
 Sex cord tumors
1. Leydig cell tumors
2. Sertoli cell tumors
 Mixed germ cell and stromal cell tumors
1. Gonadoblastoma
 Miscellaneous primary non germ cell tumors
1. Epidermoid cyst
2. Adenocarcinoma of rete testis
3. Adrenal rest tumors

18. Secondary Tumors of Testis
 Lymphoma – most common secondary tumor
- most common testicular tumor in patients
above 50 years
- most common variety is histiocytic
 Leukamic Infilteration of testis
-primary site of relapse after ALL remission
-occurs mainly in the interstitial space
-biopsy for diagnosis
- no orchidectomy
- testicular irradiation for treatment
 Metastases to testis
- rare cases reported (200 cases till now)

19. Clinical features
 Painless Swelling of One testis
 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

20. Physical Examination
 Examine contralateral normal testis.
 Firm to hard fixed area within tunica albugenia is
suspicious
 Seminoma expand within the testis as a painless,
rubbery enlargement.
 Embryonal carcinoma or teratocarcinoma may
produce an irregular, rather than discrete mass.

21. Scrotal ultrasound
 Ultrasonography of the scrotum is a rapid, reliable
technique to exclude hydrocele or epididymitis.
 Ultrasonography of the scrotum is basically an
extension of the physical examination.
 Hypoechoic area within the tunica albuginea is
markedly suspicious for testicular cancer.

22. Tumor markers
Onco-fetal Substances : AFP & HCG
Cellular Enzymes : LDH

23. ROLE OF TUMOUR MARKERS
 Helps in Diagnosis - 80 to 85% of Testicular Tumours have
Positive Markers
 Most of Non-Seminomas have raised markers
 Only 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

24.  Diagnostic Radiology
 Chest x-ray films, posterior/anterior and lateral
views
 Computed tomography (CT) scan of abdomen
and pelvis
 CT scan of chest for non seminomas and stage II
seminomas
 Ultrasound of contralateral testis

26. Serum tumor markers
LDH HCG
Miu/ml
AFP
Ng/ml
S0 _< N <N <N
S1 <1.5 x N < 5000 < 1000
S2 1.5-10x N 5000 to
50000
1000 to
10000
S3 >10x N > 50000 >10000

29. PRINCIPLES OF TREATMENT
 Treatment should be aimed at one stage above the
clinical stage
 Seminomas - Radio-Sensitive. Treat with
Radiotherapy.
 Non-Seminomas are Radio-Resistant and best
treated by Surgery
 Advanced Disease or Metastasis - Responds well to
Chemotherapy

30. PRINCIPLES OF TREATMENT
 Radical INGUINAL ORCHIDECTOMY is Standard
first line of therapy
 Lymphatic spread initially goes to
RETRO-PERITONEAL NODES
 Early hematogenous spread RARE
 Bulky Retroperitoneal Tumours or Metastatic
Tumors Initially “DOWN-STAGED” with
CHEMOTHERAPY

31. PRINCIPLES OF TREATMENT
 Transscrotal biopsy is to be condemned.
 The inguinal approach permits early control of the
vascular and lymphatic supply as well as en-bloc
removal of the testis with all its tunicae.
 Frozen section in case of dilemma.

32. Treatment of Seminomas
Stage I, IIA, ?IIB –
Radical Inguinal Orchidectomy 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 by
Chemotherapy

33. Treatment of Non-Seminoma
Stage 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 for Residual Disease

34. STANDARD CHEMOTHERAPY FOR
NON-SEMINOMATOUS GERM CELL TUMOURS
Chemotherapy Toxicity
BEP -
Bleomycin Pulmonary fibrosis
Etoposide (VP-16) Myelosuppression
Alopecia
Renal insufficiency (mild)
Secondary leukemia
Cis-platin Renal insufficiency
Nausea, vomiting
Neuropathy

35. PROGNOSIS
Seminoma Nonseminoma
Stage I 99% 95% to 99%
Stage II 70% to 92% 90%
Stage III 80% to 85% 70% to 80%

36. 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 Diminishing overall Morbidity
of Various Treatment Modalities

37. Yuvraj Singh –extra
gonadal seminoma

38. Thank you