2. Overview
Cancers of testis are relatively rare cancer accounting for approx. 1 % cancer in
males. However it is important in field of oncology as it represents a highly curable
neoplasm & the incidence is focused on young patients at their peak of
productivity
3. Anatomy
• The testis is the male gonad.
• It is homologous with the ovary in female.
• It lies obliquely within the scrotum suspended by
the spermatic cord
• The left testis is slightly lower than the right
• Shape: Oval
• Size:3.75 cm long, 2.5 cm broad, 1.8 cm thick
• Weight: about 10-15 gm.
• Has 2poles , 2surface, 2 borders
4. Descent of testis
Develops at T10-T12 segments in post abdominal wall from genital
ridge & subsequently descend to reach scrotum
Begin to descend in 2nd month of intrauterine life
3rd month reach iliac fossa
4th -6th month deep inguinal ring
7th month inguinal canal
8th month: superficial inguinal ring
9th month: scrotum
Cryptorchidism: one or both testicles fail to reach scrotum before
birth. Most of time it reached scrotum by 1 year of age. If not
orchidopexy need to be done:
5. Coverings of testis
Skin
DARTOS Muscle
External Spermatic Fascia
Cremastric Muscle
Internal Spermatic Fascia
Tunica Vaginalis
Tunica Albuginea
6. Structure of testis
• 200-300 lobules
• Each lobule has 2-3 seminiferous tubules
• Each seminiferous tubules lined by cell in
different stages of spermatogenesis
• Among the seminiferous tubules are Sertoli
cells.
• Between the loops of the seminiferous
tubules are interstitial cells, produce
testosterone.
• Seminiferous tubules join to form 20-30
straight tubules.
7. • Rete testis: network of tubules located in the
hilum of the testicle(mediastinum testis) that
carries sperm from the seminiferous
tubules to the efferent ducts
• Rete testis give rise to 12-30 efferent ductules
• Epididymis: tube about 20 feet (6 m) long that
is coiled on the posterior surface of each testis
connect efferent duct to vas deferens
• Ductus deferens :extends from the epididymis
in the scrotum on its own side into the
abdominal cavity through the inguinal canal
8. Blood Supply
Areterial supply
• The testicular artery branch of abdominal aorta .
• The testis has collateral blood supply from
1. the cremasteric artery
2. artery to the ductus deferens
Venous drainage
• The veins emerge from the back of the testis, and receive
tributaries from the epididymis;
• they unite and form convoluted plexus, called the
pampiniform plexus.
• plexus to form a single vein, which opens, on the right side,
into the inferior vena cava ,on the left side into the left
renal vein
9. Lymphatic Drainage
Drain into the retroperitoneal lymph glands between the
levels of T11 and L4, but they are concentrated at the level
of the L1 and L3 vertebrae
Lymph nodes located lateral or anterior to the inferior
vena cava are called paracaval or precaval nodes,
respectively.
Interaortocaval nodes are located between the inferior
vena cava and the aorta.
Nodes anterior or lateral to the aorta are preaortic or para-aortic
nodes, respectively
10. On the right:
Interaortocaval region, followed by the paracaval, preaortic, and para-aortic
lymph nodes.
On the left:
Preaortic and para-aortic nodes and thence to the interaortocaval
Metastatic nodal disease to the common iliac, external iliac, or
inguinal lymph nodes is usually secondary to a large volume of
disease with retrograde spread.
If the patient has undergone a herniorrhaphy, vasectomy, or other
transscrotal procedure, metastasis to the pelvic and inguinal lymph
nodes is more likely
Through the thoracic duct to lymph nodes in the posterior
mediastinum and supraclavicular fossae and occasionally to the
axillary nodes.
Contralateral spread is mainly seen with right-sided tumors.
In 15% to 20%, bilateral nodes are involved
11. Nerve Supply
• Sympathetic nerves arising from segment T10 of the spinal cord.
• Both afferent for testicular sensation and efferent to the blood vessels(vasomotor).
13. INTRODUCTION
Comprise a morphologically and clinically diverse group of tumors
Predominantly affects young males
1 -2 % of all cancers in USA
Testicular cancer forms about 1% of all malignancies in males in India.
Incidence (ASR)– 0.6 per 100000
Mortality (ASR)– 0.3 per 100000
95% are Germ Cell Tumours (GCTs)
90% GCT are in testes,2-10% in extra gonadal (eg retropreitoneum, mediastinal)
Cure rate increased with introduction of platinum based chemotherapy from 10 to 80%
14. EPIDEMOLOGY OF TESTICULAR CANCER
• Age: for GCT: median age at diagnosis is 34 years, with 50% of incident
cases between 20 and 34 years.
• In a man age: 50 years or older solid testicular mass is usually lymphoma
• Age - 3 peaks
2 – 4 yrs
20 – 40 yrs
above 50 yrs
• Geographic: Highest incidence in Denmark, Norway, and Switzerland
and the lowest in eastern Europe and Asia.
• Race: more common in young white men ,less in African Americans
15. Predisposing Factors
1. Cryptorchidism
2. Klinefelter syndrome
3. Positive family history
4. Positive personal history
5. Intratubular germ cell neoplasia
6. Trauma
7. Viral infection
8. Hormonal factors
9. Exposure to environmental oestrogen
16. Predisposing Factors
1. Cryptorchidism
• For inguinal cryptorchidism odds ratio is
5.3 for seminoma
3 for non seminoma
• This risk is further increased if the testis is intra-abdominal.
• Abdominal testis is more likely to be seminoma, testis brought to scrotum by orchiopexy
is more likely to be NSGCT.
• There is still an increased risk of developing a tumour in the contralateral normally
descended testicle in pt. with cryptorchidism
• GCT develop in 2% of cryptorchids & 5-10% of normally descended testis
• Prepubertal orchidopexy fails to prevent the subsequent development of malignancy
17. KLINEFELTER SYNDROME
• Characterised by:
• testicular atrophy
• absence of spermatogenesis
• eunuchoid habitus
• gynecomastia
Karyotype: 47XXY
Pt. are at increased risk of mediastinal GCT
18. Predisposing Factors
2. Positive family history
Men with first degree relative with testicular cancer
Median age being less by 2-3 yrs
brother of men with testicular tumor: 8-10 times more risk of
developing TGCT
Relative risk to father and sons: 2-4 times
19. Predisposing Factors
3. Positive personal history
12 folds increased risk of developing GCT in the contralateral testis
Higher risk for contralateral tumor if
• Younger age
• Seminoma
20. Predisposing Factors
4. Intratubular Germ Cell Neoplasia (ITGCN)
• Precursor lesion of all types of germ-cell tumors except spermatocytic seminoma
• Originate from primordial germ cells early during embryogenesis, possibly due to an excess
of estrogens.
No spermatogenesis
PLAP positive
Present in adjacent testicular parenchyma in 80% of pt with GCT
5-9% in unaffected contralateral testis; increases to 36% in atrophy or
cryptorchidism
50% risk of GCT in 5 yrs, 70% in 7yrs
22. 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
23. Seminoma
• Serum alpha fetoprotein is normal
• Beta HCG is elevated in 30% of patients with Seminoma
• Classification
a) classical
b) Anaplastic
c) Spermatocytic
24. Anaplastic
5% - 10
Middle age
Aggressive - lethal
Greater mitotic activity
Higher local invasion
Higher metastatic potential
Higher rate of β-HCG production
Typical/ Classical
82% - 85%
Middle age
PLAP – 90%
Syncytiotrophoblsts – ↑Beta HCG(10%)
Very slow growth
Spermatocytic
2% - 12% of seminomas
Old age > 50 yr
Does not arise from ITGC
PLAP negative
Extremely low metastatic potential
Good prognosis
25. Embryonal Carcinoma
2nd most common germ cell tumor 90% of NSGCT
Present in majority of mixed germ cell tu mors
Most men present in their 20s to 30s with a testicular mass
Highly malignant tumours; may invade the cord stuctures.epidydymis
High degree of metastasis
Serum AFP is positive in 33 5, & beta HCG is elevated in 20% of cases
26. Yolk Sac Tumour
Most common germ cell tumor ( & most common testicular tumor ) in children, where
it occurs in its pure form.
– 60% of GCT in children. First 2 years of life.
– Pure yolk sac tumor <2% of testicular tumors in adults
– 40% of mixed germ-cell tumors.
– Elevated serum levels of alpha-fetoprotein.
– Microscopically, Schiller-Duval bodies are a characteristic feature
Testicular mass the most usual presentation.
27. 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)
28. Teratoma
Teratoma in greek means “monster tumor”
Contain all three germ layers with varying degree of
diffrentiation
Occurs in its pure form in pediatric age group with a mean age
of diagnosis at 20 months
In adults, occur as a component of mixed germ cell tumor & is
identified in > 47 % of mixed tumors.
Normal serum markers.
◦ Mildly elevated AFP levels
29. Interstitial cell tumors
1. Leydig cell tumors
May affect 20-60yrs of age
A masculinising tumor, produces androgens
No association with crytochordism
Presents with painless testicular mass
Precocious puberty
Prominent external genitalia
Deep masculinised voice
Pubic hair
Gynacomastia and decreased libodo due to oestrogen production by
increased peripheral conversion
30. Interstitial cell tumors
2. Sertoli Cell Tumor
can occur in any age group including infants
No association with crytochordism
Excess estrogen production
Gynacomastia in 1/3rd of cases
10 % are malignant
31. Interstitial cell tumors
3. Gonadoblastoma
Mixed germ cell/sex cord/stromal tumor
Composed of seminoma like germ cells and Sertoli differentiation
Exclusively in patients with dysgenic gonads and intersex syndromes
80% are phenotype females with primary amenorrhoea
20% are males with crytochordism and dysgenic gonads and
hypospadias
Considered in-situ malignant form of GCT
Bilateral orchidectomy because of risk of bilateral tumours
32. 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
-Metastases to testis
- rare
33. Spread
1. Direct Spread:
This spread occurs by invasion.
Whole of testis in involved and restricted
Tunica albuginea is rarely penetrated
May be crossed by “blunder biopsy”
Scrotal skin involvement
Fungation on the anterior aspect
Spread to spermatic cord and epidedymis
may occur : points towards bad prognosis
34. Spread
2. Lymphatic spread:
Seminoma metastasize exclusively through
lymphatics
They drain primarily to para-aortic lymph nodes
From RPLN drain into cysterna chili, thoracic duct
,posterior mediastinum & left supraclavicular
Lymph
from medial side of testes run along the artery to
the vas to drain to nodes at the bifurcation of
common iliac
No inguinal nodes until scrotal skin involvement
35. Spread
3. Blood Spread
NSGCT spread through blood route
Lungs, liver, bones and brain are the usual sites usually involved
36. Clinical Features
1. Due to primary tumor
a) Painless testicular lump
b) Sensation of heaviness if size > than 2-3 times
c) Rarely dragging pain is complained of (1/3rd cases)
d) May mimic epidedymo-orchitis
e) Sudden pain and enlargement due to hemorrhage mimicking torsion
f) History of trauma (co-incidental)
37. DICTUM FOR ANY SOLID SCROTAL SWELLINGS
• All patients with a solid, Firm Intratesticular Mass that
cannot be Trans illuminated should be regarded as
Malignant unless otherwise proved.
38. Clinical Features
2. Due to metastasis
Abdominal or lumbar pain (lymphatic spread)
Dyspnoea, hemoptysis and chest pain with lung mets
Jaundice with liver mets
Hydronephrosis by para-aortic lymph nodes enlargement
Pedal oedema by IVC obstruction
Troiser’s sign
39. Clinical Features
3. Clinical examination:
a) Enlarged testis (except choriocarcinoma)
b) Nodular testis
c) Firm to hard in consistency
d) Loss of testicular sensation
e) Secondary hydrocele
f) Flat and difficult to feel epididymis
g) General examination for metastasis
40. Tumor markers
TWO MAIN CLASSES
• Onco-fetal Substances : AFP & HCG
• AFP - Trophoblastic Cells
HCG - Syncytiotrophoblastic Cells
AFP, BHCG & LDH are included in TNM staging of testicular cancers
41. 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
AFP –Alfa feto protein
normal value: below 16 ngm / ml
half life of AFP – 5 and 7 days
Raised AFP :
Pure embryonal carcinoma
Teratocarcinoma
Yolk sac Tumor
Combined tumors,
AFP not raised in pure choriocarcinoma & in
pure seminoma
42. Serum Tumor Markers (S)
LDH Beta HCG
(mIu/ml)
AFP
(ng/ml)
S1 < 1.5 x N <5000 <1000
S2 1.5-10 x N 5000-50000 1000-10000
S3 >10 x N >50000 >10000
43. ROLE OF TUMOUR MARKERS
• Helps in Diagnosis - 80 to 85% of Testicular Tumors have Positive Markers
• Most of Non-Seminomas have raised markers.
• Indicate Histology of Tumor:
If AFP elevated in Seminoma - Means Tumour has Non-Seminomatous elements
• Degree of Marker Elevation Appears to be Directly Proportional to Tumor Burden
44. ROLE OF TUMOUR MARKERS
• may predict the responsiveness of nonseminomas to treatment
• The level of beta-HCG should decrease by 90% or more every 21 days with each successful
treatment cycle of chemotherapy.
• The decline of AFP is less predictable
• Normalization of tumor marker after high inguinal orchidectomy does not ensure complete
disease removal however after Orchiectomy if Markers Elevated means Residual Disease
• Negative Tumor Markers becoming positive on follow up usually indicates -Recurrence of
Tumor
• Markers become Positive earlier than radiological studies
45. Scrotal ultrasound
• Ultrasonography of the scrotum (7.5MHZ) is
a rapid, reliable technique to exclude
• Testicular and other scrotal swelling
• Solid & cystic swelling
• Hydrocele & 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.
46. Staging Work Up
• General
History (document cryptorchidism and previous inguinal or scrotal
surgery)
Physical examination
• Laboratory Studies
CBC, LFT, RFT, LDH
• Serum assays
Alpha fetoprotein (AFP)
Beta human chorionic gonadotropin
47. • 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
48. Large left para aortic nodal mass due to GCT
causing hydronephrosis
49. “I always had the size difference there, but I didn’t
know…I would’ve still been waiting if it hadn’t started
hurting, it just got so painful I couldn’t sit on my bike
“I always had the size difference
there, but I didn’t know…I would’ve
still been waiting if it hadn’t started
hurting, it just got so painful I couldn’t
sit on my bike anymore.”
-Lance Armstrong
anymore.”
-Lance Armstrong
“I always had the size difference there, but I didn’t
know…I would’ve still been waiting if it hadn’t started
hurting, it just got so painful I couldn’t sit on my bike
anymore.”
-Lance Armstrong