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Testicular tumors
Mohammad Ihmeidan PGY2
Introduction
• Most common malignancy of urogenital tract in
males 15-35
• Its incidence has been increasing during the last
decades especially in industrialised countries.
• More common among Caucasian men
Presentation
• Signs & symptoms
– Usually painless lump
– 30-40% c/o heaviness or dull ache
– 10% acute pain
– 10% present with metastatic manifestations
• Neck mass, cough, nausea, vomiting, lumbar pain, bone pain
– Gynecomastia is present in 5% of GCTs
• Any hypoechoic area on US wthin tunica is suspicious for
tumor
Risk factors
• Cryptorchidism (4-13x risk)
– 7-10% of tumors had cryptorchidism
– 5-10% testicular tumor had cryptorchidism in
contralateral side
– Intra-abdominal testis > Intrainguial testis
– Structural abnormalities seen in cryptorchid
testis at 3 years
– Orchiopexy does not prevent cancer, but it
allows easier clinical detection
• - Family History (6-8x risk)
• - Racial Origin (Highest in Scandinavia)
• - Maternal exposure of estrogen (2.8-5.3x risk)
• - Subfertility (1.6-20x risk)
• - Contralateral testicular tumour (5-10% risk)
• Survival
– <50% prior to 1970
– >95% in 1997
• Improved survival:
– Accurate tumor markers
– Effective chemo
– Modifications of surgical technique
– Mostly radiosensitive
– Backup treatments if primary treatments fail
Testicular tumors
Classification
• Germ Cell Tumors (GCT)
– Seminoma
• Classic or Typical
• Anaplastic
• Spermatocytic
– Nonseminoma
• Embryonal Cell Carcinoma
• Yolk Sac Tumor
• Teratoma
• Choriocarcinoma
• >50% GCT are mixed
Classic Seminoma
• 82-85% of seminomas
• Mostly men in 30’s
• Clear cytoplasm, dense nucleus
• Synctiotrophoblasts in 10-15%
– Elevated B-HCG in 10%
– hCG up to 500 ng/mL
• Lymphocytes in 20%
Anaplastic Seminoma
• 5-10% of seminomas
• Greater mitotic activity
• Higher rate of local invasion
• Increased rate of metastasis
• Higher rate of B-HCG production
• Stage for stage – treatment outcomes same as
classic seminoma
Anaplastic Seminoma
Note : Pleomorphism, hyperchromasia
Spermatocytic Seminoma
• 3 sizes of cells
• 9% of seminomas
• 50% older than 50
• Very low metastatic potential
– Favorable prognosis
Embryonal Carcinoma
• Small, hard, irregular mass
• Age 25-35
• Smallest germ cell tumor
– 40% <2cm
• Invades tunica vaginalis
• Often close to rete testis
• Highly malignant
Choriocarcinoma
• Commonly present with metastasis
• Must have synctiotrophoblasts &
cytotrophoblasts
• 1-2% of tumors
• hCG elevated in >99%
• Age 20-30
• Worst prognosis
Teratoma
Derived from 2 or more embryonic germ cell layers
in various stages of maturation
• Can contain bone, cartilage, intestinal,
pancreatic, liver, muscle, neural cells
• Lined by any cell type
• Large, lobulated, nonhomogeneous
Teratoma
• Classifications
– Mature
– Immature
– With malignant transformation
– Simple epidermoid cysts
• 3% of adult, 38% of children
• Elevated AFP 20-25%
• Age 25-35
• Epidermoid cysts – benign
• Metastatic teratoma resistant to chemo & radiation
Yolk Sac Tumor
• Most common testis tumor age 0-10
– Slow growing mass
– 25% have hydrocele
– AFP elevated in >90%
• In adult mixed tumors, 1/3 have yolk sac
elements
Mixed Tumors
• 60% of tumors
• Most frequent mixed tumor
– Embryonal, seminoma, yolk sac, teratoma &
syncytiotrophoblasts
• Document % of volume for each type
• AFP & hCG can be elevated
• Age 10-30
• Managed as NSGCT
Intratubular Germ Cell Neoplasia:
((CIS of Testis))
• Precursor to all GCTs except spermatocytic seminoma
• Risk Factors
– Contralateral testis w/ unilateral ca (2-38%)
– Cryptorchidism (5-6%)
– Infertility (1%)
– Extragonadal GCT (35-50%)
– Intersex (25-100%)
• Evenly distributed through testis
– Open biopsy is reliable
– US unreliable
• Treatment Options
– Observation – treatment of choice
– Orchiectomy
– Radiation (European treatment)
– Chemo ineffective
Epidemiology of GCTs
• Incidence
– Lifetime risk white male – 1 in 500
• 1/3 lower risk for American blacks
– Highest incidence – Scandinavia, Switzerland,
Germany, New Zealand
– Lowest incidence – Asia, Africa
• Laterality
– 2-3% are bilateral
– More common on Rt ?
Tumor Markers
• NSGCTs
– Elevated AFP 50-70%
– Elevated hCG 40-60%
– Elevated either or both 90%
– 10% of advanced disease will have normal tumor markers
• Be careful
– Elevated AFP can be from liver dysfunction
– Elevated hCG can be from hypogonadism & marijuana
– Normal markers does not mean no residual disease
• 10-20% after chemo & RPLND for bulky disease have viable tumor
despite normal markers
AFP
• 5-7 day half life
• Can be elevated in:
– Testis, liver, pancreas, stomach, lung ca
• Never elevated in pure choriocarcinoma or seminoma
• Can be elevated in:
– Pure embryonal
– Teratocarcinoma
– Yolk sac
– Combined
HCG
• 24-36 hour half life
• Elevated in all choriocarcinoma, 40-60% of embryonal,
5-10% of seminomas
• Can be elevated in:
– Marijuana smokers
– Liver, pancreas, stomach, lung, breast, kidney, bladder ca
– Elevated LH - false positive HCG
LDH
• High levels in muscle, liver, kidney, brain
• High false positive rate
• Most useful as a marker for bulky disease
Patterns of Spread
• Predictable (except for choriocarcinoma)
• Spermatic cord has 4-8 lymph channels
• Right-sided tumors
– Interaortocaval at level of L2 body
– Can cross from R to L
• Left-sided tumors
– Para-aortic between L ureter, L renal vein, aorta,
origin of IMA
Staging
Staging Systems
• American Joint Committee on Cancer (AJCC) – 1997,
2002
– TNMS system
• Stage grouping
– Stage 0, Ia, Ib, Is, IIa, IIb, IIc, III
– Stage I
• No nodes, no mets
– Stage II
• Positive regional nodes
– Stage III
• Nonregional nodes or pulmonary mets
STAGING OF TESTIS TUMORS BY
THE AMERICAN JOINT COMMITTEE ON CANCER (AJCC)
• Primary Tumor
• The extent of primary tumor is
classified after radical orchiectomy
• pTX Primary tumor cannot be
assessed. (If no radical orchiectomy
has been performed, TX is used.)
• pT0 No evidence of primary
tumor (e.g., histologic scar in testis)
• pTis Intratubular germ cell
neoplasia (carcinoma in situ)
• pT1Tumor limited to the testis
and epididymis without
vascular/lymphatic invasion. Tumor
may invade into the tunica albuginea
but not the tunica vaginalis.
• pT2Tumor limited to the testis and
epididymis with vascular/lymphatic
invasion, or tumor extending through
the tunica albuginea with involvement
of the tunica vaginalis
• pT3Tumor invades the spermatic
cord with or without
vascular/lymphatic invasion
• pT4Tumor invades the scrotum
with or without vascular/lymphatic
invasion
• Regional Lymph Nodes (N) Clinical
• NX Regional lymph nodes cannot be
assessed
• N0No regional lymph node metastasis
• N1Metastasis with a lymph node mass 2
cm or less in greatest dimension; or multiple
lymph nodes, none more than 2 cm in
greatest dimension
• N2Metastasis with a lymph node mass,
more than 2 cm but not more than 5 cm in
greatest dimension; or multiple lymph nodes,
any one mass greater than 2 cm but not
more than 5 cm in greatest dimension
• N3Metastasis with a lymph node mass
more than 5 cm in greatest dimension
• Pathologic Lymph Nodes (pN(
• pNX Regional lymph nodes cannot be
assessed
• pN0No regional lymph node
metastasis
• pN1Metastasis with a lymph node
mass 2 cm or less in greatest dimension
and five or fewer nodes positive, none
more than 2 cm in greatest dimension
• pN2Metastasis with a lymph node
mass more than 2 cm but not more than
5 cm in greatest dimension; or more
than five nodes positive, none more
than 5 cm; or evidence of extranodal
extension of tumor
• pN3Metastasis with a lymph node
mass more than 5 cm in greatest
dimension
• Distant Metastasis (M(
• MX Distant metastasis cannot be
assessed
• M0 No distant metastasis
• M1 Distant metastasis
• M1a Nonregional nodal or pulmonary
metastasis
• M1b Nonpulmonary visceral metastasis
• Serum Tumor Markers (S)
• SXMarker studies not available or not
performed
• S0Marker study levels within normal limits
• S1LDH <1.5 × N and
HCG (mIU/mL) <5000 and
AFP (ng/mL) <1000
• S2 LDH 1.5-10 × N or
HCG (mIU/mL) 5000-50,000 or
AFP (ng/mL) 1000-10,000
• S3 LDH >10 × N or
HCG (mIU/mL) >50,000 or
AFP (ng/mL) >10,000
• N indicates the upper limit of normal for the LDH
assay
Testicular tumors
Testicular tumors
Treatment of GCTs
• Radical orchiectomy for local control
– Offer sperm banking prior to surgery
• 65-85% seminomas confined to testis
• 60-70% nonseminomas present as recognizable
metastatic disease
Partial Orchiectomy
• Option for
– Organ confined tumor <2cm
• Especially incidentally found, nonpalpable
– Solitary testis or w/ B/L tumors
• Careful frozen sections
Stage I Seminoma
• No nodes, survival is same with surveillance & XRT, surveillance more
common due to increased risk of secondary malignancy
• 15-25% staging error
• Radiation – treatment of choice
– 20-25 Gy to para-aortic nodes
– 5-year disease free survival >95%
– Long-term side effects
• Infertility, GI, 2nd
malignancy
– 3% relapse (outside retroperitoneum) & need chemo
• Chemotherapy
– Carboplatin
Stage IIa & IIb Seminoma
• XRT
– Ipslilateral external iliac, b/l common iliac, paracaval,
para-aortic, cisterna chyli
– Avoid kidney
– Shield contralateral testis
– 5-yr disease free survival 80%
– 3% relapse
• Chemo
– If nodes close to kidney
Stage IIc & III Seminoma
• Cisplatin-based chemo is the treatment of
choice
– Bleomycin, Etoposide, Cisplatin (BEP) x3–4
– Etoposide, Cisplatin (EP) x4
– 90% complete response to chemo at 4yrs
– 10% relapse after initial chemo response
• Postchemo residual retroperitoneal mass
– Well-delineated, >3cm – resect
• Mass = GCT, then salvage chemo (vinblastine, ifosfamide,
Stage I NSGCTs
• Staging is inaccurate in at least 25% & only way to accurately stage is RPLND
• Radiation - not used in North America, relapse rate 24%
• Surveillance
– Option for low risk:
• No vascular/lymphatic invasion (<T2)
• <40% embryonal
• Motivated, reliable pts
– Relapse 28%, survival 99%
– Protocol
• CXR, tumor markers q1mo x1yr, q2mo x1yr, q3-6mo up to 10 more yrs
• CT q2-3mo x2yrs, q6mo up to 10yrs
• Chemo – BEP x2-3
– Option for low or high risk:
• T2 or higher (vascular/lymphatic invasion)
• >40% embryonal
• Modified template RPLND
– If negative, then observe
• 70% of RPLNDs find no disease
– If <2cm nodes (N1), observe or adjuvant chemo – BEP x2 or EP x2
– If >2cm nodes (N2), adjuvant chemo – BEP x2 or EP x2
– 5-10% relapse outside field of RPLND
Stage IIa & IIb NSGCTs
• Bilateral RPLND
– N1 (nodes <2cm) – observe or adjuvant chemo –
BEP x2
– N2 (nodes 2-5cm) – adjuvant chemo – BEP x2
• Chemo – BEP x3 or EP x4
– If post-orchiectomy tumor markers elevated
– If nodes >3cm
Stage IIc & III NSGCTs
• Low Risk
– No nonpulmonary visceral mets
– AFP <1000, hCG <5000, and LDH <1.5x normal
• Intermediate Risk
– No nonpulmonary visceral mets
– Markers between low & high risk
• High Risk
– Nonpulmonary visceral mets
– AFP >10,000, hCG >50,000, or LDH >10x normal
Stage IIc & III NSGCTs
• Low risk
– Chemo – BEP x3 or EP x4
– 92% 5-yr survival
• High risk
– Chemo – BEP x4 or B/isosfamide/P
– 48% 5-yr survival
Stage IIc & III NSGCTs
• After Chemo
– Complete response (normal tumor markers, no residual mass)
• Observe
– 10% relapse & need salvage chemo
– Partial response (normal tumor markers, residual mass)
• Full B/L RPLND & resect residual mass
– 10-20% GCT – salvage chemo
– 40-50% teratoma – observe or resect
– 40% necrosis – observe
– Poor response (elevated tumor markers or no shrinkage of mass)
• Salvage chemo, high dose chemo & autologous bone marrow transplant
– 25% long term survival
Chemo & XRT Toxicity
• 2nd
Malignancy
– Up to 18% 25yrs after XRT
– Chemo
• Higher long-term incidence of leukemia, lymphoma, colon, stomach,
kidney, prostate, bladder, thyroid, rectum, pancreas, connective
tissue cancers
• Bleomycin
– Pulmonary Toxicity
• Etoposide
– Myelosuppression
• Cisplatin
– Nephrotoxicity – also Carboplatin
– Low Magnesium
– Neurotoxicity & Ototoxicity
Other Testicular Tumors
• Leydig Cell Tumor
• Sertoli Cell Tumor
• Gonadoblastoma
• Lymphoma
Leydig Cell Tumors
• 1-3% of testicular tumors
• 10% malignant
– Average survival – 3 years if malignant
• Reinke’s crystals – red extracellular lobular crystals
• Presentation
– Precocious puberty in kids
– Elevated testosterone, urinary 17-ketosteroids
– Mass
– Impotence, gynecomastia
• Treatment
– Radical orchiectomy
Sertoli’s Cell Tumors
• <1% testicular tumors
• Most common testicular tumor
• 10% malignant
• Any age
• Radical orchiectomy
– RPLND if metastatic
Others
• Gonadoblastoma
– 0.5% testicular tumors
– 80% are in phenotypically female
pts
– Good prognosis
• Epidermoid Cyst
– 1% testicular tumors
– ? Monolayer teratoma
– Benign
• Rete Testis Adenocarcinoma
– Age 20-80
– Very malignant
Adrenal Rest Tumor
B/L tumor, CAH – remission w/
corticoid treatment
Lymphoma
5% testicular tumors
Most common secondary
tumor
Most common testicular tumor
in age >50
½ are B/L
• THE END

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Testicular tumors

  • 2. Introduction • Most common malignancy of urogenital tract in males 15-35 • Its incidence has been increasing during the last decades especially in industrialised countries. • More common among Caucasian men
  • 3. Presentation • Signs & symptoms – Usually painless lump – 30-40% c/o heaviness or dull ache – 10% acute pain – 10% present with metastatic manifestations • Neck mass, cough, nausea, vomiting, lumbar pain, bone pain – Gynecomastia is present in 5% of GCTs • Any hypoechoic area on US wthin tunica is suspicious for tumor
  • 4. Risk factors • Cryptorchidism (4-13x risk) – 7-10% of tumors had cryptorchidism – 5-10% testicular tumor had cryptorchidism in contralateral side – Intra-abdominal testis > Intrainguial testis – Structural abnormalities seen in cryptorchid testis at 3 years – Orchiopexy does not prevent cancer, but it allows easier clinical detection
  • 5. • - Family History (6-8x risk) • - Racial Origin (Highest in Scandinavia) • - Maternal exposure of estrogen (2.8-5.3x risk) • - Subfertility (1.6-20x risk) • - Contralateral testicular tumour (5-10% risk)
  • 6. • Survival – <50% prior to 1970 – >95% in 1997 • Improved survival: – Accurate tumor markers – Effective chemo – Modifications of surgical technique – Mostly radiosensitive – Backup treatments if primary treatments fail
  • 8. Classification • Germ Cell Tumors (GCT) – Seminoma • Classic or Typical • Anaplastic • Spermatocytic – Nonseminoma • Embryonal Cell Carcinoma • Yolk Sac Tumor • Teratoma • Choriocarcinoma • >50% GCT are mixed
  • 9. Classic Seminoma • 82-85% of seminomas • Mostly men in 30’s • Clear cytoplasm, dense nucleus • Synctiotrophoblasts in 10-15% – Elevated B-HCG in 10% – hCG up to 500 ng/mL • Lymphocytes in 20%
  • 10. Anaplastic Seminoma • 5-10% of seminomas • Greater mitotic activity • Higher rate of local invasion • Increased rate of metastasis • Higher rate of B-HCG production • Stage for stage – treatment outcomes same as classic seminoma
  • 11. Anaplastic Seminoma Note : Pleomorphism, hyperchromasia
  • 12. Spermatocytic Seminoma • 3 sizes of cells • 9% of seminomas • 50% older than 50 • Very low metastatic potential – Favorable prognosis
  • 13. Embryonal Carcinoma • Small, hard, irregular mass • Age 25-35 • Smallest germ cell tumor – 40% <2cm • Invades tunica vaginalis • Often close to rete testis • Highly malignant
  • 14. Choriocarcinoma • Commonly present with metastasis • Must have synctiotrophoblasts & cytotrophoblasts • 1-2% of tumors • hCG elevated in >99% • Age 20-30 • Worst prognosis
  • 15. Teratoma Derived from 2 or more embryonic germ cell layers in various stages of maturation • Can contain bone, cartilage, intestinal, pancreatic, liver, muscle, neural cells • Lined by any cell type • Large, lobulated, nonhomogeneous
  • 16. Teratoma • Classifications – Mature – Immature – With malignant transformation – Simple epidermoid cysts • 3% of adult, 38% of children • Elevated AFP 20-25% • Age 25-35 • Epidermoid cysts – benign • Metastatic teratoma resistant to chemo & radiation
  • 17. Yolk Sac Tumor • Most common testis tumor age 0-10 – Slow growing mass – 25% have hydrocele – AFP elevated in >90% • In adult mixed tumors, 1/3 have yolk sac elements
  • 18. Mixed Tumors • 60% of tumors • Most frequent mixed tumor – Embryonal, seminoma, yolk sac, teratoma & syncytiotrophoblasts • Document % of volume for each type • AFP & hCG can be elevated • Age 10-30 • Managed as NSGCT
  • 19. Intratubular Germ Cell Neoplasia: ((CIS of Testis)) • Precursor to all GCTs except spermatocytic seminoma • Risk Factors – Contralateral testis w/ unilateral ca (2-38%) – Cryptorchidism (5-6%) – Infertility (1%) – Extragonadal GCT (35-50%) – Intersex (25-100%) • Evenly distributed through testis – Open biopsy is reliable – US unreliable • Treatment Options – Observation – treatment of choice – Orchiectomy – Radiation (European treatment) – Chemo ineffective
  • 20. Epidemiology of GCTs • Incidence – Lifetime risk white male – 1 in 500 • 1/3 lower risk for American blacks – Highest incidence – Scandinavia, Switzerland, Germany, New Zealand – Lowest incidence – Asia, Africa • Laterality – 2-3% are bilateral – More common on Rt ?
  • 21. Tumor Markers • NSGCTs – Elevated AFP 50-70% – Elevated hCG 40-60% – Elevated either or both 90% – 10% of advanced disease will have normal tumor markers • Be careful – Elevated AFP can be from liver dysfunction – Elevated hCG can be from hypogonadism & marijuana – Normal markers does not mean no residual disease • 10-20% after chemo & RPLND for bulky disease have viable tumor despite normal markers
  • 22. AFP • 5-7 day half life • Can be elevated in: – Testis, liver, pancreas, stomach, lung ca • Never elevated in pure choriocarcinoma or seminoma • Can be elevated in: – Pure embryonal – Teratocarcinoma – Yolk sac – Combined
  • 23. HCG • 24-36 hour half life • Elevated in all choriocarcinoma, 40-60% of embryonal, 5-10% of seminomas • Can be elevated in: – Marijuana smokers – Liver, pancreas, stomach, lung, breast, kidney, bladder ca – Elevated LH - false positive HCG
  • 24. LDH • High levels in muscle, liver, kidney, brain • High false positive rate • Most useful as a marker for bulky disease
  • 25. Patterns of Spread • Predictable (except for choriocarcinoma) • Spermatic cord has 4-8 lymph channels • Right-sided tumors – Interaortocaval at level of L2 body – Can cross from R to L • Left-sided tumors – Para-aortic between L ureter, L renal vein, aorta, origin of IMA
  • 27. Staging Systems • American Joint Committee on Cancer (AJCC) – 1997, 2002 – TNMS system • Stage grouping – Stage 0, Ia, Ib, Is, IIa, IIb, IIc, III – Stage I • No nodes, no mets – Stage II • Positive regional nodes – Stage III • Nonregional nodes or pulmonary mets
  • 28. STAGING OF TESTIS TUMORS BY THE AMERICAN JOINT COMMITTEE ON CANCER (AJCC) • Primary Tumor • The extent of primary tumor is classified after radical orchiectomy • pTX Primary tumor cannot be assessed. (If no radical orchiectomy has been performed, TX is used.) • pT0 No evidence of primary tumor (e.g., histologic scar in testis) • pTis Intratubular germ cell neoplasia (carcinoma in situ) • pT1Tumor limited to the testis and epididymis without vascular/lymphatic invasion. Tumor may invade into the tunica albuginea but not the tunica vaginalis. • pT2Tumor limited to the testis and epididymis with vascular/lymphatic invasion, or tumor extending through the tunica albuginea with involvement of the tunica vaginalis • pT3Tumor invades the spermatic cord with or without vascular/lymphatic invasion • pT4Tumor invades the scrotum with or without vascular/lymphatic invasion
  • 29. • Regional Lymph Nodes (N) Clinical • NX Regional lymph nodes cannot be assessed • N0No regional lymph node metastasis • N1Metastasis with a lymph node mass 2 cm or less in greatest dimension; or multiple lymph nodes, none more than 2 cm in greatest dimension • N2Metastasis with a lymph node mass, more than 2 cm but not more than 5 cm in greatest dimension; or multiple lymph nodes, any one mass greater than 2 cm but not more than 5 cm in greatest dimension • N3Metastasis with a lymph node mass more than 5 cm in greatest dimension • Pathologic Lymph Nodes (pN( • pNX Regional lymph nodes cannot be assessed • pN0No regional lymph node metastasis • pN1Metastasis with a lymph node mass 2 cm or less in greatest dimension and five or fewer nodes positive, none more than 2 cm in greatest dimension • pN2Metastasis with a lymph node mass more than 2 cm but not more than 5 cm in greatest dimension; or more than five nodes positive, none more than 5 cm; or evidence of extranodal extension of tumor • pN3Metastasis with a lymph node mass more than 5 cm in greatest dimension
  • 30. • Distant Metastasis (M( • MX Distant metastasis cannot be assessed • M0 No distant metastasis • M1 Distant metastasis • M1a Nonregional nodal or pulmonary metastasis • M1b Nonpulmonary visceral metastasis • Serum Tumor Markers (S) • SXMarker studies not available or not performed • S0Marker study levels within normal limits • S1LDH <1.5 × N and HCG (mIU/mL) <5000 and AFP (ng/mL) <1000 • S2 LDH 1.5-10 × N or HCG (mIU/mL) 5000-50,000 or AFP (ng/mL) 1000-10,000 • S3 LDH >10 × N or HCG (mIU/mL) >50,000 or AFP (ng/mL) >10,000 • N indicates the upper limit of normal for the LDH assay
  • 33. Treatment of GCTs • Radical orchiectomy for local control – Offer sperm banking prior to surgery • 65-85% seminomas confined to testis • 60-70% nonseminomas present as recognizable metastatic disease
  • 34. Partial Orchiectomy • Option for – Organ confined tumor <2cm • Especially incidentally found, nonpalpable – Solitary testis or w/ B/L tumors • Careful frozen sections
  • 35. Stage I Seminoma • No nodes, survival is same with surveillance & XRT, surveillance more common due to increased risk of secondary malignancy • 15-25% staging error • Radiation – treatment of choice – 20-25 Gy to para-aortic nodes – 5-year disease free survival >95% – Long-term side effects • Infertility, GI, 2nd malignancy – 3% relapse (outside retroperitoneum) & need chemo • Chemotherapy – Carboplatin
  • 36. Stage IIa & IIb Seminoma • XRT – Ipslilateral external iliac, b/l common iliac, paracaval, para-aortic, cisterna chyli – Avoid kidney – Shield contralateral testis – 5-yr disease free survival 80% – 3% relapse • Chemo – If nodes close to kidney
  • 37. Stage IIc & III Seminoma • Cisplatin-based chemo is the treatment of choice – Bleomycin, Etoposide, Cisplatin (BEP) x3–4 – Etoposide, Cisplatin (EP) x4 – 90% complete response to chemo at 4yrs – 10% relapse after initial chemo response • Postchemo residual retroperitoneal mass – Well-delineated, >3cm – resect • Mass = GCT, then salvage chemo (vinblastine, ifosfamide,
  • 38. Stage I NSGCTs • Staging is inaccurate in at least 25% & only way to accurately stage is RPLND • Radiation - not used in North America, relapse rate 24% • Surveillance – Option for low risk: • No vascular/lymphatic invasion (<T2) • <40% embryonal • Motivated, reliable pts – Relapse 28%, survival 99% – Protocol • CXR, tumor markers q1mo x1yr, q2mo x1yr, q3-6mo up to 10 more yrs • CT q2-3mo x2yrs, q6mo up to 10yrs • Chemo – BEP x2-3 – Option for low or high risk: • T2 or higher (vascular/lymphatic invasion) • >40% embryonal
  • 39. • Modified template RPLND – If negative, then observe • 70% of RPLNDs find no disease – If <2cm nodes (N1), observe or adjuvant chemo – BEP x2 or EP x2 – If >2cm nodes (N2), adjuvant chemo – BEP x2 or EP x2 – 5-10% relapse outside field of RPLND
  • 40. Stage IIa & IIb NSGCTs • Bilateral RPLND – N1 (nodes <2cm) – observe or adjuvant chemo – BEP x2 – N2 (nodes 2-5cm) – adjuvant chemo – BEP x2 • Chemo – BEP x3 or EP x4 – If post-orchiectomy tumor markers elevated – If nodes >3cm
  • 41. Stage IIc & III NSGCTs • Low Risk – No nonpulmonary visceral mets – AFP <1000, hCG <5000, and LDH <1.5x normal • Intermediate Risk – No nonpulmonary visceral mets – Markers between low & high risk • High Risk – Nonpulmonary visceral mets – AFP >10,000, hCG >50,000, or LDH >10x normal
  • 42. Stage IIc & III NSGCTs • Low risk – Chemo – BEP x3 or EP x4 – 92% 5-yr survival • High risk – Chemo – BEP x4 or B/isosfamide/P – 48% 5-yr survival
  • 43. Stage IIc & III NSGCTs • After Chemo – Complete response (normal tumor markers, no residual mass) • Observe – 10% relapse & need salvage chemo – Partial response (normal tumor markers, residual mass) • Full B/L RPLND & resect residual mass – 10-20% GCT – salvage chemo – 40-50% teratoma – observe or resect – 40% necrosis – observe – Poor response (elevated tumor markers or no shrinkage of mass) • Salvage chemo, high dose chemo & autologous bone marrow transplant – 25% long term survival
  • 44. Chemo & XRT Toxicity • 2nd Malignancy – Up to 18% 25yrs after XRT – Chemo • Higher long-term incidence of leukemia, lymphoma, colon, stomach, kidney, prostate, bladder, thyroid, rectum, pancreas, connective tissue cancers • Bleomycin – Pulmonary Toxicity • Etoposide – Myelosuppression • Cisplatin – Nephrotoxicity – also Carboplatin – Low Magnesium – Neurotoxicity & Ototoxicity
  • 45. Other Testicular Tumors • Leydig Cell Tumor • Sertoli Cell Tumor • Gonadoblastoma • Lymphoma
  • 46. Leydig Cell Tumors • 1-3% of testicular tumors • 10% malignant – Average survival – 3 years if malignant • Reinke’s crystals – red extracellular lobular crystals • Presentation – Precocious puberty in kids – Elevated testosterone, urinary 17-ketosteroids – Mass – Impotence, gynecomastia • Treatment – Radical orchiectomy
  • 47. Sertoli’s Cell Tumors • <1% testicular tumors • Most common testicular tumor • 10% malignant • Any age • Radical orchiectomy – RPLND if metastatic
  • 48. Others • Gonadoblastoma – 0.5% testicular tumors – 80% are in phenotypically female pts – Good prognosis • Epidermoid Cyst – 1% testicular tumors – ? Monolayer teratoma – Benign • Rete Testis Adenocarcinoma – Age 20-80 – Very malignant Adrenal Rest Tumor B/L tumor, CAH – remission w/ corticoid treatment Lymphoma 5% testicular tumors Most common secondary tumor Most common testicular tumor in age >50 ½ are B/L

Notes de l'éditeur

  1. Gynecomastia is systemic endocrine manifestation – hCG, prolactin, estrogen, androgens, still undefined relationship.
  2. Only higher metastatic potential
  3. Histologically benign
  4. Treatment depends on age, b/l or unilateral, atrophy, physician’s philosophy. Progression may take 15 years. Some may screen intersex or other high risk
  5. Cryptorchidism more common on R
  6. LH may cross react with HCG assays causing false positive
  7. Stage I
  8. Stage 2a&amp;b, retroperitoneal nodes &amp;lt;5cm
  9. IIC node &amp;gt;5cm, III is nonregional node or pulmonary mets, response numbers are all over the place
  10. Stage IIa&amp;b – nodes &amp;lt;2, 2-5cm
  11. Chemo tailored to this classification
  12. Growing teratoma syndrome, can transform into sarcoma or adenocarcinoma. If partial response, can omit RPLND if &amp;gt;90% response &amp; no teratoma in primary tumor.