Tumors of the

testis
S. Vahidi

M.D

Tumors of the testis

Introduction:
1-8 new cases/ 100000 male/year
90-95% germ cell tumors
Survival of patients has improved dramatically
Higher socioeconomic/lower classes 2/1
R>L
1-2%: Bilateral. Seminoma-lymphoma
7-10% of T-tumors develop in cryptorchidism
Orchiopexy does not alter the malignant
potential
Exogenous estrogen Adm. To the mother
during pregnancy

Tumors of the testis

Classification:
Primary
Secondary

Benigne
Malignant

Germ cell
Non germ cell
Germ cell tumors:
Seminoma
Nonseminomatous: Embryonal
Teratoma
Choriocarcimoma
Mixed tumors

Tumors of the testis

Tumorigenic hypothesis:

Normal spermatocyte
Totipotential germ cell
Seminoma
Embryonal carcinoma ?
( totipotential tumor cell)
Extra embryonic
differentiation
Trophoblastic
pathways

Choriocarcimoma

Yolk sac
pathways

Yolk sac tumor

Intra embryonic
differentiation

Teratoma

Tumors of the testis

Pathology

A. Seminoma (35%)

Classic (85%)
Anaplastic (5-10%)
Spermatocytic (5-10%)

B. Embryonal cell carcimoma (20%)

Adult type
Infantile type (yolk sac tumor)

C. Teratoma (5%)
D. Choriocarcinoma (<1%)
E. Mixed cell type (40%)

Teratocarcinoma

F. Carcimoma in situ (CIS)

Tumors of the testis

Patterns of metastatic spread

Step wise lymphatic fashion. (T1-T4)

RT testis: intra aortocaval at RT K.hilum
Precaval-preaortic-Paracaval-RT common Iliac- RT
ext Iliac nodes
LT testis: paraaortic area at LT K. Hilum
Pre aortic- LT common Iliac- LT ext. Iliac nodes

RT to LT crossover metastasis: common

LT to RT crossover metastasis: No
Visceral metastases: lung liver-brain bonekidney-adrenal . GI. Spleen
Hematogenous : choriocarcinoma

Tumors of the testis

Clinical
staging

T-primary tumors
TX:
T0:
Tis:
T1:
T2:
T3:
T4:

Cannot be assessed
No evidence of primary tumor
Intratubular cancer (CIS)
Limited to testis and epididymis, no vascular invasion
Invades beyond tunica albuginea or has vascular invasion
Invades spermatic cord
Invades scrotum

N-Regional lymph nodes

NX:
N1:
N2:
N3:

Cannot be assessed
No regional lymph node metastasis
Lymph node metastasis 2cm, or multiple nodes, none more than 2 cm. and<6 nodes
positive
Nodal mass>2cm and 5cm. Or 6 nodes positive
Nodal mass> 5 cm

M-Distant metastasis
MX:
M0:
M1:
M2:

Cannot be assessed
No distant metastasis
Distant metastasis present in nonregional lymph nodes or lungs
Nonpulmonary visceral metastases

S-Serum tumor markers

SX:
S0:
S1:
S2:
S3:

Markers not available

Marker levels within normalimits
Lactic acid dehydrogenase (LDH)<1.5xnormal and HCG<500 mlU/ml and
AFP<1000ng/ml
LDH 1.5-10xnormal or hCG 5000-50000mIU/ml or AFP 1000-10000 ng/ml
LDH>10xnormal or hCG>50000 mIU/ml or AFP>10000 ng/ml

Tumors of the testis

Clinical findings
A-symptoms:
Painless enlargment of testis
Acute testicalor pain (10%)
Symptoms related to metastasis (10%):
back pain-cough-dyspnea anorexianausea- bone pain- lower ext. edema
Asymptomatic (10%)

Tumors of the testis

Clinical findings
B: signs:
Testicular mass or diffuse enlargment
Node palpation
Gynecomastia
Hemoptysis

Tumors of the testis

Laboratory findings and tumor
markers:

Anemia-liver function testscreatinin

Tumor markers:

FP
HCG
LDH
PLAP-GGT

Seminoma
Teratoma
Teratocarcin
oma
Embryonal
choriocarcin

hCG(%) AFP(
%)

7
25
57
60
100

0
38
64
70
0

Tumors of the testis

Imaging
Ultrasonography
CXR
CT-Scan
Pedal

For staging

LAG

Tumors of the testis

Differential diagnosis
Epdidymitis & Epididymoorchitis
Hydrocele
Spermatocele
Hematocele
Granulomatous orchitis
Varicocele
Epidermoid cyst

Tumors of the testis

Treatment
Inguinal Exploration & radical orchiectomy
A.
Low stage seminoma: retroperitoneal irradiation
95% care
A.
high stage seminoma: primary chemotherapy
95% complete response

Tumors of the testis

Treament
C: low stage NSGCT: R.O +RPLND (N22cycles
chemotherapy)
Surveillncc:
1)NSGCT confined within tunica albuginea
2)No vascular invasion
3)normalize tumor markers
4)no evidence of disease in radiographic imaging
5)the patient is considered reliable
Modified RPLND: Nodal tissue dissection ipsilateral to the
tumor below the level of the inferior mesenteric artery
Clinical stage I+ vascular invasion: 2 cycles of chemotherapy

Tumors of the testis

Treatment
High stage NSGCT: primary chemotherapy
(+RPLND?)
Normal tumor marker+retroperitoneal mass mass
resection
tumor markersalvage chemotherapy
(upto 70% care)
High risk patients:
mediastinal primary tumor
non pulmonary visceval metastasis
S3 marker levels

Tumors of the testis

Follow up:
careful exam of remaining testis, abdomen, lymph node area
lab (AFP, BHCG-LDH)
CXR
every 3 month/ first 2 years
every 6 month/ until 5 years
and then yearly
Surveillance follow up:
tumor marker at each visit.
CXR & CT every 3-4 month
Visit:

monthly/ first 2 years

bimonthly/ third year

Tumors of the testis

Prognosis
Seminoma: R.O+radiotherapy:
stage I: 98% 5 years survival rate
stage II: 92-94% 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

Non-Germ cell tumors 5-6% of all testis tumor
leydig cell tumors most common
5-9 & 25-35 years old
no association with UDT
clinical finding: virilization (prepubertal)
asymptomatic (adults). 10% malignant
Treatment : radical orchiectomy- RPLND
Sertoli cell tumors
exceedingly rare
10% malignant
radical orchiecty+RPLND
Gonadoblastoma
in gonadal dysgenesis(80% female fenotype)
radical orchiectomy + contralateral gonadectomy

Tumors of the testis

Secondary tumors of the testis
1. lymphoma
most common t.t. in>50
years old
2. leukemia
t.Biopsy is choice
3. metastatic tumor: prostate- lung GImelanoma-kidney

Tumors of the testis

Extragonadal germ cell tumors
3% of all germ cell tumors
the most common sites:
mediastinum-retroperitoneum,
sacrococcygeal pineal gland

Tumors of the testis

Tumors of the epididymis, paratesticular tissue &
spermatic cord

T. Of epididym: commonly benign:

adenomatoid
leiomyoma
cystadenoma
T. of spermatic cord:
lipoma
Rabdomyosarcoma
leiomyosarcoma. Fibrosarcoma
liposarcoma