Neoplasms of the

Testis
Lt Col HAFIZ
CONTENT

• RISK FACTORS
• CLASSIFICATION
• DIAGNOSIS
• STAGING
• PROGNOSIS
• TREATMENT
• SECONDARY TUMORS OF TESTIS
• TUMORS OF THE TESTICULAR ADNEXA
RISK FACTORS

• White race,
• Cryptorchidism- 4 to 6 times
• Family history of testis cancer,
• Personal history of testis cancer,
• Germ cell neoplasia in situ (GCNIS),also referred to as
intratubular germ cell neoplasia (ITGCN)

• Infertile and subfertile men

WHO CLASSIFICATION
HISTOLOGIC CLASSIFICATION

• GCTs are broadly classified as GCNIS-derived (majority) and

non-GCNIS–derived
• GCNIS derived GCTs are divided into Seminoma (52-56%) and
NSGCT (44-48%)
• NSGCTs include
• Embryonal carcinoma (EC),
• Yolk sac tumor,
• Teratoma,
• Choriocarcinoma subtypes,
• Either alone as pure forms or in combination as mixed GCT
with or without seminoma.
HISTOLOGIC CLASSIFICATION

• Seminoma
• Most common type of GCT
• Occur at an older average age than NSGCT
• Fourth or fifth decade of life
• Grossly, soft tan to white diffuse or multi nodular mass
• Typically negative for CD30, positive for CD117, and strongly positive
for placental alkaline phosphatase (PLAP).
• Ability of seminoma to transform into NSGCT elements has important
therapeutic implications
HISTOLOGIC CLASSIFICATION
• Embryonal Carcinoma
• Primitive epithelial cells from early stage
• Tan to yellow neoplasm that often exhibits large areas of hemorrhage and
necrosis
• Most undifferentiated cell type, with totipotential capacity to differentiate
to other NSGCT cell types (including teratoma) within the primary
tumor or at metastatic sites

• Choriocarcinoma
• Rare and aggressive
• Highly elevated serum HCG
• Spreads by hematogenous routes
• Composed of syncytiotrophoblasts and cytotrophoblasts
HISTOLOGIC CLASSIFICATION
• Yolk Sac Tumor
• Very small fraction of adult gonadal and retroperitoneal GCTs
• More common in mediastinal and pediatric GCTs
• Almost always produce AFP but not HCG.

• Teratoma
• Elements of at least two of the three germ cell layers
• Well-differentiated tumors are labeled mature
• May cause mildly elevated serum AFP
• Resistant to chemotherapy.
DIAGNOSIS
• Signs and Symptoms
• Painless testis mass
• Pain is more common with NSGCT; (more vascular and rapid than
seminomas)
• Scrotal discomfort or heaviness
• H/O trauma to notice the lump
• Metastasis at diagnosis- two-thirds of NSGCTs and 15% of pure
seminomas,
• Symptoms related to metastatic disease- 10% to 20% of patients.
• 2% gynecomastia, (Elevated serum HCG levels, decreased androgen
production, or increased estrogen levels- Leydig cell tumors).
• Two-thirds of men with GCT have diminished fertility,
DIAGNOSIS
• Differential Diagnosis
• A firm intratesticular mass should be considered cancer until proven
otherwise and should be evaluated further with a scrotal ultrasound. In
patients with a presumptive diagnosis of epididymo-orchitis, patients
should be re-evaluated within 2 to 4 weeks of completion of an
appropriate course of oral antibiotics.
DIAGNOSIS

• Scrotal Ultrasound
• Extension of the physical
examination
• Heterogeneous- NSGCT
• Seminomas- homogenous
echo
• Increased flow on color
Doppler is suggestive of
malignancy, although its
absence does not exclude GCT
• Both testes should be
evaluated
DIAGNOSIS

• Magnetic Resonance Imaging

• If sonographic findings are equivocal
• Very helpful

• Serum Tumor Markers

• Diagnostic/Prognostic/Survillance
• Patients suspected of having a GCT- preoperative AFP, HCG, and LDH
• Should not be used to guide decision-making
DIAGNOSIS

• AFP- NSGCT
• The half-life of AFP is 5 to 7 days.
• EC and yolk sac tumors secrete AFP.
• Choriocarcinomas and seminomas do not produce AFP.
• Seminoma with elevated serum AFP are considered to have NSGCT
component.
• Raised in patients with hepatocellular carcinoma, cancers of the stomach,
pancreas, biliary tract and lung, non-malignant liver disease (infectious,
drug-induced, alcohol-induced, autoimmune), ataxic telangiectasia, and
hereditary tyrosinemia.
DIAGNOSIS

• HCG
• NSGCT > Seminoma
• Secreted by choriocarcinoma and EC
• > 5000 IU/L are usually associated with NSGCT.
• The half-life of HCG is 24 to 36 hours.
• Also raised in cancers of the liver, biliary tract, pancreas, stomach, lung,
breast, kidney, and bladder.

• LDH
• LDH1 elevated in GCT.
• LDH is expressed smooth, cardiac, and skeletal muscle, Lymphoma
• The serum half-life of LDH is 24 hours.
DIAGNOSIS

• Radical Inguinal Orchiectomy

• A trans scrotal orchiectomy or biopsy is contraindicated because it leaves
the inguinal portion of the spermatic cord intact and may alter the
lymphatic drainage of the testis, increasing the risk of local recurrence
and pelvic or inguinal lymph node metastasis.
• Radical orchiectomy –
• histologic diagnosis
• primary T stage,
• Prognostic information
• tumor histology,
• and is curative in 70% to 80%
DIAGNOSIS

• Testis-Sparing Surgery
• Highly controversial
• No role in a normal contralateral testis.
• May be considered for organ-confined tumors smaller than 2 to 3 cm (up
to 30% of testicular volume) in patients with synchronous bilateral
tumors or tumor in a solitary testis with sufficient testicular androgen
production and benign tumor or indeterminate lesion.
• Intraoperative frozen section analysis, Biopsies of the adjacent testicular
parenchyma should be done.
STAGING

• Clinical Staging Based on the

• Histopathological findings
• Pathological stage of the primary tumor,
• Post-orchiectomy serum tumor marker levels
• Metastatic disease
• Staging imaging studies.
• CS I- disease clinically confined to the testis,
• CS II- presence of regional (retroperitoneal) lymph node
metastasis,
• CS III represents non-regional lymph node and/or visceral
STAGING

• LN Spread
• “Landing zone”
• Right testis tumors- inter-aortocaval lymph nodes inferior to the renal
vessels, followed by the paracaval and para-aortic (PA) nodes.
• Left testis tumors is the PA lymph nodes, followed by the inter
aortocaval nodes
• The pattern of lymph drainage in the retroperitoneum is from right to
left.
• Right side- More bulky disease
• Gradually caudal spread to iliac and inguinal LN
STAGING

• Clinical Staging of the Abdomen and Pelvis

• CECT or MRI
• Retroperitoneal lymph nodes 5 to 9 mm in size in the primary landing
zone should be viewed with suspicion for regional lymph node
metastasis
• Currently no role for FDG-PET in the routine evaluation of NSGCT and
seminoma at the time of diagnosis
STAGING

• Serum Tumor Markers

• The presence of newly elevated and/or rising serum tumor marker levels
after orchiectomy indicates the presence of metastatic disease, and these
patients should receive induction chemotherapy.
• Stable AFP or HCG levels
• Stable but Slightly above the normal range should be interpreted
cautiously, and other causes for serum tumor marker elevation should be
ruled out before management decisions are made.
STAGING
STAGING
PROGNOSIS
PROGNOSIS
PROGNOSIS
TREATMENT

• Therapeutic Principles
• Rapid diagnosis and staging
• Expeditious application of appropriate treatment
• Administration of chemotherapy
• Performance of post chemotherapy surgery to resect residual masses
• The young age and generally good health of GCT patients permits an
aggressive treatment approach if needed.
TREATMENT
TREATMENT

• Germ Cell Neoplasia in Situ

• GCNIS is a precursor lesion
• 50% risk of developing an invasive GCT within 5 years.
• Radical orchiectomy or low-dose (≥ 20 Gy) radiation therapy is an
effective treatment option for GCNIS.
TREATMENT
• Tx of NSGCT
• CS I NSGCT is controversial. Surveillance, primary RPLND, and
primary chemotherapy with BEPx2 are accepted treatment options with
long-term survival rates approaching 100% for each.
• BEPx1 is the standard regimen for all if consent obtained.
• No LVI/EC- Surveillance
• With LVI/EC- active treatment (RPLND or BEPx2)
• Relapse on surveillance> IGCCCG risk> HIGH- induction
chemotherapy, LOW- RPLND
• pStage II- Adjuvant chemotherapy after primary RPLND
• CS IIA-B- Induction chemotherapy and primary RPLND
• CS IS, IIC, and III- induction cisplatin-based chemotherapy, regime
depends on risk stratification. RPLND if feasible.
TREATMENT
• Tx of SGCT
• CS I seminoma- Surveillance, primary radiotherapy and primary
chemotherapy with carboplatin (1–2 cycles) are accepted treatment options
with long-term survival rates approaching 100% for each.
• Surveillance- for all compliant pt.
• Relapse on surveillance- Radiotherapy
• Bulky retroperitoneal lymphadenopathy or distant metastases- IGCCCG
risk-appropriate first-line chemotherapy.
• CS IIA-B (non-bulky (<3 cm) -DL radiotherapy (25–35 Gy) and first-line
chemotherapy (BEPx3 or EPx4)
• CS IIA-B (Bulky)- First-line chemotherapy (BEPx3 or EPx4)
• CS IIC and III- first-line cisplatin-based chemotherapy and specific
regimen and number of cycles is dictated by IGCCCG risk criteria.
• Discrete, residual masses> 3 cm- After first-line chemotherapy > FDG-PET
• PETpositive- post chemotherapy surgical resection.
• PET-negative- Observed after chemotherapy.
TREATMENT
• Brain metastases
• Associated with choriocarcinoma and should be suspected in any patient
with a very high serum HCG level.
• Choriocarcinomas are highly vascular, and there is a risk of hemorrhage
during chemotherapy.
• Patients with metastatic choriocarcinoma to the brain are at risk of
intracranial hemorrhage and should be monitored for such when
chemotherapy is started.
TREATMENT
• Sex Cord-Stromal Tumors
• Approximately 90% of these tumors are benign and 10% are malignant.
• tumor size larger than 5 cm, necrosis, vascular invasion, nuclear atypia,
high mitotic index, increased MIB-1 expression, infiltrative margins,
extension beyond the testicular parenchyma, and DNA ploidy
• Radical inguinal orchiectomy>
• Testis-sparing surgery> Frozen section> +/- completion Orchiectomy
• Final staging
• CS I disease with at least 1 malignant histologic feature may be safely
observed.
• Those with 2 or more malignant features or retroperitoneal metastases
should undergo RPLND
• Metastatic tumors are resistant to chemotherapy and radiation therapy,
and survival is poor
SECONDARY TUMORS OF TESTIS

• Lymphoma- The initial treatment is radical inguinal

orchiectomy
• Leukemic Infiltration- Bilateral low dose RT
• Metastasis-
• prostate, lung, melanoma, colon, and kidney cancer.
• Tx is dictated by the primary tumor, orchiectomy may be considered for
palliative reasons
TUMORS OF THE TESTICULAR ADNEXA

• Adenomatoid Tumor-
• Mesothelial origin and is the most common paratesticular tumor,
• Inguinal exploration and surgical excision.
• Cystadenoma
• Approximately one-third of cases, which are usually bilateral, occur in
patients with von Hippel-Lindau syndrome
• Mesothelioma
• Treatment is radical inguinal orchiectomy and hemiscrotectomy.
• Sarcoma
• Wide excision of the spermatic cord and testis with high ligation.
• patients with sarcomas other than liposarcoma should undergo RPLND
and postoperative chemotherapy should be given to patients with
retroperitoneal lymph node metastasis
CONCLUSION

•QUSTION?
•THANK YOU