Tumours Of The Testes

TUMOURS OF THE TESTES

• 99% of testicular neoplasms are malignant • • 1-2 % of all malignant tumours in men •

Descent of the Testes

ANATOMY

C L A S S IF IC A T IO N

GERM CELL TUMOURS Seminoma Teratoma

NON GERM CELL TUMOURS

Stromal Tumours(Interstitial cell tumours) Leydig-cell tumours Sertoli-cell tumours Secondary Tumours Lymphoma Metastatic

• Teratomas tend to occur in younger men with the peak incidence being between 20 and 35 years, whereas the peak incidence of seminoma is between 35 and 45 years

GERM CELL TUMOURS SEMINOMA

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-O va l ce lls w ith cle a r cyto p la sm -La rg e ro u n d e d n u cle iw ith p ro m in e n t a cid o p h ilic n u cle o li -S h e e ts o f ce lls re se m b lin g sp e rm a to cyte s a re se p a ra te d b y a fin e fib ro u s stro m a -A ctive lym p h o cytic in filtra tio n o f th e tu m o u r su g g e st a g o o d h o st re sp o n se a n d a b e tte r p ro g n o sis -S p re a d Is o fte n th ro u g h lym p h a tics a n d ra re ly th ro u g h h a e m a to g e n o u s ro u te

Oval cells with clear cytoplasm

GERM CELL TUMOURS TERATOMA

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-A rise s fro m th e to tip o te n t ce lls in th e re te te stis -C la ssifica tio n is b y th e Te sticu la r Tu m o u r Pa n e l

Testicular Tumour Panel • Teratoma Differentiated 

- No histologically recognisable malignant component

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• Malignant Teratoma Intermediate (A & B)/ Teratocarcinoma 

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- Contains malignant + incompletely differentiated components - Mature tissue in type A

• Malignant Teratoma Anaplastic/ Embryonal carcinoma  

- anaplastic cells of embryonal origin - cells derived from yolk sac causes elevated α-fetoprotein levels

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• Malignant Teratoma Trophoblastic 

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- Contains all cell types + a syncytial cell mass with malignant villous or papillary cytotrophoblast - produces HCG - Spread through lymphatics and bloodstream is early

NON GERM CELL TUMOURS • Arises from Leydig cells and Sertoli cells • Leydig cell tumour masculinises  (testosterone) • Sertoli cell tumour feminises (converts testosterone to 17-beta estradiol)  - most commonly occurs postpubertal  - tumour is more likely to be

CLINICAL FEATURES • Testicular swelling • Sensation of heaviness (2-3X enlarged) • Dull, aching, dragging pain in the scrotum • • Malaise, loss of appetite, wasting, abdominal pains, dyspnoea •

EXAMINATION • Testis is enlarged, usually smooth • Epididymis may be flattened or incorporated in the growth • Secondary hydrocoele may occur if the capsule is involved • Scrotum should be normal unless tumour invasion has occurred where it may be ulcerated • Examine both testis!

• Gynaecomastia

• • Retroperitoneal deposits may be palpated in the center of the abdomen just above the level of the umbilicus

• • Inguinal lymph nodes may be palpable if the scrotum is involved

• • Occasionally there will be an enlarged supraclavicular node

DIFFERENTIAL DIAGNOSIS • Epididymo-orchitis • • Lymphoma • • Other scrotal lumps, e.g. hydrocoele, haematocoele, epididymal cyst, hernia

INVESTIGATIONS • Ultrasonography of the scrotal contents • • Chest X-ray • • CT chest & MRI • • Tumour markers

TUMOUR MARKERS • β-hCG • Alpha-fetoprotein • Lactic dehydrogenase

TREATMENT • Surgical exploration & Orchidectomy • Further management based on staging  and histological findings

STAGING S ta g e I : Te stis le sio n S ta g e II : N o d e s b e lo w d ia p h ra g m -IIanodes < 2 cm -IIbnodes 2 -5 cm -IIcnodes > 5 cm S ta g e III: N o d e s a b o ve d ia p h ra g m S ta g e IV : E xtra lym p h a tic m e ta sta se s ( Pulmonary or h e p a tic )

RADIOTHERAPY • Seminomas are radiosensitive

• • Stage I tumours – no further management/ para-aortic radiotherapy

• • Stage IIa and Iib - radiotherapy to the ipsilateral para-aortic and iliac nodes

• • Teratomas are less sensitive to radiation

CHEMOTHERAPY • Chemotherapy with BEP (bleomycin, etoposide and cisplatin) - for all cases of metastatic teratoma, and metastatic seminoma beyond stage IIb