I Wayan Yudiana

Urology Departement, Medical Faculty of Udayana

University
Sanglah General Hospital
❖ TESTICULAR CANCER

❖ PENILE CANCER
 TESTICULAR CANCER

▪ Rare cases, 1 % of male neoplasms and 5 % of urological tumors

▪ Commonly unilateral, only 1 – 2 % of cases are bilateral
▪ Predominant histology is germ cell tumor (90-95 %)
▪ Peak incidence : 20-30 yrs (non-seminoma); 30-40 yrs (seminoma)

NCCN Guidelines Version 1.2021; EAU Guidelines 2020

 TESTICULAR CANCER

▪ Phsycologic & fertility problem for a young male

▪ Associated with accurate serum tumor markers
▪ Most curable solid neoplasms (multimodality / multidisciplinary approach)
SURGERY, CHEMO-RADIO SENSITIVE

NCCN Guidelines Version 1.2021; EAU Guidelines 2020

Globocan Data,
2020
Globocan Data,
2020
Globocan Data,
2020
Globocan Data,
2020
Globocan Data,
2020
 ANATOMY TESTIS…

Champbell-Walsh-Wein Urology 12th ed 2016

 LYMPHATIC
DRAINAGE…
▪ Right testis drainage to the interaortocaval region.
▪ Left testis drainage to the para-aortic region bounded by
the left ureter, the left renal vein, the aorta, and of the inf
mesenteric artery.

▪ Testicular cancer spreads in a predictable

and stepwise fashion, except choriocarcinoma.

▪ Cross over from right to left is possible.

Champbell-Walsh-Wein Urology 12th ed 2016

 CLASSIFICATION…

o Primary neoplasms of testis

✔ Germ cell tumors
✔ Non-germ cell tumors
o Secondary neoplasms
o Paratesticular tumors
 Germ Cell Tumors
(GCTs)…
Arise from pluripotential cells (90-95%)
More than half of GCTs contain more than one cell type and are therefore
known as mixed GCTs

1. Seminoma (40 %) : - Classic seminoma

- Anaplastic seminoma
- Spermatocytic seminoma

2. Non-Seminoma (60 %) : - Embryonal carcinoma (20 – 25%)

- Teratoma (mature & immature) (25 - 35%)
- Choriocarcinoma (1%)
- Yolk sac tumor
 Non-GCTs…
Sex cord / gonadal stromal tumors (5-10%)

1. Specialized gonadal stromal tumor :

✔ Leydig cell tumor
✔ Sertoli cell tumor
✔ Granulosa cell tumor

2. Gonadoblastoma (mixed GCTs and gonadal stromal)

3. Miscellaneous neoplasms
✔ Carcinoid tumor
✔ Tumors of ovarian epithelial subtypes
 Secondary Neoplasms of
Testis…

o Reticuloendothelial Neoplasms
o Limfoma Malligna
o Leukemia
o Metastase
Commonly bilateral (1-2%)
 Paratesticular
Neoplasms…

o Adenomatoid
o Cystadenoma of epididymis
o Desmoplastic small round cell tumor
o Mesothelioma (leimyosarcoma, rhabdomyosarcoma)
o Melanotic neuroectodermal
Characteristic And Management of Testicular Cancer Patient in Sanglah General
Hospital January 2013- December 2017
Dau Daniel Oktavianus*, Yudiana I Wayan**, Oka AA Gede**
*General Surgery Department, Sanglah General Hospital, Udayana University
**Division of Urology, General Surgery Department, Sanglah General Hospital,
Udayana University
Seminoma
(8)
Germ Cell Yolk sach
(13) (4)
Non-semino
ma (5)
Primer (17) Teratoma (1)
Leydig (1)
Testis Ca Non germ
(19) cell (4)
Sarcoma (3)
Secondary Lymphoma
(2) (2)

Sanglah Hospital MR,

2018
Sanglah Hospital MR,
2018
 RISK FACTORS…

o Cryptorchidism / UDT (30% or 4-6 times)

o Familial history of testicular cancer (6-10 times)
o Personal history of contralateral testicular cancer (12 times)
o Precursor lession : GCNIS / ITGCN (50-70%)
✔ Germ Cell Tumor
✔ Atrophic testis
✔ Microlithiasis
o Infertility – subfertility (0.4% - 1.1%)
NCCN Guidelines Version 1.2021; EAU Guidelines 2020
 CLINICAL FEATURES…

▪Painless enlargement of unilateral testis, heavy sensation

▪Dull ache or scrotal pain (rapid growth, necrosis & hemorrhage)
▪Abdominal mass with UDT
▪Present with metatstasis (10%) :
✔ Cough / anorexia / vomiting / LBP
✔ Neck mass, lower limb swelling (lymphadenopathy)
▪Gynecomastia (5%)
▪Rarely : infertility
NCCN Guidelines Version 1.2021; EAU Guidelines 2020
 DIFFERENTIAL DIAGNOSIS…

o Hernia scrotalis
o Hydrocele
o Testicular TB, Syphilitic gumma,
o Spermatocele, epididymal cyst
o Epididymitis, or epididymo-orchitis
o Testicular torsion
o Testicular hematoma
 DIAGNOSTIC
TOOLS…
o Imaging :
▪ Ultrasound, Abdomino-pelvic CT scan, MRI, chest X ray

o Serum tumor markers :

▪ beta-hCG (expression of trophoblasts)
▪ AFP (produced by yolk sac cells)
▪ LDH (marker of tissue destruction)

o Histology by radical inguinal orchidectomy

NCCN Guidelines Version 1.2021; EAU Guidelines 2020
 AFP(Alpha-fetoprotein)
…
▪Normal value : < 16 ng/ ml
▪Half life : 5 - 7 days
▪Raised AFP :
✔ Pure embryonal carcinoma
✔ Yolk sac tumor
✔ Teratocarcinoma
✔ Combined tumors (mixed GCTs)
▪Normal AFP in pure choriocarcinoma & seminoma
 hCG (Human Chorionic
Gonadotrophin)…
▪Normal value : < 1 ng / ml
▪Half life of HCG : 1 – 2 days
▪Raised HCG :
✔ 100 % choriocarcinoma
✔ 60% embryonal carcinoma
✔ 55% teratocarcinoma
✔ 25% yolk cell tumour
✔ 7% seminomas
TUMOR STAGING ~
TNM
 PRINCIPLES OF
TREATMENT…

o Multimodality treatment or multidisciplinary approach :

▪ Radical inguinal orchidectomy (PA)

▪ Chemotherapy (cisplatin-based) 🡪 BEP-TIP
▪ Radiotherapy
▪ Lymphadenectomy (RPLND)
▪ Surveillance
Cure rete
80-95%
NCCN Guidelines Version 1.2021; EAU Guidelines 2020
AUA Guidelines 2018
 PENILE CANCER

▪ Uncommon in developed countries (USA, Europe, western) < 1/100.000 or

0,4 - 0,6% of all malignant neoplasms among man
▪ Developing countries (Asia, Africa, South America) incidence > 19/100.000
or 10%
▪ Incidence increases with age, with peak age in sixth decade
▪ Squamous cell carcinoma (SCC) is most common type (> 95%) with a lot
of sub-type

NCCN Guidelines Version 1.2021; EAU Guidelines 2020

Globocan Data,
2020
Globocan Data,
2020
 PENILE CANCER

▪Predisposition – Risk factors : preventable disease

✔ Phimosis (uncircumcised with poor hygiene)
✔ Chronic penile inflammation (balanoposthitis, BXO, lichen sclerosis)
✔ Chronic irritation (smegma retention)
✔ HPV (type 16 & 18) and virus infection of condyloma acuminata
✔ Social and habits (smoking, rural region, low social-economic status)

NCCN Guidelines Version 1.2021; EAU Guidelines 2020

 CLASSIFICATION…

o Benign tumor
o Premalignant lession :
✔ Leukoplakia
✔ Erythroplasia queyrat
✔ Bowen’s disease
✔ BXO
✔ Giant condyloma acuminata (basaloid and verrucous varieties)
o Malignant
LEUKOPLAKIA
…
▪ Rare, 50-70 yo, in form keratosis (acanthosis), firmly attached white patches on the mucous membranes
▪ Associated: in situ SCC and verrucous cancer of the penis
▪ Risk factors :
✔ HPV infection, DM
✔ Phimosis, poor genital hygiene
✔ Chronic irritation, inflammation and infection
 ERYTHROPLASIA OF
QUEYRAT
▪ Solitary or multiple, minimally raised, erythematous papules and plaques on the glans penis and/or
adjacent mucosal epithelium
▪ The plaques may be smooth, velvety, scaly, crusty, or verrucous.
▪ The classic lesion is described as a nontender, sharply demarcated, bright-red, glistening plaque on the
glans penis of a middle-aged to elderly uncircumcised man.
▪ Ulceration or distinct papillomatous papules within a plaque may indicate progression to invasive
squamous cell carcinoma
 BALANITIS XEROTICA
OBLITERANS…
▪ Lichen sclerosus et atrophicus of the penis
▪ Dermatological condition at male genitalia
▪ BXO is a common cause of phimosis (40%)
▪ BXO was found in 19% of circumcisions for diseases of the prepuce and penis.
▪ BXO in 60% of patients with acquired phimosis and 30% of patients with congenital phimosis.
 CONDYLOMA
ACUMINATA…
▪ Most common STD
▪ A warty lesion on the penis or scrotum
▪ The cause 🡪 HPV infection in 5% of adults aged 20-40 years
▪ Specific types of HPV ~ anogenital SCC, particularly cervical ca, anal and penile carcinoma.
▪ Located anywhere on the scrotum, penis, perineal and anal.
▪ Asymptomatic, skin-colored-to-brown, sessile, cauliflower like lesions and can measure 1 mm to a few
centimeters in size.
Leitje JAP, Kerst M, et al. Neoadjuvant Chemotherapy in Advanced Penile Canrcinoma. European Urology (52) 2007; 488-494
 CLINICAL FEATURES of Malignant Ds (SCC)...

▪ Most lesions present on the glans, followed by the prepuce, coronal

sulcus, and shaft
▪ Clinical growth pattern : flat, exophytic or ulcerated mass
▪ Lymphadenopathy 🡪 regional metastase : mobile, fixed, ulcerated or
extranodular extention
LYMPHATIC
DRAINAGE…

Step wise regional metastase

CLINICAL FEATURES…
 DIAGNOSTIC AND
STAGING…
▪ Clinically features (primary tumor
and inguinal lymph nodes) 🡪 cT
and cN
▪ Histopathologic features (biopsy
or treatment for primary tumor
and lymph node) 🡪 pT and pN
▪ Imaging (USG, x-Ray, CT, MRI) 🡪
cM
NCCN Guidelines Version 1.2021; EAU Guidelines 2020
 PRINCIPLES OF
TREATMENT…
o Treatment of primary lession :
✔ Laser, cryo therapy
✔ 5 fluorouracil (5 FU) cream
✔ Radiotherapy
✔ Surgery 🡪 circumcision, MOHS, glansectomy (penile preserving
surgery), amputation (partial, total penectomy)

o Treatment of lymph node metastasis :

• Based on staging, grading and lymphovascular invasion of primary tumor
• Ingiunal lymph node dissection (ILND)
NCCN Guidelines Version 1.2021; EAU Guidelines 2020
 Regional Metastase Management,
Why…?

▪ The presence and extent of regional lymph node metastasis has been
identified as the single most important prognostic factor to determining
long-term survival in men with penile cancer.
▪ Penile cancer can be cure in over 80% cases if diagnosis and
treatment early, but it will be a life-threatening disease when regional
lymphatic was involvement 🡪 multimodality treatment (radiotherapy,
chemotherapy).

NCCN Guidelines Version 1.2021; EAU Guidelines 2020

 OUTCOME...

▪ Locally advanced, aggressive disease or recurrence

▪ The prognosis correlates :
✔ Lymph nodes status (+) 🡪 5ysr < 5%
✔ Basaloid & sarcomatoid subtypes 🡪 worse
▪ The 5-year survival rate is 93% for stage I, 55% for stage II, and
30% for stage III disease.

NCCN Guidelines Version 1.2021; EAU Guidelines 2020

Thank You