Management of

Testicular Tumours
Dr.Sunil Shroff,

MS, FRCS (UK ), D.Urol (Lond.)

Prof & HOD SriRamachandra Medical College & Research

Institution, Chennai

TESTICULAR TUMOUR
1% of all Malignant Tumour
Affects young adults - 20 to 40 yrs when Testosterone Fluctuations are
maximum
90% to 95% of all Testicular tumours
from germ cells
99% of all Testicular Tumours are
malignant.
Causes Psychological & Fertility
Problems in young

Survival in Testicular Tumours

Improved overall survival in last 15 to
20 years due to Better understanding of Natural
History and Pathogenesis of disease
Reliable Tumour Markers
Cis-platinum based chemotherapy

CROSS SECTION OF TESTIS

Testis
Stroma
Tubules

Seminiferous
(200 to 350

tubules)

Interstitial Cells
Spermatogonia
Leydig

Supporting
or

EPIDEMIOLOGY
Incidence :
1.2 per 100,000
(Bombay)
3.7 per 100,000 (USA)
Age :
3 Peaks
- 20-40 yrs. Maximum
- 0 - 10 yrs.
- After - 60 yrs.
Bilaterality : 2 to 3% Testicular Tumour

CLASSIFICATION
I.
Primary Neoplasma of
Testis.
A. Germ Cell Tumour
B. Non-Germ Cell Tumour
II.

Secondary Neoplasms.

III.

Paratesticular Tumours.

I. PRIMARY NEOPLASMS OF TESTIS

A.

25%

Germinal Neoplasms : (90 - 95 %)

1.
Seminomas - 40%
(a) Classic Typical Seminoma
(b) Anaplastic Seminoma
(c) Spermatocytic Seminoma
2.
Embryonal Carcinoma - 20 3.

4.
5.

Teratoma - 25 - 35%
(a) Mature
(b) Immature
Choriocarcinoma - 1%
Yolk Sac Tumour

I. PRIMARY NEOPLASMS OF TESTIS

B.

Nongerminal Neoplasms : ( 5 to 10%

1.

Specialized gonadal stromal tumor

(a) Leydig cell tumor
(b) Other gonadal stromal tumor
Gonadoblastoma
Miscellaneous Neoplasms
(a) Adenocarcinoma of the rete

2.
3.
testis

(b)
(c)
(d)

Mesenchymal neoplasms
Carcinoid
Adrenal rest tumor

II. SECONDARY NEOPLASMS OF TESTIS

A.
B.

Reticuloendothelial Neoplasms
Metastases

III.

PARATESTICULAR NEOPLASMS

A.
B.
C.
D.
E.

Adenomatoid
Cystadenoma of Epididymis
Mesenchymal Neoplasms
Mesothelioma
Metastases

AETIOLOGY OF TESTICULAR TUMOUR

1. Cryptorchidism
2. Carcinoma in situ
3. Trauma
4. Atrophy

CRYPTORCHIDISM & TESTICULAR TUMOUR

Risk of Carcinoma
developing in
undescended testis is
14 to 48 times the
normal expected
incidence

CRYPTORCHIDISM & TESTICULAR TUMOUR

The cause for malignancy are as

follows:
Abnormal Germ Cell Morphology
Elevated temperature in abdomen &
Inguinal region as opposed to scrotum
Endocrinal disturbances
Gonadal dysgenesis

Testicular Tumour & Molecular Biology

(Recent Advances)

Molecular & Genetic Research

may help Future patient with
Testicular Tumours:

Earlier diagnosis

Identify Susceptible
Individuals

Testicular Tumour & Molecular Biology

PROTO-ONCOGENES in Germ Cell Tumours

Seminoma &
Embryonal
Carcinoma
Seminoma
Immature
Teratomas

N-myc expression

c-Ki-ras expression

c-erb B-1 expression

(Shuin et

Testicular Tumour & Molecular Biology

(Recent Advances)

Testicular germ cell tumour

show consistent expression of
both:
Parental alleles of H19
IGF-2 genes.

Clinical Staging of Testicular Tumour

Staging A or I - Tumour confined to testis.
Staging B or II - Spread to Regional nodes.
IIA - Nodes <2 cm in size or < 6 Positive
Nodes
IIB - 2 to 5 cm in size or > 6 Positive Nodes
IIC - Large, Bulky, abd.mass usually > 5 to 10
cm
Staging C or III - Spread beyond
retroperitoneal

Requirements for staging

To properly Stage Testicular Tumours
following
are pre-requisites:
(a)

Pathology of Tumour Specimen

(b)

History

(c)

Clinical Examination

(d)

Radiological procedure - USG / CT /

MRI / Bone Scan

(e)

Tumour Markers - HCG, AFP

TNM Staging of Testicular Tumour

T0
=
T1s
=
T1
=
T2
=
Albuginea
T3
=
T4
=

No evidence of Tumour
Intratubular, pre invasive
Confined to Testis
Invades
beyond
Tunica
or into Epididymis
Invades Spermatic Cord
Invades Scrotum

N1
N2
N3

Single < 2 cm
Multiple < 5 cm / Single 2-5 cm
Any node > 5 cm

=
=
=

Epididymis or Scrotal skin Lymph drainage to Inguinal Nodes

Pathogenesis & Natural History of

Testicular Tumour
Course of Spread of Germ Cell Tumours
are predictible once Histology of Tumour
cofirmed
Lymphatic Spread has a set pattern
depending on side of Tumour
Seminoma may have nonseminomatous metastasis
High Grade Tumours spread by both
Vascular invasion & via Lymphatics

Investigation
1.
2.
3.
4.

Ultrasound - Hypoechoic area

Chest X-Ray - PA and lateral views
CT Scan
Tumour Markers
- AFP
- HCG
- LDH
- PLAP

CLINICAL FEATURES
Painless Swelling of One Gonad
Dull Ache or Heaviness in Lower Abdomen
10% - Acute Scrotal Pain
10% - Present with Metatstasis
- Neck Mass / Cough / Anorexia / Vomiting /
Back Ache/ Lower limb swelling
5% - Gynecomastia
Rarely - Infertility

DICTUM FOR ANY SOLID SCROTAL SWELLINGS

All patients with a solid, Firm

Intratesticular Mass that
cannot be Transilluminated
should be regarded as
Malignant unless otherwise
proved

Tumour Markers
TWO MAIN CLASSES
Onco-fetal Substances : AFP & HCG
Cellular Enzymes : LDH & PLAP
( AFP - Trophoblastic Cells
HCG - Syncytiotrophoblastic Cells )

AFP ( Alfafetoprotein )
NORMAL VALUE: Below 16 ngm / ml
HALF LIFE OF AFP 5 and 7 days
Raised AFP :
Pure embryonal carcinoma
Teratocarcinoma
Yolk sac Tumour
Combined Tumour

REMEMBER: AFP Not raised is Pure Choriocarcinoma or Pure Semino

HCG ( Human Chorionic Gonadotropin )

Has and polypeptide chain
NORMAL VALUE: < 1 ng / ml
HALF LIFE of HCG: 24 to 36 hours
RAISED HCG 100 %
- Choriocarcinoma
60%
- Embryonal carcinoma
55%
- Teratocarcinoma\
25%
- Yolk Cell Tumour
7%
- Seminomas

ROLE OF TUMOUR MARKERS

Helps in Diagnosis - 80 to 85% of Testicular
Tumours have Positive Markers
Most of Non-Seminomas have raised markers
Only 10 to 15% Non-Seminomas have normal
marker level
After Orchidectomy if Markers Elevated means
Residual Disease or Stage II or III Disease
Elevation of Markers after Lymphadenectomy
means a STAGE III Disease

ROLE OF TUMOUR MARKERS cont...

Degree of Marker Elevation Appears to be
Directly Proportional to Tumour Burden
Markers indicate Histology of Tumour:
If AFP elevated in Seminoma - Means Tumour
has Non-Seminomatous elements
Negative Tumour Markers becoming positive on
follow up usually indicates Recurrence of Tumour
Markers become Positive earlier than X-Ray
studies

PRINCIPLES OF TREATMENT
Treatment should be aimed at one stage
above the clinical stage
Seminomas - Radio-Sensitive. Treat with
Radiotherapy.
Non-Seminomas are Radio-Resistant and
best treated by Surgery
Advanced

Disease

or

Metastasis

Responds well to Chemotherapy

PRINCIPLES OF TREATMENT
Radical INGUINAL ORCHIDECTOMY is
Standard first line of therapy
Lymphatic spread initially goes to
RETRO-PERITONEAL NODES
Early hematogenous spread RARE
Bulky Retroperitoneal Tumours or
Metastatic Tumors Initially DOWNSTAGED with CHEMOTHERAPY

Treatment
Seminomas
Stage I,of
IIA,
?IIB
Radical Inguinal Orichidectomy followed by
radiotherapy to Ipsilateral Retroperitonium &
Ipsilateral Iliac group Lymph nodes (2500-3500
rads)

Bulky stage II and III Seminomas Radical Inguinal Orchidectomy is followed

by Chemotherapy

Treatment of Non-Seminoma
Stage I and IIA:
RADICAL ORCHIDECTOMY
followed by RETROPERITONEAL LYMPH
NODES DISSECTION
Stage IIB:
RPLND with possible ADJUVANT
CHEMOTHERAPY
Stage IIC and Stage III Disease:
Initial CHEMOTHERAPY followed by SURGERY
for Residual Disease

STANDARD CHEMOTHERAPY FOR

NON-SEMINOMATOUS GERM CELL TUMOURS

Chemotherapy
BEP Bleomycin

Toxicity
Pulmonary fibrosis

Etoposide (VP-16)

Myelosuppression
Alopecia
Renal insufficiency (mild)
Secondary leukemia

Cis-platin

Renal insufficiency
Nausea, vomiting
Neuropathy

Left

Right

Axial CT Section demonstarating - Left Hydronephrosis, due

to large Para-Aortic Nodal Mass from a Germ cell tumour

Limits of Lymph Nodes Dissection For Right &

Left Sided Testicular Tumours

THERAPY OF PATIENT WITH SEMINOMA

Stage I, IIA, ? IIB

Stage IIB, IIC, III

B - Bleomycin
Abdominal Radiotherapy E - Etoposide (VP-16) 4 cycles
P - cis-platin

Follow Up Stable/Regress Relapse/Growth

F/U

? RPLND
? Chemotherapy
? XRT

Therapy of Nonseminomatous Germ Cell Testicular Tumours

Radical Inguinal Orchidectomy
Stage I, II (minimum)
RPLND
Stage I, II B1

Stage II B2

Observe

BEP 2 cycles
Bleomycin
Etoposide
Cis-platin

Therapy of Nonseminomatous Germ Cell Testicular Tumours

Radical Inguinal Orchidectomy
Stage II C (advanced) / III
Complete Response
Observe
Cancer
V-Vinblastine
I-Ifosfamide
P-cis-platin

BEP 4 cycles
Partial Response Progress
RPLND

VIP or Autologous
Bone marrow
Transplant
Teratoma / Fibrosis

OBSERVE

PROGNOSIS
Seminoma

Nonseminoma

Stage I

99%

95% to 99%

Stage II

70% to 92%

90%

Stage III

80% to 85%

70% to 80%

CONCLUSION
Improved Overall Survival of Testicular
Tumour due to Better Understanding
of the Disease, Tumour Markers and
Cis-platinum based Chemotherapy
Current Emphasis is on Diminishing
overall Morbidity of Various Treatment
Modalities