Testicular Tumors: Types, Classification, and Clinical Findings
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DEPARTMENT OF UROLOGY,
SCHOOL OF MEDICINE,
BAHÇEŞEHİR UNIVERSITY
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Introduction:
Introduction:
Intratesticular - malignant
Intratesticular - malignant
90-95% germ cell tumors
90-95% germ cell tumors
1-2% Bilateral
1-2% Bilateral
-
-
lymphoma
lymphoma
7-10% of
7-10% of
testis
testis
tumors develop in cryptorchidism
tumors develop in cryptorchidism
Orchiopexy does not alter the malignant potential
Orchiopexy does not alter the malignant potential
Exogenous estrogen
Exogenous estrogen
t
t
o the mother during
o the mother during
pregnancy
pregnancy
Survival of patients has improved dramatically
Survival of patients has improved dramatically
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Classification:
Classification:
Primary
Primary
Benign
Benign
Secondary
Secondary
Malignant
Malignant
Germ cell
Germ cell
Non germ cell
Non germ cell
Germ cell tumors:
Germ cell tumors:
Seminoma
Seminoma
Non
Non
-
-
seminomatous: Embryonal
seminomatous: Embryonal
Teratoma
Teratoma
Choriocarcimoma
Choriocarcimoma
Mixed tumors
Mixed tumors
Primary Testicular Cancer
GERM CELL
•
Seminoma 3
5
%
•
Classic (85%)
Classic (85%)
•
Anaplastic (5-10%)
Anaplastic (5-10%)
•
Spermatocytic (5-10%)
Spermatocytic (5-10%)
•
Embryonal 4%
•
Adult type
Adult type
•
Infantile type (yolk sac
Infantile type (yolk sac
tumor)
tumor)
•
Teratoma 10%
•
Choriocarcinoma 1%
•
Mixed
cell type
40%
•
Teratocarcinoma
Teratocarcinoma
NONGERM CELL
•
Leydig 1-3%
•
Sertoli <1%
•
Gonadoblastoma 0.5%
Seminoma
Embriyonal carcinoma
•
Grossly, the tumors are
large, often
hemorrhagic and
necrotic producing
at
cut surface.
Pathologic features of yolk sac tumor
•
Gross: The cut surface is
gray-white and may be
cystic.
Choriocarcinoma: large, hemorrhagic, necrotic tumor.
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Clinical findings
Clinical findings
A-symptoms:
A-symptoms:
Painless enlargment of testis
Painless enlargment of testis
Acute testic
Acute testic
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r pain (10%)
r pain (10%)
Symptoms related to metastasis (10%): back pain-
Symptoms related to metastasis (10%): back pain-
cough-dyspnea anorexia-nausea- bone pain- lower
cough-dyspnea anorexia-nausea- bone pain- lower
ext. edema
ext. edema
Asymptomatic (10%)
Asymptomatic (10%)
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Clinical findings
Clinical findings
B: signs:
B: signs:
Testicular mass or diffuse enlargment
Testicular mass or diffuse enlargment
Node palpation
Node palpation
Gynecomastia
Gynecomastia
Tumors of the testis
Tumors of the testis
Laboratory findings and tumor markers:
Laboratory findings and tumor markers:
Anemia-
Anemia-
increased l
increased l
iver function tests-
iver function tests-
increased
increased
creatinin
creatinin
Tumor markers:
Tumor markers:
A
A
FP
FP
Β
Β
-
-
HCG
HCG
LDH
LDH
Alpha
Feto
P
rotein
•
Expressed by the early embryo (also liver and
GI tract)
•
Half-life: 5-7 days
•
Produced by pure embryonal,
teratocarcinoma, yolk sac, mixed tumors
(NOT pure choriocarcinoma or seminoma)
•
Falsely elevated in liver dysfunction, viral
hepatitis
Beta
Human Chorionic Gonadotrophin
•
Secretory product of the placenta
•
Half-life: 24-36 hours
•
Produced by syncytiotrophoblastic tissue
•
All choriocarcinomas, 60% embryonal, 10%
seminoma
•
Falsely elevated in hypogonadism and
marijuana use
–
Presents normally in smooth, cardiac and skeletal
muscle, liver and brain
–
Most useful in advanced seminoma or tumors
where other markers are not elevated
–
Many false positives
Lactic Acid Dehydrogenase
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Imaging
Imaging
Ultrasonography
Ultrasonography
CT-Scan
CT-Scan
MR
MR
Risk Factors
•
Cryptorchidism: 7-10% of patients with
testicular cancer have a history of
cryptorchidism
•
Abnormal germ cell morphology
•
Elevated temperature
–
5-10% of patients with testicular cancer and a
history of cryptorchidism develop cancer in the
contralateral testis
–
Orchidopexy does not prevent development of
cancer
•
Gonadal Dysgenesis
–
20-30% develop cancer (gonadoblastoma)
•
Trauma
•
Hormones
–
Estrogen in the pregnency
•
Atrophy (nonspecific vs. mumps orchitis)
–
Speculative
Risk Factors
II
Differential diagnosis
Differential diagnosis
Epdidymitis & Epididymoorchitis
Epdidymitis & Epididymoorchitis
Hydrocele
Hydrocele
Spermatocele
Spermatocele
Hematocele
Hematocele
Granulomatous orchitis
Granulomatous orchitis
Varicocele
Varicocele
Epidermoid cyst
Epidermoid cyst
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Radical Orchiectomy
•
Inguinal approach
best
way for the surgery
•
Avoid seeding the
scrotum and disrupting
lymphatics
Treatment
Treatment
Inguinal Exploration & radical orchiectomy
A.
Low stage seminoma: retroperitoneal irradiation
95% care
A.
high stage seminoma: primary chemotherapy
high stage seminoma: primary chemotherapy
95% complete response
95% complete response
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Treament
C: low stage NSGCT:
R
adical orchiectomy
1)
C
onfined within tunica albuginea
?
2)
V
ascular invasion
?
3)tumor markers
?
4)radiographic imaging
?
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Treatment
Treatment
of h
of h
igh stage NSGCT:
igh stage NSGCT:
primary chemotherapy +RPLND
primary chemotherapy +RPLND
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Follow up:
Follow up:
every 3 month/ first 2 years
every 3 month/ first 2 years
every 6 month/ until 5 years
every 6 month/ until 5 years
and then yearly
and then yearly
C
C
areful exam of remaining testis, abdomen, lymph node
areful exam of remaining testis, abdomen, lymph node
area
area
tumor marker at each visit.
tumor marker at each visit.
CT every 3-4 month
CT every 3-4 month
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Prognosis
Prognosis
Seminoma: R.O+radiotherapy:
Seminoma: R.O+radiotherapy:
stage I: 98% 5 years survival rate
stage I: 98% 5 years survival rate
stage II: 92% 5 years survival rate
stage II: 92% 5 years survival rate
stage III (chemotherapy): 35-75%
stage III (chemotherapy): 35-75%
NSGCT: stage I: 96-100%
NSGCT: stage I: 96-100%
low, volume stage II: 90%
low, volume stage II: 90%
stage III: 55-80%
stage III: 55-80%
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Secondary tumors of the testis
Secondary tumors of the testis
1. lymphoma
1. lymphoma
: M
: M
ost common t
ost common t
estis
estis
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t
umour
umour
in>50 years old
in>50 years old
2. leukemia
2. leukemia
:
:
Testis b
Testis b
iopsy is choice
iopsy is choice
3. metastatic tumor:
3. metastatic tumor:
prostate- lung
prostate- lung
–
–
GI-melanoma-kidney
GI-melanoma-kidney
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Extragonadal germ cell tumors
Extragonadal germ cell tumors
3% of all germ cell tumors
3% of all germ cell tumors
the most common sites: mediastinum-
the most common sites: mediastinum-
retroperitoneum, sacrococcygeal
retroperitoneum, sacrococcygeal
–
–
pineal
pineal
gland
gland
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Tumors of the epididymis, paratesticular tissue & spermatic cord
Tumors of the epididymis, paratesticular tissue & spermatic cord
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umor
umor
o
o
f epididym: commonly benign:
f epididym: commonly benign:
adenomatoid
adenomatoid
leiomyoma
leiomyoma
cystadenoma
cystadenoma
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T
umor
umor
of spermatic cord:
of spermatic cord:
lipoma
lipoma
Rabdomyosarcoma
Rabdomyosarcoma
leiomyosarcoma.
leiomyosarcoma.
Fibrosarcoma
Fibrosarcoma
liposarcoma
liposarcoma
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Sex cord-stromal tumors of the testis
Leydig cell tumor key facts:
•
Can develop at any age from infancy to old
age
•
Most are benign, some are malign
•
Most tumors are hormonally active, but some
are inactive
•
May secrete androgens or estrogens
-Androgen excess: Premature puberty &
macrogenitosomia
-Estrogen excess: Gynecomastia in adult males
Sertoli cell tumor
•
These tumors are more rare than Leydig cell
tumors.
•
They elaborate androgens or estrogens.
•
Occasionally, they cause gynecomastia but
sexual precocity is infrequent.
Thank You
Testicular tumors are predominantly malignant, with germ cell tumors being the most common type. This article delves into the classification of testicular tumors, including primary and secondary, benign and malignant, germ cell, and non-germ cell tumors. Clinical findings such as painless enlargement of the testis, acute testicular pain, and symptoms related to metastasis are highlighted. Additionally, specific types of tumors like seminoma, embryonal carcinoma, yolk sac tumor, and choriocarcinoma are discussed alongside their pathologic features. Early detection and understanding of testicular tumors can significantly impact patient outcomes.
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Presentation Transcript
TESTICULAR TUMOURS PROF. DR. METE K LC LER DEPARTMENT OF UROLOGY, SCHOOL OF MEDICINE, BAH E EH R UNIVERSITY
Tumours of the testis Introduction: Intratesticular - malignant 90-95% germ cell tumors 1-2% Bilateral-lymphoma 7-10% of testis tumors develop in cryptorchidism Orchiopexy does not alter the malignant potential Exogenous estrogen to the mother during pregnancy Survival of patients has improved dramatically
Tumours of the testis Classification: Primary Secondary Benign Malignant Germ cell Non germ cell Germ cell tumors: Seminoma Non-seminomatous: Embryonal Teratoma Choriocarcimoma Mixed tumors
Primary Testicular Cancer GERM CELL Seminoma 35% Classic (85%) Anaplastic (5-10%) Spermatocytic (5-10%) Embryonal 4% Adult type Infantile type (yolk sac tumor) Teratoma 10% Choriocarcinoma 1% Mixed cell type 40% Teratocarcinoma NONGERM CELL Leydig 1-3% Sertoli <1% Gonadoblastoma 0.5%
Embriyonal carcinoma Grossly, the tumors are large, often hemorrhagic and necrotic producing at cut surface.
Pathologic features of yolk sac tumor Gross: The cut surface is gray-white and may be cystic.
Tumors of the testis Clinical findings A-symptoms: Painless enlargment of testis Acute testicular pain (10%) Symptoms related to metastasis (10%): back pain- cough-dyspnea anorexia-nausea- bone pain- lower ext. edema Asymptomatic (10%)
Tumors of the testis Clinical findings B: signs: Testicular mass or diffuse enlargment Node palpation Gynecomastia
Tumors of the testis Laboratory findings and tumor markers: Anemia-increased liver function tests- increased creatinin Tumor markers: AFP -HCG LDH hCG(%) AFP(%) Seminoma Teratoma Teratocarcinoma Embryonal choriocarcinoma 7 0 25 57 60 100 38 64 70 0
Alpha Feto Protein Expressed by the early embryo (also liver and GI tract) Half-life: 5-7 days Produced by pure embryonal, teratocarcinoma, yolk sac, mixed tumors (NOT pure choriocarcinoma or seminoma) Falsely elevated in liver dysfunction, viral hepatitis
Beta Human Chorionic Gonadotrophin Secretory product of the placenta Half-life: 24-36 hours Produced by syncytiotrophoblastic tissue All choriocarcinomas, 60% embryonal, 10% seminoma Falsely elevated in hypogonadism and marijuana use
Lactic Acid Dehydrogenase Presents normally in smooth, cardiac and skeletal muscle, liver and brain Most useful in advanced seminoma or tumors where other markers are not elevated Many false positives
Tumors of the testis Imaging Ultrasonography CT-Scan MR
Risk Factors Cryptorchidism: 7-10% of patients with testicular cancer have a history of cryptorchidism Abnormal germ cell morphology Elevated temperature 5-10% of patients with testicular cancer and a history of cryptorchidism develop cancer in the contralateral testis Orchidopexy does not prevent development of cancer
Risk Factors II Gonadal Dysgenesis 20-30% develop cancer (gonadoblastoma) Trauma Hormones Estrogen in the pregnency Atrophy (nonspecific vs. mumps orchitis) Speculative
Tumors of the testis Differential diagnosis Epdidymitis & Epididymoorchitis Hydrocele Spermatocele Hematocele Granulomatous orchitis Varicocele Epidermoid cyst
Radical Orchiectomy Inguinal approach best way for the surgery Avoid seeding the scrotum and disrupting lymphatics
Tumors of the testis Treatment Inguinal Exploration & radical orchiectomy Low stage seminoma: retroperitoneal irradiation 95% care high stage seminoma: primary chemotherapy 95% complete response A. A.
Tumors of the testis Treament C: low stage NSGCT: Radical orchiectomy 1)Confined within tunica albuginea? 2)Vascular invasion? 3)tumor markers? 4)radiographic imaging?
Tumors of the testis Treatment of high stage NSGCT: primary chemotherapy +RPLND
Tumors of the testis Follow up: every 3 month/ first 2 years every 6 month/ until 5 years and then yearly Careful exam of remaining testis, abdomen, lymph node area tumor marker at each visit. CT every 3-4 month
Tumors of the testis Prognosis Seminoma: R.O+radiotherapy: stage I: 98% 5 years survival rate stage II: 92% 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 Secondary tumors of the testis 1. lymphoma : Most common testis tumour in>50 years old 2. leukemia : Testis biopsy is choice 3. metastatic tumor: prostate- lung GI-melanoma-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 Tumor of epididym: commonly benign: adenomatoid leiomyoma cystadenoma Tumor of spermatic cord: lipoma Rabdomyosarcoma leiomyosarcoma. Fibrosarcoma liposarcoma
Leydig cell tumor key facts: Can develop at any age from infancy to old age Most are benign, some are malign Most tumors are hormonally active, but some are inactive May secrete androgens or estrogens -Androgen excess: Premature puberty & macrogenitosomia -Estrogen excess: Gynecomastia in adult males
Sertoli cell tumor These tumors are more rare than Leydig cell tumors. They elaborate androgens or estrogens. Occasionally, they cause gynecomastia but sexual precocity is infrequent.
