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Testicular tumours. Urology 2012 . Case presentation. History 25 C/o hemoptysis, abdominal discomfort; History of UDT, right side-operated No child. 2. On exam: Generally well Scar R groin Nodes palpable, inguinal Big R testis, normal L testis What next?. Outcomes. - PowerPoint PPT Presentation
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Testicular tumours
Urology2012
Case presentation
• HistoryHistory• 2525• C/o hemoptysis, abdominal discomfort; C/o hemoptysis, abdominal discomfort; • History of UDT, right side-operatedHistory of UDT, right side-operated• No childNo child
2
o On exam:On exam:o Generally wellGenerally wello Scar R groinScar R groino Nodes palpable, inguinalNodes palpable, inguinalo Big R testis, normal L testisBig R testis, normal L testiso What next?What next?
Outcomes
• Clinical presentation –age, Metastasis
• Classification• Diagnosis• Differential diagnosis• Management
Epidemiology
• Incidence• 2-3/100 000 in whites• <1/100 000 in blacks• R > L 2-3% bilateral• 95% Germ cell
• Age• 16-35 yrs
Aetiology
• Gonadal dysgenesis• Hereditary not clear• Environmental factors• Chemical carcinogens• Infections• 7-10% in undescended testis- Dysgenesis,
temp, Abn blood supply, endocrine dysf(x)
Risk Factors
• Previous history of testicular tumor
• UDT• Infertility• Atrophic testis • CIS
Anatomy
Classification
• Germ cell– Seminoma– Non seminoma
– Embryonal– Choriocarcinoma– Teratocarcinoma– Yolk sac tumour– Mixed variant
• Non Germ cell– Leydig cell– Sertoli cell– Sarcoma– leukaemia– Lymphoma– metastasis
Frequency
• Seminoma -30%• Embryonal Carcinoma- 30%• Teratoma- 10%• Teratocarcinoma- 25%• Choriocarcinoma -1%• Combined- 15%o
Tumour markers
• AFP• B-HCG• LDH
Metastatic pattern
• Local • Lymphatic• hematogenous
Clinical presentetion
• 50% have metastasis on diagnosis• 10% present with this as first sx• Neck mass, respiratory, GIT, bone pain, neurological,
lower extremities
• Local• Heavy feeling or painless swelling• 10% acute testicular pain
• 5% Gynecomastia
Examination
• Local exam• Contra lateral vs.
ipsilateral testis , • Epydidimis• Spermatic cord
• Abdominal• General
Differential diagnosis
• Testicular torsion • Epidydimo-orchitis• Hydrocoele• Inguinoscrotal hernia• paratesticular tumours
Investigations
• Laboratory
• Serum tumour markers• FBC, U&E,LFT`s
• Radiological
– Sonar– CXR– CT scan abdomen– Role of MRI?
Sonar
CT Scan
MRI
staging
– Clinical and surgical– Tumor type– degree of infiltration– Vascular invasion– Lymph metastasis– Distant metastasis– Serum tumor markers
Staging
• A- confined to testis• B -Retroperitoneal spread
– B1-3• C- Metastatic disease • Or TNMS staging
Prognosis
• Mortality • 50% in 1970• Cure rate of > 95 % now!
• Morbidity– Tumour related – Treatment related– Fertility?,QOL
Prognosis
• Seminoma –overall cure rate is > 90%• Age – older patients• Sperm cryopreservation?• B HCG positive in 5-10%• very radio & chemosensitive
Non seminoma
• Choriocarcinoma- Can present with extensive metastasiss with paradoxically small primary
• Teratoma- mature and immature elements• Yolk sac tumour- In infants and young children
treatment
• NB Multimodal
• Radical orchidectomy• Radiotherapy• Chemotherapy• Retroperitoneal lymph
node dissection• Follow up
General comments
• Misdiagnosis common• No transscrotal
biopsies • Good work-up• Quick referral• Follow up !
Other
• Extragonadal germ cell tumours• Leydig cell – 10% malignant, present in
children with virilising and in adults feminising.
• Sertoli cell- any age.10% malignant• Gonadoblastoma- In dysgenetic gonads
Secondary tumours
• Lymphoma• Leukaemic infiltration• Metastasis- prostate, Breast, kidney
Thank you