testicular tumors

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1 : TUMOURS OF THE TESTES Dr Rahul Kenawadekar Dept Of Surgery JNMC Belgaum
2 : Nutty facts: number one When a man in Ancient Rome was required to give an oath, he would cup his testicles with his hand as he spoke. It's from this that we get the words testify, testimonial and testament.
3 : Introduction Testicular cancer is the most common form of cancer in males aged from 15 - 45. It is affecting more young men each year The incidence of testis cancer varies significantly according to geographic area and is increasing, the highest reported incidence in Scandinavia, Switzerland, and Germany; intermediate in the United States and Great Britain; lowest in Africa and Asia. Approximately 8,000 new cases and 380 deaths from testicular cancer are expected in the United States in 2007. Testicular cancer causes around 70 deaths in the UK each year.
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9 : The lymphatic drainage of the testes is to the para-aortic lymph nodes near the origin of the gonadal vessel. Lymphatics from the medial side of the testis may run with the artery to the vas and drain into a node at the bifurcation of the common iliac artery. The contralateral para-aortic lymph nodes are sometimes involved by tumour spread, but the inguinal lymph nodes are affected only if the scrotal skin is involved.
10 : Most testicular neoplasms are malignant; testicular neoplasm is one of the most common forms of cancer in young men. Maldescent undoubtedly predisposes to malignancy. Even when the testis is located in the scrotum, tumours often escape detection until they have metastasised. Campaigns for regular testicular self-examination help raise awareness of the condition and may lead to earlier diagnosis
11 : Nutty facts: number two According to records kept during World War II detailing the health of conscripted men, there were nine cases of men with three testicles.
12 : Possible Risk Factors Being Male!!!!!!!!!! Age Undescended testicle Family history Previous cancer HIV virus Race & ethnicity
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14 : Nutty Facts: number 3 Over the course of a lifetime, the testicles generate an average of fourteen gallons of ejaculate (cum). Human ejaculation occurs at an average speed of twenty-seven miles an hour.
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16 : Tumours of the testis are classified according to their predominant cellular type: • seminoma (40%); • teratoma (32%); • combined seminoma and teratoma (14%); • interstitial tumours (1.5%); • lymphoma (7%); • other tumours (5.5%).
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18 : Seminoma A seminoma compresses neighbouring testicular tissue. The enlarged testis is smooth and firm. The cut surface is homogeneous and pinkish cream in colour. Occasionally, fibrous septa form lobules. In rapidly growing tumours there may be areas of necrosis. Seminomas metastasise via the lymphatics and haematogenous spread is uncommon.
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20 : A seminoma consists of oval cells with clear cytoplasm and large, rounded nuclei with prominent acidophilic nucleoli. Sheets of cells resembling spermatocytes are separated by a fine fibrous stroma. Active lymphocytic infiltration of the tumour suggests a good host response and a better prognosis.
21 : Teratoma A teratoma arises from totipotent cells in the rete testis and often contains a variety of cell types, of which one or more predominate. The tumour may be tiny but can reach the size of a coconut. Even a large tumour is moulded by the tunica albuginea so that the overall outline of the testis is maintained although the surface may be distorted. The usual type of teratoma is yellowish in colour with cystic spaces containing gelatinous fluid . Nodules of cartilage are often present.
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23 : Histology • Teratoma differentiated (TD) (uncommon): has no histologically recognisable malignant components but it can metastasise. The best known is a dermoid cyst, which may contain cartilage and muscle as well as glandular elements. • Malignant teratoma intermediate, teratocarcinoma (MTI; types A and B) (most common): contains definitely malignant and incompletely differentiated components. There is mature tissue in type A but not in type B.
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25 : • Malignant teratoma anaplastic (MTA), embryonal carcinoma: contains anaplastic cells of embryonal origin. Cells presumed to be from the yolk sac are often responsible for elevated alpha-fetoprotein levels. MTA is not always radiosensitive. • Malignant teratoma trophoblastic (MTT) (uncommon): Contains within other cell types a syncytial cell mass with malignant villous or papillary cytotrophoblasts (choriocarcinoma). It often produces human chorionic gonadotrophin (HCG). Spread by the bloodstream and lymphatics is early. It is one of the most malignant tumours known.
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29 : Interstitial cell tumours Interstitial cell tumours arise from Leydig or Sertoli cells. A Leydig cell tumour masculinises; a Sertoli cell tumour feminises. Prepubertal interstitial cell tumours excrete androgens, which cause sexual precocity and extreme muscular development. Regression of the symptoms after orchidectomy may be incomplete because of hypertrophy of the contralateral testis. Postpubertal interstitial cell tumours usually arise from Sertoli cells with output of feminising hormones leading to gynaecomastia, loss of libido and aspermia. As a rule, the tumour is benign and orchidectomy cures.
30 : Clinical features patient may not seek advice for several months testicular lump A sensation of heaviness occurs when the testis is 2x to 3x normal size minority of patients experience pain Recent trauma to the affected side calls attention to the testicular enlargement
31 : The testis is enlarged, smooth, firm and heavy Testicular sensation is often lost, a lax secondary hydrocele The vas is never thickened and rectal examination is normal. Secondary retroperitoneal deposits may be palpable, especially just above the umbilicus on the ipsilateral tumour. There may be hepatic enlargement. Sometimes, an enlarged supraclavicular node is the presenting sign of a testicular tumour
32 : Occasionally, the predominant symptoms are those of metastatic disease. Intra-abdominal disease may cause abdominal or lumbar pain and the mass may be discovered in the epigastrium. Lung metastases are usually silent but they can cause chest pain, dyspnoea and haemoptysis in the later stages of the disease. Atypical cases may simulate epididymo-orchitis; there may even be a urinary infection. All testicular swellings should be treated with suspicion, and failure to respond to antibiotics raises the possibility of a cancer. Rarely, patients present with severe pain and acute enlargement of the testis because of haemorrhage into a neoplasm. Between 1% and 5% of cases have gynaecomastia (mainly the teratomas). The hurricane tumour is a malignancy that kills in a matter of weeks. A few teratomas grow slowly with increasing enlargement of the testis over 2 or 3 years.
33 : Cannonball metastases from carcinoma of the testis. Testicular ultrasound: the homogeneous tissue of the testicular teratoma on the left of the image produces multiple ultrasound reflections.
34 : Scrotal exploration and orchidectomy for suspected testicular tumour The spermatic cord is displayed by dividing the external oblique aponeurosis through a groin incision. A soft clamp placed across the cord stops dissemination of malignant cells as the testis is mobilised into the wound. If necessary, the testis should be bisected along its anterior convexity to examine its internal structure. If there is a tumour or doubts still remain even after frozen section, the cord should be double ligated and divided at the level of the inguinal ring and the testis removed.
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36 : Staging of testicular tumours The stages are: • stage 1: testis lesion only – no spread; • stage 2: nodes below the diaphragm only; • stage 3: nodes above the diaphragm; • stage 4: pulmonary or hepatic metastases.
37 : Teratomas are less sensitive to radiation. Stage 1 tumours can be managed by monitoring the levels of serum markers and by repeated CT. Teratomas at stages 2–4 are managed by chemotherapy. Cisplatin, methotrexate, bleomycin and vincristine have been used in combination with great success. There are also those who advocate adjuvant chemotherapy for stage 1 teratomas, arguing that effective prophylaxis is less troublesome to the patient than prolonged surveillance.
38 : Management by staging and histological diagnosis (after orchidectomy) Seminomas are radiosensitive and excellent results have been obtained by irradiating stage 1 and stage 2 tumours. More recently, the tumour has been shown to be highly sensitive to cisplatin, which is already being used for patients with metastatic disease. Experts are divided as to whether patients with stage 1 disease should be treated with adjuvant chemotherapy.
39 : Retroperitoneal lymph node dissection is sometimes needed when retroperitoneal masses remain after chemotherapy The tissue removed may contain only necrotic tissue, but some patients have foci of mature teratoma or active malignancy. The operation can be formidable if the tumour is large, retrograde ejaculation is likely unless steps are taken to preserve the sympathetic outflow to the bladder neck.
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42 : Prognosis Prognosis of testicular tumours depends on the histological type and the stage of the growth. Seminoma If there are no metastases, 95% of patients will be alive 5 years after orchidectomy and radiotherapy or chemotherapy. If there are metastases, the survival rate drops to 75%. Teratoma A 5-year survival rate of more than 85% is achievable in patients with stage 1 or 2 teratoma. Among patients with stage 3 and 4 disease, the 5-year survival rate is about 60% and getting better with improvements in chemotherapy
43 : Testicular tumours in children These are usually anaplastic teratomas. They occur before the age of 3 years and are often rapidly fatal. TUMOURS OF THE EPIDIDYMIS These may be benign mesothelioma or malignant sarcoma or secondary carcinoma. They are extremely rare but should not be forgotten when the patient presents with a non-cystic lump in the epididymis.
44 : Testicular Self Examination Best performed either in the shower or after a warm bath, when the scrotal skin is relaxed.
45 : What to feel for A hard lump on the front or side of a testicle Swelling or enlargement of a testicle An increase in firmness of a testicle Pain or discomfort in a testicle or in the scrotum An unusual difference between one testicle and the other. A heavy feeling in the scrotum A dull ache in the lower stomach, groin or scrotum


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