Testicular Tumor

Anatomy

 Sertoli cells -support developing

spermatozoa
Leydig cell -secrete testosterone

Blood supply

Lymphatic drainage
Primary site of Rt.
testis : interaortocaval
region
Primary site of Lt.
testis : para-aortic area
Right-to-left crossover
metastases are
common

Testicular Tumor
1-1.5% of male neoplasm
Most common malignancy in men in 20-35 year
age group
Most common :Germ cell tumor(90-95%)
Seminoma : 4th decade of life
Non-seminoma : 3th decade of life
More common on the right side (only 12% are
bilateral)
Survival rate is 99% in localized tumor and 96%
in tumor with regional lymph nodes spreading

Risk factor
Benign

Recent trauma
UTI
STD
Urethral instrument

 Malignant

Undescended testis (Cryptorchidism)

Age
HIV
Family history of testicular cancer
Carcinoma in situ
Previous testicular cancer
Race/Ethnics
Hematopoietic malignancy
Marijuana use

Classification
1.Germ cell tumor

Intratubular germ cell neoplasia,unclassified

type(IGCNU)
Seminoma
Spermatocytic seminoma
Embryonal carcinoma
Yolk sac tumor
Choriocarcinoma
Teratoma
Tumor with more than one histological types

 2.Sex cord /gonadal stromal tumor

Laydig cell tumor

Malignant Laydig cell tumor
Sertoli cell tumor
Malignant sertoli cell tumor
Granulosa cell tumor
Thecoma/Fibroma
Other sex cord/Gonadal stromal tumors
Gonadoblastoma

 3.Miscellaneous non- specific stromal

tumors

Ovarian epithelial tumours

Tumours of the collecting ducts and rete
testis
Tumours (benign and malignant) of nonspecific stroma

4.Secondary testicular cancers :

lymphoma
5.Carcinoma in situ

Testicular cancer
History taking

Present illness :detect after

trauma ,detect by sexual partner
Past history: hx of undescended
testis,Klinfelter syndrome
Family history of testicular cancer

Clinical finding
Most common : painless enlargement testis (if
severe pain : hemorrhage in tumor),heavy sensati
on
Gradual enlargement
Diffuse enlargement
Unilateral
Testicular mass/lump
Gynecomastia (brest growth/soreness)
30-50% in Sertoli cell, Laydig cell tumor
5% germ cell tumor

Metastasis symptoms
Low back pain : retroperitoneal
metastasis,involved nerve roots
Chest pain,cough,dyspnea,hemoptysis:lung
metastasis
Anoraxia,nausea,vomiting:retroduodenal
metastasis
Bone pain:bone metastasis
Lower extremities swelling:vena cava obstruction
Belly pain: liver metastasis,lymphadenopathy
Headache/confusion: brain metastasis

Physical examination
Testicular mass: firm not tender
Diffuse enlargement
Epididymis difficult to feel
Fever: tumor necrosis
Retroperitoneal
lymphadenopathy,pelvic
lymphadenopathy
PR:normal

Differential dignosis
Painful mass
Epididymitis/Orchitis
Fournier gangrene
Strangulated hernia
Torsion
Tumors

 Painless mass (adult)

Testicular tumor
Hydrocele
Varicocele
Inguinal hernia
Chylocoele
Fibrous pseudotumor of tuniga albuginea
Mesothelioma of tuniga vaginalis
Scortal edema

 Painless mass (children)

Hydrocoele
Varicocoele
Teratoma
Rhabdomyosarcoma

Epididymitis
Usually caused by Bacterial infection
Infant/boys : E. coli (UTI, GU congenital
anomaly)
Sexually active less than 35
(unprotected intercourse): STD bacteria
>>> Gonorrhea, Chlamydia
Elder: E. coli (BPH, UTI, catheterization)

Epididymitis
Symptoms

Acute (gradual onset ; several days VS. testicular

torsion;hours)
Gradual onset of scrotal pain and swelling
Usually located on 1 side
Dysuria, frequency, or urgency
Fever and chills
no nausea or vomiting
Urethral discharge preceding the onset of acute
Chronic
history of pain Scrotum that is not usually swollen but may
be indurated in long-standing cases : scrotal pain> 6 weeks
Urinary symptoms ; dysuria, urgency, frequency
Fever

Epididymitis
Physical Examination

Swelling
Tenderness
Erythema
Normal cremasteric reflex (negative in
testicular torsion)
Prehns sign : Lift the testicle if pain is
relieved.
(+) epididymis ; not sensitive
(-) testicular torsion

Testicular torsion
1) Intravaginal torsion

Twisting of spermatic cord

within tunica vaginalis
resulting in ischemia to ep
ididymis and testis
adolescent (12-18 years)

2) Extravaginal torsion

Twisting of tunica
vaginalis and spermatic c
ord together
neonate

Testicular torsion
Risk factor:

Undescended testis
Testicular tumor
Bell-clapper deformity => tunica vaginalis joins
high on the spermatic cord, testis lack a normal
attachment to tunica vaginalis and hang freely

Testicular torsion
Symptom

Sudden onset of severe unilateral scrotal pain

at a distinct point in time with subsequent swell
ing
Nausea and vomiting (1/3)
Fever (+/-)
Abnormal testicle direction
History of trauma or physical activities; sports

Testicular torsion
PE

Swollen, asymmetric scrotum with tender and

high-riding testicle, horizontal testis
Absence of cremasteric reflex
Negative Prehns sign

Hydrocele

Cause
Infant patent processus vaginalis

peritoneal fluid

scortum
Adult
secretory imbalance
tunica vaginalis

Hydrocele
Sign & symptom
Painless mass (Cyst) scrotal area
No reducible mass

ass.symptom

Hydrocele

Diagnosis
Transilluminate
u/s Ultrasound is the first modality usually

used to evaluate hydroceles. It presents as a sim

ple fluid collection surrounding the testis. It is ava
scular on Doppler evaluation. It may contain sept
ations, calcifications and cholesterol

Varicocele
Cause
Enlargement of vein pampiniform
plexus
Most common on Left side

the angle at which the left testicular vein enters the

left renal vein
the lack of effective antireflux valves at the juncture
of the testicular vein and renal vein
the increased renal vein pressure due to its
compression between the superior mesenteric arter
y and the aorta

Varicocele
Investigation

Color-flow Doppler ultrasonography

The color of the signal identifies the blood flow and

direction within the varicocele. The characteristic reverse
flow of varicoceles is confirmed by prolonged flow augme
ntation within a colored flow area

Varicocele
Venogram

Inguinal hernia
abdominal wall hernia is a protrusion of
the intestine through an opening or area
of weakness in the abdominal wall.
There are various types of hernia,
including inguinal hernia(common), umbili
cal hernia, femoral hernia, epigastric herni
a, incisional hernia, incarcerated hernia, st
rangulated hernia.

Inguinal hernia
Type
1.indirect inguinal hernia
-hernia lateral to Hesselbach triangle,through the
inguinal canal
- patent processus vaginalis
2.Direct inguinal hernia
-hernia within Hesselbach triangle, directly through
abdominal wall without through inguinal canal
- abdominal wall

Inguinal hernia
Clinical presentation

discomfort or pain in the groin

feelings such as weakness, heaviness, burning, or
aching in the groin
a swollen or an enlarged scrotum
The bulge may increase in size over time and
usually disappears when lying down
Local sign : tender, skin change
Systemic sign : fever, leukocytosis

Inguinal hernia
Physical examination
get above sign negative

indirect direct
1. int.inguinal ring pt.
indirect
direct @ medial

2. scortal sac
Ext.ring
indirect

Diagnostic Testing
1. Scrotal Ultrasonography
2. Serum Tumor Markers

1. Scrotal Ultrasonography

Size, echogenicity, and vascularity.

Procedures

high frequency linear transducer (7.5-10 MHz)

- at least 2 planes : longitudinal and transverse axis
-

Normal finding
homogeneous medium echo of testis
hyperecho in epididymis as compared to testis
hypoecho in spermatic cord as compared to testis
Pros
- Intratesticular vs extratesticular lesions
- Few millimeters in size of lesions
- non-invasive
- inexpensive

 Germ cell tumor

- hypoechoic mass
- increased vascularity
Seminoma
- homogeneous hypoechoic mass
- except large lesion - heterogeneous echo
Nonseminomatous germ cell tumor
- Heterogenous hypoecho mass

Seminoma

Nonseminomatous germ cell tumo

(Reference: .. . Scrotal Ultrasound. 2556)

Additional to
Ultrasonography

Color Doppler ultrasound (CDUS)

- to evaluate blood supply
epididymis
- incresed flow = suggestive of malignancy
CT
MRI

2. Serum Tumor Markers

Accurate test for testicular cancer
Consist of AFP, hCG, and LDH
Diagnosis, prognosis, treatment and
monitoring

Alpha-fetoprotein (AFP)
NSGCT

- Low-stage (CS I,IIA, IIB) NSGCT : elevate 50-70%

- Advanced (CS IIC, III) NSGCT : elevate 60 80%
Embryonic carcinoma
Yolk sac tumors
Half-life = 5-7 days
Can also be elevated in
hepatocelllular carcinoma
CA stomach/pancrease/biliary tract/lung
infectious
drug-induced
alcohol-induced
autoimmune

Do not found in Choriocarcinomas and seminomas

Human Chorionic Gonadotropin

(hCG)
NSGCT

Low stage NSGCT : 20-40%

Advanced stage NSGCT : 40-60%

Seminomas
Choriocarcinoma
Embryonal Carcinoma (EC)
Half-life = 24-36 hours
Can also be elevated in
CA stomach/pancrease/biliary tract/lung/ liver/breast/kidney/
bladder
False-positive in primary hypogonadism
- cross reactivity with LH
- distinguish by taking testosterone, normal levels in 48-72 hours

Lactate dehydrogenase
(LDH)

Non-specific for GCTs

Mainly for prognostic assessment
Half-life = 24 hours
Can also be elevated in
lymphoma
smooth, cardiac, skeletal muscle

Testicular cancer
Classification
Primary ( 94%)

Germ cell (90%) Malignancy

Seminoma
Non seminoma (embryonal cell, choriocarcinoma,
yolk sac, teratoma)
Mixed type

Non germ cell (4%) Usually benign

Leydig cell
Sertoli cell

Secondary (6%)
Lymphoma
Leukemia

GERM CELL TUMOR

SEMINOMA

Seminoma
The commonest variety of testicular
tumor
Adults are the usual target (40-50
years) ;never seen in infancy
Right > Left testis
Seminoma metastasizes initially via
lymphatics to the paraaortic lymph n
odes to the mediastinal and supracla
vicular nodes.

Seminoma
Serum alpha-fetoprotein is normal
Beta HCG is elevated in 10-15% of
patients (Syncytiotrophoblast)
Classication (of no clinical
significance)
Typical
Anaplastic
Spermatocyte

Seminoma
Macroscopically:

Characterized by a
circumscribed lobular
gray white fleshy tu
mor that have areas
of necrosis and hemo
rrhage
Cut surface in
homogenous an
d greyish white or
pinkish in color

 Microscopically
1.Typical seminoma
Monotonous of large cells with clear cytoplasm
and densely staining nuclei , syncytiotrophoblastic
elements are seen in some cases
2.Anaplastic seminoma
Presence of three or more mitoses per high-power field
and the cell demonstrate a higher degree of nuclear
pleomorphism
Patients tend to present at more advanced stages than
those with classic seminoma, but stage prognosis is
similar.

3. Spermatocytic seminoma
Cell vary in size and are
characterized by densely staining
cytoplasm and round
nuclei that contain condensed
chromatin

Seminoma
Seminoma account for one third of
testicular germ cell tumors (GCTs)
The risk of testis cancer is 10-40
times higher in patients with a histor
y of cryptorchidism

Seminoma
Signs and symptoms

- A male aged 15-35 years presents with a

painless testicular lump that has been
noticeable for several days to months
- Patients commonly have abnormal findings
on semen analysis at presentation, and they
may be subfertile
- Patients may present with a hydrocele, and
scrotal ultrasonography may identify a
nonpalpable testis tumor

Seminoma
Seminoma
Staging

- TNM
Classification
for Seminoma
Testicular
Cancer

Seminoma
Seminoma staging : Anatomic stage/
prognostic groupings

Seminoma
Sx:no serum tumour markers available
S0:within normal limits
S1:
alpha fetoprotein: <1000 ng/ml
beta hCG: <5000 IU/L
LDH: <1.5x upper limit of normal
S2:
alpha fetoprotein: 1,000-10,000 ng/ml
beta hCG: 5,000-50,000 IU/L
LDH: 1.5-10x upper limit of normal
S3:
alpha fetoprotein: >10,000 ng/ml
beta hCG: >50,000 IU/L
LDH: >10x upper limit of normal

Seminoma
stage I:confined to testis,
epididymis, spermatic cord, scrotum
stage II: lymph nodes involved but
no distant metastases and serum
tumour markers are not very high
stage III: distant metastases or
moderately high serum tumour
markers

Seminoma
Treatment

Treatment for stage I and nonbulky stage

II disease is as follows:
- Radical orchiectomy
- Radiotherapy/Chemotherapy

Seminoma
Treatment for stage II bulky or stage III
disease is as follows :
- Radical orchiectomy and metastatic
workup
- Chemotherapy without radiotherapy
- While the optimal chemotherapeutic
regimen is
debatable, 3 cycles of bleomycin,
etoposide, and
cisplatin (BEP) ,4 cycles of cisplatin and et
oposide are standard.

Seminoma
After treatment, patients require
lifelong follow-up.
Surveillance for stage I seminoma is as
follows:
- History and physical examination and
serum tumor markers (bhCG, LDH, AFP)
every 3-4 months the first year, every 6 mo
nths the second year, then annually thereaft
er
- Imaging: Chest radiography each visit; CT
scan of the pelvis annually for 3 years if stat
us post para-aortic radiotherapy

Seminoma
Surveillance for stage IIa/b seminoma is as
follows:
- History and physical examination and
serum tumor markers every 3-4 months in
years 1-3, every 6 months in year 4, and t
hen annually thereafter
-Imaging: Radiography each visit; CT scan
of the abdomen and pelvis during month 4
of the first year

Seminoma
Surveillance for stage IIc, III seminoma is
as follows:
- History and physical examination and
serum tumor markers every 2 months the
first year, every 3 months the second yea
r, every 4 months the third year, every 6
months the fourth year, and then annually
thereafter
- Imaging: Chest radiography each visit;
CT scan of the abdomen and pelvis during
month 4 of the first year status post surger
y (otherwise, every 3 months until stable);

GERM CELL TUMOR

NON-SEMINOMA

Embryonal carcinoma
2nd most common germ cell tumor(Adult
type and infantile type)
Present in majority of mixed germ cell tumor
Most men present in 20-30 years
Highly malignant tumors may invade the
cord structures
High degree of metastasis
Serum AFP is normal & Beta HCG is elevated
in 60% of cases

Embryonal carcinoma
Macroscopically

Tan to yellow neoplasm that exhibit large areas of

hemorrhage and necrosis
Less well defined and less well homogenous

Microscopically

Undifferentiated malignancy cells with crownded

pleomorphic nuclei
Solid sheet
Papillary
Glandular
Tubular arrangement of cell

Choriocarcinoma
A rare and aggressive tumor
Typically elevated hCG
Metastasis to lungs and brain(lymphatic
and bloodstream):an aggressive fashion
characterized by early hematogenous s
preading.
Primary is very small and often present
with no testicular enlargement.
Small palpable nodule

Choriocarcinoma
Macroscopically

May present a hemorrhagic mass

surrounded by a discernible rim of white to t
an tumor
Present as a nodules

Microscopically

Consists of both syncytiotrophoblast and

cytiotrophoblast
Prominent areas of hemorrhage and necrosis

Yolk sac tumor

Most common germ cell tumor in
children
Testicular mass the most usual
presentation
Always produce AFP and no hCG
Easily detectable ,lower relapse

Yolk sac tumor

Macroscopically

White to tan masses, with myxoid & cystic

changes

Microscopically

Reticular network of medium sized cuboidal

cellwith cytoplasm and extracytoplasmic
eosinophil, hyaline like goblets (84%)
Glandular, papillary or microcystic pattern
Schiller-Duval bodies are characteristic

Teratoma
May be seen in both children and adults
containing more than one germ cell layers(
endoderm, mesoderm and ectoderm) in va
rious stages of maturation and differentiati
on. All may rage from mature to immature,
can all metastasis.
Normal serum marker (Mildly elevated AFP
level)
Histologically benign but found metastatic
site

Teratoma
Microscopically:

Largely depends on elements within it

with solid and cystic area

Macroscopically:

Contain more than one germ cell layers

Treatment
Low stage nonseminomatous germ cell
tumors
High stage nonseminomatous germ cell
tumors

Low stage
Orchiectomy with or without RPLND
Surveillance in stage I NSGCT was
proposed will be relapse

How to surveillance in low stage

1-2 2
3 3
4 4
6 5
Tumor marker and chest x-ray

How to surveillance in
low stage

CT-scan

2-3 1
3-4 2
4 3
6 4
1 5

8-10
Chemotherapy
Surgery

Low stage
Orchiectomy with or without RPLND
Surveillance in stage I NSGCT was
proposed will be relapse

RPLND
Has been the preferred treatment of lowstage NSGCT in USA
Pt with negative nodes or N1 do not require
adjuvant therapy
N2 : receive 2 cycles of chemotherapy
With standard RPLND, sympathetic nerve
fibers are disrupted => result in loss of
seminal emission
Now can preserve ejaculation by dissection
below the level of inferior mesenteric artery

High stage

Pt. with bulky mass / retroperitoneal nodal

metastasis
Treat with primary platinum based combination
chemotherapy following orchiectomy
1. If tumor marker normalize and residual mass is
apparent on imaging studies => resection of tha
t mass is mandatory
2. If tumor marker failed to normalize => following
primary chemotherapy and salvage
chemotherapy is required
3. If patient with normal tumor markers and no
mass on CT or CXR => some investigations
advocate on RPLND because viable germ cell tu
mor may be seen up to 10 % of cases

High risk patient group

1. Mediastinal primary tumor
2. Non-pulmonary visceral metastasis or s3 marker
levels
3. May be fail to response and may have potential
complication from chemotherapy

Sepsis
Neuropathy
Renal toxicity
Death

4. Rate if decline if serum tumor markers during

chemotherapy has also been used to predict respo
nse in high risk patient

NON GERM CELL TUMOR

Leydig cell tumor

Leydig cell carcinoma

10% are malignant
Most common in non-germ cell tumor
Metastasis by blood to lungs and
retroperitoneum
May affect 20-60 yrs of age
No association with crytochordism

Leydig cell carcinoma

Present with painless testicular mass
Gynecomastia and decrease libido
due to estrogen production by
peripheral conversion
Precocious puberty
Prominent external genitalia
Deep masculinized voice
Pubic hair

Sertoli cell tumor

Sertoli cell tumor

Considered a post pubertal tumor
But can occur in any age group
including infants
No association with crytochordism
Gynecomastia in 1/3 of cases
10% are malignant
Benign lesion -> Well circumscribed
Malignant lesion -> ill-defined borders

SECONDARY TUMOR

Lymphoma
Primary testicular Non-Hodgekins
lymphoma is rare
Most common secondary testicular
tumor
Mostly involvement of testis by
dissemination from other sites
Bilateral involvement in 35 % cases
Present as a painless testicular mass
10% CNS involvement

Lymphoma
Gross examination

Bulging, gray or pink lesion with illdefined margins

Hemorrhage and necrosis are common

Microscopically

Diffuse histiocytic lymphoma is the most

common type

Leukemic infiltration
Relapse of ALL in testis
Diagnosis by biopsy
Should include the contralateral
testis: Bilateral involvement

Metastases
Most common primary site is
prostate
Others : Lung, GI tract, melanoma
and kidney
The typical pathologic finding is
neoplastic cells in the interstitium wit
h sparing of the seminiferous tubules