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Testicular tumours

Aetiology and epidemiology:

Maldescended testes (particularly those retained within the abdomen) have a 40% greater chance of malignant change than does a normal testes
Otherwise the cause is unknown
Incidence is 2-3 per 100,000 per year
Are rare before puberty
Teratomas have a peak incidence at 20-30 years
Seminoma have a peak incidence at 30-40 years
Lymphomas (which are often bilateral) have a peak incidence at 60-70 years

Pathological features:

Classification of germ cell tumours is as follows:

Seminoma
Teratoma
Mixed:

These consist of both seminomatous and teratomatous elements, but should be treated as teratomas

Teratomas of the testis:

Differentiated – teratoma differentiated (TD)
Intermediate – malignant teratoma intermediate (MTI)
Undifferentiated – malignant teratoma undifferentiated (MTU)
Trophoblastic – malignant teratoma trophoblastic (MTT)

Symptoms:

10% give a history of previous orchidopexy and in 5% the tumour is bilateral
Often a recent history of trauma (is not a cause but merely draws the patient’s attention to the presence of a lump)
Painless swelling which causes a dragging sensation in the scrotum
In 30%, the swelling is painful
Patients with choriocarcinoma may develop gynaecomastia
Others present with symptoms from secondary deposits such as:

Backache
Haemoptysis
Neurological complaints

Signs:

A hard lump in the body of the testis
Diffuse testicular enlargement
Absence of tenderness on gently squeezing the testicle
Hydrocele

Investigation:

Tumour markers:

α-fetoprotein (AFP)
ß-human chorionic gonadotrophin (ß-HCG)
LDH
Placental ALP (seminomas)

Ultrasound:

Helpful for determining the nature of the mass if this is not possible clinically
The normal testis has a homogeneous appearance
Malignant tumours are inhomogeneous, may be cystic and are often associated with speckled calcification

CT scan of the chest and abdomen:

To identify pulmonary deposits and lymphadenopathy

Staging:

Stage Findings

I Tumour limited to testis

II Tumour of testis and retro-peritoneal lymph nodes

III Involvement of infra- and supra-diaphragmatic lymph nodes

IV Extra-lymphatic metastases

Management:

Improvements in therapy mean that the majority of testicular tumours should be regarded as curable

Surgery:

Orchidectomy is done through a groin incision (operations through the scrotum have a high incidence of tumour implantation)
In order to reduce the risk of disseminating malignant cells by manipulation of the testis, the cord is mobilised and occluded with a non-crushing intestinal clamp before the testis is delivered from the scrotum
In men with a small or atrophic contralateral testis, or a history of subfertility, a biopsy from the contralateral testis should be taken:

Up to 5% of men will have carcinoma in situ involving the other testis

Supplementary management:

If chemotherapy is to be used, the patient should be advised to store semen prior to the chemotherapy
Patients with testicular tumours are often subfertile and chemotherapy may result in irreversible germ cell damage

Supplementary management of seminoma and teratoma after orchidectomy:

Stage Seminoma Teratoma

I Pelvic and para-aortic irradiation Surveillance

Platinum-based chemotherapy

IIa/b Irradiation Platinum-based chemotherapy

Radical retroperitoneal lymphadenectomy

IIc Platinum-based combination As for IIa/b

chemotherapy

Prognosis:

Stage I – 100% of patients survive
Stage II/III – 5-year survival is between 80-90%
Seminoma:

For a tumour localised to the testis, >95% of patients should survive 5 years
For those who present with metastatic disease, the 5-year survival is ~75%

Non-seminomatous germ-cell tumours:

For those with a tumour confined to the testis and low tumour markers, 90% survive 5 years
If the tumour markers are grossly elevated and metastases are confined only to the lungs, 80% survive 5 years
If there are visceral metastases and grossly elevated tumour markers, the 5-year survival falls to 45%


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	Testicular tumours Aetiology and epidemiology: Maldescended testes (particularly those retained within the abdomen) have a 40% greater chance of malignant change than does a normal testes Otherwise the cause is unknown Incidence is 2-3 per 100,000 per year Are rare before puberty Teratomas have a peak incidence at 20-30 years Seminoma have a peak incidence at 30-40 years Lymphomas (which are often bilateral) have a peak incidence at 60-70 years Pathological features: Classification of germ cell tumours is as follows: Seminoma Teratoma Mixed: These consist of both seminomatous and teratomatous elements, but should be treated as teratomas Teratomas of the testis: Differentiated – teratoma differentiated (TD) Intermediate – malignant teratoma intermediate (MTI) Undifferentiated – malignant teratoma undifferentiated (MTU) Trophoblastic – malignant teratoma trophoblastic (MTT) Symptoms: 10% give a history of previous orchidopexy and in 5% the tumour is bilateral Often a recent history of trauma (is not a cause but merely draws the patient’s attention to the presence of a lump) Painless swelling which causes a dragging sensation in the scrotum In 30%, the swelling is painful Patients with choriocarcinoma may develop gynaecomastia Others present with symptoms from secondary deposits such as: Backache Haemoptysis Neurological complaints Signs: A hard lump in the body of the testis Diffuse testicular enlargement Absence of tenderness on gently squeezing the testicle Hydrocele Investigation: Tumour markers: α-fetoprotein (AFP) ß-human chorionic gonadotrophin (ß-HCG) LDH Placental ALP (seminomas) Ultrasound: Helpful for determining the nature of the mass if this is not possible clinically The normal testis has a homogeneous appearance Malignant tumours are inhomogeneous, may be cystic and are often associated with speckled calcification CT scan of the chest and abdomen: To identify pulmonary deposits and lymphadenopathy Staging: Stage Findings I Tumour limited to testis II Tumour of testis and retro-peritoneal lymph nodes III Involvement of infra- and supra-diaphragmatic lymph nodes IV Extra-lymphatic metastases Management: Improvements in therapy mean that the majority of testicular tumours should be regarded as curable Surgery: Orchidectomy is done through a groin incision (operations through the scrotum have a high incidence of tumour implantation) In order to reduce the risk of disseminating malignant cells by manipulation of the testis, the cord is mobilised and occluded with a non-crushing intestinal clamp before the testis is delivered from the scrotum In men with a small or atrophic contralateral testis, or a history of subfertility, a biopsy from the contralateral testis should be taken: Up to 5% of men will have carcinoma in situ involving the other testis Supplementary management: If chemotherapy is to be used, the patient should be advised to store semen prior to the chemotherapy Patients with testicular tumours are often subfertile and chemotherapy may result in irreversible germ cell damage Supplementary management of seminoma and teratoma after orchidectomy: Stage Seminoma Teratoma I Pelvic and para-aortic irradiation Surveillance Platinum-based chemotherapy IIa/b Irradiation Platinum-based chemotherapy Radical retroperitoneal lymphadenectomy IIc Platinum-based combination As for IIa/b chemotherapy Prognosis: Stage I – 100% of patients survive Stage II/III – 5-year survival is between 80-90% Seminoma: For a tumour localised to the testis, >95% of patients should survive 5 years For those who present with metastatic disease, the 5-year survival is ~75% Non-seminomatous germ-cell tumours: For those with a tumour confined to the testis and low tumour markers, 90% survive 5 years If the tumour markers are grossly elevated and metastases are confined only to the lungs, 80% survive 5 years If there are visceral metastases and grossly elevated tumour markers, the 5-year survival falls to 45%
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