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Testicular tumors

Testicular tumors. Mostafa El- Haddad. Anatomie. Blood Supply? Lns distribution: Cross over from Rt to Lt but not from Lt. to Rt. Scrotal Lymphatic's disruption. Epidemiology. Age: 20-35ys. Seminoma patient is older. Don’t forget that yolk sac tumor can occur in children. Where?

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Testicular tumors

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  1. Testicular tumors Mostafa El- Haddad

  2. Anatomie • Blood Supply? • Lns distribution: • Cross over from Rt to Lt but not from Lt. to Rt. • Scrotal Lymphatic's disruption.

  3. Epidemiology • Age: 20-35ys. • Seminoma patient is older. • Don’t forget that yolk sac tumor can occur in children. • Where? • Social problem.

  4. Etiology and Risk Factors • Intrauterine exposure to Estrogen. • Un-descended testis: intra-abdminal > inguinal. • Family history : very important. • AIDS: RPL and stage is difficult to predict. Stage for stage is ok. Or c h id o p e x y d o e s n o t r e d u c e r i s k i n al l a g e g r o u ps b u t f a c i l i t a t e s e x a m i n a t i o

  5. Intratubular neoplasm? How we detected? • Present in the contralateral testis in 10%. • Bilateral testicular tumor do exist.

  6. Pathology • Germ Cell tumors. • Supporting Cell tumors. • Lymphoma. • Metastasis including sanctuary site.

  7. WHO ClassificationAndBritish Testicular Tumor Panel and Registry

  8. Mixed Germ Cell Tumors Are Considered NSGCT

  9. Isochromosome 12 • What is isochromosome? • Value? • Pathognomonic feature of GCT of all histologic types, whether of gonadal or extragonadal origin. • Can be an early marker (reported in insitu tumors). • The presence of three or more copies of i(12p) has been correlated with poor prognosis GCT.

  10. Natural History • Seminoma associated with more ureteric obstruction? • NSGCT is more aggressive go blood.

  11. RT LT

  12. Other Lymph Nodes • External Iliacs • Obturator. • Inguinal .

  13. SpermatocyticSeminoma • Sixth decade. • Bilateral more. • Indolent course. • Treatment surgery. • -ve PLAB

  14. AnaplasticSeminoma

  15. Intratubular Germ cell Neoplasia • Precursor but not for SS: • Found in high risk group. • Found adjacent to cancer. • 50% risk to transform at 5 years. • 100% risk at 8 years. • Treatment : Radiotherapy 18 to 20Gy.

  16. Symptoms and Signs • Pain: local, Back. • Gynecomastia? • DD: testicular torsion, hydrocele, varicocele, spermatocele, and epididymitis

  17. Orchiectomy may occasionally be delayed in metastatic cases to control primary disease . • Orchiectomy should be done? • When orchiectomy should not be done?

  18. Staging and Risk Assessment

  19. HCG • HCG: alpha unit and beta unit. • prostate, bladder, ureteral, and renal cancers may show increase in B-HCG elevation. • Spurious elevations have been noted in persons using marijuana. • Cis-platinum-induced testicular atrophy in the remaining testis, resulting in lower levels of testosterone, with a compensatory hypersecretion of LH to stimulate Leydig cell secretion of testosterone.

  20. To Make Life More Complicated • Neuroendocrine tumors and cancers of the bladder, kidney, lung, head and neck, GI tract • Specifically gastric, pancreatic, biliary, and colorectal cancers, cervix, uterus, and vulva.

  21. In addition, there are case reports of elevations in hCG in lymphoma and leukemia.

  22. HCG produced by Scincytiotrophoblast. • Seminoma can produce HCG 5-40% of cases. • Not more than 100 IU.

  23. AFP • Pregnant women (Hamel). • Hepatitis. • Hepatocellular carcinoma. 3 H

  24. LDH • Gene that encodes LDH isoenzyme 1 maps to chromosome 12. • The serum level of LDH isoenzyme 1 has been shown to correlate with the number of copies of i(12p) in the tumor, a fairly specific genetic marker of germ cell malignancies. • Furthermore, the presence of three or more copies of i(12p) has been correlated with a worse prognosis.

  25. Very Important • Up to 30% of patients with early-stage non-seminomatous GCT will have normal serum markers, so the absence of marker elevation should not influence the decision to perform an orchiectomy. • Eventhough markers should be done before and After Surgery.

  26. PET-CT • FDG-PET was unable to detect mature teratomas as well as lesions smaller than 5 mm in diameter. Not routinely used or recommended in initial staging. • Can be used to differentiate between residual disease and fibrotic bands?

  27. Other Investigations • Brain imaging in Choriocarcinoma. • In patients with clear clinical examination and Elevated markers don’t forget to investigate the other testis.

  28. ASCO Guidelines For the Use of Tumor Markers

  29. Treatment

  30. Stage I Seminoma • Orchiectomy PLUS 1- Observation When? Or 2- Radiotherapy When? Or 3- Chemotherapy What?

  31. Chemotherapy in advanced Stage • BEP or EP • Cisplatin is better than Carboplatin

  32. Spermatic cord involvement necessitates a radiation field that covers the entire inguinal orchiectomy scar, whereas scrotal skin involvement mandates radiation to the hemiscrotum

  33. Residual Disease Post Chemo • Less than 3 cm or more than 3cm. • Post chemotherapy field of radiation??

  34. Radiotherapy Technique

  35. Consent. • Preparation. • Positioning. • Simulator. • 30 degrees rotation of the remaining testis from the patient’s long axises.

  36. TesticualtIrrdiation • Intratubular germ cell tumor. • Testicular leukemia or lymphoma. • Position is the Key. • Penis. • Beam arrangement. • Energy: deep X- Electron, Photon. • Bolus Where???

  37. Technical consideration • Adjuvant radiotherapy to the hemiscrotum and ipsilateral inguinal lymph nodes is recom- mended. • The scrotal field is matched to the tattoo at the inferior border of the dog-leg field.

  38. Non Seminoma • Vascular/lymphatic invasion • Embryonal carcinoma elements (>30%) • Absence of yolk sac elements • Absence of AFP preorchiectomy • Less than 50% teratoma • Local extension into paratesticular structures

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