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REGUB Surgery - Testicular Tumours (Exam (enlarged testis, protruding…
REGUB Surgery - Testicular Tumours
Classified as germ cell or non-germ cell
germ cell (90%)
Seminomas (48%)
non-seminomas (NSGCTs - 42%)
embryonal carc
choriocarc
yolk sac tumour
teratoma
mixed
non-germ cell (10%)
gonadal stromal tumours (3%)
Sertoli
Leydig (make testosterone)
mixed
other (7%)
epidermoid cyst
adenomatoid tumours
carcinoid
adenocarc of rete testis
lymphoma (5%)
mets (1%)
Intro
bilat in 1-2%
1% = mets from another site
rare in Ire but slowly rising
1% of all male cancers
most common solid cancer in men aged 15-35
10 yr survival = 96%
testes should be 2 degrees lower than normal body temp
Risk factors
age
"troops (young) get teratoma, sergeants (older) get seminoma"
20-45: germ cell tumours
35-35: seminomas
50% of men >60 with testicular neoplasms have lymphoma
race: white:black = 3:1
undescended tests (cryptorchidism) a/w 10% testis cancer cases
x5-15 increase risk compared with normally descended testes
sooner tx better
infertility - poor semen analysis
genetics - +ve hx in 1st degree relatives
hx of contralat testicular cancer
microcalcifications
Hx
painless unilateral testicular swelling/nodule
sensation of heaviness in scrotum
scrotal/lower abdo pain in 10%
trauma usually brings attention to previously existing nodule
symptoms due to mets in 10%
Exam
enlarged testis
protruding nodule may be palpable
10% have secondary hydrocoele
epididymis may be difficult to palpate
para-aortic (drains testis) or inguinal (drains scrotal wall) lymphadenopathy
hepatomegaly
signs of other distant mets
occasionally mimic acute epididymo-orchitis
Dx
trans-scrotal US
serum markers
AFP (yolk sac)
B-HCG (choriocarc)
LDH (indicates inflamm/increased cell turnover)
CXR - pul mets
CT-TAP - staging
Tumour markers
must be assessed prior to tx
90% of NSGCTs will have 1+ +ve tumour markers
onco-foetal proteins
B-HCG
circulating levels n low in normal males
syncytiotrophoblastic elements of some GCTs
all chorios, 40-60% of embryonal, 5-10% of seminomas
T1/2 = 24-36 hrs
AFP
tumours in testis, liver, pancrea, lung
yolk sac, 50-70% of teratomas
T1/2 = 5-7 days
NEVER raised in pure seminomas
LDH
cellular enzyme
ubiquitous
non-specific
useful marker of tumour bulk
seminomas 10-20%
monitoring tumour response
TNM staging
Tx - cannot be assessed
T0 - no evidence of tumour
T1 - limited to testis + epididymis
T2 - limited to testis + epididymis, vasc +/- lymphatic invasion present
T3 - invades spermatic cord
T4 - invades scrotum
Tx
radical orchidectomy
via groin pull out spermatic cord so as to not disturb lymphatics
curative in 80%
pre-op discussion: sperm banking, prosthesis
inguinal incision + testis delivered into inguinal canal
NOT scrotal approach (higher recurrence/seeding)
early clamping of cord @ deep ring
exploration + frozen section rarely
histology will note: size + extent of tumour, vasc invasion, sub-type components
chemo combo = BEP
bleomycin
etoposide
cisplatin-platinum
give 3-4 cycles if mets
radio no longer 1st line
retroperitoneal lymph node dissection (RPLND)
if symp Ns T12-L2 not spared causes antejaculation
for residual mass
of seminoma...
80% confined to testis @ presentation
risk of relapse 15-20% @ 5 yrs
esp if tumour >4cm, infiltration of rete tesits, vasc invasion
12% recurrence in low risk
32% recurrence in high risk
after relapse cure rate > 99%
advanced disease: radiation + BEP
of NSGCT...
30-50% of those clinically stage 1 have clinically undetectable mets
hence relapse rate @ 6 months = 28-50%
surveillance (US) vs 2 cycles of BEP (UK/Ire)