TESTICULAR TUMORS TESTICULAR TUMORS & DISORDERS OF & DISORDERS OF EXTERNAL GENITALIAEXTERNAL GENITALIA

DEPARTMENT OF UROLOGY IAŞI – 2010

TESTICULAR TUMORSTESTICULAR TUMORS

rare [0.8 (Japan) – 6.7 (Scandinavia) new cases/100,000 males/yr] 90-95% are germ cell tumors (seminoma & nonseminoma) effective combination chemotherapy overall 5-year survival

rate: 78% (1975) & 91% (1985) 1-2% are bilateral – 50% with history of cryptorchidism risk factors

congenital – cryptorchidism (7-10%) acquired – exogenous estrogen administration during

pregnancy, trauma & infection-related testicular atrophy (?) tumor development – totipotential germ cell

normal differentiation spermatocyte abnormal development seminoma or embryonal

carcinoma

TESTICULAR TUMORSTESTICULAR TUMORS

embryonal carcinoma (totipotential tumor cell) teratoma (intraembryonic diff.), choriocarcinoma or yolk sac tumor (extraembryonic diff.)

PATHOLOGY seminoma (35%) – 4th decade of life; grossly, coalescing gray

nodules; syncytiotrophoblastic elements (10-15%) hCG embryonal cell carcinoma (20%) – adult & infantile type (yolk sac

tumor = endodermal sinus tumor, most common in children); microscopically, embryoid bodies

teratoma (5%) – mature: benign structures from ectoderm, mesoderm and endoderm; imature: undifferentiated primitive tissue

choriocarcinoma (<1%) – aggressive tumors, early hematogenous spread; microscopically, syncytio- & cytotrophoblast

TESTICULAR TUMORSTESTICULAR TUMORS

mixed cell type (40%) – teratocarcinomas etc.METASTATIC SPREAD & CLINICAL STAGING

stepwise lymphatic spread – regional lymph nodes at the level of the renal hilum; for the right testis: interaortocaval area precaval preaortic right common iliac right external iliac; for the left testis: para-aortic area preaortic left common iliac left external iliac

no crossover metastases to the right side, but common right-to-left metastases (!)

choriocarcinoma – early hematogenous spread visceral metastases: lung, liver, brain, bone, kidney, adrenal,

gastrointestinal tract, spleen

STADIERESTADIERETNM classification for testicular cancer (UICC, 2002, 6th edition)

pTis Intratubular germ cell neoplasia (carcinoma in situ)pT1 Tumour limited to testis and epididymis without vascular/lymphatic invasion:

tumour may invade tunica albuginea but not tunica vaginalispT2 Tumour limited to testis and epididymis with vascular/lymphatic invasion, or

tumour extending through tunica albuginea with involvement of tunica vaginalispT3 Tumour invades spermatic cord with or without vascular/lymphatic invasionpT4 Tumour invades scrotum with or without vascular/lymphatic invasionN1 Metastasis with a lymph node mass 2 cm or less in greatest dimension or multiple

lymph nodes, none more than 2 cm in greatest dimensionN2 Metastasis with a lymph node mass more than 2 cm but not more than 5 cm in

greatest dimension, or multiple lymph nodes, any one mass more than 2 cm but not more than 5 cm in greatest dimension

N3 Metastasis with a lymph node mass more than 5 cm in greatest dimensionM1 Distant metastasisM1a Non-regional lymph node(s) or lungM1b Other sitesSx Serum marker studies not available or not performedS0 Serum marker study levels within normal limits

LDH (U/l) hCG (mIU/ml) AFP (ng/ml)S1 < 1.5 x N and < 5,000 and < 1,000S2 1.5-10 x N or 5,000-50,000 or 1,000-10,000S3 > 10 x N or > 50,000 or > 10,000

TESTICULAR TUMORSTESTICULAR TUMORS

CLINICAL FINDINGS symptoms

painless enlargement of the testis, testicular heaviness acute testicular pain (10%) – intratesticular hemorrhage or

infarction metastatic disease (10%) – back pain (retroperitoneal); cough

or dyspnea; anorexia, nausea or vomiting; bone pain; lower extremity swelling (venacaval obstruction)

signs testicular mass (firm, nontender) or diffuse enlargement hydrocele may accompany the tumor palpation of the abdomen – bulky retroperitoneal disease supraclavicular or inguinal nodes gynecomastia (5%)

TESTICULAR TUMORSTESTICULAR TUMORS

INVESTIGATIONS elevated serum creatinine – ureteral obstruction biochemical markers

AFP – NSGCTs β-hCG – NSGCTs (choriocarcinoma – 100%) & seminomas (7%) LDH – NSGCTs & seminomas

imaging scrotal US chest x-ray CT scan (abdomen & pelvis)

inguinal orchiectomy

TESTICULAR TUMORSTESTICULAR TUMORS

DIFFERENTIAL DIAGNOSIS epididymitis or epididymoorchitis, granulomatous orchitis hydrocele, spermatocele, hematocele, varicocele, epididymal

cysts

AJCC (American Joint Committee on Cancer) STAGE GROUPING0 Tis N0 M0 S0I T1-4 N0 M0 SX II T1-4 N1-3 M0 SX III T1-4 N0-3 M1 SXIA T1 N0 M0 S0 IIA T1-4 N1 M0 S0-1 IIIA T1-4 N0-3 M1a S0-1IB T2-4 N0 M0 S0 IIB T1-4 N2 M0 S0-1 IIIB T1-4 N1-3 M0/M1a S2IS T1-4 N0 M0 S1-3 IIC T1-4 N3 M0 S0-1 IIIC T1-4 N1-3 M0/M1a S3 sau M1b S0-3

TESTICULAR TUMORSTESTICULAR TUMORS

TREATMENT radical orchiectomy low-stage seminoma (I, II-A/B) retroperitoneal irradiation (25-

30 Gy) high-stage seminoma (II-C/III) primary chemotherapy (PEB,

VAB-6, cisplatin + etoposide) low-stage NSGCT (I, II-A/B) RPLND or surveillance high-stage NSGCT (II-C/III) primary chemotherapy ± RPLND

PRIAPISMPRIAPISM

prolonged painful erection; no sexual excitement or desire idiopathic (60%) secondary (40%) – leukemia, sickle cell disease, pelvic tumors,

pelvic infections, penile trauma, spinal cord trauma or use of medications (intracavernous injection)

obstruction of the venous drainage highly viscous, poorly oxigenated blood within the corpora cavernosa interstitial edema and fibrosis of the corpora cavernosa impotence

epidural or spinal anesthesia, evacuation of sludged blood from the corpora cavernosa through a large needle, intracavernous adrenergic agents (norepinephrine, Levophed), shunt between the glans penis and corpora cavernosa (biopsy needle), anastomosing the superficial dorsal vein to the corpora cavernosa, corpora cavernosa to corpus spongiosum and saphenous vein to corpora cavernosa

PEYRONIE DISEASEPEYRONIE DISEASE

plastic induration of the penis – painful erection, curvature of the penis and poor erection distal to the involved area

examination – palpable dense, fibrous plaque, usually near the dorsal midline, involving the tunica albuginea of the penile shaft

spontaneous remission ≈ 50% of cases p-aminobenzoic acid (powder or tablets) or vitamin E (tablets) for

several months refractory cases – excision of the plaque with replacement with a

dermal graft, the use of tunica vaginalis grafts after plaque incision and incision of the plaque with insertion of penile prostheses in the corpora cavernosa

additional methods – radiation therapy and injection of steroids, dimethyl sulfoxide or parathyroid hormone into the plaque

PHIMOSISPHIMOSIS

the contracted foreskin cannot be retracted over the glans cause - chronic infection (balanoposthitis) from poor local hygiene calculi and squamous cell carcinoma may develop under the

foreskin signs – edema, erythema and tenderness of the prepuce, purulent

discharge incision of the dorsal foreskin circumcision (posthectomy), after the infection is controlled

PARAPHIMOSISPARAPHIMOSIS

the foreskin, once retracted over the glans, cannot be replaced in its normal position

cause – chronic inflammation under the redundant foreskin contracture of the preputial opening (phimosis)

tight ring behind the glans venous congestion edema and enlargement of the glans arterial occlusion and necrosis of the glans

squeeze of the glans for 5 min, then reduction (phimosis) incision of the constricting ring, under local anesthesia circumcision – after inflammation has subsided

VARICOCELEVARICOCELE

10% of young men dilatation of the pampiniform plexus above the testis (left side

most commonly affected !) ! sudden development of a varicocele in an older man ≈ late sign

of renal tumor, that has invaded the renal vein, occluding the spermatic vein

examination – mass of dilated, tortuous veins lying posterior to and above the testis; degree of dilatation can be increased by the Valsalva maneuver; testicular atrophy (impaired circulation); sperm concentration and motility are significantly decreased (65-75%) infertility

ligation of the internal spermatic veins; percutaneous methods (balloon catheter, sclerosing fluids) to occlude the veins, following percutaneous spermatic venography

HYDROCELEHYDROCELE

collection of fluid within the tunica or processus vaginalis may develop rapidly secondary to local injury, radiotherapy,

acute nonspecific or tuberculous epididymitis or orchitis and testicular neoplasm !

diagnosis – rounded cystic intrascrotal mass, that is not tender; the mass transilluminates

differential diagnosis – testicular tumor – US indications for treatment – tense hydrocele that embarrass

circulation to the testicle or large, bulky mass, uncomfortable for the patient

hydrocele sac is opened and stitched together to collapse the wall (Lord’s procedure)

SPERMATIC CORD - SPERMATIC CORD - TORSIONTORSION

most often seen in adolescent males congenital abnormality (voluminous tunica vaginalis, that inserts

well up on the cord and allows the testis to rotate) + contraction of the cremaster muscle left testis rotate counterclockwise and right testis clockwise vascular occlusion ischemic death of the testis and epididymis

diagnosis – young boy suddenly develops severe pain in one testicle, followed by swelling of the organ, reddening of the scrotal skin, lower abdominal pain, nausea and vomiting

examination – swollen, tender organ, that is retracted upward (shortening of the cord by volvulus); pain may be increased by lifting the testicle up (pain from epididymitis is usually alleviated) – Prehn’s maneuver

SPERMATIC CORD - SPERMATIC CORD - TORSIONTORSION

differential diagnosis – acute epididymitis, acute orchitis and trauma – color Doppler US (absence of arterial flow in torsion, hypervascularity in inflammatory lesions); scintillation scan (99mTc-pertechnetate) – avascular (torsion), increased vascularity (testicular tumor) or decreased vascularity (trauma)

manual detorsion may be attempted (the right testis should be “unscrewed” and the left one “screwed up”) after local anesthesia; ! surgical fixation of both testes should be done within the next few days

if manual detorsion fails immediate surgical detorsion & orchydopexy

detorsion within 6 h of onset – good result; delayed beyond 24 h –orchiectomy