Testicular Cancer and Retroperitoneal Lymph Node Dissection

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Testicular Cancer andRetroperitoneal Lymph Node
Dissection
Dr Manish Patel Urological Cancer Surgeon,
Westmead Hospital Senior Lecturer, University of
Sydney
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Normal Testicle
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Testicular Tumors-WHO Classification
Lymphoid and Haematopoietic tumors Lymphoma,
plasmacytoma, leukaemia Paratesticular Tumors
Adenomatoid tumor Mesothelioma Adenoma
Carcinoma Desmoplastic small round cell
tumors Soft tissue tumors Secondary tumors Tumor
like lesions
Germ Cell Tumors CIS Seminoma
Classic, Anaplastic , spermatocytic NSGCT
Embryonal Yolk Sac Choriocarcinoma
Teratoma Sex Cord/gonadal stromal tumors

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Carcinoma in-situ

• High Risk Cryptorchidism (3), Infertile men
  (1), Extragonadal GCT (40).
• Thought to be the precursor of GCT.
• Found in most testis with GCT.
• Found in 5 of contralateral testis.
• Will all eventually develop GCT.

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Germ Cell tumors-Seminoma

• 35-70 of GCT
• Aged 30-40 y.o
• Can contain synsytiotrophoblasts
• No AFP elevation,
• 15 have HCG elevation.

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Germ Cell Tumors- Non Seminoma

• Approx 40 GCT
• Combination of
• Embryonal
• Yolk Sac
• Chriocarcinoma
• Teratoma-benign, malignant transformation.

T
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Gonadal Stromal Tumors
Leydig Cell Tumor

• From the stromal cells of the testis.
• Approx 10 metastasise.
• Leydig Cell Tumors
• 3 of testicular tumors.
• Adults 30 feminisation.
• Sertoli Cell Tumors
• 2 of adult tumors
• More benign.

Sertoli Cell Tumor
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Testis cancer-Epidemiology

• Most frequent malignancy of white males aged
  20-34.
• Rare in Asian and African populations.
• Frequency Increasing. ?Why
• Encourage testicular self exam- no evidence of
  clear benefit.

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Predisposing Conditions

• Family History
• Brothers increase risk much more than fathers or
  other 1st degree relatives
• Undescended Testicles
• Other causes of testicular atrophy
• Maternal Estrogen exposure?

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Testis CancerPresentation

• Painless swelling of the testis.
• Painful testis (10)
• Tender breasts.
• Back pain, abdominal mass
• Cough, haemoptysis, SOB
• Neck mass
• Often Delayed Presentation Because of
  Embarrassment.

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Testicular Tumor-Investigation and Diagnosis.

• Clinical suspicion.
• Tumor markers
• AFP
• HCG
• LDH
• Ultrasound
• Orchidectomy

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Radical (Inguinal) orchidectomy
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NSGCT-Stage ITumour confined to Testicle

• 35-75 chance of micrometastatic disease in RP
• Assess risk by pathology
• Embryonal, lymphovascular invasion.
• Options
• Surveillance
• Chemotherapy (X2 cycles)
• RPLND

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NSGCT- Stage IIDisease in RP
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NSGCT- Stage IIDisease in RP

• Options
• Chemotherapy
• Chemotherapy
• Chemotherapy
• RPLND

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NSGCT- Stage IIIDisease in chest or other viscera

• 85 survival
• Treatment
• Chemotherapy

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Seminoma- Stage IConfined to the Testicle

• 20 chance of micrometastasis to RP
• Options
• XRT to RP
• Surveillance
• Chemotherapy (single cycle)

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Seminoma-Stage IIDisease in the RP

• Options for treatment
• Chemotherapy
• XRT if mass lt5cm

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Seminoma- Stage IIIDisease in chest or other
viscera

• Options
• Chemotherapy

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Which Chemotherapy?

• IGCCCG classification.
• Good Risk
• Tesicular or RP primary, nomets other then lungs,
  low tumour markers.
• GET BEPx3 or EPx4
• Intermediate and Poor Risk
• BEP X4

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Chemotherapy Complications

• Bleomycin
• Lung and Vessel fibrosis.
• Etoposide
• Late secondary malignancies
• Cisplatin
• Renal toxicity
• Neuro toxicity
• All
• Haemopoetic

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Fertility

• Reduced fertility even before orchidectomy.
• Orchidectomy will possibly reduce sperm count a
  little.
• Chemotherapy
• Reduced fertility for approx 2 years
• XRT (dogleg) will reduce fertility.
• Solution
• Sperm banking

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The Residual Mass after Chemotherapy

• Can occur in
• RP
• LUNGs
• Liver
• Other sites.

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What is it made off?NSGCT

• Necrosis/ fibrosis 50
• Teratoma 45
• Viable cancer 5
• Can you predict?
• Degree of shrinkage
• Teratoma in primary
• Size of the mass

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What is it made of?Seminoma

• Depends on size.
• lt3cm only 2/74 had viable cancer
• gt3cm 25 had viable cancer
• PET scan is useful for seminoma masses.

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Retroperitoneal Lymphnode Dissection (RPLND)

• What is it done for?
• Removal of all retroperitoneal nodes after chemo
  (including and mass).
• Removal of retroperitoneal tumour when still
  growing and have run out of chemotherapy
• Occasional for other cancer types eg. Renal
  cancer or TCC of the bladder.

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Boundries of RPLND
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A Severe Case.
Duodenum
Mass
Aorta
IVC
Kidney
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Lumber Sympathetic Nerves Control Ejaculation
Sympathetic chain
Lumber Sympathetic Nerves
Hypogastric plexus
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Nerve sparingDissection of individual
sympathetic nerves
Left Sympathetic nerves
Aorta
IVC
Right Sympathetic nerves
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Post-op course

• Ileus
• Respiratory
• Pain
• Fluid shifts
• Warm legs

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Complications

• Short term
• Prolonged ileus
• Bowel obstruction
• Respiratory failure
• PE
• Ascites (chylous)

• Long-term
• Anejaculation
• Adhesive bowel obstruction

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Follow-up

• Depends on cancer stage and presense of residual
  disease.
• Generally dont need abdo CTs
• Tumour Markers
• Chest XR