Commonest testicular tumour is: (DBC Dec 2009)
|D||Yolk sac tumour|
a. Testicular cancer is the most common cancer in men between the ages of 20 and 35 years.. For more than 90% of patients, testicular cancer is curable.
b. Any patient with a solid testicular mass, which has been confirmed on ultrasound, is considered to have testicular cancer until proven otherwise, and should undergo a radical orchiectomy to make a definitive diagnosis.
c. Prior to surgery, serum markers for testicular cancer should be obtained. The two markers used in routine clinical practice are human chorionic gonadotropin (hCG) and follicle-stimulating hormone (FSH).
d. When performing a radical orchiectomy, the surgery should be performed by an inguinal approach rather than a scrotal approach.
e. The primary metastatic landing sites for left and right testicular cancers are the para-aortic and the interaortocaval nodes in the retroperitoneum, respectively.
f. The lymphatic drainage of the scrotum, on the other hand, is to the inguinal nodes.
g. If the scrotum is surgically violated by performing a scrotal orchiectomy, metastatic spread to both the retroperitoneal and the inguinal nodes becomes possible.The diagnosis of testicular cancer is made based on the pathology of the orchiectomy specimen.
h. Approximately 95% of testicular cancers are germ cell tumors, while approximately 4% of testicular cancers are nongerm cell tumors such as Leydig cell tumors and Sertoli cell tumors.
i. Germ cell tumors are further classified as seminomas and nonseminomas.
j. For clinically localized nonseminomas that are at high risk for recurrence, the options include a prophylactic retroperitoneal lymph node dissection, two cycles of prophylactic chemotherapy or observation with very close follow-up.
k. The treatment of metastatic germ cell tumor generally involves chemotherapy.
l. Most chemotherapy protocols employ a combination of bleomycin, etoposide and cis-platinum
a. Physical examination of the testis is performed by bimanual examination of the scrotal contents, beginning with the normal contralateral testis.
b. Physical examination of the testis is performed by careful palpation of the testis between the thumb and the first two fingers of the examining hand.
c. The normal testis is homogeneous in consistency, freely movable, and separable from the epididymis.
d. Any firm, hard, or fixed area within the substance of the tunica albuginea should be considered suspicious until proved otherwise.
e. Further examination of the suspected tumor should be directed toward possible involvement of the cord, scrotal investments, or skin. In general, seminoma tends to expand within the testis as a painless, rubbery enlargement.
f. Embryonal carcinoma or teratocarcinoma may produce an irregular, rather than discrete, mass, although this distinction is not always easily appreciated.
g. Testicular tumors tend to remain ovoid, being limited by the tough investing tunica albuginea.
h. In 10% to 15% of patients, spread to the epididymis or cord may occur.
j. Routine assessment of the supraclavicular lymph nodes may reveal adenopathy in patients with advanced disease.
k. Examination of the chest may disclose gynecomastia or the presence of respiratory tract involvement.
Three subtypes of pure seminomas have been described: classic, anaplastic, and spermatocytic.
The histologic and biochemical properties, natural history, and response to therapy of these subtypes have been characterized.
a. Typical, or classic, seminoma accounts for 82% to 85% of all seminomas and occurs most commonly in men in their thirties
b. Histologically, it is composed of islands or sheets of relatively large cells with clear cytoplasm and densely staining nuclei separated by fibrous septae containing lymphocytes..
d. The slower growth rate of seminomas may be inferred from the observation that treatment failures may become evident 2 to 10 years after apparently adequate irradiation of metastatic sites.
a. Anaplastic seminoma accounts for 5% to 10% of all seminomas and has an age distribution similar to that of the typical subtype.
b. Though it is rare but it has to be a differential always in mind as mortality is 30% of such cases.
c. A number of features suggest that anaplastic seminoma is a more aggressive and potentially more lethal variant of typical seminoma.
d. These characteristics include (1) greater mitotic activity, (2) higher rate of local invasion, (3) increased rate of metastatic spread, and (4) higher rate of tumor marker (β-hCG) production.
a. This lesion is composed of cells that vary in size and have deeply pigmented cytoplasm and rounded nuclei containing characteristic filamentous chromatin.
b. The cells closely resemble different phases of maturing spermatogonia.
c. Spermatocytic seminoma accounts for 2% to 12% of all seminomas, and nearly half occur in men older than age 50 years.
d. Bilateral tumors have been reported, but no cases have occurred in conjunction with cryptorchidism.
The metastatic potential of spermatocytic seminoma is extremely low, and prognosis is accordingly favorable.