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Surgery.(General 1).Scrotum > 4. Testicular Tumours > Flashcards

4. Testicular Tumours Flashcards

1
Q

Incidence of Testicular Tumours

A
  • Practically 99% of testicular neoplasms are malignant

* They constitute 1-2% of malignant tumours in males

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2
Q

Age of Testicular Tumours

A

Occur at a relatively young age.

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3
Q

Side of Testicular Tumours

A

Bilateral in 3-5% of cases

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4
Q

ETIOLOGY of Testicular Tumours

A
  • Incompletely descended testes, especially the intra-abdominal variety.
  • Klinefelter’s syndrome
  • An isochromosome 12p is present in about 80 % of the testicular cancers.
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5
Q

Meaning of isochromosome 12p in ETIOLOGY of Testicular Tumours

A

The short arm of chromosome 12 on both sides of
the centromere

An isochromosome is a chromosome that has lost one of its arms and replaced it with an exact copy of the other arm

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6
Q

CLASSIFICATION of Testicular Tumours

A
  1. Germ cell tumours 86%
  2. Interstitial tumours (rare). 1.5%
  3. Lymphoma (Extra nodal) 7%
  4. Other tumours 5.5 %
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7
Q

Germ cell tumours in CLASSIFICATION of Testicular Tumours

A
  • Seminoma 40%
  • Teratoma 32%
  • Combined seminoma and teratoma 14%
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8
Q

Alternative name for Teratoma in Germ cell tumours in CLASSIFICATION of Testicular Tumours

A

Non seminomatous Germ Cell Tumors “NSGCT”

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9
Q

Pathology of Testicular Tumours

A
  • Germ cell tumours 86%

* Interstitial tumours (rare). 1.5%

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10
Q

Germ cell tumours Pathology of Testicular Tumours

A
  1. Seminoma

2. Teratoma

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11
Q

Seminoma in Germ cell tumours Pathology of Testicular Tumours

A
  • Age
  • CeII of origin
  • Macroscopic Picture
  • Cut Section
  • Microscopic Picture
  • Spread
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12
Q

Age in Seminoma in Germ cell tumours Pathology of Testicular Tumours

A

35-45 years of age.

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13
Q

CeII of origin of Seminoma in Germ cell tumours Pathology of Testicular Tumours

A

Seminiferous tubules

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14
Q

Macroscopic Picture of Seminoma in Germ cell tumours Pathology of Testicular Tumours

A

شبه البطاطس لما تتحمر
* Moderate to large

  • firm and smooth
  • sometimes it is lobulated
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15
Q

The reason why the tumour is sometimes lobulated in Macroscopic Picture of Seminoma in Germ cell tumours Pathology of Testicular Tumours

A

due to the presence of fibrous septa

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16
Q

Cut Section of Seminoma in Germ cell tumours Pathology of Testicular Tumours

A
  • homogenous

* pink creamy in colour.

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17
Q

Microscopic Picture of Seminoma in Germ cell tumours Pathology of Testicular Tumours

A
  • Cells resemble spermatocytes (rounded or oval with clear cytoplasm & large rounded nuclei).
  • Lymphocytic infiltration of the tumour.
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18
Q

Significance of Lymphocytic infiltration of the tumour in Microscopic Picture of Seminoma in Germ cell tumours Pathology of Testicular Tumours

A

Indicates good immunity and good Localization

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19
Q

Spread of Seminoma in Germ cell tumours Pathology of Testicular Tumours

A

Lymphatics to the para-aortic and iliac L.Ns.

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20
Q

Teratoma in Germ cell tumours Pathology of Testicular Tumours

A
  • Age
  • CeII of origin
  • Macroscopic Picture
  • Cut Section
  • Microscopic Picture
  • Spread
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21
Q

Age in Teratoma in Germ cell tumours Pathology of Testicular Tumours

A

20-35 years of age

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22
Q

CeII of origin of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A

Embryonic totipotent cells in the rete testes

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23
Q

Meaning of Embryonic totipotent cells

A

Can give rise to Endo ecto mesoderm

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24
Q

Macroscopic Picture of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A
  • Variable size.

* always having a smooth surface

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25
Q

The reason why the tumour is always having a smooth surface in Macroscopic Picture of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A

Usually molded by the tunica albuginea so always having a smooth surface

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26
Q

Cut section of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A
  • Heterogenous
  • yellowish in colour
  • showing cysts that contain gelatinous material & cartilage nodules.
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27
Q

Microscopic Picture of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A

Teratomas are subdivided into 5 subtypes based on histopathologic characteristics:

  1. Differentiated teratoma
  2. Malignant teratoma intermediate “MTl”
  3. Malignant teratoma anaplastica “MTA”
  4. Malignant teratoma trophoplastica ‘MTT”
  5. Endodermal sinus tumour “EST”
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28
Q

Meaning of histopathologic characteristics in Microscopic Picture of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A

Degree of differentiation

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29
Q

Prognosis of Differentiated teratoma in Microscopic Picture of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A

Good

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30
Q

Alternative name for Malignant teratoma intermediate in Microscopic Picture of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A

Teratocarcinoma.

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31
Q

Malignant teratoma anaplastica in Microscopic Picture of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A
  • Alternative name

* Behavior and prognosis

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32
Q

Alternative name for Malignant teratoma anaplastica in Microscopic Picture of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A

Embryonal carcinoma

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33
Q

Behavior and prognosis of Malignant teratoma anaplastica in Microscopic Picture of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A

It a highly malignant tumour with very bad prognosis

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34
Q

Malignant teratoma trophoplastica in Microscopic Picture of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A
  • Alternative name
  • Meaning of Trophoblastica
  • Incidence
  • Behavior
  • Pathogenesis
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35
Q

Alternative name for Malignant teratoma trophoplastica in Microscopic Picture of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A

choriocarcinoma

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36
Q

Meaning of Trophoblastica in Malignant teratoma trophoplastica in Microscopic Picture of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A

Similar to placenta

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37
Q

Incidence of Malignant teratoma trophoplastica in Microscopic Picture of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A

rare

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38
Q

Behavior of Malignant teratoma trophoplastica in Microscopic Picture of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A

It is the most aggressive malignant tumour known

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39
Q

Pathogenesis of Malignant teratoma trophoplastica in Microscopic Picture of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A

Cytotrophoblast and syncytiotrophoblast without villus formation.

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40
Q

Endodermal sinus tumour in Microscopic Picture of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A
  • Alternative name
  • Incidence
  • Prognosis
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41
Q

Alternative names for Endodermal sinus tumour in Microscopic Picture of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A
  • Yolk sac tumour “YST”

* Infantile embryonal carcinoma

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42
Q

Incidence of Endodermal sinus tumour in Microscopic Picture of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A

It is the most common testicular tumor in infants under 3 and young boys

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43
Q

Prognosis of Endodermal sinus tumour in Microscopic Picture of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A

Excellent prognosis

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44
Q

Spread of Teratoma in Germ cell tumours Pathology of Testicular Tumours

A

Blood spread mainly to the lungs & liver.

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45
Q

Carcinomas spread by blood :

A
  • FTC
  • Teratoma
  • Prostatic carcinoma
  • Breast carcinoma
  • Bronchogenic carcinoma
  • Renal cell carcinoma
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46
Q

Interstitial cell tumours Pathology of Testicular Tumours

A
  1. Leydig cell tumour

2. Sertoli cell tumour

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47
Q

Leydig cell tumour in Interstitial cell tumours Pathology of Testicular Tumours

A
  • Age

* Pathogenesis

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48
Q

Age of Leydig cell tumour in Interstitial cell tumours Pathology of Testicular Tumours

A

Usually occurs before puberty

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49
Q

Pathogenesis of Leydig cell tumour in Interstitial cell tumours Pathology of Testicular Tumours

A
  • It produces excessive amounts of androgens

* leading to infant Hercules

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50
Q

infant Hercules in Pathogenesis of Leydig cell tumour in Interstitial cell tumours Pathology of Testicular Tumours

A

sexual precocity and extreme muscular development due to excessive amounts of androgens produced by Leydig cell tumour

51
Q

Sertoli cell tumour in Interstitial cell tumours Pathology of Testicular Tumours

A
  • Age
  • Pathogenesis
  • Behavior
52
Q

Age of Sertoli cell tumour in Interstitial cell tumours Pathology of Testicular Tumours

A

Occurs after puberty

53
Q

Pathogenesis of Sertoli cell tumour in Interstitial cell tumours Pathology of Testicular Tumours

A
  • It produces estrogens

* leading to gynaecomastia, loss of libido & aspermia

54
Q

Behavior of Sertoli cell tumour in Interstitial cell tumours Pathology of Testicular Tumours

A

The tumour is benign and orchiectomy cures.

55
Q

CLINICAL PICTURE OF Testicular Tumours

A
  • Typical presentation

* Atypical presentation

56
Q

Typical presentation in CLINICAL PICTURE OF Testicular Tumours

A
  • Symptoms

* Examination

57
Q

Symptoms in Typical presentation in CLINICAL PICTURE OF Testicular Tumours

A
  1. Painless enlargement of the testis.
  2. Sense of heaviness
  3. History of trauma
58
Q

Sense of heaviness in Symptoms in Typical presentation in CLINICAL PICTURE OF Testicular Tumours

A

occur when the testes reaches 2-3 times its normal size.

59
Q

History of trauma in Symptoms in Typical presentation in CLINICAL PICTURE OF Testicular Tumours

A

In 10% of cases the patient gives history of trauma that merely attracts his attention to the presence of a swelling

60
Q

Examination in Typical presentation in CLINICAL PICTURE OF Testicular Tumours

A
  1. The testis
  2. The epididymis
  3. Secondary hydrocele
  4. The para-aortic lymph nodes
  5. The inguinal lymph nodes
61
Q

The testis Examination in Typical presentation in CLINICAL PICTURE OF Testicular Tumours

A
  • Enlarged, hard, smooth and heavy, later, soft protuberances appear.
  • Testicular sensation is lost early in the course of the disease.
62
Q

The epididymis Examination in Typical presentation in CLINICAL PICTURE OF Testicular Tumours

A

وهم

  • at first it is normal.
  • Later on there is obliteration of the epididymal sinus.
  • Then it becomes infiltrated with the tumour
63
Q

Secondary hydrocele in Examination in Typical presentation in CLINICAL PICTURE OF Testicular Tumours

A
  • Lax secondary hydrocele is present in 10% of cases

* Just rim of fluid in tunica vaginalis

64
Q

The para-aortic lymph nodes Examination in Typical presentation in CLINICAL PICTURE OF Testicular Tumours

A

May be palpable just above the umbilicus

65
Q

The inguinal lymph nodes Examination in Typical presentation in CLINICAL PICTURE OF Testicular Tumours

A

Are not affected unless the scrotal skin is infiltrated

66
Q

Atypical presentation in CLINICAL PICTURE OF Testicular Tumours

A
  1. Occult presentation
  2. An abdominal mass with an empty scrotal compartment
  3. Hormonal effects
  4. Hurricane type
  5. Simulation of acute epididymo-orchitis
  6. Acute hydrocele.
67
Q

Occult presentation in Atypical presentation in CLINICAL PICTURE OF Testicular Tumours

A
  • Meaning of occult
  • Cough, dyspnea and haemoptysis with Teratoma
  • Enlarged supraclavicular L.N, particularly on the left side with Seminoma
68
Q

Meaning of occult in Occult presentation in Atypical presentation in CLINICAL PICTURE OF Testicular Tumours

A

Silent presentation in local organ but spread to distant organs

69
Q

The reason why left supraclavicular LN++ is indicative of abdominal malignancy

A

Para aortic drain to cisterna chyli then to thoracic duct
Due to obstruction of drainage of thoracic duct to left innominate vein by malignant cells then flow is reversed so malignant cells reach left supraclavicular

So left supraclavicular LN++ is indicative of abdominal malignancy

70
Q

An abdominal mass with an empty scrotal compartment in Atypical presentation in CLINICAL PICTURE OF Testicular Tumours

A

Should raise the suspicion of malignant transformation in an abdominal undescended testis.

71
Q

Hormonal effects in Atypical presentation in CLINICAL PICTURE OF Testicular Tumours

A
  • Infant Hercules with Leydig cell tumours

* Gynaecomastia with Sertoli cell tumours

72
Q

Hurricane type in Atypical presentation in CLINICAL PICTURE OF Testicular Tumours

A

Fatal termination occurs due to metastases from highly malignant tumours

73
Q

highly malignant tumours in Hurricane type in Atypical presentation in CLINICAL PICTURE OF Testicular Tumours

A
  • Malignant Teratoma Trophoplastica (Choriocarcinoma)

* Malignant Teratoma Anaplastica “MTA”

74
Q

Simulation of acute epididymo-orchitis in Atypical presentation in CLINICAL PICTURE OF Testicular Tumours

A

Acute pain and swelling are due to haemorrhage in the tumour

75
Q

Pathogenesis of Acute hydrocele in Atypical presentation in CLINICAL PICTURE OF Testicular Tumours

A

Due to transudation

76
Q

Differential Diagnosis of Testicular Tumours

A
  1. Old clotted haematocele.

2. Calcified hydrocele

77
Q

Staging of Testicular Tumours

A

Stage I

Stage ll

Stage lll

Stage lV

78
Q

Stage I in Staging of Testicular Tumours

A

Tumour in the testis only.

79
Q

Stage ll in Staging of Testicular Tumours

A

involvement of lymph nodes below the diaphragm.

80
Q

Stage lll in Staging of Testicular Tumours

A

Involvement of lymph nodes above the diaphragm

81
Q

Stage lV in Staging of Testicular Tumours

A

Systemic metastases mainly pulmonary & hepatic metastases

82
Q

Investigations of Testicular Tumours

A

(A) Diagnostic Investigations for 1ry lesion

(B) Investigations for secondaries

83
Q

Diagnostic Investigations for 1ry lesion in Investigations of Testicular Tumours

A
  1. Scrotal ultrasound :
  2. Frozen section biopsy via inguinal approach
  3. Tumour markers
84
Q

Benefits of Scrotal ultrasound in Diagnostic Investigations for 1ry lesion in Investigations of Testicular Tumours

A
  • Confirms the presence of the testicular tumour

* Differentiates it from other lesions.

85
Q

Frozen section biopsy via inguinal approach in Diagnostic Investigations for 1ry lesion in Investigations of Testicular Tumours

A
  • Alternative name
  • Cautions
  • Procedures
86
Q

Alternative name for Frozen section biopsy via inguinal approach in Diagnostic Investigations for 1ry lesion in Investigations of Testicular Tumours

A

Chevassu technique

87
Q

Cautions in Frozen section biopsy via inguinal approach in Diagnostic Investigations for 1ry lesion in Investigations of Testicular Tumours

A

Biopsy should never be taken through the scrotum neither by incision nor by needle aspiration

88
Q

The reason why Biopsy should never be taken through the scrotum neither by incision nor by needle aspiration in Cautions in Frozen section biopsy via inguinal approach in Diagnostic Investigations for 1ry lesion in Investigations of Testicular Tumours

A

as this will lead to local implantation with subsequent involvement of the inguinal L.N.

89
Q

Procedures of Frozen section biopsy via inguinal approach in Diagnostic Investigations for 1ry lesion in Investigations of Testicular Tumours

A

a. Through an inguinal incision the spermatic cord is identified and isolated at the internal inguinal ring.
b. A vascular clamp is applied as high as possible on the spermatic cord
c. The testis split opened & any doubtful lesion is subjected to frozen biopsy

90
Q

The reason why A vascular clamp is applied as high as possible on the spermatic cord in Procedures of Frozen section biopsy via inguinal approach in Diagnostic Investigations for 1ry lesion in Investigations of Testicular Tumours

A

to avoid the risk of blood dissemination while manipulating the tumour.

91
Q

Tumour markers in Diagnostic Investigations for 1ry lesion in Investigations of Testicular Tumours

A

a. Beta fraction of human chorionic gonadotrophin (B- HCG)
b. Alpha fetoprotein (alpha - FP) :
c. Lactate dehydrogenase ( LDH ).

92
Q

Beta fraction of human chorionic gonadotrophin in Tumour markers in Diagnostic Investigations for 1ry lesion in Investigations of Testicular Tumours

A
  • Raised in 100% of patients with MTT.

* Raised in 10% of patients with seminoma.

93
Q

Alpha fetoprotein in Tumour markers in Diagnostic Investigations for 1ry lesion in Investigations of Testicular Tumours

A

Elevated in 75% of teratocarcinomas

94
Q

Lactate dehydrogenase in Tumour markers in Diagnostic Investigations for 1ry lesion in Investigations of Testicular Tumours

A

Also tumour marker in :

  • leukemia
  • lymphoma
95
Q

Investigations for secondaries in Investigations of Testicular Tumours

A
  1. Chest X-ray & C.T scan chest.
  2. CT scan abdomen
  3. I.V.P : OLD
96
Q

CT scan abdomen in Investigations for secondaries in Investigations of Testicular Tumours

A

For para-aortic lymph nodes and liver deposits”

97
Q

I.V.P in Investigations for secondaries in Investigations of Testicular Tumours

A
  • Detects the position of the kidneys to be shielded during radiotherapy.
  • Detects the presence and extent of retroperitoneal metastases
98
Q

TREATMENT of Testicular Tumours

A
  • Plan of management
  • Treatment of seminoma
  • Treatment of Teratoma
99
Q

Plan of management in TREATMENT of Testicular Tumours

A
  1. Initial treatment is by high retrograde Inguinal orchiectomy.
  2. Further management depends on the pathology and stage of the tumour.
100
Q

Treatment of seminoma in TREATMENT of Testicular Tumours

A
  • Plan of management

* Stage by stage management

101
Q

Plan of management in Treatment of seminoma in TREATMENT of Testicular Tumours

A
  • Treat one stage ahead To achieve complete recovery As it is curable
  • So we must be aggressive with the TTT
102
Q

Stage by stage management in Treatment of seminoma in TREATMENT of Testicular Tumours

A

Stage I Treatment

Stage ll Treatment

Stage lll Treatment

Stage lV Treatment :

103
Q

Stage I Treatment in Stage by stage management in Treatment of seminoma in TREATMENT of Testicular Tumours

A
  • Radiotherapy to para-aortic lymph nodes and iliac lymph nodes
  • in the form of inverted Y technique .
104
Q

Stage ll Treatment in Stage by stage management in Treatment of seminoma in TREATMENT of Testicular Tumours

A
  • Stage I Treatment

* Radiotherapy is extended to the mediastinum and left supraclavicular L.N.

105
Q

Stage lll Treatment in Stage by stage management in Treatment of seminoma in TREATMENT of Testicular Tumours

A

Radiotherapy & chemotherapy using cisplatinum

106
Q

Stage lV Treatment in Stage by stage management in Treatment of seminoma in TREATMENT of Testicular Tumours

A

Mainly chemotherapy using cisplatinum with or without radiotherapy

107
Q

Treatment of Teratoma in TREATMENT of Testicular Tumours

A
  • Note about Teratoma
  • Stage by stage management
  • Retroperitoneal lymphadenectomy
108
Q

Note about Teratoma in Treatment of Teratoma in TREATMENT of Testicular Tumours

A

The tumour is radio-resistant

109
Q

Stage by stage management in Treatment of Teratoma in TREATMENT of Testicular Tumours

A

Stage I Treatment

Stage ll-lV Treatment

110
Q

Stage I Treatment in Stage by stage management in Treatment of Teratoma in TREATMENT of Testicular Tumours

A
  • Follow up by tumour markers

* Repeated C.T scanning.

111
Q

Stage ll-lV Treatment in Stage by stage management in Treatment of Teratoma in TREATMENT of Testicular Tumours

A

Chemotherapy using combination of :

  • Cisplatinum
  • methotrexate
  • bleomycin
  • vincristine
112
Q

Significance of Cisplatinum in TREATMENT of Testicular Tumours

A

Perfect in germ cell tumours

113
Q

Retroperitoneal lymphadenectomy in Treatment of Teratoma in TREATMENT of Testicular Tumours

A
  • Indication

* Disadvantage

114
Q

Indication of Retroperitoneal lymphadenectomy in Treatment of Teratoma in TREATMENT of Testicular Tumours

A

sometimes needed in teratoma for residual LN

after Chemotherapy

115
Q

Disadvantage of Retroperitoneal lymphadenectomy in Treatment of Teratoma in TREATMENT of Testicular Tumours

A

Retrograde ejaculation occurs after this operation due to interruption of the sympathetic nerve supply to the bladder neck

116
Q

Alternative name for bladder neck in Disadvantage of Retroperitoneal lymphadenectomy in Treatment of Teratoma in TREATMENT of Testicular Tumours

A
  • Sphincter vesicae

* Internal urethral sphincter

117
Q

PROGNOSIS of Testicular Tumours

A
  • Seminoma Prognosis

* Teratoma Prognosis

118
Q

Seminoma Prognosis in PROGNOSIS of Testicular Tumours

A
  • Stage I & II Prognosis

* Stage III & IV Prognosis

119
Q

Stage I & II Prognosis in Seminoma Prognosis in PROGNOSIS of Testicular Tumours

A

5 years survival rate is 95%.

120
Q

Stage III & IV Prognosis in Seminoma Prognosis in PROGNOSIS of Testicular Tumours

A

5 years survival rate is 75%.

121
Q

Teratoma Prognosis in PROGNOSIS of Testicular Tumours

A
  • Stage I & II Prognosis

* Stage III & IV Prognosis

122
Q

Stage I & II Prognosis in Teratoma Prognosis in PROGNOSIS of Testicular Tumours

A

5 years survival rate is 85%

123
Q

Stage III & IV Prognosis in Teratoma Prognosis in PROGNOSIS of Testicular Tumours

A

5 years survival rate is 60%

Surgery.(General 1).Scrotum (8 decks)

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