Overview of the Testicles

The three cell types to be concerned with are the sperm producing cells, Sertoli cells (supporting cells in the tubules) and the Leydig cells that are found between the tubules and produce testosterone.

Now the diseases…

Cryptorchidism

·         Condition where one or both of the testes fail to descend

·         Incidence is 1% in 1 year old boys

·         The testes can either be lodged in the abdomen, inguinal ring (where it is exposed to trauma), or upperscrotal region (most common).

·         This condition can lead to seminomas in 10% of patients and aspermatogenosis

·         Must be treated before the age of 2 or patient will never develop sperm in affected testes

Testicular Torsion

·         Violent and sudden twisting of the testes

·         Leads to an occlusion of the blood vessels (veins are affected first then the arteries), blood continues to come in but can’t get out leading to an infarct

·         Extremely painful
 

Testicular Tumors

Broken into two groups:

• Germ Cell tumors
  • 95% of all testicular tumors
  • Most common tumor in males between the ages of 15 and 34
  • Predominately occurs in whites (5:1 white to black ratio)
  • Very aggressive tumors
  • Predisposing factors -cryptorchidism,genetic,
    testicular dysgenesis
• Non germ cell tumors: include tumors of the Sertoli and Leydig cells

This is the specific list of testicular tumors that was given in class:

The tumors of one histological pattern are more common in children (Yolk Sac tumor being the most common) and tumors of multiple histological patterns are more common in adults.

Clinically, these tumors are classified by two groups, seminomas or non-seminomas.

Seminomas

• Most common type of GCT and tend to mimic gonadal structures
• Tumors peak in the 30s
• Comprised of three histological variants
  • Classic
  • Anaplastic
  • Spermatocytic:  occur most frequently in elderly men.  More mature germ cells in these tumors mean a better prognosis
• Tumors can grow to replace almost the entire testes
• Histologically, there are usually islands of the seminoma found.  Also in close proximity there may be areas of intratubular preneoplastic cells. (there are histological pictures online)

Non-seminomas (comprised of the following types)

• Embryonal carcinoma
• Yolk Sac tumor
• Choriocarcinoma
• Teratoma
• Mixed tumors

Embryonal Carcinoma:  tend to be hemorrhagic and necrotic and are very aggressive.  Histologically there are no clear cells or distinctive cell borders because they overlap each other.
 

Teratomas:  can be mature (seen in children) or immature (seen in adults).  In the mature form, the cells have fully developed and differentiated into what they are supposed to become.  Immature teratomas may show signs of what they are supposed to become, but they haven’t fully developed yet.  It’s important to remember when dealing with teratomas, there are usually residual masses left after treatment.  These can compress vital organs and cause serious problems. (pictures online show cartilage in the testicles)
 

Mixed germ cell tumor:  exactly what it says it is.  (there is a picture online of a teratoma (cartilage) and an embryonic carcinoma in the same testicle)

Clinical features of testicular cancer:

• Testicular masses are always considered neoplastic unless proven otherwise
• Usually present as painless emlargements
• The mode of spread can either be lymphatic or hematologic
• There are biological markers that can be used to detect tumors, contribute to the staging or help determine if the tumor has reoccurred. (α-fetoprotein in yolk sac tumors and HCG in choriocarcinoma)
   

Tumor Staging

Stage 1:  local disease

Stage II:  Lymph node involvement

            -IIa- has a lymoh node mass of <2 cm

            -IIb-  lymph node mass from 2 to 5 cm

            -IIc-  lymph node mass >5 cm

Stage III:  Distant metastases
 

Treatment of testicular tumors

• Local excision:  the cord needs to be resected also
• For seminomas, radiotherapy can be used as prophylaxis
• For NSGCT and advanced seminomas, patients need to be carefully monitored with retroperitoneal lymphadenectomy or chemotherapy
   

Prognosis:

• Seminomas
  • Radiation and chemotherapy work very well
  • 70% are only stage I
  • Can remain localized in the testes for a very long time, leading to a better prognosis
  • 95% of Stage I and II can be cured
• Non seminomas
  • 60% will present in the advanced stages
  • Tend to metastasize more quickly leading to a worse prognosis (usually by hematogenous spread)
  • Tend to be resistant to radiation
  • Treatment is geared toward the non seminoma group regardless of the specific type
  • 85% can achieve remission with aggressive therapy
  • Cure rate is 60% for patients with a poor prognosis

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