testicular cancer

1. ROLE OF SURGERY IN
TESTICULAR CANCER
Dr.A.Joseph Stalin

2. Testicular cancer
vs
Squamous cell carcinoma/
Adenocarcinoma

3. Biology of Testicular malignancy
• Primordial germ cells
• Over expression of stem cell genes
• Rapidly dividing cells
• Highly responsive to Chemo & Radiotherapy.

4. Testicular cancer Vs SCC/Adeno ca
• Radiotherapy dose : 20-30 Gy.
• Chemotherapy dose :
Cisplatin -20 mg/m2
Bleomycin -30 units weekly

5. Surgery has limited and selective
role in management of Testicular
cancer

6. Role of Surgery
• 1.Radical High Inguinal Orchidectomy
- PRIMARY TREATMENT of testicular malignancy
- STAGING
- PROGNOSTICATION
- MANAGEMENT PROTOCOL based on surgery.

8. PRINCIPLES OF ORCHIDECTOMY
– Early ligation of cord at
deep ring level
– Stump should be pushed
into retro peritoneum
( future removal with
RPLND)
8

9. CHEVASSU MANEUVER

10. 2. Hemi Scrotectomy
with Radical orchidectomy
• In patients who have undergone trans scrotal
procedures.
• Risk of Inguinal and pelvic lymphatic spread.

11. Chemotherapy should never be
started without doing Radical High
Inguinal orchidectomy & Post
orchidectomy tumour markers.

12. 3.RPLND
• In Pure Seminoma , RPLND has NO ROLE
except for ,
- Post chemo residual mass (>3 cm) with
normal tumour markers and PET positive cases.

13. RPLND
• In Non Seminomatous GCT, role can be
- Prophylactic RPLND
- Therapeutic RPLND
- Post chemo RPLND
- Desperate RPLND

14. Prophylactic RPLND
• Indication : NSGCT Stage: IA,IB
• Rationale: 30 % of stage I harbour occult mets.
• Advantage:
Defnitive patholoigcal nodal staging
Disadvantage : Surgical morbidity/over treatment.

15. Therapeutic RPLND
• Indication :
NSGCTStage II (Low burden, markers negative)
• Advantage: Complete removal of viable GCT,
Chemo resistant teratoma.

16. Post Chemo - RPLND
-Post Chemo - RPLND is indicated in the setting of normalized
tumor markers with radiographic evidence of a residual
retroperitoneal mass (≥ 1 cm) after induction chemotherapy
• Done at 6 weeks following chemotherapy.

17. HISTOLOGY in retroperitoneal
specimen
after induction chemotherapy
• Necrosis/fibrosis – 45%
• Teratoma-40%
• Viable GCT-15%
AFTER SECOND LINE
CHEMOTHERAPY
• Viable GCT- 50%
• Teratoma - 40%
• Necrosis / Fibrosis -10%

19. Role of Chemo after Post Chemo -
RPLND
• Two additional cycles of chemotherapy following complete resection of
viable GCT (> 10% of the specimen)after first chemotherapy remains a
common standard of care with a cure rate of 70%
• When necrosis or teratoma is present, no additional chemotherapy is
required

20. Why is it important to remove
teratoma?
• Teratoma though benign is biologically
unpredictable
• Left un-resected, possesses the potential to
invade adjacent organs (growing teratoma
syndrome)
• Undergo malignant transformation
• Increases the risk of late relapse

21. GROWING TERATOMA SYNDROME
• Tumor growth with declining tumor markers
occurring during chemotherapy
• Needs early surgical intervention and
completion of chemotherapy after surgery

22. DESPERATION RPLND
• Persistently elevated or increasing tumor markers after
primary induction chemotherapy, failed salvage
chemotherapy
• Completely resectable retroperitoneal masses
• Technically difficult
• 20% to 55% - 5-year survival rate

23. ANATOMY
1. Lymphatics of the testis drain into the
retroperitoneal lymphnode chain extending
from T11 to L5,concentrated in the renal hilum
2. Common embryologic origin with kidney
3. Surgical mapping studies by Donohue et al
divides the retro-peritoneum into specific
anatomic regions

24. • The sympathetic fibers that mediate
seminal emission originate primarily
from the T12 to L3 thoraco lumbar
spinal cord.
• After leaving the sympathetic trunk,
the fibers converge towards the
midline and form the hypogastric
plexus near the takeoff of the inferior
mesenteric artery (IMA) just above
the aortic bifurcation.

26. TYPES OF RPLND
EXTENT OF DISSECTION
Bilateral supra hilar/extended template
Bilateral infra hilar / Standard template
Nerve Sparing
Unilateral modified template
Nerve dissecting bilateral template

27. Suprahilar
• Supra-hilar metastasis
rare in low stage NSGCT
• Reserved for residual
hilar or suprahilar
masses following
chemotherapy
• Higher complication
rates
• Chylous ascites

31. Complications
• Retrograde Ejaculation
• Infertility
• Prolonged ileus
• Hemorrhage
• Ureteral injury
• Injury to major viscera
• Mortality <1%
• Lymphocele
• Wound infection
• Atelectasis
• Pulmonary embolism
• Bowel obstruction
• Wound dehiscence

32. Role of surgery
• EXTRA GONADAL Germ cell tumour :
Sacro coccyxeal region, mediastinum
• NON GERM CELL TUMOUR :
Surgery is the main modality of treatment

33. CONCLUSION
• Role of Surgery :
• High Inguinal Orchidectomy is the primary
treatment.
• Other surgical options include :
Hemi scrotectomy.
RPLND
Metastectomy/Wide local excision.

34. Thank You