testicular tumor, infertility

TESTICULAR TUMOURS

 About 99 per cent of testicular neoplasms are malignant.

 About 1—2 per cent of total malignant tumours in men Any solid testicular mass in young patient – must rule out malignancy Slightly more common in right testis (corresponds with slightly higher incidence of right-sided cryptorchidism)

 Primary tumour • Most common solid malignancy in males aged 15-34 years

 • Undescended testicle has increased risk (10-40x) of malignancy Types germ cell tumours 95 % (all are malignant); seminoma nonseminomatous germ cell tumours (NSGCT); embryonal cell carcinoma, teratoma, choriocarcinoma, yolk sac tumour, mixed cell type non-germinal cell tumours (usually benign) • Leydig (testosterone, precocious puberty) • Sertoli (gynecomastia, decreased libido) Secondary tumour It usually occur in male more than 50 years of age, metastases (e.g. lung, prostate, GI) Etiologic factors • Congenital: cryptorchidism • acquired: trauma, atrophy, sex hormones abnormalities Signs and symptoms The patient may not seek advice for several months after first noticing that he has a painless testicular lump. A sensation of heaviness or sever pain if intratesticular hemorrhage or infarction happens. • Firm, non-tender mass • Dull, heavy ache in lower abdomen, anal area or scrotum • associated hydrocele •In advanced disease; gynecomastia due to secretory tumour effects, Metastatic disease related back pain, supraclavicular and inguinal nodes involvements • Abdominal mass (retroperitoneal lymph node metastases) Investigations • Testicular ultrasound (hypoechoic area within tunica albuginea = high suspicion of testicular cancer) • Chest x-ray (lung metastases) •Tumour markers for staging (human chorionic gonadotrophin, alpha-foetoprotein and lactate dehydrogenase). • CT abdomen/pelvis (retroperitoneal nodes enlarged) • Needle aspiration contraindicated Diagnosis is established by orchiectomy and histopathologic exam. Staging Clinical staging • Stage 1: testis lesion only —no spread; • Stage 2: lymph nodes below the diaphragm only; • Stage 3: lymph nodes above the diaphragm; • Stage 4: pulmonary or hepatic metastases. Pathologic staging (at orchiectomy) • T1 – tumour confined to testicular body • T2 – tumour extends beyond tunica albuginea • T3 - tumour involves rete testis/epididymis • T4A – tumour invades spermatic cord • T4B – tumour invades scrotal wall Tumour markers • ?-human Chorionic Gonadotropin and Alfa Fetoproteins are positive in 85% of non-seminomatous tumours • Pre-orchiectomy elevated marker levels return to normal post-operatively if no secondaries Treatment • Radical inguinal orchiectomy and radiation (90% survival) • Adjuvant chemotherapy for metastatic disease Prognosis • 99% cured with Stage I, Stage II • 70-80% completes remission with advanced disease INFERTILITY Infertility is defined as the inability to conceive after 1 year of unprotected sexual intercourse. Infertility affects approximately 15% of couples. Roughly 40% of cases involve a male factor, 40% involve a female factor, and the remainder involves both sexes. Male Reproduction _ hypothalamus-pituitary axis _ LH ––> Leydig (intersititial) cells ––> testosterone synthesis/secretion _ FSH ––> Sertoli cells ––> structural and metabolic support to developing spermatogenic cells _ Sperm route: epididymis ––> vas deferens ––> ejaculatory ducts ––> prostatic urethra Etiology Hormonal • hypothalamic-pituitary-testicular axis. Testicular • varicocele. • tumour • Congenital (Klinefelter’s triad: small, firm testes, gynecomastia and azoospermia) • cryptorchidism • post infectious (epididymo-orchitis, STDs) • Torsion not corrected within 6 hrs iatrogenic • Radiation, antineoplastic and antiandrogen drugs can interfere with sperm transport and production lifestyle (“bad habits”) • drugs (marijuana, cocaine, tobacco, EtOH, prescription) • increased testicular temperature (sauna, hot baths, tight pants/briefs) surgical complications • Testes (vasectomy, hydrocelectomy) • Inguinal (inadvertant ligation of vas deferens) • Bladder/prostate (damage to bladder neck causing retrograde ejaculation, damage to ejaculatory ducts) • Abdomen (damage to sympathetic nerves causing retrograde ejaculation) Semen Transport • Cystic fibrosis (typical - obstructive azoospermia; atypical – congenital absence of the vas deferens, Bilateral ejaculatory duct obstruction,or bilateral obstructions within the epididymis) • Kartagener’s syndrome • Congenital absence of vas deferens, obstruction of vas deferens Investigations • Normal semen analysis (at least 2 specimens) - Volume: 2-5 mL - Concentration: > 20 million sperm/mL - Morphology: > 30% normal forms - Motility: > 50% (most important abnormality) - Liquefaction: complete in 20 minutes - PH: 7.2-7.8 - WBC: < 10 per high power field or < 106 WBC/ml semen • hormonal evaluation • Testosterone for evaluation of HPA (hypothalamic-pituitary- adrenal) • FSH measures state of sperm production • Serum LH and prolactin are measured if testosterone or FSH are abnormal • Chromosomal studies (Klinefelter’s Syndrome - XXY) • Immunologic studies (antisperm antibodies in ejaculate and blood) • Testicular biopsy • Scrotal U/S (varicocele, testicular size) • vasography (assess patency of vas deferens) Treatment Lifestyle • Regular exercise, healthy diet • cut out “bad habits” Medical • Endocrine therapy (see Endocrinology Chapter) • Therapy for retrograde ejaculation (finding of sperm within postejaculate bladder urine) • discontinue anti-sympathomimetic agents, may start alpha-adrenergic stimulation (phenylpropanolamine, pseudoephedrine, or ephedrine) • treat underlying infections surgical • varicocelectomy • vasovasostomy (vasectomy reversal) • epididymovasostomy • Transurethral resection of blocked ejaculatory ducts Assisted reproductive technologies (ART) ––> refer to Ob/Gyn specialist • Sperm washing + intrauterine insemination (IUI) • In vitro fertilization (IVF) • Intracytoplastmic sperm injection (ICSI) auterine insemination (IUI) • In vitro fertilization (IVF) • Intracytoplastmic sperm injection (ICSI)