Testis

​
 * Epidemiology : || An estimated 7600 new cases will be diagnosed each year, resulting in 400 deaths. The incidence is reported to be 3.8 per 100,000 men, and is the leading malignancy in men between ages 20 and 34. The highest incidence is reported in white males in the United States, United Kingdom, and Denmark.¹⁴ ||
 * Etiology: || Risk factors include race with white males having the highest risk factor, and the lowest is found in Asians, Africans, Puerto Ricans, and North American blacks. There is also a higher incidence of disease in those with cryptorchidism, or undescended testes. Patients with one testicular tumor are at increased risk for developing a contralateral malignancy. 5% may develop a contralateral lesion within 5 years.¹ Approximately 50% of men with carcinoma in situ develop develop malignancy within 5 years.¹⁵ ||

Table 1. Diagnostic workup for tumors of the testis 19 || Two broad categories are:
 * Signs & Symptoms: || Usually presents as painless swelling in the scrotum. Sometimes there is pain or tenderness, with 10% reporting acute pain which may be related to torsion of the testicle. Patients rarely display symptoms of metastatic disease such as a neck mass, respiratory problems, or low back pain.¹⁴ ||
 * Diagnostic Procedures: || [[image:Testis.JPG]]
 * Histology: || Germ cell tumors account for 95% of all testicular tumors.
 * 1) Pure seminomas, there are three histological subtypes recognized: classical, anaplastic and spermaatocytic. A newer classification has a variant described as "seminoma with synctiocytotrophoblastic cells."
 * 2) Nonseminomatous germ cell which are more radioresistant are: embryonal carcinoma, teratocarcinoma, yolk sac tumors (the most common chilhood testis tumor) and pure choriocarcinoma. ||
 * Lymph Node Drainage: || Pure seminoma has a greater tendency to remain localized or involve only the lymph nodes. Seminoma spreads in an orderly fashion first to the retroperitoneal lyph nodes (para-aortics) then to the mediastinum and supraclavicular fossae. 19

Figure 1. Primary sites for testicular tumors in retroperitoneal nodes 20

Figure 2. Para-aortic nodes with reference to Pelvic nodes 21 || || __Chemo Therapy__: Cisplatin - nausea, vomiting and alopecia, short term myelosuppresion. Bleomycin - pulmonary fibrosis. In general, late toxicities for chemotherapy include: high-tone hearing loss, neurotoxicity, Raynaud's phenomenon, ichemic heart disease, hypertension, renal dysfunction, pulmonary toxicity. The occurences are low however. Bleomycin, etopiside and cisplation can cause azoospermia but most patient's regain normal spermatogenisis after a time. __Surgery__: mortality rate is less than 1 %. After nodal dissection infection, pulmonary embolus, chylous ascities and hypotension can occur but all are very rare. All of this information is according to Chao, et al. 1 || __Nonseminoma__: the majority of stage I and small lesion stage II patients will survive. Patient's with retroperitoneal or testicular primary tumors have a much better prognosis than patients with mediastinal primary tumors. 5 || __Nonseminoma__ : Initial treatment is radical inguinal orchiectomy followed with chemotherapy. The chemotherapy is four courses of cisplatin, vinblastine and bleomycin or bleomycin, VP-16 and cisplatin. 12 Remaining radiographically demonstrated disease should be resected with irradiation being reserved for palliation in metastatic disease. 13 || Fractionated dose(Gy)- Tetstes-1 Kidney-20, Liver-30, Spine-50, Gastrointestinal-50 1/3 Organ Volume- Kidney 50, Liver-50. 2/3 Organ Volume- Kidney 30, Liver-35 3/3 Organ Volume- Kidney 23, Liver 30.¹⁷ || Figure 1 Figure 2 Figure 3 & 4 ||
 * Metastatic Spread: || Seminoma usually spreads to the retroperitoneum lymph nodes, mediastinum lymph nodes, supraclavicular lymph nodes, lung parynchema, bone, liver, and brain. "Although the routes of dissemination are similar for seminoma and non-seminoma, the propensity for involvement of various sites differs." Non-seminoma will normally involve the lungs and liver.¹⁶ ||
 * Grading: || [[image:table41.2.jpg width="449" height="712"]] ||
 * Staging: || [[image:testesstaging1.JPG width="335" height="270"]]
 * Radiation Side Effects: || __Radiation Therapy__: moderate to sever dyspepsia in 5-6% of patients with doses 30-40 Gy. Peptic ulceration in 2-3% of patients with doses 30-40 Gy. No major complications with doses below 25 Gy. Possible compromise of spermatogenisis.
 * Prognosis: || __Seminoma__ : According to Chao, et. al. it depends highly on the stage and disease extent. Neither histologic subtype nor serum beta-hCG are indicators of prognois. Stage 1 - risk of relapse is 13.4% to 19% with the site of relapse normally being the retroperitonium or the inguinal nodes. Overall survival of 583 patients from 3 different studies was 99.3%. Patients should be followed for 10 years. 2 Stage II prognosis is dependent upon the dissemination of retroperitonial disease. Stage II patients with tumors less than 5 cm have a 95-100% survival rate and patients with tumors greater than 10 cm have an 85-95% survival rate. 3 Stages III and IV have a much worse prognosis than stage II, however, it is rare for a patient to be at this stage at presentation. 4
 * Treatments: || __Seminoma__: Stage I treatment is radical orchiectomy with radiation to the ispsilateral pelvic lymph nodes and the para-aortic lymph nodes with a dose normally to 25 Gy using 160-180 cGy fractions. 6 ​ The fields would be AP and PA in the form of an inverted Y beginning from T10 down to the top of the obturator foramen with one arm only of the Y covering the ispsilateral pelvic nodes with the width of the fields would be 10-12 cm wide in order to cover lymph nodes and the ipsilateral renal hilum. 7 Stage IIA treatment would be the same dose and treatment field as in Stage I. 8 Stage IIB treatment would modify the inverted Y field to ensure coverage of the para-aortic nodes, ipsilateral pelvic nodes and any larger gross disease with a dose to 25-30 Gy using 160-180 cGy per fraction with an additional boost of 5-10 Gy using a reduced field with a minimum 2 cm lesion margin and 180-200 cGy per fraction. 9 Stage IIC treatment is customized to the patient's disease extent and location; however, this applies only if the tumor is centrally located and it does not overlap a kidney or the liver. If the lesion does overlap a kidney or majorly overlaps the liver, then chemotherapy is the primary treatment with a cisplatin containing combination and stage IID should also be treated with cisplatin containing combination chemotherapy. 10 Stage III and stage IV treatment is four courses of cisplatin containing combination chemotherapy along with consolidation radiation therapy to any remaining gross disease if needed and the treatment field shapes and doses in the latter stages would be customized to the extent of the remaining disease if radiation therapy was needed. 11
 * TD5/5: || Single dose (Gy)- Testes-2, Kidney-10, Liver-15, Spine-15, Gastrointestinal-5
 * || [[image:Seminoma_3.jpg]]
 * __References__**

1. Chao KS, Perez CA., Brady LW. //Radiation Oncology - Management Decisions//. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002:478-479. 2. Chao KS, Perez CA., Brady LW. //Radiation Oncology - Management Decisions//. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002:473-475. 3. Roach III M, Small E, Reese DM, et. al. Urologic and male genital cancers. In: Rubin P, ed. //Clinical Oncology: A Multidisciplinary Approach// //for Physicians and Students//. 8th ed.Philadelphia, PA: W.B. Saunders Company; 2001:553. 4. Chao KS, Perez CA., Brady LW. //Radiation Oncology - Management Decisions//. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002:474. 5. Chao KS, Perez CA., Brady LW. //Radiation Oncology - Management Decisions//. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002:474. 6. Kuban DA. Male reproductive and genitourinary tumors. In: Washington CM, Leaver D, eds. //Principles and Practice of Radiation Therapy//. 2nd ed. St. Louis, MO: Mosby; 2004:828. 7. Kuban DA. Male reproductive and genitourinary tumors. In: Washington CM, Leaver D, eds. //Principles and Practice of Radiation Therapy//. 2nd ed. St. Louis, MO: Mosby; 2004:829. 8. Chao KS, Perez CA., Brady LW. //Radiation Oncology - Management Decisions//. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002:475. 9. Kuban DA. Male reproductive and genitourinary tumors. In: Washington CM, Leaver D, eds. //Principles and Practice of Radiation Therapy//. 2nd ed. St. Louis, MO: Mosby; 2004:828. 10. Kuban DA. Male reproductive and genitourinary tumors. In: Washington CM, Leaver D, eds. //Principles and Practice of Radiation Therapy//. 2nd ed. St. Louis, MO: Mosby; 2004:828-829. 11. Kuban DA. Male reproductive and genitourinary tumors. In: Washington CM, Leaver D, eds. //Principles and Practice of Radiation Therapy//. 2nd ed. St. Louis, MO: Mosby; 2004:828-829. 12. Kuban DA. Male reproductive and genitourinary tumors. In: Washington CM, Leaver D, eds. //Principles and Practice of Radiation Therapy//. 2nd ed. St. Louis, MO: Mosby; 2004:829. 13. Chao KS, Perez CA., Brady LW. //Radiation Oncology - Management Decisions//. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002:476. 14. Washington CM, Leaver D, eds. //Principles and Practice of Radiation Therapy//. 2nd ed. St. Louis, MO: Mosby. 2004. 15. Chao KS, Perez CA., Brady LW. //Radiation Oncology - Management Decisions//. 2nd edition. Philadelphia, PA: Lippincott, Williams & Wilkins. 2002. 16. Washington CM, Leaver D, eds. //Principles and Practice of Radiation Therapy//. 2nd ed. St. Louis, MO: Mosby; 2004. 17. Chao KS, Perez CA., Brady LW. Radiation Oncology- Management Decisions. 2nd edition. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002, pg 104. 18. www.wikispaces.com/upload. Accessed 01/29/2010 bmp Images; Figure 1-4 19. Chao KS, Perez CA., Brady LW. //Radiation Oncology - Management Decisions//. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002 20.www.cancernetwork.com Accessed 1/29/10 21 . [|www.cancerhelo.org.uk] Accessed 1/29/10