Clinicopathological study of testicular tumors: an experience in a tertiary care hospital in Kashmir valley, Jammu and Kashmir, India

INTRODUCTION

Tumors are the major pathology affecting testis. Testicular cancer comprises 1% of all the male cancers worldwide.¹ Testicular tumors are most commonly encountered in 15-35 years age group.² In western countries incidence of these tumors is on rising trend.³ However, in India, its incidence is low i.e. 15.92%.⁴

Majority of the testicular tumors arise from germ cells and more than 50% of tumors comprise of more than one histological type of tumor. The exact cause and pathogenesis of these tumors is unknown; however, it is postulated that the disease process begins in fetal life and comprise of abnormal proliferation of primordial germ cells.^5,6 There are various risk factors for development of testicular cancer which include cryptorchidism (testicular maldescent), carcinoma in situ (intratubular germ cell neoplasia), history of testicular cancer or extragonadal germ cell tumor, family history, HIV infection, Down syndrome, and testicular trauma.⁷

The commonest presentation of testicular tumor is a nodule or painless swelling of one gonad. Other signs and symptoms include undescended testis or cryptorchidism, epididymo-orchitis, hydrocele, dull ache or dragging sensation in the lower abdomen or scrotum, and rarely infertility.^8-11

Marked advances have been achieved in the treatment of testicular tumors with complete remission possible in the early cases; thus, institution of an early and correct histopathological diagnosis is indispensable.

In 2004, WHO has classified testicular and paratesticular neoplasia into various subgroups and same were incorporated in present study.¹²

The objective of this study was to analyze the patterns of testicular tumors at a tertiary level hospital in Kashmir valley highlighting the patient’s demography, clinical presentation, diagnostic evaluation and pathological finding.

METHODS

The present (retrospective and prospective) study was conducted in the Department of Pathology in collaboration with the Department of Surgery, Government Medical College, Srinagar, Jammu and Kashmir, India and included all orchidectomies done for testicular tumors received in the department over a period of five years (January 2012 to December 2016). For the retrospective study, all cases of testicular tumors, their histopathological reports and required clinical details were searched from records maintained in the Department of Pathology, GMC Srinagar. All clinically relevant data including patient’s age, laterality, history of risk factors and serum tumor markers was collected from the records. For the prospective study, the orchiedectomy specimens were received from department of Surgery, GMC Srinagar. Tissue specimen received by our department after proper labeling were subjected to gross and detailed histopathological examination. The specimens were fixed in 10% buffered formalin. After fixation, a comprehensive examination of the gross specimen was done under following headings: laterality, external surface, color and consistency, size of tumor, encapsulation, appearance of cut surface, presence of necrosis, cystic change or hemorrhage, surrounding testicular tissue, epididymis and spermatic cord. Lymph nodes, if any were also studied. The most representative areas of each case were found and 1.5 x 1 cm sized sections were taken from tumor. The tissue was processed as per standard procedure. 3-4 micron thick sections were cut on microtome and stained by haematoxylin and eosin stain. The tumors were classified according to WHO classification (2004).¹²

Inclusion criteria

All patients attending the surgery OPD who presented with testicular swelling and those admitted in the wards with a solid, firm intratesticular mass that can’t be transilluminated.

Exclusion criteria

Patients in whom swelling was found to be non-neoplastic on clinicopathological examination were excluded from study.

RESULTS

A total of 37 cases of clinically recognized testicular masses were evaluated during the study period of 5 years. All these cases were studied clinically and detailed histopathological examination was done. Preoperative assay of relevant tumor markers were also noted from case records.

Various aspects of clinical presentation were studied. Out of 37 cases studied, 51.35 % of patients presented with scrotal swelling only. Swelling was associated with pain in 4 cases and with hydrocoele in 2 cases. A history of cryptorchidism (undescented testis) was noted in 9 cases and family history of testicular neoplasm in 1 case (Table 1).

In the present study predominant right side involvement was seen comprising of 26 cases (70.3%). There was no bilateral involvement in present study (Table 2).

Preoperative assay of tumour markers showed elevated α-fetoprotein and β-human chorionic gonadotrophin levels in 3 (8.10%) and 16 cases (43.24%) respectively.

The present study witnessed a wide range of age distribution ranging from 2 years to 70 years. Maximum number of cases was seen in the age group of 41-50 years followed by 31-40 years with a mean age of 35.1 years. All cases of mature cystic teratoma were seen in 1^st and 2^nd decade, whereas, lymphomas were seen in 60-70 year age group (Table 3).

The study work comprised of 37 cases of testicular tumors among which 31 (83.78%) cases were malignant and 6 (16.22%) were benign (Table 4).

Out of total 37 cases, 36 (97.3%) cases were testicular and 1 (2.7%) was a paratesticular neoplasm. On histologic typing of the 37 cases according to the WHO classification, a predominance of Germ cell tumors was seen. Of the 37 cases, 28 (75.7%) were Germ cell tumors of one histological types including 15 cases of Classical Seminoma, 8 cases of Teratoma, 2 cases each of embryonal carcinoma and spermatocytic seminoma and 1 case of yolk sac tumor and 5 (13.51%) were testicular germ cell tumors of mixed histological types. A single case of paratesticular neoplasm was reported as Leiomyosarcoma (Table 5).

DISCUSSION

In the present study, 37 patients of testicular and paratesticular tumors were studied. Various parameters relating to clinicopathological aspect were studied thoroughly and findings were compared with the various other renowned authors who studied testicular tumors. In our study, wide age range was observed ranging from 2-70 years with a mean age of 35.1 years age. Our findings were quite similar to the findings of Salako AA et al who found age variation from 4-70 years of age.¹³ Peak age incidence was seen in the age group of 41-50 years followed by 31-40 years. Lattin H et al also found the peak prevalence to be in the 3^rd and 4^th decade.¹⁴

Testicular tumors in present study were predominantly right sided (70.3%). Right sided predominance for testicular tumors was observed by various other authors in their studies as Deotra et al (60%) and Shirish et al (56%).15,16 There was no bilateral involvement in present study.

Scrotal swelling was the commonest mode of presentation seen in 25 (67.57%) patients. Tan et al found testicular swelling in 100% of cases.¹⁷ In present study undescended testis was seen in 9 cases (24.32%). The incidence of undescended testis in our study was slightly higher as compared to study by Woodward (3.5-14.5%).¹⁸

In this study, germ cell tumors were the commonest testicular tumors. Of 33 germ cell tumors, 28 (84.48 %) tumors were of one histological type, and 5 (15.15%) tumors were of more than one histological type comparable to the findings of Naqvi et al and Chandanwale et al.^19,20 Among the tumors of one histologic type, seminoma was the most common neoplasm in the present study constituting about 40.54 % of all tumors. Our finding was comparable with the studies of Moghe et al (41.6%) and Mushtaq et al (44.4%).^21,22

In present study, most common non-seminomatous germ cell tumor of one histologic type was found to be teratoma which constituted 21.62% of all testicular tumors. Salako et al found 12.5% of teratomas out of 26 cases of testicular and paratesticular tumors studied over 17 years.¹³ The most common combination of germ cell tumours in present study was teratocarcinoma (immature teratoma with embryonal carcinoma) accounting for 3/5 cases (60%) followed by 1 case (20%) of yolk sac tumor with embryonal carcinoma and 1 case (20%) of seminoma with teratoma. Our findings were in accordance with previous study in which teratocarcinoma was commonest subtype.¹⁵

Primary malignant lymphomas of testis are rare and constitute about 5% of all testicular neoplasm.²³ In present study lymphomas were second most common tumour constituting about 8.1% of all testicular tumors with mean age of 66.66 years. These findings were in accordance with the series from Pakistan which showed Non Hodgkin’s lymphoma were quite frequent, which was reason for second peak in over 60 year’s age group.^22,24

In present study we also observed 1 case of paratesticular neoplasm in a 50 year old person which on histology was seen to be leiomyosarcoma (Figure 6 and 7). Immunohistochemistry was also done for confirmation. In contrast to our study, rhabdomayosarcomas were most common variety of paratesticular neoplasm in a study from south western Nigeria.¹³

CONCLUSION

The incidence of testicular neoplasm still remains low in India. Peak age incidence was seen in the age group of 41-50 years followed by 31-40 years. Testicular tumors in our study were predominantly right sided and the commonest presentation was a painless scrotal swelling. Histologically germ cell tumours accounted for highest percentage of cases with a commonest subtype of seminoma followed by mixed germ cell tumour. 6 cases were reported as benign in present study, which highlights that any testicular swelling should be evaluated thoroughly with clinicopathological correlation to rule out malignancy. From this study we conclude that despite new techniques in imaging and tumor marker assay, the diagnosis of testicular tumors is dependent upon histopathological examination.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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