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Testicular lesions

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									Testis and Adnexae
Normal Testis
         Lesions of the Testis

• 1.Inflammatory
• 2.Neoplastic
• 3.Others
        Inflammatory Lesions
GONORRHEA
MUMPS
 20% of adult males with mumps
 Complications: may cause atrophy and sterility
TUBERCULOSIS
 Epididymitis
 granulomatous inflammation, caseous necrosis
                  Syphilis
Testis may show gumma
Manifestation of tertiary syphilis
Microscopy : Obliterative endarteritis
 with plasma cell infiltration – characteristic
 histologic finding
               Torsion of Testis
• Causes:
• Violent movement
• Physical trauma
• Cryptorchid testis
- Venous + arterial
   obstruction
• Hemorrhagic Infarction
• Acute surgical emergency
• Untwist , orchiopexy-
   within 6 hrs
Testicular Neoplasms
                 Objectives
• Classification of testicular tumors
• Etiology of Testicular tumors
• Morphological features of
  – Seminoma
  – Teratoma
• Spread of testicular tumors
• Clinical features
• Diagnosis
            Epidemiology

– most important cause of painless
  enlargement of testis
– whites > blacks (US),5:1 ratio
– peak incidence 15-34 yrs
        Testicular tumors


                   NON GERM CELL TUMORS
GERM CELL TUMORS   ( SEX CORD STROMAL TUMORS)


 95%                   Rare
 Malignant             Benign
 Aggressive
             Germ Cell Tumors
Predisposing factors:
• Cryptorchidism (higher the location ↑↑ risk)

• testicular dysgenesis (feminisation, Klinefelter’s
  syndrome)

• Genetic factors -siblings 10 fold ↑ risk, i(12p))-
  additional copy of the short arm, mainly by
  isochromosome of the short arm
  TYPES OF GERM CELL TUMORS
                           >60 % mixed
                         germ cell tumors
 Seminoma                 Eg: seminoma+
                         embryonal ca etc

Embryonal carcinoma
Yolk sac tumor             Non-
                           Seminomatous
Choriocarcinoma            Germ cell tumors
Teratoma
Mixed germ cell tumors
   Non- Germ cell tumors ( Sex –cord
               stromal tumors)

• Leydig cell tumor
  Sertoli cell tumor
               Seminoma

• Most common germ cell tumor
• Peaks in 3rd decade
• Gross : bulky masses, testicular contour is
  maintained, c/s- homogenous grey-white
  lobulated surface, no h’age/necrosis
Seminoma-gross
        • Fairly well
          circumscribed,
          pale, fleshy,
          homogenous mass
Seminoma
Seminoma
    •    A small rim of
        remaining normal
        testis appears at the
        far right. The tumor
        is composed of
        lobulated soft tan to
        brown tissue
seminoma
Seminoma Gross Morphology
             • The cut surface
               shows a cream-
               colored, soft,
               fleshy, multinodular
               tumor bulging from
               the surrounding
               testicular
               parenchyma. Note
               a satellite nodule
               on the lower left.
Seminoma Gross Morphology
             • The tumor consists
               of multiple soft
               pink-tan nodules.
               The firm whitish
               areas nearby
               showed extensive
               intratubular germ
               cell neoplasia.
 Seminoma-microscopy
Normal       tumor
Seminoma-high power
Seminoma-Microscopy
Seminoma
     • Diffuse sheets of
       tumor cells with
       clear cytoplasm
       separated by
       fibrous trabeculae
       containing
       lymphocytes
Seminoma
     • The lymphocytic
       infiltrate in the
       fibrous trabeculae
       separating tumor
       cells is more clearly
       seen here
Seminoma Lymphoid Infiltrate
               • Note the
                 lymphocytic
                 infiltrate
                 surrounding
                 clusters of tumor
                 cells creating a
                 pseudoglandular
                 appearance.
Seminoma
     • The cytoplasm of
       seminoma cells is
       usually clear to lightly
       eosinophilic. The
       cytoplasmic clearing is
       due to glycogen content
       which can be
       demonstrated by PAS
       positivity. The nuclei are
       round to oval with
       granular chromatin and
       prominent nucleoli.
Seminoma Lymphoid Reaction
              • Lymphocytic infiltrate
                in fibrous trabeculae
                and perivascular
                spaces is seen in
                virtually all cases of
                classic seminoma.
                Occasional cases such
                as this one show florid
                lymphoid reaction
                with formation of
                germinal centers.
Spermatocytic Seminoma
Spermatocytic Seminoma Touch Prep
                • This air-dried and
                  DiffQuik-stained touch
                  prep from freshly-
                  sectioned surface of a
                  spermatocytic seminoma
                  clearly demonstrated 3
                  cell populations:
                  numerous small
                  lymphocyte-like cells,
                  intermediate cells with
                  filamentous chromatin,
                  and rare giant cells.
Spermatocytic Seminoma Touch Prep

                  • This alcohol-fixed
                    and hematoxylin &
                    eosin-stained touch
                    prep also
                    demonstrates the
                    three cell
                    populations seen in
                    spermatocytic
                    seminoma.
Spermatocytic Seminoma
            • The tumor cells are
              arranged in diffuse
              sheets. Note the
              filamentous
              chromatin and
              prominent nucleoli
              in the intermediate
              cells.
             Teratoma
• Group of complex tumors having
  various cellular or organoid
  components reminiscent of normal
  derivatives from more than one
  germ layer.
         Teratoma




                    Teratoma with
Mature   Immature     malignant
                    transformation
              Teratoma

– Up to 10% of GCT
– Most frequently components of mixed germ
  cell tumors
• May occur at any age from infancy to adult
  life.
• Pure forms common in infants and children,
  second only in frequency to yolk sac tumors.
• In adults, pure are rare, constituting 2% to 3%
  of germ cell tumors.
         Teratoma
      Morphology-Gross
• Usually large, ranging
  from 5 to 10 cm in
  diameter.
• Composed of various
  tissues, the gross
  appearance is
  heterogeneous, with
  solid, sometimes
  cartilaginous and cystic
  areas.
            Teratoma-Morphology.
• Hemorrhage and necrosis usually indicate
  admixture with embryonal carcinoma,
  choriocarcinoma, or both.
TERATOMA- variegated cut surface
          with cysts
Mature teratoma
• Immature
  teratoma
             Teratoma

             Microscopy




Ectodermal   Mesodermal   Endodermal
                Microscopy
• Composed of a heterogeneous, helter-skelter
  collection of differentiated cells or organoid
  structures.
• neural tissue,
• muscle bundles,
• islands of cartilage,
• clusters of squamous epithelium,
• structures reminiscent of thyroid gland,
  bronchial or bronchiolar epithelium, and bits
  of intestinal wall or brain substance,
• all embedded in a fibrous or myxoid stroma.
• Elements may be
  – mature (resembling various tissues within the
    adult) or
  – immature (sharing histologic features with fetal or
    embryonal tissue).
• Dermoid cysts and epidermoid cysts, common
  in the ovary, are rare in the testis.
• Shows disorganized collection of glands,
  cartilage, smooth muscle ,and immature
  stroma.
Teratoma-Shows disorganized
collection of glands, cartilage,
               Mature teratomas
display a variety of somatic-type tissues, including cartilage
Teratoma-Microscopy
Teratoma-Microscopy
Teratoma-Microscopy
Teratoma-Microscopy
Teratoma-microscopy
Islands of squamous epithelium in mature
                teratoma
Intestinal-type glands complete with goblet
          cells in mature teratoma
Teratoma-Microscopy
           • The intestinal-type
             glands show
             nuclear
             hyperchromasia;
   Immature teratoma. -Low-grade immature
myxomatous stroma surrounds a tubular structure
Islands of small hyperchromatic cells (blastema) are surrounded
          by myxomatous stroma and primitive glands
Immature teratoma
Immature teratoma
         • Primitive
           neuroepithelium
           consisting of small
           hyperchromatic cells
           arranged in rosettes
Immature Teratoma-Glands, cartilage, smooth muscle
              and immature stroma
Immature Teratoma-Glands& stroma
Immature Teratoma-Immature neural & epithelial
                  elemets
  Teratoma with malignant transformation

• Malignancy in derivatives of one or more
  germ cell layers.
• There may be a focus of
   – squamous cell carcinoma,
   – mucin-secreting adenocarcinoma, or
   – sarcoma.
Testis: Teratoma with malignant transformation
Teratoma with malignant transformation
             Teratoma-Prognosis
• In children, mature teratomas behave as benign
  tumors, all have a good prognosis.
• In the postpubertal male, all are regarded as
  malignant and capable of metastatic behavior,
  regardless of whether the elements are mature or
  immature.
• It is not critical to note histologic differentiation in a
  postpubertal male with a testicular teratoma.
          CLINICAL FEATURES-Testicular tumours



• Painless Swelling of
  One Gonad
• Dull Ache or
  Heaviness in Lower
  Abdomen
• 10% - Acute Scrotal
  Pain
              CLINICAL FEATURES-Testicular tumours


• 10% - Present with
  Metatstasis
   - Neck Mass / Cough /
   Anorexia / Vomiting / Back
   Ache/ Lower limb swelling
• 5% - Gynecomastia
• Rarely - Infertility
    DICTUM FOR ANY SOLID SCROTAL SWELLINGS




All patients with a solid, Firm Intratesticular
     Mass that cannot be Transilluminated
    should be regarded as Malignant unless
               otherwise proved
• Risk factors- 1.Cryptorchidism
               2.Testicular dysgenesis
               3.Family history
               4.Caucasians>African Americans
 Diagnosis-1.Ultrasound:hypoechoic intratesticular
  mass
            2.tumor marker studies
            3.Radical orchidectomy
            4.Staging:CXR abdominal or chest CT
      Spread of testicular tumors
• Lymphatic-
   – retroperitoneal
   – para-aortic nodes,
   – mediastinal-
   – supraclavicular.
• Heamtogenous-
   – lung,
   – liver
   – brain and
   – bones
         Investigation
1.Ultrasound - Hypoechoic area
2.Chest X-Ray - PA and lateral views
3.CT Scan
4.Tumour Markers
          - AFP
          - HCG
          - LDH
          - PLAP
               Tumor markers:


• AFP : elevated in Yolk sac tumors
• HCG α & β units : Choriocarcinoma
• PLAP : elevated in seminomas
        Tumour Markers


TWO MAIN CLASSES
• Onco-fetal Substances : AFP & HCG
• Cellular Enzymes : LDH & PLAP
( AFP - Trophoblastic Cells
HCG - Syncytiotrophoblastic Cells )
 HCG – ( Human Chorionic Gonadotropin )


Has   and   polypeptide chain

NORMAL VALUE: < 1 ng / ml
HALF LIFE of HCG: 24 to 36 hours
RAISED HCG -
100 % - Choriocarcinoma
60% - Embryonal carcinoma
55% - Teratocarcinoma\
25% - Yolk Cell Tumour
7% - Seminomas
            ROLE OF TUMOUR MARKERS


• Helps in Diagnosis - 80 to 85% of Testicular
  Tumours have Positive Markers
• Most of Non-Seminomas have raised markers
• Only 10 to 15% Non-Seminomas have normal
  marker level
• After Orchidectomy if Markers Elevated means
  Residual Disease or Stage II or III Disease
• Elevation of Markers after Lymphadenectomy
  means a STAGE III Disease
           ROLE OF TUMOUR MARKERS contd...

• Degree of Marker Elevation Appears to be Directly
  Proportional to Tumor Burden
• Markers indicate Histology of Tumor:
  If AFP elevated in Seminoma - Means Tumor has Non-
  Seminomatous elements
• Negative Tumor Markers becoming positive on follow up
  usually indicates -
  Recurrence of Tumor
• Markers become Positive earlier than X-Ray studies
                 AFP –( Alfafetoprotein )
        NORMAL VALUE: Below 16 ngm / ml
        HALF LIFE OF AFP – 5 and 7 days

        Raised AFP :
        • Pure embryonal carcinoma
        • Teratocarcinoma
        • Yolk sac Tumour
        • Combined Tumour



REMEMBER: AFP Not raised is Pure Choriocarcinoma or Pure Seminoma
        Embryonal Carcinoma

• Embryonal carcinomas occur mostly in the 20-
  to 30-year age group.
• These tumors are more aggressive than
  seminomas.
               Morphology.
• Grossly, the tumor is smaller than seminoma
  and usually does not replace the entire testis.
• Extension through the tunica albuginea into
  the epididymis or cord is not infrequent.
         Embryonal carcinoma
• There is a rim of normal testis superiorly. The
  tumor is soft and much more variegated than
  the seminoma, with red to tan to brown areas,
  including prominent hemorrhage and
  necrosis.
                  Histology
• The cells grow in alveolar or tubular patterns,
  sometimes with papillary convolutions
• Embryonal carcinomas lack the well-formed
  glands with basally situated nuclei and apical
  cytoplasm seen in teratomas.
• More undifferentiated lesions may present
  sheets of cells.
• The neoplastic cells have an epithelial
  appearance and are large and anaplastic, with
  hyperchromatic nuclei having prominent
  nucleoli.
• In contrast to seminoma, the cell borders are
  usually indistinct, and there is considerable
  variation in cell and nuclear size and shape.
• .
Embryonal carcinoma-microscopy
                • Sheets of
                  undifferentiated cells
                  and primitive
                  glandular
                  differentiation
                • Nuclei are large and
                  hyperchromatic
         Embryonal carcinoma
• This is the histologic pattern. Sheets of blue
  cells are trying to form primitive tubules
            Choriocarcinoma
• Highly malignant

• Identical tumors – placenta, ovary,
  totipotential cells
• Gross : small nodular lesion
• h’age and necrosis is common
• Known for widespread metastasis
              Choriocarcinoma


• i. Highly malignant with widespread
   metastasis
  ii. Gross-often small primaries with extensive
   hemorrhage and necrosis
  iii. Micro-proliferation of syncitiotrophoblasts
   and cytotrophoblasts
  iv. Tumor marker:β-hCG
  v. Hematogenous spread to lung and liver
Choriocarcinoma


         • Cytotrophoblast and
           syncitiotrophoblast
            Morphology.
• On cut surfaces,
  the mass is often
  variegated, poorly
  demarcated at the
  margins, and
  punctuated by foci
  of hemorrhage or
  necrosis.
• Mitotic figures and tumor giant cells are
  frequent.
• Within this background, syncytial cells
  containing HCG, cells containing AFP, or both
  may be detected by immunoperoxidase
  techniques
             Teratocarcinoma

• Embronal carcinoma mixed with teratoma in
  which islands of bluish white cartilage from
  the teratoma component are more prominent.
  A rim of normal brown testis appears at the
  left.
                Teratocarcinoma

• It is composed mostly of embryonal carcinoma, but
  there are scattered firmer white areas that
  histologically are teratoma. Thus, this testicular
  neoplasm is mixed embryonal carcinoma plus
  teratoma
              Teratocarcinoma
• A small testicular carcinoma is shown here. There is a
  mixture of bluish cartilage with red and white tumor
  tissue. This neoplasm microscopically contained
  mainly teratoma, but areas of embryonal carcinoma
  were also present.
  Teratoma+ Embryonal carcinoma
• At the bottom is a focus of cartilage. Above this is a
  primitive mesenchymal stroma and to the left a focus
  of primitive cells most characteristic for embryonal
  carcinoma. This is embryonal carcinoma mixed with
  teratoma
       Mixed germ cell tumor
• About 60% of testicular tumors are composed
  of more than one of the pure patterns
• Common mixtures include
       a. Seminoma +Embryonal carcinoma
       b. Teratoma + Embryonal carcinoma +
  yolk sac tumor
       c. Embryonal carcinoma+ Teratoma
  (teratocarcinoma)
        Mixed germ cell tumor
• testicular neoplasm that is mostly teratoma,
  but embryonal carcinoma and seminoma were
  found microscopically. In contrast with the
  ovary, pure benign teratomas of the testis are
  very rare
   Yolk sac tumor (Endodermal sinus tumor)


1.Most common germ cell tumor in children
2.Good prognosis in children
3.In adults, it is often mixed with other
    components
4.Micro: schiller-duval bodies
5.Tumor marker: alpha feto protein(AFP)
             Yolk sac tumor
• An endodermal sinus tumor of the testis is
  shown composed of primitive germ cells that
  form glomeruloid or embryonal-like structures
Yolk sac tumor
    Sex cord stromal tumors

1.Leydig cell tumors
2.sertoli cell tumors
      Testicular lymphoma
 Most common tumor in men over the age of
50 yrs
 Type-NHL-large cell type

								
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