L28. Testis and Penis pathology

Question 1

What are the causes of scrotal swelling

Answer 1

1. Can either be due to Testicular or Non testicular (uncommon)
2. NT: hernia, hydrocoele, haematocoele (blood clot), epididymitis
3. Testicular can be due to Non neoplastic or Neoplastic.
4. Neoplastic are testicular germ cell tumours. There are ones that are benign paediatric and spermatocytic less common but the main ones are
   a) . Seminoma
   b) Non-seminomatous germ cell tumour= Embryonal carcinoma, teratoma, choriocarcinoma, yolk sac tumour

Question 2

What are the risk factors for Testicular germ cell tumour

Answer 2

Commonest solid cancer for 20-40 yrs. Seminoma more common in older people. Lowest incidence in people of african descent, slight increase in family members. higher risk with undescended testes.
Predisposing conditions: Cryptorchidism, gonadal dysgenesis, and germ cell neoplasia in situ.

Question 3

What are is the pathogenesis of Testicular germ cell tumours, which cells do they originate from and where are they found

Answer 3

Originate from totipotent cells. the precursor is germ cell neoplasia in situ. Usually increased copies of 12p - isochromosome with many other chromosomal gains and losses, and these are seen in seminoma and NSGCT not in paediatric GCT.

Question 4

What is the difference between Seminoma and Non seminomatous GCT from their cells of origin and macroscopic appearance when cut/micro

Answer 4

Seminoma is from gonadal germ cell that is undifferentiated, whereas NSGCT is from embryonic cells and extra embryonic differentiation

• Choriocarcinoma is from amnion,
• Teratoma and Embryonal carcinoma from embryo
• Yolk sac tumour from yolk sac

Macro: all expand the testis replacing the normal tissue but are confined by the tunica albuginea.

• Seminoma: homogenous cream with granular necrosis; micro: undifferentiated, lymphocyte infiltrate
• Choriocarcinoma: Haemorrhagic
• Teratoma: Variegated; cartilage, cysts, cream/grey necrotic areas; micro can show immature or mature tissues
• Yolk sac: grey gelatinous.
• embryonic: micro: tubules, increased staining and size.

Question 5

How is diagnosis of testicular germ cell tumour done

Answer 5

Clinical + pathological exam, US to confirm, inguinal orchidectomy - no biopsy to confirm diagnosis because could be contaminating scrotum with tumour cells.

Tumour markers help with staging

• HCG : choriocarcinoma, malignant teratoma and some seminomas containing syncytiotrophoblastic cells.
• AFP: yolk sac tumours, Malignant teratomas

Question 6

How is staging of the TesticularGCT done and what is the spread

Answer 6

using serum tumour markers as well as finding spread using CXR and CT scan of chest, abdo and pelvis.

• Local invasion is uncommon
• Lymphatic would go to para-aortic and inguinal nodes
• Haematogenous spread is most common to the lung, liver etc, and this happens later in seminoma

Question 7

How is TGCT treated after orchidectomy

Answer 7

Depending on stage, Seminoma/Not, and patient preference:

• Observation for metastases
• further treatment with chemotherapy or radiotherapy as the tumour is very sensitive. 95% cure rate

Question 8

What type of cancer affects the penis, risk factors, which sites affected, and what is the spread and management

Answer 8

Squamous cell carcinoma related to HPV infection. Higher incidence in 70+, with circumcision protective.
Mostly affects the distal penis: glans, coronal sulcus but can affect the shaft.
Spreads to inguinal nodes.
Treated by surgical removal of the tumour. Depends on staging and spread. If T2- spread into the corpus spongiosum or T3 corpus cavernosum there is higher risk of lymph node spread so some lymph node resection. however side effect is increased oedema in the legs.