L8 - Pathology of the Testes

Question 1

label A & B

Answer 1

A = seminiferous tubule

B = tunica vaginalis

Question 2

ACUTE EPIDIDYMO-ORCHITIS

i) where does inflammation start? where does it spread to?
ii) what is the most common age group that it occurs in?
iii) which two STIs does it occur with?
iv) what is the most common cause in men over 40yrs?

Answer 2

i) inflam starts in the epididymis and spreads to the testes
ii) 20-39 years
iii) chlamidya and gonorrhea
iv) ecoli bacteria

Question 3

PRESENTATION AND MANAGEMENT OF ACUTE EO

i) name things that may seen/felt in the epididymis? what causes this? which cell predominates here?
ii) how is causative bacteria identified?
iii) which marker may be raised?
iv) which imaging method can epididymo-orchitis be differentiated from torsion?
v) give three ways it can be treated
vi) what can be a consequence of it healing with scarring?

Answer 3

i) pain and swollen epididymis
- caused by inflammation > neutrophils

ii) culture urethral secretions
iii) CRP
iv) Ultrasound
v) antibiotics, pain relief, supportive care eg scrotal elevation
vi) scarring can cause sterility (SNTs are replaced)

Question 4

TORSION

i) how quickly must this be treated?
ii) why does it occur?
iii) what happens if its left untreated?
iv) how does it present? what may this be related to?
v) up to how many hours can testis still be viable if untwisted?
vi) what should be done to the contralateral testis to reduce further risk of torsion?

Answer 4

i) urological emergency
ii) twisting of the spermatic cord which cuts off veous drainage from the testes
iii) untreated > infarction of testis

iv) persent with sudden onset of testicular pain
- may or may not be related to trauma

v) up to 6 hours
vi) contralateral testis should be fixed to the scrotum to reduce risk of torsion again

Question 5

EPIDEMIOLOGY OF TESTICULAR CANCER

i) in what age group is it the most common solid malignant tumour?
ii) is there higher incidence in caucasian or black men?
iii) what is the % increase since the 1990s?
iv) what % of new cancers in the UK does it account for?

Answer 5

i) 30-34 years
ii) caucasian men
iii) 28% increase
iv) 1% of all new cancers

Question 6

CAUSES OF TESTICULAR CANCER

i) how many x does cryptorchidism/undesc testes increase risk?
ii) which two genetic abnormalities increase risk?
iii) exposure to which hormone in utero can increase risk? how does it do this?
iv) give three other causes

Answer 6

i) 4-8 times
ii) Klinefelters syndrome (XXY) and Downs syndrome
iii) exposure to oestrogens in utero
iv) history of prev testicular cancer, family histpory or males with infertility problems

Question 7

CLASSIFICATION OF TESTICULAR TUMOURS

i) what are the two main classes of germ cell tumour? give two examples of each
ii) which two tumours are sex cord/stromal tumours?
iii) are germ cell or sex cord tumours more common?

Answer 7

i) seminomatous - classical seminoma and spermatocytic seminoma
- non seminomatous - embryonal carcinoma, yolk sac tumour, choriocarcinoma and teratoma

ii) leydig cell and sertoli cell tumour

iii) germ cell tumours are more common
- sex cord make up 5% of testicular tumours

Question 8

GERM CELL TUMOURS

i) what % of testicular cancers does it account for?
ii) what are the two classes of GCT?
iii) what do mixed GCTs consist of?
iv) what is the precursor lesion called?

Answer 8

i) >90%
ii) seminoma and non seminomatous
iii) mixed = seminoma and non seminomas
iv) precusor = germ cell carcinoma in situ/intra-tubular germ cell neoplasia

Question 9

SEMINOMAS

i) do they grow and spread more quickly or slowly than non seminom tumours?
ii) what are the two main subtypes?
iii) which subtype is more commonly found in young people? which age group? which is found more in older people? over the age of what?
iv) which subtype constitues 95% of seminomas?
v) which subtype grows slower and is less likely to spread?

Answer 9

i) grow and spread slower
ii) classical and spermatocytic

iii) young - classical (25-45yrs)
old - spermatocytic (65+)

iv) classical is 95% of all seminomas
v) spermatocytic grow slower and are less likely to spread

Question 10

NON SEMINOMATOUS GCTS

i) what two age groups do they most commonly occur in?
ii) what are the four main types?

Answer 10

i) late teens and early 30s
ii) embryonal carcinoma, choriocarcinoma, teratoma, yolk sac tumour

Question 11

EMBRYONAL CARCINOMA

i) what type of GCT are most of these?
ii) what do tissues look like under the microscope?
iii) do they grow slow or fast? how likely are they to spread?
iv) what % of testicular tumours do they represent

Answer 11

i) mixed GCT
ii) like very early embryos
iii) grow fast and spread = aggressive
iv) 40%

Question 12

YOLK SAC TUMOUR

i) what do cells look like under the MS?
ii) which age group is it the most common form of testicular cancer in?
iii) are pure YS tumours rare or common in adults?
iv) do adults or children have a better prognosis?

Answer 12

i) like the yolk sac of the early embryo
ii) most common testic cancer in children
iii) rare in adults
iv) children have a better prognosis

Question 13

CHORIOCARCINOMA

i) is it common? does it grow slow or fast?
ii) what type of choriocarcinomas spread rapidly to other body areas?
iii) what type of GCTs do they usually present in? what is associated with this?
iv) in what situation may these present in females?
v) which hormone is elevated in both men and women

Answer 13

i) very rare and fast growing
ii) pure choriocarcinoma
iii) usually present in mixed GCT with assoc haemmorhage
iv) present postnatally due to trophoblast proliferation
v) both have elevanted bHCG

Question 14

TERATOMAS

i) what is it derived from?
ii) how common are pure teratomas of testicles? are tumour markers raised?
iii) what type of GCT are most teratomas?
iv) what do the cells of mature teratomas resemble? do they spread? how are they usually treated?
v) what do cells of immature teratomas resemble? do they spread?
vii) can testicular teratomas be benign?

Answer 14

i) three germ cell layers
ii) rare - tumour markers arent raised
iii) mixed GCTs

iv) mature - resemble similar adult tissues
- rarely spread
- treated with surgery (may recur)

v) immature - resemble cells of early embryo
- more likely to metastasise outside testes and recur

vi) all testicular teratomas are malignant

Question 15

CLINICAL PRESENTATION OF TESTICULAR TUMOURS

i) what may be found in the testis? would be seperate from the testes or not?
ii) what type of sensation may be felt in the lower abdomen?
iii) give two ways which advanced cancer and mets may present?
iv) how may a patient with lung mets present? (4)
v) how may a patient with HCG secreting tumours present? which tumour may do this?

Answer 15

i) swelling/nodule (cancer til proven otherwise)
- not seperate from the testis

ii) dull ache or heavy sensation
iii) adv cancer - back pain due to enlarged para aortic LNs supraclavicular lymphadenopathy
iv) cough, chest pain, haemoptysis, SOB

v) bHCG > gynaecomastia
- choriocarcinoma

Question 16

IMAGING TESTICULAR CANCER

i) name three things a US can distinguish between?
ii) what may a CT scan be used for?
iii) what may MRI be used for?
iv) what may a PET scan be used for?

Answer 16

i) US > tumour in or external to testes
- complex (malignant) or simple (benign) cyst
- solid tumour and a cyst

ii) CT to look for mets to LNs, liver and lungs
iii) mets to bone or brain
iv) PET to look for disease recurrence (hot when viable cancer)

Question 17

TUMOUR MARKERS IN TESTICULAR CANCER

i) which marker may be secreted by yolk sac tumours and embryonal carcinomas?
ii) what hormone do choriocarcinomas/embryoonal carcinoma/seminomas produce?
iii) which tumour secretes LDH?
iv) which tumour markers are raised in mixed GCTs?
v) name one other use for tumour markers

Answer 17

i) YS and EC - AFP (always yolk sac)
ii) bHCG
iii) seminomas secrete LDH
iv) all TM will be raised in mixed GCT
v) follow up for patients after therapy

Question 18

CASE HISTORY - SEMINOMA

i) which tumour marker may be raised?
ii) what surgery may be done?
iii) what appearance does the seminoma have macroscopically?
iv) how do seminoma cells look microscopically? (2)

Answer 18

i) LDH
ii) orchidectomy
iii) potato appearance
iv) large cells and may have lymphocytic infiltrate

Question 19

TERATOMA - CASE REPORT

i) how may it be treated?
ii) what might it secrete?
iii) what may it be lined with?

Answer 19

i) treated by orchidectomy
ii) mucin secreting
iii) lined with large bowel epithelium (mucin secreting)

Question 20

MIXED GCT - CASE HISTORY

i) which tumour markers may be raised?
ii) how may this be treated?
iii) what may it consist of?

Answer 20

i) all - eg AFP and HCG
ii) orchidectomy
iii) seminoma, choriocarcinoma, embryonal

Question 21

PROGNOSTIC FACTORS FOR TESTICULAR TUMOURS

i) which type of tumour has a good prognosis?
ii) what staging system is used to classify?
iii) what does high levels of tumour markers in the blood indicate?

Answer 21

i) seminoma
ii) TNM
iii) high TM > high tumour load

Question 22

TREATMENT FOR TESTICULAR TUMOURS

i) how may an isolated mass be treated? (2)
ii) how may a mass with metastases be treated?
iii) what would be seen on pathological exam if there had been complete chemo response?
iv) what may a patient be offered prior to surgery?

Answer 22

i) radical orchidectomy then adjuvant chemo
ii) neo adjuvant chemo then orchidectomy
iii) no tumour remaining
iv) sperm banking