Male reproductive system

Question 1

a. How would you treat prostate core biopsies in the laboratory? (7 marks)

Answer 1

1. Confirm patient identification on the request form with that on the container provided
2. measure the greatest dimension of the biopsy
3. Embed the sections in cassette (with blue foam if necessary) and add a drop of eosin
4. Place in formalin and leave it for processing.

Question 2

b. Describe the role of immunohistochemistry in the diagnosis of prostate cancer. (10 marks)

Answer 2

The criteria for definitive diagnosis of prostate carcinoma includes infiltrative growth pattern, presence of atypical nuclei, prominent nucleoli and lack of basal cells. However, the histological picture of prostatic carcinoma may resemble benign lesions. Moreover, the absence of basal cells may be difficult to assess on haematoxylin and eosin sections as certain cells such as stromal fibroblasts and crush tumour cells can mimic these cells.
Tumour cells of the prostate express a-methyl acyl-CoA racemase (AMACR) in their cytoplasm and this is used to confirm prostate adenocarcinoma, however, benign glands can weakly express this as well. Therefore, it is used in conjunction with P63 and high molecular weight cytokeratin (HMWCK) which are basal cell marker and should be absent in prostate adenocarcinoma. Therefore, the use of these three markers enhances the accuracy of diagnosis, especially when histology is inconclusive.

Question 3

c. Describe how you would treat an orchidectomy specimen for tumour in the laboratory. (8 marks)

Answer 3

1. The specimen is received in formalin or fresh (suspicion of lymphoma), the patients de-mographics on the request form are checked that the details on the request form. The patients history is checked to see what is to be looked for, including history of radiological imaging.
2. Identify the different structure resected and document the type and location from where it was taken and document whether it was submitted fresh or in formalin.
3. Weigh the specimen and measure the different structures present including the testes spermatic cord, epididymis and the vas deferens.
4. Palpate the specimen to look for the lesion and comment about the location e.g. close to the upper pole of the testes
5. Comment on the appearance of the tunica vaginalis and cut through it’s anterior surface and give a description of any liquids that accumulated in this area.
6. Examine the inner surface of the tunica albuginea for thickening or exophytic growths.
7. Shave the spermatic cord margin and submit sections of the proximal, mid and distal por-tions.
8. Bivalve the testes with a sharp knife along the anterior surface and leave to fix overnight to prevent putrefaction which could be misidentified as necrosis.
9. The testis are section along its axis in parallel with the initial dissection. The epididymis is sectioned from the posterior region perpendicular to its long axis. A description of the me-diastinum and any lesion or abnormalities are documented.
10. Submit sections of the tumour and normal testes and the tumour relationship with the tuni-ca albuginea, the mediastinum of the testis as tumour tends to invade here, and sections of the epididymis.

Question 4

d. Describe how you would treat an radical prostectomy in the laboratory. (8 marks)

Answer 4

1. The patients demographics on the request form are checked that they match the details on the request form. The patients history is checked to see what is to be looked for, including radiological imaging.
2. Orient the specimen, according to its anterior surface (convex) and posterior surface (flat). The posterior surface also has the insertions points for the seminal vesicles and vas def-erens.
3. Document the resected specimen including any additional structures such as seminal vesi-cles and give a description including the maximum dimension, weight, location it was tak-en from and appearance. Any additional structures are measured separately.
4. Document the appearance and palpate for any lesions. The location of the lesion is also noted.
5. Ink surfaces of the prostate to see extent of tumour to the surgical margin and leave to fix if fresh
6. Take a section of the proximal urethral and vas deferens surgical margins and place them in cassettes.
7. Section the prostate into thin and parallel slices from apex to base and submit sections of the distal apical margin.
8. Investigate all the sections for the tumour and give a description while maintaining their ori-entation.
9. Submit sections of the tumour, normal prostate, posterior and anterior section form the right and left sides. Section the seminal vesicles near the point of insertion to the prostate and submit.
10. If pelvic lymph nodes are present – submit each one for histological investigation, indicat-ing clearly the number of lymph nodes submitted.

Question 5

a. How are primary testicular tumours generally classified? (8 marks) Mention one tumour from each category. (16 marks)

Answer 5

Primary testicular tumours are divided into germ cell tumours which are produced from reproductive cells and sex cord stromal tumours. These are further subdivided into seminomas, yolk sac, teratoma, choriocarcinoma and embryonal carcinoma. Seminomas made of germ cells that multiply without differentiating into other types of cells such as classic seminoma. Yolk sac tumours are endodermal sinus tumours and are very common in children, teratomas may contain all types of tissues and Choriocarcinoma arising from syncytiotrophoblast and cytotrophoblast as well as embryonal carcinoma which arise in embryonic pluripotent stem cells. 
Another class is sex cord stromal tumours that may arise from Leydig cell or Sertoli cells but these tumours are usually benign. Leydic cell tumours are hormonally active and can result in increased male sex hormones as well as female hormones leading to premature puberty if patient is young, feminisation, delayed pubery, gynecomastia etc. sertolli cell tumours are non-hormone producing and do not produce such symptoms.

Question 6

b. Is a previous history of surgically corrected cryptorchidism relevant? Why? (16 marks)

Answer 6

Yes cryptorchidism is hidden testicles, these develop in the abdominal cavity and fail to descend to scrotum. This results in undeveloped or abnormally developed testicles. The risk of developing testicular cancer due to a cryptorchid testis is increased to 5–10 times that of the general male population. This increased risk for a cryptorchid or previously cryptorchid individual is indicative of long-term damage, despite early orchiopexy in many cases. Very little is known about mechanisms of Testicular Germ cell tumours tumorigenesis

Question 7

c. What laboratory method is used to help differentiate between the different types of testicular tumours? (8 marks)

Answer 7

An orchidectomy is the removal of the testicles – usually the testicle together with spermatic cord is removed.

Question 8

f. If the tumour was in a 79-year old male, had the same gross (macroscopic) appearance and a piece was taken for flow cytometry, what tumour would be suspected? (5 marks)

Answer 8

Testicular lymphoma