Pathology of the testis

Question 1

Outline the clinical presentation of acute epididymo-orchitis

Answer 1

Pain, swelling of the epididymis and inflammation with a predominance of neutrophils.
raised C-Reactive Protein (CRP)

Question 2

How is epididymo-orchitis treated?

Answer 2

culture and sensitivity of urethral secretions to identify causative bacteria.
ultrasound scan to differentiate epididymo-orchitis from torsion.
antibiotics, pain relief and supportive care.
may heal with scarring leading to sterility.

Question 3

Outline the histology and appearance of epididymo-orchitis

Answer 3

Testis covered in fibrous adhesions, necrosis at cut surface. abscess formation.

Question 4

What is torsion and what can it lead to?

Answer 4

Twisting of the spermatic cord cutting off the venous drainage of testis.
If untreated leads to haemorrhagic infarction of the testis.

Question 5

What is the clinical presentation of torsion?

Answer 5

sudden onset of testicular pain which may or may not be related to trauma

Question 6

How is torsion treated?

Answer 6

If ‘untwisted’ within 6 hours the testis can remain viable.

The contralateral should be fixed to the scrotum (orchidopexy) to risk reduce risk of torsion.

Question 7

What are the causes of testicular cancer?

Answer 7

Undescended testis / cryptorchidism
History of previous testicular cancer
Genetic abnormality: Klinefelter’s syndrome (47XXY) and Down’s syndrome (47XY).
FH of testicular cancer
Infertility problems
Exposure to oestrogens in utero → cryptorchidism

Question 8

What are the types of germ cell tumours?

Answer 8

Seminomatous tumours: classical seminoma, spermatocytic seminoma
Non-seminomatous tumours: embryonal carcinoma, yolk sac tumour, choriocarcinoma, teratoma

Question 9

What are the different tumour markers?

Answer 9

Alpha-fetoprotein (AFP)
Human chorionic gonadotropin (HCG) 
Lactate dehydrogenase (LDH)

Question 10

What is the precursor lesion of germ cell carcinoma?

Answer 10

intra-tubular germ cell neoplasia

Question 11

What are the features of spermatocytic seminomas?

Answer 11

grows more slowly than classical seminomas and less likely to spread

Question 12

What are the features of embryonal carcinomas?

Answer 12

tends to grow rapidly and spread outside the testis, blood AFP and hCG are both raised

Question 13

What are the features of yolk sac tumours?

Answer 13

most common form of testicular cancer in children, blood AFP always raised

Question 14

What are the features of choriocarcinomas?

Answer 14

A very rare and fast-growing testicular cancer in adults, associated raised hCG, usually present in mixed germ cell tumours with associated haemorrhage

Question 15

What are the features of teratomas?

Answer 15

Derived from 3 germ cell layers of the embryo - endoderm, mesoderm and ectoderm. no increase in AFP or hCG levels. most teratomas are components of mixed germ cell tumours.

Question 16

What are the types of teratomas?

Answer 16

Mature teratomas:
rarely spread, can usually be cured with surgery, but may recur after treatment.
Immature teratomas:
less well-developed cancers with cells that resemble those of an early embryo.
more likely to invade nearby tissues, metastasise outside the testicle and recur years after treatment.
Dermoid cyst of the ovary is benign, testicular teratomas are always malignant.

Question 17

What is the clinical presentation of testicular cancer?

Answer 17

Painless swelling or nodule in one testis.
dull ache or heavy sensation in lower abdomen.
Advanced cancer and mets may present with:
back pain due to enlarged para-aortic L nodes.
supraclavicular lymphadenopathy.
cough, chest pain, haemoptysis and shortness of breath due to metastases to lungs.
marked gynaecomastia in patients with tumours secreting beta HCG e.g. choriocarcinoma.

Question 18

What does an ultrasound scan distinguish between?

Answer 18

tumour in the testis and external to the testis.
complex cyst, most likely malignant and a simple cyst, most likely benign.
solid tumour and a cyst

Question 19

What is the microscopic appearance of a seminoma?

Answer 19

Seminoma cells are large with prominent lymphocytic infiltrate

Question 20

What is the macroscopic appearance of an early teratoma?

Answer 20

Irregular tumour and mucin secretion. fibrosis surrounding cystic spaces with seminiferous tubules in background.

Question 21

What are the prognostic factors of testicular cancer?

Answer 21

TNM stage: tumour, node, metastasis.
type of tumour, size of tumour (T stage), extension outside testis (T stage).
presence of vascular invasion – enables spread to LN and other organs.
lymph node metastasis (N stage).
distant metastases to liver or lung (M stage).
high levels of tumour markers in blood indicates high tumour load.

Question 22

How is testicular cancer treated?

Answer 22

Radical orchidectomy with isolated testicular mass followed by adjuvant chemotherapy.
If metastases are present patients receives neo-adjuvant chemotherapy then orchidectomy.
Patients are offered sperm banking prior to orchidectomy and a prosthesis after orchidectomy.