Pathology of the Testis Flashcards
1
Q
How would you be able to recognise a normal testicular sample?
A
- It’s smooth and soft
- you would be able to pull out a string of tissue that is very long
- the coiled seminiferous tubules
2
Q
Review this image and identify key structures
A
3
Q
What is the aetiology of Acute Epididiymo-orchitis?
A
- Most cases of acute epididymo-orchitis occur in men aged 20 – 39 years
- Associated with sexually transmitted diseases such as Chlamydia trachomatis and Neisseria gonorrhoea
- In older men over 40 years the most common cause is E.coli infection
- The inflammation is initially confined to the epididymis and later spreads to the testis
4
Q
What is Acute Epididymo-orchitis and what are its symptoms/ presentations?
- clinical investigations
A
- inflammation of the epididymis
- Pain and swollen epididymis due to inflammation with a predominance of neutrophils
- Clinical investigations show
- raised C-Reactive protein
- a culture and sensitivity of urethral secretions to identify the bacterial cause
- ultrasound scan to differentiate epididymo-orchitis from torsion
5
Q
What is the treatment and management for epididymo-orchitis
A
- Treat with antibiotics, pain relief and supportive care (scrotal elevation)
- If not resolved may require inpatient care
- May heal with scarring leading to sterility
6
Q
Why does Torsion occur and how is it managed?
-
A
- Torsion occurs due to twisting of the spermatic cord which cuts off the venous drainage of the testis
- Presents with sudden onset of testicular pain which may or may not be related to trauma
- If untreated leads to infarction of the testis
- If ‘untwisted’ within 6 hours there is a chance that the testis will remain viable
- The contralateral testis should be fixed to the scrotum (orchidopexy) to risk reduce risk of torsion
7
Q
What is this an image of?
A
Torsion of the Testis
8
Q
Give an overview of the epidemiology of Testicular Cancer
A
- Most common solid malignant tumour in men 30-34 years of age
- Incidence of testicular cancer higher in caucasian men than black men
- Testicular cancer accounts for less 1% of all new cancers in the UK with 28% increase since the early 1990s
9
Q
What are the causes of Testicular Cancer?
A
- Cryptorchidism/undescended testis increases the risk of cancer 4 – 8 times
- History of previous testicular cancer (father and brother)
- Genetic abnormality: Klinefelter’s syndrome (47XXY) & Down’s syndrome (trisomy 21)
- FH of testicular cancer – First degree relatives have a higher risk than the general population
- Men with infertility problems are more likely to develop testicular cancer
- Exposure to oestrogens (diethylstilbestrol) in utero → cryptorchidism→ increases the risk of testicular cancer
- given to women who are threatened risk of miscarriage –> increases risk of undescended testis –> increase risk of testicular cancer
10
Q
How are Testicular Tumours classified?
A
- Germ Cell Tumours
- Seminiomatous tumours
- non-seminomatous tumours
- Sex Cord/Stromal Tumours (Less than 5% of testicular tumours)
- Leydig cell tumour
- Sertoli tumour
11
Q
Give an overview of Germ Cell Tumours
A
- More than 90% of cancers of the testis arise in germ cells
- Germ cells produce the sperm
- Germ cell tumours are divided into seminomas and non-seminomatous
- Mixed germ cell tumours consists of seminoma and non-seminomatous components
- Germ cell carcinoma in situ or intra-tubular germ cell neoplasia is the precursor lesion (precancerous)
12
Q
Explain what type of Tumours Semnomas are
A
- Seminomas tend to grow and spread more slowly than non-seminomatous tumours, they are a type of Germ Cell layer tumour
- There are two main sub-types:
-
Classical Seminoma:
- Constitutes more than 95% of seminomas
- Affect men between 25 and 45 years of age
- Tumours markers can be normal or raised
-
Spermatocytic Seminoma/Tumour:
- Rare tumour; affects older men; average age of 65yrs
- Grow more slowly than classical seminomas and are less likely to spread to other parts of the body
13
Q
Explain what Non-seminomatous Tumours are
A
- germ cell tumours that usually occur in men in their late teens and early 30s
- Four main types of non-seminomatous germ cell tumours
- Embryonal carcinoma
- Yolk sac carcinoma/tumour
- Choriocarcinoma
- Teratoma
14
Q
Explain what Embryonal Carcinomas are
A
- They are a form of Non-seminomatous germ cell tumour
- Present in about 40% of testicular tumours
- Pure embryonal carcinoma occurs in only 3% to 4% of cases
- tend to present as part of the mixed GCT
- Microscopically, looks like tissues of very early embryos
- Tends to grow rapidly and spread outside the testis (very aggressive tumour)
15
Q
Explain what Yolk Sac Carcinoma/Tumour is
A
- a type of non-seminomatous GCT
- The cells look like the yolk sac of an early embryo
- The most common form of testicular cancer in children
- Pure yolk sac tumours are rare in adults
- Have better prognosis in children than adults
16
Q
Explain what a Choricarcinoma is
A
- a type of non-seminomatous GCT
- A very rare and fast-growing testicular cancer in adults
- Pure choriocarcinoma tends to spread rapidly to other parts of the body, including the lungs, bones, and brain
- Usually present in mixed germ cell tumours with associated haemorrhage
- can present in women after pregnancy, due to abnormal trophoblastic proliferation
- both will have raised beta-HCG
17
Q
Explain what a Teratoma is
A
- a non-seminomatous GCT from three layers of the embryo
- Endoderm (innermost layer)
- Mesoderm (middle layer)
- Ectoderm (outer layer)
- Pure teratomas of the testicles are rare
- No increase tumour markers
- Most teratomas are components of mixed germ cell tumours
18
Q
What types of Teratomas are there?
A
-
Mature teratomas
- Tumours are formed by cells similar to adult tissues
- They rarely spread, can usually be cured with surgery, but may recur after treatment
-
Immature teratomas
- Are less well-developed cancers with cells that resemble those of an early embryo
- More likely than a mature teratoma to invade nearby tissues, metastasise outside the testis and recur years after treatment.
- teratomas are always malignant int the testis but not malignant in the ovaries
19
Q
What are the clinical presentation of testicular cancer?
A
- Any painless swelling or nodule in the testis is cancer until proved otherwise
- Mass or nodule not separate from the testis
- Dull ache or heavy sensation in the lower abdomen
- Advanced cancer + 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 the lungs
- Marked gynecomastia in patients with tumours secreting beta HCG as in choriocarcinoma
20
Q
What imaging is used in Testicular Cancer?
A
-
Ultrasound scan (USS) will distinguish between:
- A tumour in the testis and external to the testis
- is it from the epididymis
- A complex cyst: most likely malignant and a simple cyst: most likely benign
- A solid tumour and a cyst
- A tumour in the testis and external to the testis
- CT scan: chest, abdomen and pelvis to assess for metastases in the lymph nodes, liver and lungs
- MRI of brain and bone if metastases suspected
- PET scan for recurrent disease after treatment lesions appear ‘hot’ when there is a viable cancer
21
Q
What are the tumour markers in testicular cancer?
A
- Different tumours secrete specific TMs
- Alpha-fetoprotein (AFP) - yolk sac tumour, embryonal carcinoma
- Human chorionic gonadotropin (HCG) - Choriocarcinoma, embryonal carcinoma, seminoma
- Lactate dehydrogenase (LDH) - seminoma
- All TMs are raised in a mixed germ cell tumour
- TMs used for follow-up of patients after therapy
22
Q
What is the treatment for Testicular cancer?
A
- Radical orchidectomy with isolated testicular mass followed by adjuvant chemotherapy
- If metastases are present at the time of presentation patients receive neo-adjuvant chemotherapy then orchidectomy
- There maybe no tumour in the removed testis on the pathological examination which is termed complete pathologic response to chemotherapy
- Patients are offered sperm banking prior to orchidectomy
- Patients are offered a prosthesis after orchidectomy
