PBL 4

Question 1

MILD bilateral gynaecomastia

Answer 1

benign enlargement of male breast tissue, on both sides

Question 2

Undescending right testicle

Answer 2

a testicle which hasn’t moved into the scrotum

Question 3

Variegated consistency

Answer 3

 having streaks, marks, or patches of different colours

Question 4

organomegaly

Answer 4

abnormal enlargement of organs

Question 5

Homogenous intratesticular mass

Answer 5

a mass in the testicles which exhibits essentially the same physical properties at every point throughout the mass

Question 6

Low echogenicity

Answer 6

unable to bounce an echo very well; i.e. a dense mass in an USS

Question 7

retroperitoneal lymph node dissection

Answer 7

removal of the retroperitoneal lymph nodes

Question 8

Non-seminomatous germ cell tumour

Answer 8

one of the main groups of germ cell tumours

Question 9

what are the testicular cancer statistics

Answer 9

The most common cancer in men aged 25-49
Median age of diagnosis: 33
2,300 men diagnosed in 2015 in the UK
Testicular cancer is rare in non-caucasians
Incidence of testicular cancer has more than doubled from the mid-1970s
Survival rates are now >95%

Question 10

incidence rates of testicular cancer in different ethnicity of men

Answer 10

White: 6.6 per 100,000
Hispanic: 4.8 per 100,000
Native American: 4.5 per 100,000
Asian/Pacific Islander: 1.9 per 100,000
African American: 1.4 per 100,000

Question 11

risk factors of testicular cancer

Answer 11

Baby boys who are born with undescended testicles

• This accounts for ~3-5% of boys born
• They have a 4-10 times higher risk of developing testicular cancer

Baby boys born with an indirect inguinal hernia

• Inguinal hernias are when abdominal cavity contents enter the inguinal canal
• They are the most common type of hernia
• two main types: direct or indirect

Family history of testicular cancer

Using marijuana

• 70% higher risk of developing testicular cancer
• Linked to more aggressive forms of the cancer

Smoking
- Twice as likely to develop testicular cancer if you have a 12 year history of smoking

Height

• Men who are 190-194 cm (6’ 2” – 6’ 4”) tall are twice as likely to develop testicular cancer
• Men who are above 194 cm are thrice as likely to develop testicular cancer
• Men who are less than 170 cm (5’ 6”) have a 20% decreased chance of developing testicular cancer

Predispositionary genes and environmental factors
- These will have a joint effect on key signalling pathways in the body
- This causes impaired differentiation of primordial germ cells
Primordial germ cells which are common origins of spermatozoa and oocytes
- So the spermatozoa and oocytes cannot be formed

The genes which maintain the germ cell niche do not get deactivated

• This leads to the development of testicular germ cell tumours
• Since there is an ideal environment, the germ cells continue to grow indefinitely

Question 12

what are the signs and symptoms of testicular cancer

Answer 12

Firm, often painless mass/lump on the testicle

• 25-50% of lumps cause some pain
• Growth or swelling of the testicle
• Abnormality in shape or consistency of one testicle when compared to the other
• Associated abdominal pain that occurs with the above symptoms
• 10% of cases are asymptomatic

Question 13

what is the function of the testicles

Answer 13

• production of spermatozoa

- production of the sex hormone testosterone

Question 14

what are spermatozoa

Answer 14

The male gamete
Gametes are haploid cells which carry one copy of each chromosome
These are reproductive cells produced through meiosis
It is the mature motile male sex cell

Question 15

what do spermatozoa do

Answer 15

fertilises the ovum

Question 16

what does testosterone do

Answer 16

Stimulates the accessory male sexual organs

Causes the development of the masculine extra-genital sex characteristics

Question 17

describe the anatomy of the testicle

Answer 17

• There are two testicles
• They are covered by a sac of skin called the scrotum
• This hangs below the penis, between the legs
• Each testicle is covered by a tough, fibrous layer called the tunica
• This is further subdivided into the tunica vaginalis (outer) and tunica albuginea (inner) layers
• The testicle is divided into parts called lobules
• Each lobule will contain tubes called seminiferous tubules where spermatozoa are produced
• These seminiferous tubules open up into a series of uncoiled, interconnected channels called the rete testis
• Ducts connect the rete testis to a tightly coiled tube called the epididymis (this is where sperm is stored)
• This further joins to the long, large duct called the vas (ductus) deferens
• Each testicle is held inside the scrotum by the spermatic cord
• Each spermatic cord is made of tough CT and muscle
• They will contain the vas deferens, blood vessels, lymph vessels, and nerves

Question 18

describe the lymph fluid draining from the testicles

Answer 18

• Lymph fluid travels through vessels in the spermatic cord and drains from the testicles into several groups of lymph nodes at the back of the abdomen
• These lymph nodes are called the retroperitoneal lymph nodes

Question 19

Describe the tunica albuginea

Answer 19

The tunica albuginea is the inner part of the fibrous capsule (tunica) which surrounds the testes
It will penetrate each of the testicles and forms the connective tissue which separates the lobules

Question 20

what do bloods tests show in testicular cancer

Answer 20

• tumour markers are found in the blood of men with germ cell tumours,
• Doctors may test these levels in order to check the progress of/presence of cancer
• differentiate between seminoma and non-seminoma cancers
• High levels of αFP, ßHCG, and LDH are all blood markers for germ cell cancers

Question 21

What are the non seminoma types of tumours

Answer 21

Embryonal carcinoma
Choriocarcinoma
Yolk sac carcinoma
Teratoma

Question 22

How do you use ultrasound for diagnosis

Answer 22

You lie on your back and a clear gel is placed on the scrotum, following which an ultrasound probe is used to image it
This helps to determine if the lumps are solid or fluid filled, and also if they are inside or outside of the testicle

Question 23

What is histogenesis

Answer 23

the differentiation of cells into specialised tissues and organs during growth

Question 24

describe how testicular cancer develops

Answer 24

• Usually, the oncotic mutations accumulate before the rapid growth period of puberty
• TGCT derives from abnormally arrested fetal gonocytes
• Gonocytes are the earliest undifferentiated sex cell, and are initially not in the gonads
• At birth, gonocytes will reside within the centre of seminiferous cords, and are in a state of mitotic arrest
• Following birth, the gonocytes need to differentiate and undergo spermatogenesis to form spermatozoa
• This occurs in the basement membrane of the seminiferous tubules during puberty
• Spermatozoa are then stored in the epididymis
  TGCT is a histological heterogenous disease
• This means that there are many possible causes
• The high level of this heterogenicity is because gonocytes are highly pluripotent (capable of differentiating into various different types of cells
• As the gonocytes have been arrested abnormally, at puberty these gonocytes do NOT form proper spermatogonia
• These arrested gonocytes will accumulate genetic adaptations and mutations throughout childhood and before the onset of puberty
• This becomes germ cell neoplasia in situ (GCNIS) in childhood and young adulthood
• Finally, this emerges as invasive TGCT in the young adult

Question 25

describe staging of testicular cancer

Answer 25

Stage I: Contained in the testicle
Stage II: Lymph node spread, but no distant metastases yet
Stage III: Spread to lymph nodes in the thorax
Stage VI: Spread another organ e.g. the lungs

Question 26

describe lymph node drainage in testicular cancer

Answer 26

• Lymph node drainage is always a fear with cancer
• Drainage of the testes goes to the para-aortic lymph nodes
• Lymphatic drainage of the scrotum goes to the superficial inguinal lymph nodes
• These are retroperitoneal lymph nodes (i.e. abdominal lymph nodes)
• Seminomas will metastasise through the lymphatics
• They go into the retroperitoneal lymph nodes which are located anterior to T11 to L4 vertebral bodies

Question 27

How do you treat testicualr cancer

Answer 27

• radical orchiectomies and retroperitoneal lymph node dissections are important
• surveillance
• seminomas are sensitive to radiation and chemotherapies
• non seminimoas are not sensitive to radiation

Question 28

How do you self examine

Answer 28

Examine yourself once a month, preferably after a bath or shower
Know your normal, and any deviation is worth seeing your GP about

• check one testicle at a time
• hold testicle between thumb and fingers of both hands and roll it gently between the fingers
• if you notice hard lumps, smooth or rounded bumps and changes in size, shape or consistency then see a GP

Question 29

what are checkpoints in the cell cycle

Answer 29

G1-S (1/2 mark) transition that the cell organelles have been replicated and that the cell has enough organelles to divide. (1/2 mark)
G2-M (1/2 mark) transition that the DNA has been replicated appropriately and accurately. (1/2 mark)
Exit M (1/2 mark) phase transition that the chromosomes have attached to the mitotic spindle. (1/2 mark)

Question 30

3 things for informed consent to happen

Answer 30

• The patient must have capacity (Competence).
• The patient must be offered adequate information (Adequate Disclosure).
• The patient’s decision must be non-coerced/voluntary (Non-Coercion/Voluntariness)