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MRCS B pathology > Scrotum pathology > Flashcards

Scrotum pathology Flashcards

1
Q

What are complications of cryptorchidism?

A

-Testicular cancer, with a 40 fold increased risk
-Infertility.

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2
Q

What is the most common location of an undescended testis?

A

70% in the inguinal canal, under external oblique

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3
Q

What contributes to the aetiology of an undescended testicle?

A

-Low birth weight, premature birth
-positive family history
-Down syndrome
-Increased abdominal pressure (gastroschisis)

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4
Q

In a neonate with cryptorchidism what management option would you recommend?

A

Management is normally withheld until 6 months of age to allow the testicle to descend spontaneously

After 6 months, spontaneous descent is rare

The child should have an
orchidoplexy, where the testis is mobilized and then fixed in a dependent position in the scrotum.

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5
Q

Does orchidoplexy reduce the risk of infertility and testicular cancer?

A

Orchidoplexy is thought to reduce the risk of both infertility and testicular cancer; however, it does not reduce either to normal levels.

A major benefit of the testes new location in the
scrotum is the facilitation of self-examination, allowing earlier detection of a suspicious lump

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6
Q

Would the surgical management differ for a 20 year old with a unilateral undescended testis?

A

Yes. The recommendation would be to offer an orchidectomy, as the risk of testicular cancer is high.

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7
Q

What are the different types of testicular cancer?

A

95% of testicular tumours are germ cell tumours
-divided into pure seminomas and
nonseminomatous germ cell tumours
-second group is subdivided into teratomas,
choriocarcinomas, yolk sac tumours and mixed germ cell tumours.

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8
Q

What is the peak age for teratomas and seminomas?

A

Teratomas have a peak incidence between the ages of 20-30
Seminomas have a peak incidence between the ages of 30-40

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9
Q

What are the risk factors for testicular tumours>

A

Cryptoorchidism
Fhx
Contralateral testicular tumour
Klinefeltr’s syndrome, downs
Caucasian ethnicity

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10
Q

From your examination you suspect testicular cancer. What tumour markers might be useful?

A

The tumour markers for teratomas include:

beta-HCG (Human chorionic gonadotrophin)
AFP

The tumour markers for seminomas include:

Placental alk phos
Sometimes beta-HCG

Both: LDH marker for tumour volume and necrosis

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11
Q

In what other cancer could you find high AFP levels?

A

Hepatocellular carcinoma (HCC) may also have high AFP levels

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12
Q

What initial imaging would you arrange?

A

A scrotal ultrasound

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13
Q

How would you manage a patient with suspected testicular cancer both clinically and on ultrasound?

A

-Surgical work up: bloods and staging CTTAP
-biopsy not done as risks seeding tumour
-MDT discussion
-Management stage dependent: usually orchidectomy +/- lymph node dissection +/- chemo/radiotherapy

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14
Q

Is radiotherapy effective for testicular tumours?

A

Radiotherapy is used in the management of seminomas, but not for nonseminomatous germ
cell tumours.

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15
Q

What is the overall prognosis of testicular cancer?

A

Prognosis depends on tumour stage. 5-year survival ranges from 92-94% for patients with
good prognostic features to 50% for patients with poor prognostic features

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16
Q

What follow up investigations are used to monitor for possible recurrence?

A

Both:
-Regular clinic
-Regular tumour markers (beta hcg, ldh, ((AFP))

Seminomas:
-Regular clinic review for 10 yrs
-placental ALP, Beta-HCG and LDH monitoring
-abdominal and pelvic CT scan repeated
every 6 months for the first 5 years, then annually.

Nonseminomas are monitored in similar way
-with regular clinic
-beta-HCG, LDH, AFP, CEA
-6-12 monthly CT abdo pelvis.

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17
Q

What is metastasis?

A

Metastasis is the survival and growth of cells at a site distant from their primary origin.

18
Q

Where do testicular tumours metastasise to?

A

Testicular cancers tend to metastasis to the lung, colon bladder and pancreas

19
Q

What are differential diagnoses for groin swellings?

A

Above inguinal ligament
-inguinal hernia
-Undescended testis
-encysted hydrocele/lipoma of cord
-Iliac node

Below inguinal ligament
-femoral hernia
-lymph node
-Saphena varix
-femoral aneurysm
-psoas abscess

20
Q

Differential diagnosis for scrotal swelling

A

Extra testicular
-Inguinal hernia
-Hydrocele
-Varicocele

Intra-testicular
-Testicular tumour
-Epididymo-orchitis
-Testicular torsion

21
Q

What are the characteristic features of a varicocele>

A

Bag of worms
Heaviness/dragging sensation
Renal symptoms if left sided: compression of left renal vein (left spermatic vein opens at sharp angle into left renal vein, right opens into IVC)

22
Q

What are the characteristic features of testicular torsion>

A

Horizontal lie
Absent cremasteric reflex

23
Q

What are the characteristic features of epididymo-orchitis

A

Pain
Swelling
Elevation relieves pain
Raised CRP/white cells

24
Q

What organisms commonly cause epididymo-orchitis?

A

Male <35: chlamydia, gonorrhea

Male >35: enteric organism from uti e.g. e.coli, klebsiella, proteus

25
Q

What organisms commonly cause epididymo-orchitis?

A

Male <35: chlamydia, gonorrhea

Male >35: enteric cause from UTI-e.coli, proteus, klebsiella

26
Q

What are the charactersistic features of a hydrocele?

A

Transilluminates
Testis not palpable
Can get above swelling
no cough impulse
not reducible
fluctuant

27
Q

How does an undescended testis contribute to increased risk of testicular ca?

A

-3-5 fold higher risk testicular ca
-arises from foci of intratubular germ cell neoplasia in the atrophic tubules

28
Q

What are the complications of cryptorchidism?

A

-infertility
-Cancer
-Testicular torsion
-Inguinal hernia

29
Q

Scenario: 35 yr old with left groin mass, on examination single palpable testis

histo report:
—> Teratoma
–> postiive margins
–> lymphovascular invasions
–> T4 Nx Mx (ie nodal/metastatic disease cannot be assessed)

Discuss the pathology report with the family in 3 simple lines

A

-Cancer in testis
-Incomplete resection
-With lymphatic spread

30
Q

Where does a teratoma spread to first?

A

Para aortic lymph nodes

31
Q

Where would it spread next?

A

Locoregional

32
Q

In what other conditions is beta hcg elevated?

A

Pregnancy

33
Q

What is the value of serum markers in testicular tumours?

A

-In evaluating testicular masses
-In staging: after orchidectomy persistent elevation of hcg/alp suggests lymphatic spread even if normal on imaging
-in assessing tumour burden
-In monitoring response to therapy and assessing for recurrence

34
Q

Scenario: 35 yr old with left groin mass, on examination single palpable testis

After a few months pt develops a small pneumothorax, what is the cause?

A

-Lung metastasis

35
Q

Scenario: 35 yr old with left groin mass, on examination single palpable testis

One year later the patient came back with para-aortic lymph node compressing renal artery and vein + SOB + PE. Why PE in this patient?

A

Venous stasis
Hypercoagulable state

36
Q

Scenario: 35 yr old with left groin mass, on examination single palpable testis

Why hypercoagulable state?

A

-Tumour cells produce and secrete procoagulant substances which activate coagulation cascade
-Tissue factor is over-expressed in malignant cells

37
Q

Scenario: 35 yr old with left groin mass, on examination single palpable testis

One year later the patient came back with para-aortic lymph node compressing renal artery and vein + SOB + PE.

Which part of virchow’s triad is missing in this patient?

A

Endothelial injury

Present are:
–> venous stasis
–> hypercoagulable state

38
Q

What is choriocarcinoma and what is its tumour marker?

A

-Highly malignant form of testicular tumour
-Histologically contain two types of cell: syncyctiotrophoblast, cytotrophoblast
-Tumour marker is Beta Hcg

39
Q

What is the most common testicular tumour in men over 60?

A

Non hodgkins lymphoma

40
Q

What is the cell origin of seminoma?

A

Most testicular germ cell tumours originate from precursor lesion called intratubular germ cell neoplasia (ITGCN)

41
Q

Scenario: 35 yr old with left groin mass, on examination single palpable testis

Histopathology showed papillary thyroid tissue and GIT adenocarcinoma, why?

A

Teratoma has the 3 germ cell lines (mesoderm, endoderm, ectoderm)

MRCS B pathology (14 decks)

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