Testis and Epididymis Flashcards
Cryptorchidism
1st transabdominal phase: mullerian-inhibiting substance
2nd inguinoscrotal phase: androgen-dependent release of calcitonin gene-rated peptide from genitofemoral n.
Defect in testicular develop. And cell differentiation
* Inguinal canal; testis small, firm, fibrotic * Uninvolved testis has similar changes * Most u/l, 25% b/l * Arrested germ cell development – marked hyalinization and thickening of BM of spermatic tubules * Tubules – dense cords of hyaline outlined by prominent BM * Leydig cells spared * Progressive tubular atrophy
Asymptomatic – empty scrotal sac
Sterile
1% of 1yo
Prone to trauma, crushing injuries when in inguinal canal
Risk of testicular CA
Testicular atrophy
- Progressive atherosclerotic narrowing of blood supply
- End stage inflammatory orchitis
- Cryptorchidism
- Hypopituitarism
- Generalized malnutrition or cachexia
- Irradiation
- Prolonged antiandrogens
- Exhaustion atrophy – follow persistent high PSH
Like Cryptorchism
Old age
Kleinfelter syndrome
Nonspecific Epididymitis and Orchitis
UTI infections reach vas deferens or lymphatics of spermatic cord – C. trachomatis, N. gonorrhoeae
- Congestion, edema, infiltration by neutrophils, macrophages, lymphocytes
- Early – limited to interstitial connective tissue
- Later involves tubules, progress to abscess or complete suppurative necrosis of entire epididymis
- Similar reaction in testis
- Fibrous scarring → sterility
- Leydig cells not totally destroyed
Adults – sexually active under 35
> 35 – E. coli, Pseudomonas
Granulomatous Orchitis
Autoimmune
• Granulomas restricted to spermatic tubules
Tender testicular mass of sudden onset
fever
Middle age
Torsion
Twisted spermatic cord cuts off venous drainage → infarction
Bell-clapper abnormality – “Adult” type – increased mobility of testes
- Intense congestion to widespread hemorrhage to testicular infarction
- Advanced: testis enlarged, soft, necrotic, hemorrhagic tissue
Neonatal: lacks assoc anatomic defect
“Adult”: adolescence, sudden onset of testicular pain w/o injury, may occur during sleep
Lipomas
Retroperitoneal adipose tissue pulled into inguinal canal with hernia
• Proximal spermatic cord
Identified during inguinal hernia repair
Adenomatoid tumor
- Mesothelial
- Small nodules near upper pole of epididymis
- Well circumscribed, minimally invasive
One of few benign tumors near testis
Most common malignant paratesticular tumors: rhabdomyosarcomas – kids; liposarcomas – adults
Germ Cell Tumors
Mutations in KIT (seminomas) and BAK – apoptosis inducers and gonadal development
12p duplication – i(12p) – invasive germ cell tumors
Retain OCT3/4 and NANOG expression – maintains pluripotent stem cells
- Atypical primordial cells, large nuclei, clear cytoplasm
- Seminomatouos tumors: cells resemble primordial germ cells or early gonocytes
- Nonseminomatous tumors: undifferentiated cells – resemble embryonic stem cells
- ITGCN arise in utero, dormant until puberty → progress to tumors
15-34 yo, Blacks
4x higher risk father-son; 8-10 high risk in brothers Assoc with: testicular dysgenesis syndrome: cryptorchisim, hypsadias, poor sperm quality; exposure to pesticides, nonsteroidal estrogens
Precursor lesion: intratubular germ cell neoplasia (ITGCN) (except yolk sac tumors, teratomas, adult spermatocytic seminomas which have uncertain origin)
Seminoma
i(12p), express OCT3/4 and NANOG
25% KIT amplification and overexpression (role in gonadal development)
Minimal hCG
- Bulky masses 10x size of normal testis
- Homogenous, gray-white, lobulated, devoid of hemorrhage or necrosis
- Does not penetrate tunica albuginea
- Occasionally extend to epididymis, spermatic cord, scrotal sac
- Sheets, poor demarcated lobules by delicate fibrous septa w/ lymphocytes
- Cell: large, round-polyhedral, distinct cell membrane, clear/watery cytoplasm, large central nucleus, 1 or 2 prominent nucleoli
- Some have anaplastic features – frequent tumor giant cells, greater mitotic activity
- KIT, OCT4, placental alkaline phosphatase PLAP
- Scattered keratin+ cells
- 15% contain syncytiotrophoblasts – elevated hCG (minimally)
- ill-defined granulomatous reaction
30s
never in infants
Spermatocytic seminoma
- soft, pale gray, mucoid cysts
- cell populations: medium-sized cells, round nucleus, eosinophilic cytoplasm, spireme chromatin; smaller cells with narrow rim of eosinophilic cytoplasm; scattered giant cells uni- or multinucleate> 65 yo
No mets, slow growing
Excellent prognosis
NO: lymphocytes, granulomas, syncytiotrophoblasts, extra-testicular sites of origin, admix of other germ cell tumors, assoc. with ITGCM
Embryonal carcinoma
OCT ¾, PLAP, cytokeratin, CD30
- smaller tumors, extend through tunica albuginea into epididymis or cord
- variegated, poorly demarcated margins, foci of hemorrhage or necrosis
- Alveolar or tubular patterns, papillary convolutions
- Undifferentiated lesions – sheets of cells
- No well formed glands
- Epithelial appearance, large and anaplastic, hyperchromic nuclei, prominent nucleoli
- Cell borders indistinct
- Mitotic figures and tumor giant cells frequently seen
- OCT ¾, PLAP, cytokeratin, CD30 positive
20-30 yo
more aggressive than seminomas
Negative for KIT
Yolk Sac Tumor
Alpha-fetoprotein (AFP)
- Nonencapsulated, homogenous, yellow-white, mucinous appearance
- Lacelike (reticular) network – medium sized cuboidal or flattened cells
- Papillary structures, solid cords of cells
- Schiller-Duval bodies – endodermal sinuses: mesodermal core with central capillary, visceral and parietal layer of cells resemble primitive glomeruli
- Eosinophilic, hyaline-like globules – AFP, a1-antitrypsin
under 3 yo – very good prognosis
Elements frequently occur with embryonal carcinoma
Choriocarcinoma
hCG
• Hemorrhage and necrosis
• Syncytiogrophoblasts (eosinophilic, hCG) and cytotrophoblasts (cords or masses)
Small palpable nodule
Rare, highly malignant
No testicular enlargement
Teratoma
Non-germ cell malignancy: i12p
- Large, heterogenous with solid, cartilaginous, cystic areas; hemorrhage and necrosis (admix w/embryonal carcinoma, choriocarcinoma)
- Neural tissue, muscle bundles, cartilage islands, squamous epithelial clusters, thyroid gland, bronchial epithelium, intestinal wall, brain in fibrous or myxoid stroma
Pure form – infants, kids; rare in adults
Postpubertal male – regarded as malignant
Malignant non-germ cell tumors arise in teratomas – squamous cell carcinoma, mucin-secreting adenocarcinomas, sarcomas
-secondary tumors chemoresistant
Mixed tumors
HCG – choriocarcinoma, seminomas (w/syncytiotrophoblastic giant cels)
AFP - yolk sac tumors
lactate dehydrogenase (tumor burden)
• Mets different from testicular lesion – minor commponents in primary tumor unresponsive to chemo survive and become dominant met pattern
Stage I: confined to testis, epididymis, spermatic cord
• Seminomas
Stage II: distant spread confined to retroperitoneal LN below diaphragm
• NSGCT
Stage III: mets outside of retroperitoneal nodes or above diaphragm
• NSGCT – pure choriocarcinoma
Painless enlargement of tesis
Prognosis worsened by more aggressive element
Teratoma, embryonal carcinoma, yolk sac tumor, seminoma with embryonal carcinoma, embryonal carcinoma with teratoma (teratocarcinoma)
Lymphatic spread – retroperitoneal para-aortic nodes first → mediastinal and supraclavicular nodes
Hematogenous spread – lungs, liver, brain, bones
