Testicular Lesions And Tumors PDF

TESTICULAR LESIONS AND TUMOURS DR.SAINT NWAY AYE Lecturer (Pathology) [email protected] Learning outcomes At the end of the learning process, the student must be able to:  Describe the aetiology and pathophysiology of cryptorchidism and testicular...

TESTICULAR LESIONS AND TUMOURS DR.SAINT NWAY AYE Lecturer (Pathology) [email protected] Learning outcomes At the end of the learning process, the student must be able to:  Describe the aetiology and pathophysiology of cryptorchidism and testicular atrophy.  List the aetiological factors of non-specific and specific inflammations of the testis.  Describe the pathophysiology and morphology of testicular torsion.  Classify testicular neoplasms.  Describe the clinical presentations and diagnosis of testicular neoplasms. Cryptorchidism  Most common genital problem encountered in pediatrics.  Undescended or Maldescended testis  Seen in 3% of full-term newborns  And 1% in infants aged 6 months to 1 year.  More prevalent (30%) in premature neonates  Spontaneous descent after the first year of life is uncommon Risk factors for Cryptorchidism:  Prematurity  Low birth weight  Small for gestational age  Twin gestation  Maternal exposure to oestrogen during the first trimester  Common in siblings with cryptorchidism  Testicular Dysgenesis Syndrome Pathophysiology:  Abnormal growth of vertebrae and pelvis affects the transabdominal descent  Absence of firm attachment of gubernaculum to scrotum  Abnormality in hormonal and mechanical factors  Decreased Intra-abdominal pressure, required for trans-ingunial descent  Prune belly syndrome, omphalocele, gastroschisis Image Courtesy: https://www.bupacromwellhospital.com/ Consequences of Cryptorchidism  Impaired germ cell maturation and infertility  Increased incidence of testicular cancers (40% more risk)  Pre pubertal orchipexy reduces the risk of cancers  Associated hernia  Testicular torsion  Injury against the pubic bone  Psychological effects of empty scrotum Epididymo-Orchitis  Inflammatory reaction of Epididymitis and Testis secondary to infection Non-specific Epididymitis and Orchitis  Usually begin as a primary urinary tract infection  Spreads to the testis through the vas deferens or the lymphatics of the spermatic cord  Mumps, tuberculosis  Bacterial causes in sexually active men  Testicular atrophy is a common complication Aetiology for Epididymo-Orchitis :  Mumps infection in pre-pubertal males  Rare cases following MMR vaccination  Rare viral causes: Coxsackievirus, herpes, varicella, Echoviruses  Bacterial infection is sexually active men:  Neisseria gonorrhoeae, Chlamydia trachomatis, Escherichia coli, Pseudomonas aeruginosa  Immunocompromised patients: Mycobacterium avium complex, Cryptococcus, Toxoplasma Testicular Atrophy 1. Progressive atherosclerotic narrowing of the blood supply in old age 2. End-stage inflammatory orchitis 3. Cryptorchidism 4. Hypopituitarism or generalized malnutrition or cachexia 5. Irradiation 6. Prolonged administration of anti-androgens 7. Cirrhosis of liver 8. Klinefelter syndrome 9. Exhaustion atrophy, persistent stimulation by high levels of follicle-stimulating pituitary hormone Torsion of Testis  Twisting of Spermatic Cord  Can occur at any age  Most common in adolescents ( frequent cause of testicular loss)  Some cases seen with congenital anomaly  Bell clapper deformity: High attachment of tunica vaginalis  Torsion associated with venous and later arterial occlusion  Ischaemic or Hemorrhagic Infarction Clinical features:  Acute onset of Testicular Pain / Swelling  Associated with trauma, sports, exercise, sexual activity, tumour, cryptorchidism  Others: Nausea, vomiting, abdominal pain, fever  Severe tenderness, elevated testis  Scrotal oedema, absence of cremasteric reflex  No pain relief on scrotal elevation (absent Prehn sign) Image Courtesy: https://www.medscape.com/ Management of testicular torsion  Surgical emergency  Early diagnosis and prompt urologic consultation  Diagnosis is most often clinical; ultrasound, radionuclide scan helps  Analgesics for pain  Manual detorsion: Within 6 hrs of pain onset  Difficult cases need open surgical detorsion or orchipexy or orchiectomy Testicular Tumors Classification: I. Germ cell tumour (90-95%) 1) Seminoma Spermatocytic tumour 2) Non seminomatous germ cell tumor i. Embryonal CA ii.Yolk sac tumor iii. Choriocarcinoma iv. Teratoma  Mixed form II. Non-Germ cell tumours (1) Sex cord stromal tumour - Sertoli-Leydig cell tumour - Granulosa cell tumour - Gonadoblastoma - Mixed form (2) other tumours -Lymphoma -Metastatic tumour  95% of testicular tumours arise from germ cells, and all are malignant  Tumours from Sertoli or Leydig cells (sex cord– stromal tumors) are uncommon and usually benign  Cryptorchidism is associated with a three- to five- fold increase in the risk of cancer  Family history is important, brothers of males with germ cell tumorus have an 8- to 10-fold increased risk of cancer  Chromosomal abnormalties, dysgenetic gonads  Pathogenesis remain unclear Morphology of Testicular tumours Seminomas  Peaks at 40–50 years of age  isochromosome 12p  soft, well-demarcated, solid uniform, gray-white tumours that bulge from the cut surface of the affected testis  Microscopically, seminomas are composed of large, uniform cells with distinct cell borders, clear, glycogen-rich cytoplasm, and round nuclei with conspicuous nucleoli  Lymphocytic infiltration in thin fibrous stroma  In 15% of cases, syncytiotrophoblasts are present which produce ß hCG  Seminoma Path Spring Images: https://www.cram.com/ Spermatocytic Tumor  Elderly, usual more than 65 years old  slow-growing tumor and does not metastasize  treated by surgical resection, excellent prognosis.  Morphology resembles seminoma  tumour is not associated with germ cell neoplasia in situ, lacks isochromosome 12p  characteristically associated with gain of chromosome 9q Embryonal carcinomas  20–30 years of age  Small, ill-defined, invasive masses containing foci of haemorrhage and necrosis  Histology: tumour cells are large and primitive looking, with basophilic cytoplasm, indistinct cell borders, and large nuclei with prominent nucleoli  Mixed with other type of germ cell tumours  Embryonal carcinoma Image Courtesy: https://www.uaz.edu.mx/histo/pathology https://www.webpathology.com Yolk sac tumours:  Most common primary testicular neoplasm in children younger than 3 years of age  Tumours are large and well demarcated  Histology: composed of low cuboidal to columnar epithelial cells forming microcysts, lace like (reticular) patterns, sheets, glands, and papillae  A distinctive feature is the presence of structures resembling primitive glomeruli, the so-called Schiller-Duvall bodies. Yolk Sac tumor Choriocarcinomas  Usually, young adults 20-30 years  Small, non palpable lesions, with extensive systemic metastases  Histology: composed of sheets of small cuboidal cells irregularly intermingled with large, eosinophilic syncytial cells containing multiple dark, pleomorphic nuclei; these represent cytotrophoblastic and syncytiotrophoblastic differentiation  Extensive haemorrhage & necrosis  Testicular Choriocarcinoma Image Courtesy: https://www.webpathology.com Teratomas:  Occur at any age from infancy to adult life  Pure teratomas are rare  Most are seen in combination with other histologic types  Histology: composed of a heterogeneous, helter- skelter collection of differentiated cells or organoid structures, such as neural tissue, muscle bundles, islands of cartilage  Clusters of squamous epithelium, thyroid tissue, bronchial epithelium, intestinal wall or brain substance  Teratomas are typically benign  If there is immature tissue –immature (malignant teratoma) Clinical features of Testicular tumours  Painless testicular mass  Dull ache or heavy sensation in the lower abdomen  At the time of diagnosis there is widespread metastases especially in non-seminomatous germ cell neoplasms  Seminomas usually remain confined to the testis for long intervals with no symptoms  Gynaecomastia and Hyperthyroidism  If tumour has foci of choriocarcinoma- produce human chorionic gonadotropin (HCG) Physical examination:  Any solid, firm mass within the testis  Mass/nodule cannot be separated from the testis  Differential diagnosis for testicular mass: Epididymitis, epididymo-orchitis, testicular torsion, hydrocele, inguinal hernia, haematocele, spermatocele, pyocele, varicocele, and syphilitic gumma  Examine for Lymphadenopathy, hepatomegaly, bone tenderness, and gynaecomastia. Diagnosis of Testicular tumours  Liver function test  Tumour markers  Testicular ultrasonography  CT scan, MRI, PET scan Tumour marker for Testicular tumours  Seminoma- 90% of cases Placental alkaline Phosphatase (PLAP), OCT 3/4 -10% of cases have elevated level of β-hCG  Lactate dehydrogenase (LDH)  Yolk sac tumor-90% of patients have elevated AFP  Choriocarcinoma-100% of patients have elevated β- hCG References:  Kumar V, Abbas AK, Aster JC. Robbins basic pathology. 10th Ed. Elsevier; 2018.  Kumar V, Abbas AK, Aster JC. Robbins & Cotran Pathologic basis of Disease, 9th Edition. Elsevier; 2015. Additional Images:  Klatt EC. Robbins and Cotran atlas of pathology, 3 rd Edition. Elsevier; 2015. Quiz Which tumour marker can be used to diagnose seminoma of testis? A. Placenta alkaline phosphatase (PLAP) B. Alpha feto protein (AFP) C. Human chorionic gonadotropin (HCG) D. Prostatic specific antigen (PSA) A 35-year-old man comes to infertility clinic for evaluation. There is no remarkable past medical or surgical history history apart from experiencing fever and swelling of cheek at the age of 20. Examination reveals atrophy of both testes. Which infection is the most likely the cause for his clinical presentation? A. Cytomegalovirus B. Herpes infection C. Mumps D. Syphilis