Lecture 9: Testis
Teratoma of testis Mature teratoma in child - benign All teratomas in post-pubertal male - malignant
When is this benign? When is it malignant?
Left: seminoma Right: embryonal carcinoma - more aggressive
Which one is more aggressive?
More aggressive Approximately 60% of cases present with advanced disease at diagnosis. - para-aortic lymph nodes (retroperitoneal) - distant metastasis - hematogenous and lymphatic spread. Treatment - surgical (radical orchiectomy) - retroperitoneal lymph node dissection - chemotherapy
Describe the prognosis and management of non-seminomatous germ cell tumors.
Seminoma and non-seminomatous Seminomatous-cells resemble primordial germ cells or early gonocytes. - seminoma - "spermatocytic seminoma" - slow growing, affects older men Non-seminomatous tumors resemble embryonic stem cells or other lineages. - embryonal carcinoma - yolk sac tumor - choriocarcinoma - teratoma Testicular tumors can be mixed, but as a pure form, seminoma are more common.
How are testicular germ cell tumors divided?
Seminoma - bulky, lobulated masses - homogenous - tan/fleshy - devoid of hemorrhage/necrosis usually Usually low-stage at diagnosis, 70% confined to testes Treatment: - surgery (radical orchiectomy) - radiation
Treatment?
Associated with urinary tract infections - urethritis, cystitis, prostatitis; secondary involvement of the testis/epididymis Children - (cong. urinary tract anomalies) - gram - rods Sexually active - chlamydia, gonorrhea Older men - E. coli, pseudomonas
What are inflammatory conditions of the testes and epididymis associated with? What do children normally get? sexually active people? older adults?
Most cases unknown cause Cryptorchidism (10%) Genetic factors (white > black) Strong family predisposition.
What are risk factors for germ cell tumors?
- HCG (human chorionic gonadotropin) - AFP (alpha fetoprotein) - LDH (lactate dehydrogenase) - PLAP (placental alkaline phosphatase) Evaluation of testis tumor, staging, assessment of tumor burden, monitoring response to therapy.
What are serum tumor markers for germ cell tumors? What are they used for?
Germ cell 95% - 50% single histologic type - 50% mixed histologic type 5% sex cord stroma: usually benign - Leydig cell tumor - Sertoli cell tumor Lymphoma - older patients
What are the categories of testicular tumors?
- painless/painful enlargement - metastasis (with clinically occult or unapparent tumor) - extragonadal signs/symptoms (more common in non-seminomatous) - diagnosis on histopathology
What are the clinical features of testicular germ cell tumors?
Idiopathic granulomatous orchitis - not related to TB or fungal infection. - can present with or without pain - nodules composed of lymphocytes, plasma cells, and macrophages
What condition affecting the testes is this?
Hydrocele: an accumulation of fluid secreted by tuica vaginalis - can aspirate to treat. Hematocele: accumulation of blood between the layers of tunica vaginalis may develop after trauma or hemorrhage into a hydrocele. Spermatocele: A cyst formed from protrusions of widened efferent ducts of the rete testis or epididymis - lined by cuboidal epithelium that contains spermatozoa in various stages of degeneration
What is a hydrocele? Hematocele? Spermatocele?
Dilation of pampiniform plexus - can cause infertility b/c raises temperature.
What is a varicocele?
Failure of testicular descent into scrotum. Cause not well understood, unilateral in 75% of cases. 95% inguinal (partial descent), 5-10% abdominal. Only rarely associated with well-defined hormonal disorder Consequence: - progressive atrophy and fibrosis may lead to sterility; changes start as early as 2 years - 3-5x increased risk for testicular cancer - more exposed to trauma Treatment: - majority descend spontaneously into scrotum within 1st year - orchioplexy - surgical placement of testis into scrotal sac, preferably before 2 years of age
What is cryptorchidism? What is the consequence? How to treat?
Yolk sac tumor AFP (alpha fetoprotein) detectable in serum most common in young children well-circumscribed with pale yellow, mucoid cut surface
What is detectable in serum?
Choriocarcinoma of testes elevated serum beta-HCG rare in pure form most aggressive - early hematogenous metastasis Present with other signs - e.g. hemoptysis secondary to pulmonary metastasis
What is elevated in this? How do patients present?
Venous occlusion +/- arterial compromise Two types: Neonatal and adolescent Pain May be associated with: - incomplete descent - atrophy - defective scrotal ligaments - Bell-clapper abnormality Pathologic features: - congestion - enlargement - hemorrhage - infarction/necrosis Surgical emergency (manually untwisted within 6 hours) -> orchiopexy
What is testicular torsion?
Intratubular germ cell neoplasia Seen adjacent to all germ cell tumors in adults except for spermatocytic seminima and epidermoid and dermoid cysts. It is usually not seen in pediatric tumors (teratomas, yolk sac tumors) Untreated ITGCN progresses to invasive germ cell tumor in approximately 50% of cases over 5 years of follow-up. Associated with: - cryptorchidism - prior germ cell tumors - strong family history of germ cell tumor - androgen insensitivity syndrome - gonadal (testicular) dysgenesis syndrome - isochromosome 12p (reduplication of short arm of chromosome 12), also associated with invasive germ cell tumors.
What is the most common origin of germ cell tumors?
Mumps orchitis - 20-30% of adults with mumps develop orchitis - testis becomes painful and swollen 4-6 days after parotitis. - acute and chronic inflammation of seminiferous tubule and interstitial tissue.
What is this?
