Testis Dr. Raid Jastania

Objectives By the end of this session the student should be able to: List common causes of scrotal swelling Classify testicular tumors List the gross and microscopic features of germ cell tumors

Scrotum Scrotal enlargement Squamous cell carcinoma and chimney sweeps Hydrocele: accumulation of serous fluid in the tunica vaginalis Hematocele Chylocele Squamous cell carcinoma and chimney sweeps

Cryptorchidism Undescended testis 0.7-0.8% of males Descent occurs in the last 2 months of intrauterine life Risk factors: Hormonal abnormalities Prematurity Testicular abnormalities Mechanical problems Congenital syndormes

Cryptorchidism Right > left Can result in infertility Risk of malignancy : x4 May result in atrophy Tubular atrophy, hyalinization Hyperplasia of leydig cells Intratubular germ cell neoplasia

Epididymitis, Orchitis Infections (acute, chronic, granulomatous) Follow UTI Associated with mumps in 20% of adults, rare in children

Granulomatous orchitis

Testicular torsion and infarction

Testicular Neoplasm Most common cause of painless, firm enlargement of the testis 2/100,000 male 15-35 year Classification Germ cell tumors Sex cord tumors

Germ cell tumors Seminoma Non-Seminoma 1. Teratoma 2. Embryonal carcinoma 3. Yolk sac tumor 4. Choriocarcinoma Mixed Germ cell tumors (60%)

Genetic finding: Isochromosome 12 Risk factors: Testicular abnormalities: undesceded testis, testicular dysgenesis Chromosomal syndromes: Klinefelter Family history White > Black Intratubular germ cell neoplasia Genetic finding: Isochromosome 12

Case Presentation

A 35-year-old healthy male with a past history of cryptorchidism repaired at age 5 presented with painless enlargement of the left testis. The mass was opaque on transillumination. A testicular ultrasound examination revealed the enlargement to be composed of soft tissue without a cystic component. Laboratory data included serum HCG of 90 mU/mL (ref. range < 5 mU/mL) and AFP of 7 ng/mL (ref. range 0-44 ng/mL). A radical left orchiectomy was performed.

The left testicle was dominated by a 4. 0-cm, pink-tan nodular mass The left testicle was dominated by a 4.0-cm, pink-tan nodular mass. An abdominal CT scan revealed para-aortic lymphadenopathy; a chest x-ray was normal. Radiotherapy was given to the abdominal retroperitoneal region.

Seminoma Age 40-50 years Large, soft, well-demarcated, homogenous mass, gray-white (may show hemorrhage, necrosis) Large cells, round nuclei with porminent nucleoli Inflammatory cells Malignant

Teratoma All ages Firm mass, may contain cartilage Types Mature Immature Teratoma with malignant transformation All are considered malignant except mature teratoma in children.

Embryonal carcinoma Age 20-30 years Ill-defined mass with hemorrhage and necrosis Large cells, large nuclei with glandular structures Malignant

Yolk Sac tumor Children: 3 years Large tumor, well demarcated Cuboidal cells forming microcysts Eosinophilic hyaline globules Schiller-Duvall bodies Alpha feto protien (AFP) Malignant

Choriocarcinoma Age 20-30 years Small, hemorrhagic Cytotrophoblasts, Syncytiotrophobalsts hCG Malignant

Mixed Germ cell tumor 60% Teratoma + Embryonal carcinoma Teratoma + Yolk sac tumor

Clinical Issues Stage I: tumor limited to testis Stage II: Retroperitoneal lymph nodes Stage III: beyond retroperitoneal lymph nodes Tumor markers hCG AFP Seminoma is radiosensitive

70 year old man with testicular mass