Testicular tumors and Testicular tumors and STDsSTDs

Dr. Basu MDDr. Basu MD

Our topic Our topic A.A. Classification of Classification of

testicular tumor.testicular tumor.B.B. SeminomaSeminomaC.C. Embryonal carcinomaEmbryonal carcinomaD.D. Yolk sac tumor Yolk sac tumor E.E. ChoriocarcinomaChoriocarcinomaF.F. TeratomaTeratomaG.G. Diagnosis of these Diagnosis of these

tumorstumors

What you should know about a What you should know about a Testicular tumorTesticular tumor

AgeAgeGross and microscopyGross and microscopyMarkersMarkersClinical PresentationClinical Presentation

Classification of testicular tumor.Classification of testicular tumor.

1.1. Tumor arising from the Germ Tumor arising from the Germ cellscells

2.2. Tumor arising from Leydig Tumor arising from Leydig cells( produce endocrine cells( produce endocrine abnormality).abnormality).

3.3. Tumor arising from Sertoli cells.Tumor arising from Sertoli cells.

Tumor arising from the Germ Tumor arising from the Germ cellscells

1.1. Tumors with Tumors with one one histologicalhistological pattern patternA.A. SeminomaSeminomaB.B. Embryonal carcinomaEmbryonal carcinomaC.C. Yolk sac tumor Yolk sac tumor D.D. ChoriocarcinomaChoriocarcinomaE.E. TeratomaTeratoma

2.2. Tumor with Tumor with more than onemore than one histological patternhistological pattern

3.3. MiscellaneousMiscellaneous

Seminoma Vs Non seminomatous tumor of Seminoma Vs Non seminomatous tumor of testis testis

Seminoma Seminoma Embryonal Embryonal carcinoma, Yolk carcinoma, Yolk sac tumor, sac tumor, choriocarcinomachoriocarcinoma

Radiosensitive Radiosensitive NotNot

Late metastasis Late metastasis Early Early

Good prognosis Good prognosis BadBad

Tumors and the diagnostic Tumors and the diagnostic pointspoints

Classic Classic SeminomaSeminoma

Seminoma Seminoma cells.cells.

Lymphocyte Lymphocyte in stroma.in stroma.

Cells are Cells are positive for positive for PASPAS

Embryonal Embryonal CarcinomaCarcinoma

Primitive Primitive cells.cells.

Both AFP and Both AFP and beta hcG beta hcG elevatedelevated

ChoriocarcinomChoriocarcinomaa

Malignant Malignant trophoblast.trophoblast.

Elevated beta Elevated beta hcGhcG

Yolk sac tumorYolk sac tumor Schillar Duval Schillar Duval body – body – glomeruloid glomeruloid bodybody

Elevated AFP Elevated AFP

TeratomaTeratoma

Pure TeratomaPure Teratoma Tissues of all Tissues of all three germ-cell three germ-cell layer.layer.

No No specific specific markermarker

Teratoma + foci Teratoma + foci of of choriocarcinomachoriocarcinoma

Tissues of all Tissues of all three germ-cell three germ-cell layer + malignant layer + malignant trophoblasttrophoblast

Increased Increased beta-hcGbeta-hcG

Teratoma + foci Teratoma + foci of Embryonal of Embryonal carcinomacarcinoma

Tissues of all Tissues of all three germ-cell three germ-cell layer + Embryonal layer + Embryonal carcinomacarcinoma

Increased Increased AFP & hcG AFP & hcG

Seminoma [Classic]Seminoma [Classic]

1.1. Most common types of testicular Most common types of testicular neoplasm. neoplasm.

2.2. Age : 15 to 34 yearsAge : 15 to 34 years

3.3. Note:Note: Some Seminoma may contain Some Seminoma may contain

trophoblastic content.trophoblastic content. In these type of Seminoma Beta-In these type of Seminoma Beta-

HCG will be mildly elevated.HCG will be mildly elevated.

Variant of Variant of SeminomaSeminoma

Variant : Variant : Spermatocytic SeminomaSpermatocytic Seminoma In this case metastasis is rare, In this case metastasis is rare,

common in old people.common in old people. Three types of cell are seenThree types of cell are seen

1.1. large multinucleated cells, large multinucleated cells,

2.2. medium size cells and medium size cells and

3.3. small cells that reminiscent of small cells that reminiscent of spermatocytesspermatocytes

Seminoma Gross Seminoma Gross

Features : large, soft, homogenous, grey-white

Seminoma : MicroscopySeminoma : Microscopy1.Seminoma cells ([ PAS positive] : Large

cells with distinct border , round nuclei and prominent nucleoli.

2.Lymphocytes, plasma cell in stroma.

Seminoma counterpart in Seminoma counterpart in OvaryOvary

DYSGERMINOMADYSGERMINOMA

Embryonal carcinomaEmbryonal carcinoma

Age : 20-30 years.Age : 20-30 years.FeaturesFeatures : : 1.1.Often multiple metastasis is Often multiple metastasis is

present at the time of diagnosis.present at the time of diagnosis.2.2.Often it contain other foci of Often it contain other foci of

Yolk sac tumor, teratoma Yolk sac tumor, teratoma and and Chorio-carcinomaChorio-carcinoma..

3.3.So both AFP and beta hcG will So both AFP and beta hcG will be elevated be elevated ( non specific) ( non specific)

Embryonal carcinomaEmbryonal carcinoma

Features : Red to tan to brown areas, including prominent hemorrhage and necrosis.

Sheets of primitive looking blue Sheets of primitive looking blue cells.cells.

Embryonal carcinoma and Embryonal carcinoma and Teratoma Teratoma [ Teratocarcinoma][ Teratocarcinoma]

Features : Chondroid white areas (teratoma) in a Embryonal carcinoma.

Solid cystic mass in Ultra sound- Solid cystic mass in Ultra sound- TeratocarcinomaTeratocarcinoma

Teratoma in testisTeratoma in testis

Age = all agesAge = all agesAlmost always malignantAlmost always malignant ( unlike ( unlike

ovary – where it is usually ovary – where it is usually benign)benign)

Yolk sac tumor [ endodermal Yolk sac tumor [ endodermal sinus tumor]sinus tumor]

Age : 3 yearsAge : 3 yearsHistology : Presence of Histology : Presence of

Schiller –Duvall bodySchiller –Duvall body ( glomeruloid body)( glomeruloid body)

Specific Marker = Specific Marker = AFP AFP

Schillar Duval body – Schillar Duval body – glomeruloid structureglomeruloid structure

in yolk sac tumor ; locate itin yolk sac tumor ; locate it

ChoriocarcinomaChoriocarcinoma

Age = 20 -30 Age = 20 -30 Pure Chorio carcinoma is rare in Pure Chorio carcinoma is rare in

testistestis.. It is alwaysIt is always mixed mixed with Teratoma, or with Teratoma, or

other tumor even with Seminoma.other tumor even with Seminoma. Histology : Malignant cyto and Histology : Malignant cyto and

syncytiotrophoblast without villous syncytiotrophoblast without villous formation.formation.

Specific Marker = beta hcGSpecific Marker = beta hcG

Mixed tumorMixed tumor

Add………….Add………….

Leydig cell tumor : Clinical Leydig cell tumor : Clinical featuresfeatures

Small( 1-3 cm), nodular, Small( 1-3 cm), nodular, circumscribed tumor, yellowish circumscribed tumor, yellowish

in colourin colour

Bilateral gyenecomastiaBilateral gyenecomastia and and testicular enlargementtesticular enlargement force the force the patient to seek medical assistance. patient to seek medical assistance.

Quiz : name the markersQuiz : name the markers

Yolk sac tumorYolk sac tumor

ChoriocarcinomaChoriocarcinoma

Teratoma + Yolk sac Teratoma + Yolk sac tumortumor

Teratoma + Teratoma + choriocarcinomachoriocarcinoma

Teratoma + Teratoma + Embryonal carcinomaEmbryonal carcinoma

AFAFPPhchcGGAFAFPP

hchcGGAFP and AFP and hcGhcG

Testicular tumor; clinical Testicular tumor; clinical featuresfeatures

1.1. Painless swellingPainless swelling

2.2. Seminoma Seminoma usually confined to usually confined to testis.testis.

3.3. Other non-seminomatous Other non-seminomatous tumor tumor widely metastasize .widely metastasize .

4.4. Metastasis occur by Metastasis occur by both both hematgenous and lymphatic hematgenous and lymphatic routeroute..

Rest your eyes : Time for Rest your eyes : Time for Sexually transmitted diseaseSexually transmitted disease

At a glance- STDsAt a glance- STDsPathogens Pathogens DiseasesDiseases Diagnostic pointsDiagnostic points

HPV ( 6,11)HPV ( 6,11) Condylomata Condylomata acuminataacuminata

Koilocyte in the Koilocyte in the squamous squamous epithelial cells.epithelial cells.

Chlamydiae Chlamydiae TrachomatiTrachomatiss

Urethritis, Urethritis, Epididymitis.Epididymitis.LymphogranulLymphogranuloma Venereum.oma Venereum.

Granuloma and Granuloma and Neutrophils NeutrophilsMucopurulent Mucopurulent urethral urethral discharge.discharge.Culture Culture negativenegative

STDsSTDsPathogens Pathogens DiseasesDiseases Diagnostic Diagnostic

pointspoints

Neisseria Neisseria GonorrhoeaGonorrhoeaee

EpididymitisEpididymitis,,

salpingitis salpingitis

Mucopurulent Mucopurulent discharge.discharge.

Culture Culture positivepositive..

Hemophilus Hemophilus ducreyiducreyi

Chancroids Chancroids

(soft (soft chancre)chancre)

Tender ulcer, Tender ulcer, exudates exudates present at present at ulcer base.ulcer base.

Syphilis ; Treponema Syphilis ; Treponema pallidum pallidum

Primary Primary syphilissyphilis

Hard chancreHard chancre

Negative Negative serological serological tests tests

Painless ulcer, Painless ulcer, clean moist clean moist base of the base of the ulcer. ulcer.

Positive for Positive for treponoma treponoma pallidum in pallidum in scrap smearscrap smear

Secondary Secondary syphilissyphilis

SecondarSecondary y syphilissyphilis

Generalized Generalized lymphadenopatlymphadenopathy.hy.Maculopapular Maculopapular rash.rash.Condylomata Condylomata latalata

Serological Serological testes testes positivepositive

Strongly Positive both Strongly Positive both Anti treponomal Anti treponomal antibody test and antibody test and Nontrepomomal testNontrepomomal test

SyphilisSyphilis

Tertiary Tertiary syphilissyphilis

Cardiovascular Cardiovascular disease.disease.

NeurosyphilisNeurosyphilis

( general ( general paresis)paresis)

Development Development of gumma in of gumma in bone , skin, bone , skin, mucus mucus membrane.membrane.

Positive Positive anti anti treponomal antibody treponomal antibody test.test.

Negative Negative – – Nontrepomomal Nontrepomomal antibody testantibody test

STDsSTDs

CalymmatobaCalymmatobacterium cterium donovanidonovani

Granuloma Granuloma InguinaleInguinale

Ulcerative papular lesions on the external genitalia.

Genital Genital herpes herpes simplexsimplex

Painful Painful erythematouerythematous vesicless vesicles

Presence Presence of cowdry of cowdry type A type A inclusioninclusion

Condylomata acuminata ( HPV Condylomata acuminata ( HPV infection type 6,11) : infection type 6,11) : Genital Genital

Warts Warts

Gonorrhea ; clinical featuresGonorrhea ; clinical features

Male :Male : Epididymitis, may involve Epididymitis, may involve prostate.prostate.

Female : Female : salpingitis, infertilitysalpingitis, infertilityInfants ( during delivery) : Infants ( during delivery) :

Purulent infection of the eye : Purulent infection of the eye : Ophthalmia neonatorum).Ophthalmia neonatorum).

Lymphogranuloma Venereum, LGV Lymphogranuloma Venereum, LGV lymphadenopathy.lymphadenopathy.

Mixed Granulomatous and neutrophilic inflammation.

Diagnosis - Diagnosis - LGVLGV

Demonstration of organism in Biopsy Demonstration of organism in Biopsy section / exudates- section / exudates- in active lesionin active lesion. .

ELISA performed on serum.ELISA performed on serum.

““Soft chancre” –Soft chancre” –ChancroidChancroid in in Hemophilus ducreyiHemophilus ducreyi

infection. infection. Ulcer contain yellowish Ulcer contain yellowish exudates.exudates.

Syphilis ( Primary- Painless Syphilis ( Primary- Painless clear base ulcer, no clear base ulcer, no

exudates) ; exudates) ; hard chancrehard chancre

Syphilis ( secondary – Syphilis ( secondary – maculopapular rash)maculopapular rash)

Histology shows plasma cells and lymphocytes

Syphilis - Secondary :: Syphilis - Secondary :: Condylomata lata - This broad base, elevated lesion

seen in the moist areas.

Cause of false positive VDRL Cause of false positive VDRL testtest

1.1. SLESLE

2.2. Lepromatous leprosyLepromatous leprosy

3.3. PregnancyPregnancy

4.4. Antiphospholipid syndromeAntiphospholipid syndrome

Granuloma Inguinale ; ulcerated Granuloma Inguinale ; ulcerated papular lesionpapular lesion

Calymmatobacterium donovaniCalymmatobacterium donovani

Genital herpes simplexGenital herpes simplex: Painful erythematous vesicles: Painful erythematous vesicles

Etiology : HSV type 2 and 1

Gonorrhea Gonorrhea Neisseria gonorrheaNeisseria gonorrhea

Syphilis Syphilis Treponema pallidumTreponema pallidum

Genital Herpes Genital Herpes Herpes simplex,Herpes simplex, Type2 (mostly), Type2 (mostly), occasionally HSV-1 occasionally HSV-1

Genital Warts Genital Warts Human papillomaHuman papilloma virusvirus (HPV) (HPV)

Granuloma Granuloma Inguinale Inguinale

CalymmatobacteriuCalymmatobacterium donovanim donovani

Chlamydial Chlamydial Infections Infections

Chlamydia Chlamydia trachomatistrachomatis

Lymphogranuloma Lymphogranuloma Venereum Venereum

C. trachomatisC. trachomatis

Chancroid Chancroid Haemophilus ducreyiHaemophilus ducreyi

Best of luckBest of luck