Stem 2 A 69-year-old male presented with 1 month history of bilateral groin lumps. O/E firm non-tender lumps with grey scales. Doppler ultrasound findings include diffuse testicular infiltration, enlargement with hypervascularity, or multifocal areas of hypoechoic, solid and hypervascular nodules within testes. Orchidectomy was done & testicles were found to be white tan pink & fleshy. Pathology report: Malignant cells are pleomorphic and non-cohesive, with large irregular nuclei and prominent nucleoli. There is vascular invasion and sclerosis of seminiferous tubules. No intratubular germ cell neoplasia. The neoplastic cells typically express CD20 In light of the pathology report given, what's the diagnosis? SpoilerLymphoma Talk about classification of testicular tumours & give an example for each? Germ Cell Tumour SpoilerSeminoma: classic, spermatocytic, anaplastic. Teratoma Choriocarcinoma Yolk sac Non-germ cell tumour SpoilerSex cord stromal:Non-seminoma: Leydig cell tumour Sertoli cell Others: metastasis and lymphoma Describe the microscopic morphology of testicular teratoma vs seminoma? Seminoma SpoilerSheet-like cord of cells separated by fibrous septa that contain lymphocytes. Large, prominent nucleoli Teratoma !Composed of various types of cells or organs component He presents with PE a year later & is found to have large mass at the region of para-aortic LNs compressing renal vessels. Debulking surgery done, but tumour can't be totally resected. Frozen section showed thyroid tissue. Why? SpoilerTeratoma has the 3 germ cell lines (mesoderm, endoderm, ectoderm) which can differentiate to any of its derivatives Whats name for a monodermal thyroid-predominant teratoma specifically in the ovary SpoilerIt is called struma ovarii Explain findings in adenocarcinoma SpoilerFailure of differentiation and subsequent malignant transformation of epithelial differentiation line. What's the composition of PE? SpoilerPlatelets Polymerized fibrin Admixed circulatory cells Which clotting factor allowing polymerization of fibrin? SpoilerActivated factor 8 Explain coagulation cascade Intrinsic Pathway SpoilerTrigger: Internal damage to the blood vessel wall (e.g. plaque rupture). Initiation: Exposure of negatively charged surfaces, such as collagen, activates factor XII (Hageman factor).Initiation: Cascade: A series of reactions involving factors XII, XI, IX, VIII, and X. Extrinsic Pathway SpoilerTrigger: External trauma causing tissue injury Initiation: Tissue factor (TF) is released from damaged cells, which activates factor VII Cascade: Cascade: Activated factor VII (VIIa) activates factor X. Activated factor X (Xa) joins the common pathway Common Pathway Convergence: Both the intrinsic and extrinsic pathways converge at the activation of factor X. Thrombin Formation: Factor Xa, along with factor V, calcium, and phospholipids, activates prothrombin to form thrombin. Fibrin Formation: Thrombin converts fibrinogen into fibrin, which forms a mesh-like structure that traps platelets and blood cells, forming a blood clot What is the cause of PE in this patient? Explain SpoilerVenous stasis (compression) Hypercoagulable state (tumour) Where could a β-hCG found in a normal male? SpoilerSeminal plasma

IE & AS 49 years old women referred for surgery replacement of her aortic valve she has one year history of palpitation and progressive cardiac failure. There is no significant medical history but tobacco smoking four months post surgery she present with fatigue and arm weakness suspected infective endocarditis. the original native valve is describe to have calcification and fibrosis , whatare the two common causes for this ? At the age described . Spoiler1- Later degenerative changes due Rheumatic heart disease 2- Bicuspid aortic valve disease What is the physiology of stenosis or how stenosis happens? Since this patient has bicuspid aortic valve SpoilerThey will be calcifications—>That cause valve thickening—->Nodular fibrosis Fixed architecture why Bicuspid valve has risk ot sudden Death? SpoilerThis Because of obstructive cardiac hypertrophy associated with risk of MI and arrhythmia . surgical replacement is undertaken with metal prothesis what anticoagulant to be used post operatively in this patient ? Spoilerwarfarin to stop thrombus formation by prothesis how warfarin works ? mechanism of action ? Spoilerit works By inhibition of vitamin K dependant factor 10 9 7 2 in addition to routine investigations what investigations will help to give further information about cardiovascular system? Spoiler1. Cardiac catheterization Echo what is vitamin K dependants factors ? Spoiler10 9 7 2 What is role of activating factor 10 in clotting ? Spoilerto activate Factor 2 which is prothrombin to active form Thrombin what is normally help to activate Factor 10? Spoilercalcium what is infective endocarditis ? SpoilerInfection usually bacterial process or vegitation localized in valve or valve replacement What is hand sign in infective endocarditis? SpoilerJaneway lesion :no painful raised lesion due to septic imply emboli Osler nodes: Painful raised red lesion due to immune complex position. Splinter haemorrhage : tiny blood clots under nails Clubbing : in long standing How does infective endocarditis get into valve ? SpoilerVia haematogenous spread into thrombotic matter Why arm weakness? SpoilerIt is likely due to emboli to cerebral circulation from vegetation or infective thrombus What is thrombus? SpoilerProduct of clotting pathway and is blood clot that form in situ on the wall of blood vessel from constitution of the blood What type of complications happens to non displace thrombus ? SpoilerInfection. Inflammation. Occlusion. What test you will do if you are suspected the thrombus is infected? SpoilerCBC Inflammatory markers CRP ESR Blood culture What to look in the blood culture.? SpoilerCommon, organisms like staph aurius, strep veridians HACEK group which are homophiles species , aggrigobacter species cardiobactrium species ,eikenella corrodens , kingella Why some cases of infective endocarditis develop heart block? SpoilerBecause infective endocarditis will spread and extended into tissue around AV node What is CRP? SpoilerAcute phase routine produce in response to inflammation Where it produced? SpoilerIn the liver Why it raised in infective endocarditis? SpoilerBecause it produces an increase amount following raised of interleukin 6 and 1 from macrophages What is the commonest bacterial organisms can be found in infective endocarditis? Spoiler1 staph aurius 2 streptococcus veridans Situation is not settled and valve replacement was done why valve replacement? SpoilerSeptic focus source It will form biofilm Valve histology show large amount of thrombotic matter with fungal elements name two organisms? SpoilerCandida albican. Aspirgalosis What is type of infective endocarditis is associated with adenocarcinoma? SpoilerLibman suck endocarditis What is the pathological test to be used by surgical team to try to identify the septic agent? Spoiler1- repeated sample blood culture 2-aerobic and nonaerobic culture bottle for both What is the antibiotic guideline inpatient was aortic stenosis? SpoilerNice guideline no need for prophylactic antibiotic unless it is major surgery or high infected procedure What would you see microscopically infective endocarditis? SpoilerAschoff bodies which is granulomatous inflammation consist of central zone degenerated ECM and infiltration lymphocytes plasma and activated macrophages Investigation of choice to identify vegetations in infective endocarditis? Spoiler2D echo (Transoesophageal or Transthoracic) What to look for in 2D echo? SpoilerValvular regurgitation Leaflet: Prolapse, -annular dilatation Chordal elongation Increased echogenicity of sub valvular apparatus Pericardial effusion Ventricular dilatation and dysfunction Abscess What is difference Mechanical vs Tissue valve SpoilerMechanical - Warfarin for life, lasts long time Tissue - may need replacing, doesnt need warfarin