Mock 4 Testicular

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A 32-year-old male presents with a 1 month history of right groin lump.
O/E: Firm non-tender lump. Testicle not palpable in scrotum.
USS showed a 6cm partially cystic & solid mass at internal ring infiltrating the local soft tissues and extending into the abdomen. No other pathology is seen.

Differential diagnosis?

Undescended testes
Inguinal lymphadenopathy
Inguinal hernia
Femoral artery pseudoaneurysm
Testicular tumour
Soft tissue tumour

Orchidectomy & bone biopsy from a suspicious region done & pathology is as follows.
Testicular teratoma with involved margins, local tissue, lymphatic & skeletal invasion.
Discus this pathology report with the family in simple lines

This is a tumour of testicle
With incomplete resection
The patient may need another surgery or chemotherapy
Spreading locally and reaching bone & lymphatic glands

To where dose teratoma initially spread?

Para-aortic lymph nodes.

Types of testicular tumours according to age groups?

Teratoma common in all ages
in young age, yolk sac and embryonic carcinoma
middle age, seminoma
in elderly, lymphoma

What's choriocarcinoma?

Malignant teratomatous neoplasm with placenta-like differentiation.

What immunohistochemical marker confirms diagnosis of choriocarcinoma?

β-hCG

Other type of malignancy at this age?

Seminoma

What's alpha fetoprotein?

Protein normally produced by yolk sac in foetus
It may indicate yolk sac differentiated teratoma

Mention another non germ tumour with high AFP (alpha fetoprotein)?

Hepatocellular carcinoma

What's the value of LDH in testicular cancer?

It reflects tumour load and rate of growth, therefore helps in evaluation of tumour

Post-Op he developed haematoma. What are the stages of haematoma resolutions?

Lysis of the clot by macrophages (about 1 week)
Growth of fibroblasts into the hematoma (2 weeks)

After few months, he developed small pneumothorax. Cause?

Lung metastasis

Define metastasis?

Survival and growth of cells at a site distant from their primary origin

Is β-hCG normally released in men? β-hCG is released what does this indicate?

Seminal plasma

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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?

Lymphoma

Talk about classification of testicular tumours & give an example for each?
Germ Cell Tumour

Seminoma: classic, spermatocytic, anaplastic.
Teratoma
Choriocarcinoma
Yolk sac

Non-germ cell tumour

Sex cord stromal:Non-seminoma:

Leydig cell tumour
Sertoli cell
Others: metastasis and lymphoma

Describe the microscopic morphology of testicular teratoma vs seminoma?
Seminoma

Sheet-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?

Teratoma 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

It is called struma ovarii

Explain findings in adenocarcinoma

Failure of differentiation and subsequent malignant transformation of epithelial differentiation line.

What's the composition of PE?

Platelets
Polymerized fibrin
Admixed circulatory cells

Which clotting factor allowing polymerization of fibrin?

Activated factor 8

Explain coagulation cascade
Intrinsic Pathway

Trigger: 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

Trigger: 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

Venous stasis (compression)
Hypercoagulable state (tumour)

Where could a β-hCG found in a normal male?

Seminal plasma

isurg

Mock 4 Testicular