– due to fusion of tissues during early embryonic development
Splenogonadal Fusion
– fusion of spleen and gonad
Adrenal Heteropia
– adrenal tissue may be found in inguinal hernia sac, spermatic cord, epididymis or rete testis
"Celes"
– accumulation of fluid
Variocele
– dilated tortuous veins of pampiniform plexus of spermatic cord; seen more prominently when upright
Hydrocele
– accumulation of serous fluid within tunica vaginalis
Hematocele
– accumulation of blood within tunica vaginalis
Spermatocele
– diverticulum arising from an efferent ductule near rete testis or epididymis Þ contains spermatozoa
Cysts
– fluid-filled structures lined by a membrane
Mesothelial Cysts
– cystic accumulation of serous fluid lined by mesothelium; visceral and parietal tunica vaginalis mesothelium are identical to pleura or peritoneum
Simple Cyst of rete testis
– lined by rete testis tubular epithelium
Torsions
Spermatic cord torsion
– torsion of testis within the tunica sac (Bell-Clapper Deformity); torsion produces venous and then arterial ischemia and eventually infarction unless corrected within 6 hours
Torsion of embryonic remnants
– torsion of appendix epididymis and appendix testis causing infraction
Inflammatory/Reactive Conditions
Acute Epididymitis
–abundant neutrophilic inflam. of epididymis, tender; Chronic epididymitis– same but non-tender
Idiopathic scrotal/epidymal calcinosis
– rare probably a late sequela of chronic epididymitis
Sperm Granuloma
– exuberant foreign body giant cell reaction to extravasated spermatozoa; common after vasectomy
Vasitis Nodosa
– sequela of sperm granuloma; characterized by ductular proliferation in an attempt to recanalize the vas deferens after disruption; can also be idiopathic
Funiculitis
– painful enlargement of spermatic duct; many etiologies (TB, incarcerated inguinal hernia, etc.)
Benign Neoplasms
Lipoma
– most common para-testicular tumor; 90% of spermatic cord tumors
Adenomatoid tumor
– most common tumor of epididymis; derived from mesothelium
Papillary Cystadenoma of Epididymis
– 2nd most common epididymal tumor; commonly bilateral, associated with von Hippel-Llindau Syndrome
Malignant Neoplasms
Liposarcoma
– most common para-testicular sarcoma in adults; 10% fetal
Rhabdomyosarcoma
– most common para-testicular sarcoma in childhood; peak incidence at 9 yrs. old; 20% fatal
Malignant Mesothelioma
– most arise in tunica vaginalis; mean age 55; 50% fatal
– presence in wrong location; sometimes appear in superficial inguinal canal, femoral perineum (Scarpa’s triangle), pubopenile (on back of penis), pelvis (pouch of Douglas), "Crossed Ectopia" (both in same scrotal pouch)
– viral (mumps), bacterial (malakoplakia), or granulomatous of known etiology (TB, syphilis, leprosy, sarcoidosis, fungi, parasites) or unknown etiology
Systemic arteritides
– rheumatoid arthritis and polyarteritis nodosa may involve testicular arteries
Testicular Infarct
– from spermatic cord torsion, surgery in inguinal canal, polycythemia, sickle cell disease, trauma
Testicular Tumors
– six classifications:
different tumor types predominate at different ages: young people
Þ teratoma; pubertyÞ germ cell; elderlyÞ lymphoma
(1) Germ Cell Tumors (GST’s)
conditions associated with
Ý risk of Testicular GCT: cryptochidism (undescended testis (UDT)), prior testicular GCT, family history, androgen insensitivity syndrome (AIS), gonadal dysgenesis
Intratubular Germ Cell Neoplasia (ITGCN)
– differentiated or undifferentiated types; precursor of invasive GCT
associated with infertility, cryptochidism, family history of testis GCT, gonadal dysgenesis, or GCT
50% develop invasive GCT within 5 years, seminoma is the most common tumor arising in ITGCN background
does not give rise to spermatocytic seminoma, pediatric yolk sac tumor, or pediatric teratoma
GST’s of One Histologic Type
Classic Seminoma
– most common testicular tumor; accounts for 40-50% of all GCT’s
patients are usually 35-45 years old, rarely
< 15 or > 50; 10% present with symptoms related to metastases
if Alphafeto protein (AFP)
Ý assume a component of Yolk Sac Tumor (YST, see below) and better prognosis
Spermatocytic Seminoma
– distinct (not a sub-type of seminoma); 1-2% of all GCT’s; 4-10% bilateral; never mixed
patients are usually
> 50 years old; rarely produces metastases, so excellent prognosis
NOTE:
These two (classic and spermatocytic seminoma) are called Seminomatous Germ Cell Tumors (SGCT)
all other germ cell tumors, even if they predominantly involve a seminoma, are non-SGCT, or NSGCT
this is important for management, as NSGCT’s are harder to treat; 20 years ago, only SGCT’s were considered curable
Embryonal Carcinoma
– usu. unilateral; only 2-3% pure; most have component of Yolk Sac Tumor (YST, see below)
patients are usually 20-30 years old; 33% present with metastases; survival 80-95%, varying with stage
occasional gynecomastia, and serum AFP and HCG (human chorionic gonadotrophin) may be
Ý
Yolk Sac Tumor (YST)
– presence in stage I mixed GCT lessens likelihood of metastases
in children: pure form accounts for 75% of all testicular tumors
Þ good prognosis
in adults: rarely pure, component in 40-50% of mixed GCT’s; assoc with
Ý AFP, rapid growth
more chemoresistant once metastatic
Choriocarcinoma
– only 0.3% are pure; testis infiltrated in 20-65% of cases
patients usually are between puberty and 30 years old
most present with metastases or gynecomastia;
Ý serum HCG; prognosis is very guarded
Teratoma
– mature, immature, and monodermal types
in children: account for 14-18% of tumors; considered benign, no metastases
in adults: usually mixed; component of
> 50% of mixed GCT; malignant, prognosis guarded
GST’s Mixed Histologic Type
mixed germ cell tumors
– account for 2/3 of NSGCT’s (see box above) and 1/3 of all GCT’s; prognosis varies
any combination is possible; patients are usually 20-35 years old, with
Ý AFP (60%) and HCG (55%)
polyembryoma, diffuse embryoma
(2) Sex Cord Stromal Tumors
– include Leydig cell tumor, Sertoli cell tumor, Granulosa cell tumor, Mixed sex cord-stromal cell tumors, and Unclassified sex cord-stromal cell tumors
(3) Mixed Germ Cell/Sex Cord-Stromal Tumors
Gonadoblastoma
– aggregates of germ cells/sex cord stromal cells arranged in discrete nests; 60% associated with malignant GCT
associated with gonadal dysgenesis or intersex syndromes; 1/3 bilateral; most are <20 years
Unclassified mixed GC/SCS tumors
– germ cells and SCS cells haphazardly intermingled; biologically benign
no association with gonadal dysgenesis/intersex
(4) Tumors of the Rete Testis
Adenocarcinoma
– bad prognosis (36% survival); patients usually 30-90 years old, Caucasians at greater risk
Adenoma and Hyperplasia
– rare and not well defined
(5) Tumors of Hematopoietic Origin
Lymphoma
– probably manifestation of systemic disease; 20% of cases are bilateral, most are diffuse large B cell
Plasmacytoma
– Rare; looks like multiple myeloma
Leukemia
– testis infiltrated in 20-65% (especially Acute Lymphocytic Leukemia, ALL)