Dr. Roopam Jain, Professor & Head, Dept. of Pathology & Blood Bank

1. MALE GENITAL SYSTEM
- TESTICULAR TUMOURS
DR. ROOPAM JAIN
PROFESSOR & HEAD, PATHOLOGY

2. TESTICULAR
TUMOURS

3. Classification
of testicular
tumours

4. • all testicular tumours are divided into 3 groups:
germ cell tumours,
sex cord-stromal tumours
mixed forms.
• Vast majority of the testicular tumours (95%) arise from
germ cells or their precursors in the seminiferous tubules,
while less than 5% originate from sex cord-stromal
components of the testis.
• From clinical point of view, germ cell tumours of the testis
are categorised into 2 main groups—
seminomatous
non-seminomatous

5. Distinguishing features of seminomatous
(SGCT) & non-seminomatous (NSGCT) germ
cell tumours of testis

6. TESTICULAR TUMOURS
ETIOLOGIC FACTORS
• 1. Cryptorchidism
• 2. Other developmental disorders
• 3. Genetic factors
• 4. Other factors
i) Orchitis
ii) Trauma
iii) Carcinogens

7. HISTOGENESIS
4 Classification, incidence and histogenesis of testicular tumours

8. CLINICAL FEATURES AND DIAGNOSIS
• The usual presenting clinical symptoms of testicular
tumours are gradual gonadal enlargement and a dragging
sensation in the testis.
• Metastatic involvement may produce secondary symptoms
such as pain,
• lymphadenopathy,
• haemoptysis and
• urinary obstruction

9. SPREAD
• Since testicular germ cell tumours originate from totipotent germ cells, it
is not unusual to find metastases of histologic types different from the
primary growth.
• Testicular tumours may spread by both lymphatic and haematogenous
routes:
• 1. Lymphatic spread occurs to retroperitoneal para-aortic lymph nodes,
mediastinal lymph nodes and supraclavicular lymph nodes.
• 2. Haematogenous spread primarily occurs to the lungs, liver, brain and
bones.

10. TUMOUR MARKERS
• Germ cell tumours of the testis secrete polypeptide hormones and
certain enzymes which can be detected in the blood. Two tumour
markers widely used in the diagnosis, staging and monitoring the
follow-up of patients with testicular tumours are: human chorionic
gonadotropin (hCG) and alpha-foetoprotein (AFP). In addition,
carcinoembryonic antigen (CEA), human placental lactogen (HPL),
placental alkaline phosphatase, testosterone, oestrogen and
luteinising hormone may also be elevated.
• 1. hCG is synthesised by placental syncytio-trophoblast such as in
various non-seminomatous germ cell tumours of the testis (e.g. in
choriocarcinoma, yolk sac tumour and embryonal carcinoma).
However, ectopic hCG production may occur in a variety of non-
testicular non-germ cell tumours as well.
• 2. AFP is normally synthesised by the foetal liver cells, yolk sac and
foetal gut. Its levels are elevated in testicular tumours associated
with yolk sac components. However, elevated serum AFP levels are
also found in liver cell carcinoma.

11. PROGNOSIS
• For selecting post-orchiectomy treatment (radiation, surgery,
chemotherapy or all the three) and for monitoring prognosis, 3 clinical
stages are defined:
• Stage I: tumour confined to the testis.
• Stage II: distant spread confined to retroperitoneal lymph nodes below
the diaphragm.
• Stage III: distant metastases beyond the retroperitoneal lymph nodes.

12. GERM CELL TUMOURS
• Germ cell tumours comprise approximately 95% of all testicular tumours
and are more frequent before the age of 45 years.
• Testicular germ cell tumours are almost always malignant

13. Classic Seminoma
• Seminoma is the commonest malignant tumour of the testis and
corresponds to dysgerminoma in the female.
• It constitutes about 45% of all germ cell tumours, and in another 15%
comprises the major component of mixed germ cell tumour.
• Seminoma is divided into 2 main categories: classic and spermatocytic.
• Classic seminoma comprises about 95% of all seminomas and has a
peak incidence in the 4th decade of life and is rare before puberty.
• Undescended testis harbours seminoma more frequently
• About 10% pure seminomas are associated with elevated hCG

14. Classic Seminoma
MORPHOLOGIC FEATURES
• Grossly, the involved testis is enlarged up to 10 times its normal size
• The larger tumour replaces the entire testis, whereas the smaller tumour
appears as circumscribed mass in the testis.
• Cut section of the affected testis shows homogeneous, grey-white
lobulated appearance (Fig.). Necrosis and haemorrhage in the tumour
are rare.
• Microscopically, the tumour has the following characteristics (Fig.

15. Seminoma testis
The testis is enlarged but without distorting its contour.
Sectioned surface shows replacement of the entire testis by
lobulated, homogeneous, grey-white mass.

16. Seminoma testis
Microscopy of the tumour shows lobules of monomorphic seminoma
cells separated by delicate fibrous stroma containing lymphocytic
infiltration.

17. prognosis
• The prognosis of classic seminoma is better than other germ cell
tumours.
• The tumour is highly radiosensitive.

18. Embryonal Carcinoma
• Pure embryonal carcinoma constitutes 30% of germ cell tumours but
areas of embryonal carcinoma are present in 40% of various other germ
cell tumours.
• These tumours are more common in 2nd to 3rd decades of life.
• About 90% cases are associated with elevation of AFP or hCG or both.
• They are more aggressive than the seminomas

19. Yolk Sac Tumour
(Endodermal Sinus Tumour, Orchioblastoma,
Infantile Embryonal Carcinoma)
• This characteristic tumour is the most common testicular tumour of
infants and young children up to the age of 4 years.
• In adults, however, yolk sac tumour in pure form is rare but may be
present as the major component in 40% of germ cell tumours.
• AFP levels are elevated in 100% cases of yolk sac tumours
• Schiller-Duval bodies
• PAS-positive hyaline globules, many of which contain AFP

20. Choriocarcinoma
• Pure choriocarcinoma is a highly malignant tumour composed of
elements consisting of syncytiotrophoblast and cytotrophoblast.
• However, pure form is extremely rare and occurs more often in
combination with other germ cell tumours.
• The patients are generally in their 2nd decade of life.
• The primary tumour is usually small and the patient may manifest
initially with symptoms of metastasis.
• The serum and urinary levels of hCG are greatly elevated in 100% cases.

21. Choriocarcinoma
MORPHOLOGIC FEATURES
• Grossly, the tumour is usually small and may appear as a soft,
haemorrhagic and necrotic mass.
• Microscopically, the characteristic feature is the identification of
intimately related syncytiotrophoblast and cytotrophoblast without
formation of definite placentaltype villi.
• i) Syncytiotrophoblastic cells are large with many irregular and bizarre
nuclei and abundant eosinophilic vacuolated cytoplasm which stains
positively for hCG.
• ii) Cytotrophoblastic cells are polyhedral cells

22. Teratoma
• Teratomas are complex tumours
• composed of tissues derived from more than one of the three germ
cell layers—endoderm, mesoderm and ectoderm.
• Testicular teratomas are more common in infants and children and
constitute about 40% of testicular tumours in infants, whereas in adults
they comprise 5% of all germ cell tumours.
• teratomas are found in combination with other germ cell tumours
(most commonly with embryonal carcinoma) in about 45% of mixed
germ cell tumours.
• About half the teratomas have elevated hCG or AFP levels or both.

23. Teratoma
MORPHOLOGIC FEATURES
• Testicular teratomas are classified into 3 types:
• 1. Mature (differentiated) teratoma
• 2. Immature teratoma
• 3. Teratoma with malignant transformation.
• Grossly, most teratomas are large, grey-white masses enlarging the
involved testis.
• Cut surface shows characteristic variegated appearance—grey-white
solid areas, cystic and honey-combed areas, and foci of cartilage and
bone (Fig.).

24. Immature teratoma testis.
The testis is enlarged and nodular distorting the testicular contour. Sectioned
surface shows replacement of the entire testis by variegated mass having grey-
white solid areas, cystic areas, honey-combed areas and foci of cartilage and bone

25. Teratoma
MORPHOLOGIC FEATURES-Microscopically
• the 3 categories of teratomas show different appearances:
• 1. Mature (differentiated) teratoma
• 2. Immature teratoma
• 3. Teratoma with malignant transformation

26. Immature teratoma testis.
Microscopy shows a variety of incompletely differentiated
tissue elements

27. Mixed Germ Cell Tumours
• About 60% of germ cell tumours have more than one of the above
histologic types (except spermatocytic seminoma) and are called mixed
germ cell tumours.
• The clinical behaviour of these tumours is worsened by inclusion of more
aggressive tumour component in a less malignant tumour.
• The most common combinations of mixed germ cell tumours are as under:
• 1. Teratoma, embryonal carcinoma, yolk sac tumour & syncytiotrophoblast.
• 2. Embryonal carcinoma and teratoma (teratocarcinoma).
• 3. Seminoma and embryonal carcinoma.

28. Leydig (Interstitial) Cell Tumour
• Leydig cell tumours are quite uncommon.
• They may occur at any age but are more frequent in the age group
of 20 to 50 years.
• Characteristically, these cells secrete androgen, or both androgen
and oestrogen, and rarely corticosteroids.
• Bilateral tumours may occur typically in congenital adrenogenital
syndrome.

29. Leydig (Interstitial) Cell Tumour
• MORPHOLOGIC FEATURES
• Grossly, the tumour appears as a small, well-demarcated and lobulated
nodule.
• Cut surface is homogeneously yellowish or brown.
• Histologically, the tumour is composed of sheets and cords of normal-
looking Leydig cells. These cells contain abundant eosinophilic cytoplasm
and Reinke’s crystals and a small central nucleus.

30. Sertoli Cell Tumours
(Androblastoma)
• Sertoli cell tumours correspond to arrhenoblastoma of the ovary.
• They may occur at all ages but are more frequent in infants and children.
• These tumours may elaborate oestrogen or androgen and may account for
gynaecomastia in an adult, or precocious sexual development in a child.
• MORPHOLOGIC FEATURES
• Grossly, the tumour is fairly large, firm, round, and well circumscribed.
Cut surface of the tumour is yellowish or yellow-grey.
• Microscopically, Sertoli cell tumour is composed of benign Sertoli cells
arranged in well-defined tubules.

31. Granulosa Cell Tumour
• This is an extremely rare tumour in the testis and
• resembles morphologically with its ovarian counterpart

32. Gonadoblastoma
• Dysgenetic gonads and undescended testis are predisposed to develop
such combined proliferations of germ cells and sex cord-stromal
elements.
• The patients are commonly intersexuals, particularly phenotypic females.
• Most of the gonadoblastomas secrete androgen and therefore produce
virilisation in female phenotype. A few, however, secrete oestrogen
• MORPHOLOGIC FEATURES
• Grossly, the tumour is of variable size, yellowish-white and soft.
• Microscopically, gonadoblastoma is composed of 2 principal cell types—
large germ cells resembling seminoma cells, and small cells resembling
immature Sertoli, Leydig and granulosa cells. Call-Exner bodies of a
granulosa cell tumour may be present

33. DEVELOPMENTAL AND INFLAMMATORY
DISORDERS OF PENIS
PHIMOSIS
• Phimosis is a condition in which the prepuce is too small to permit its
normal retraction behind the glans.
• It may be congenital or acquired.

34. DEVELOPMENTAL AND INFLAMMATORY
DISORDERS OF PENIS
PHIMOSIS
• Phimosis is a condition in which the prepuce is too small to permit its
normal retraction behind the glans.
• It may be congenital or acquired.

35. DEVELOPMENTAL AND INFLAMMATORY
DISORDERS OF PENIS
HYPOSPADIAS AND EPISPADIAS
• Hypospadias is a developmental defect of the urethra in which the
urethral meatus fails to reach the end of the penis, but instead, opens
on the ventral surface of the penis
• Similar developmental defect with resultant urethral opening on the
dorsal surface of the penis is termed epispadias

36. DEVELOPMENTAL AND INFLAMMATORY
DISORDERS OF PENIS
BALANOPOSTHITIS
• Balanoposthitis is the term used for non-specific inflammation of the
inner surface of the prepuce (balanitis) and adjacent surface of the glans
(posthitis).
• It is caused by a variety of microorganisms such as staphylococci,
streptococci, coliform bacilli and gonococci.
• Balanoposthitis usually results from lack of cleanliness resulting in
accumulation of secretions and smegma.

37. TUMOURS

38. TUMOURS
PREMALIGNANT LESIONS (CARCINOMA IN SITU)
• In the region of external male genitalia, three lesions display cytological
changes of malignancy. These conditions are:
• Bowen’s disease,
• erythroplasia of Queyrat
• bowenoid papulosis.

39. MALIGNANT TUMOURS
Squamous Cell Carcinoma
• 3-4 times more common in blacks than in whites.
• In some Asian, African and Latin American countries, its incidence is
about 10% of all cancers.
• Relationship of penile cancer with HPV has been well supported; high-risk
HPV types 16 and 18 are strongly implicated and their DNA has been
documented in the nuclei of malignant cells.
• Carcinoma of the penis is quite rare in Jews and Muslims
• Circumcision provides protection against penile cancer due to prevention
of accumulation of smegma which is believed to be carcinogenic.
• The greatest incidence of penile cancer is between 45 and 60 years

40. MALIGNANT TUMOURS
Squamous Cell Carcinoma

41. Squamous cell carcinoma penis
Microscopy shows whorls of malignant squamous cells
with central keratin pearls

45. (b) Hemorrhage inflammation
(c) Anti-GBM antibody
(d) Diffuse alveolar involvement

52. • 81. A 35-year-old woman Sumitra has had type 1
diabetes mellitus for 20 years. She is now developing
advanced disease with visual complaints, foot ulcers,
and renal disease. Which of the following features
that might be seen on renal biopsy is most specific
for diabetic glomerulosclerosis?
(a) Mesangial IgA deposits
(b) Necrotic epithelial cells in tubules
(c) Nests of cells with abundant clear cytoplasm
(d) Ovoid, PAS-positive, hyaline masses

57. 83.6. The crescent forming glomerulonephritis
is:
• (a) Acute GN
• (b) Rapidly progressive glomerulonephritis
• (c) Membranous GN
• (d) Membranoproliferative GN