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Testes and Epididymis Pathelective.Com Drs Katherine Saunders, DO @SaraEWobker #GUPathElective Testes and Epididymis PathElective.com Drs. Katherine Saunders and Sara E. Wobker Anatomy: • Location • During development (around the 26th week of gestation), the testes descend from the posterior abdomen through the inguinal canal to reach the scrotum where they are then suspended from the abdomen by the spermatic cord • Spermatic cord contains vessels, nerves, and the vas deferens (***important margin for tumor staging***) • The layers which surround the testis and epididymis from superficial to deep: skin (scrotum)→ dartos fascia (continuous with Colles fascia of the perineum and Scarpa’s fascia of the abdomen)→ external spermatic fascia → cremaster muscle → internal spermatic fascia → tunica vaginalis → tunica albuginea (only surrounds the testis, not epididymis) • The tunica vaginalis is the serous pouch that covers the testes and epididymis • It is derived from the peritoneum • The tunica albuginea is the fibrous capsule of the testis, which divides the tissue of the testis into lobules; it does not cover the epididymis • Structure Katherine Saunders, DO @SaraEWobker #GUPathElective • Testes: • The testes are oval shaped and consist of a series of lobules, each containing hundreds of convoluted seminiferous tubules which are supported by interstitial tissue • The seminiferous tubules travel to the mediastinum where they become straight seminiferous tubules and then form the rete testis • The rete testis gives rise to efferent ductules which connect with the head of the epididymis • Epididymis: The epididymis is located on the posterolateral aspect of each testicle and is split into the head, body, and tail • Head: Most proximal portion which connects with the efferent ductules of the testis • Body: Heavily coiled duct structure • Tail: Most distal portion; origin of the vas deferens which then travels up the spermatic cord • Function • Testes: site of sperm production and hormone synthesis Katherine Saunders, DO @SaraEWobker #GUPathElective • Epididymis: sperm storage and maturation, during which time they gain their motility • Arterial supply • Testes are supplied by paired testicular arteries, which originate from the abdominal aorta and descend to the scrotum through the inguinal canal • Collateral blood supply is from branches of the cremasteric artery (from the inferior epigastric artery) and the artery of the vas deferens (from the inferior vesical artery) • The scrotum is supplied by the internal pudendal artery, which is a branch of the internal iliac artery • Venous drainage • Blood drains via the pampiniform plexus in the scrotum • The veins in the plexus ascend through the inguinal canal and form the paired testicular veins • The left testicular vein drains into the left renal vein • The right testicular vein drains into the inferior vena cava • Lymphatic drainage • The testes are drained by the pre-aortic and lateral aortic lymph nodes • The scrotum is drained by the inguinal lymph nodes Histology: • Seminiferous tubules: • Contains two cell types within a basement membrane: spermatogenic (germ) cells and Sertoli cells (support cells) • The spermatogenic cells constantly multiply, go through multiple cycles of spermatogenesis, and differentiate into mature sperm • Spermatogonia → primary spermatocytes → secondary spermatocytes → spermatids → spermatozoa • The Sertoli cells nourish the spermatogenic cells Katherine Saunders, DO @SaraEWobker #GUPathElective • Please see this diagram about spermatogenesis Seminiferous tubule with spermatogenesis, high power • The tubules are surrounded by loose connective tissue and testosterone secreting Leydig cells • Leydig cells: polyhedral in shape with a round nucleus, 1-2 prominent nucleoli and bright eosinophilic (pink) cytoplasm • Can also see cytoplasmic granules called crystals of Reinke Katherine Saunders, DO @SaraEWobker #GUPathElective • Rete testis: • Anastomosing network of delicate channels located at the testicular mediastinum which receives the contents of the seminiferous tubules and moves it to the efferent ductules • Histology: the channels are lined by a single layer of cuboidal epithelial cells Katherine Saunders, DO @SaraEWobker #GUPathElective Rete testis, low power • Efferent ductules: • Consist of multiple convoluted tubules that arise from the rete testis which then connect to the epididymis • Histology: Some cells are tall columnar and ciliated (which function to move spermatozoa to the epididymis) and some cells are short and non-ciliated • The alternating pattern of tall columnar and cuboidal cells gives the efferent ductules a “sawtooth pattern” • See this link for histologic photos • Epididymis: • One very long, highly convoluted duct, where at the lower pole of the testis it becomes the ductus deferens • Histology: The duct is a tube of smooth muscle lined by pseudostratified ciliated epithelium and basal cells • In the proximal epididymis, there is one layer of smooth muscle while the distal end (tail) has three layers Katherine Saunders, DO @SaraEWobker #GUPathElective Common Benign Entities • Cryptorchism Katherine Saunders, DO @SaraEWobker #GUPathElective • Definition: Failure of the testes to descend into the scrotum, which causes atrophy • Occurs in 3% of full term newborns; more common in preterm and low birth weight infants • Presents as bilateral or unilateral mass in the inguinal or high scrotal area, although about 20% of undescended testes are not palpable due to being atrophic or present in the abdomen • Associated with increased risk of testicular germ cell tumor (seminoma is most common) • Treatment: Orchiopexy (surgical fixation of testis within scrotum) • Histology: Seminiferous tubules will appear atrophic: the basement membrane will be thickened without any evidence of spermatogenesis • Sertoli and Leydig cells are still present • Hydrocele • Definition: Accumulation of serous fluid within the tunica vaginalis • Most common cause of scrotal enlargement • Histology: Loose connective tissue with a mesothelial lining • Spermatocele • Definition: Dilatation of the efferent ductules in the rete testis or head of the epididymis • Histology: Thin wall of fibromuscular soft tissue with an often ciliated flat cuboidal epithelial cyst lining • Luminal contents = spermatozoa and proteinaceous fluid Common Malignancies Germ cell tumors (GCTs): Clinically classified as seminomas and non-seminomatous GCTs • Classic Seminoma • Definition/pearls: Most common type of GCT, derived from transformed spermatogenic cells • Presents in young men (ages 30-49) with a unilateral palpable mass Katherine Saunders, DO @SaraEWobker #GUPathElective • Serum LDH and PLAP may be elevated; AFP should not be increased • Macroscopic: Well-demarcated with a homogenous, solid, gray-white, lobulated cut surface without necrosis or hemorrhage • Histology: • Sheets or lobular configuration of tumor with fibrous septae • Uniform polygonal tumor cells with clear cytoplasm, distinct cell borders, and large nuclei with prominent nucleoli (fried egg appearance) • Immunohistochemistry/Special stains: • Positive: PLAP, OCT 3/4, CD117, D2-40, SALL4 • Negative: CD30, AFP, AE1/AE3 Seminoma, low power - note the fibrous septae Katherine Saunders, DO @SaraEWobker #GUPathElective Seminoma, high power - note the fried egg cells • Non-seminomatous GCTs: • Embryonal carcinoma • Definition/pearls: • Second most common pure GCT, but more commonly seen as a component of a mixed GCT • Presents earlier than seminoma - men in their 30’s • Large proportion have metastases at presentation • No specific tumor marker, but can see elevated AFP and HCG • Macroscopic: Poorly circumscribed, variegated with necrosis and hemorrhage • Histology: • Characterized by large highly pleomorphic tumor cells with minimal features of differentiation • Solid, pseudoglandular, alveolar, tubular, or papillary patterns • Cells have prominent nucleoli, indistinct cell borders with nuclear overlapping • Frequent mitoses and apoptosis Katherine Saunders, DO @SaraEWobker #GUPathElective Embryonal carcinoma, glandular growth pattern Katherine Saunders, DO @SaraEWobker #GUPathElective Embryonal carcinoma, low power; note the nuclear pleomorphism and prominent nucleoli • Immunohistochemistry/Special stains: • Positive stains: CD30, Oct 3/4, SALL4, PLAP • Negative stains: CD117, EMA, CEA, hCG • Yolk sac tumor • Definition/pearls: • Most common testicular tumor in infants and young children • Usually presents with elevated AFP • Two age peaks: • 16-18 months (prepubertal, pure yolk sac tumor) • 25-35 years old (postpubertal, yolk sac tumor in mixed GCT) • Macroscopic: • Poorly circumscribed, nonencapsulated, gray to white with a gelatinous/myxoid cut surface • If postpubertal tumor, hemorrhage and necrosis are more common • Histology: • Variable growth patterns! • Most common = microcystic, solid, and myxomatous Katherine Saunders, DO @SaraEWobker #GUPathElective • Microcystic: Anastomosing cords of flattened cells making a honeycomb meshwork appearance • Endodermal sinus pattern: (example below) contains Schiller-Duval bodies (central vessel surrounded by tumor cells, a space, and surrounded by another layer of flat tumor cells) • 50% of tumors contain these structures • Hyaline globules are common (PAS-D+ and alpha-1-antitrypsin+) Yolk sac tumor; festoon pattern (resembles undulating ribbons) Katherine Saunders, DO @SaraEWobker #GUPathElective Schiller-Duval body • Immunohistochemistry/Special stains: • Positive stains: AFP, Glypican 3, SALL4 • Negative stains:
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