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Interpretation of testicular biopsy

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Interpretation of testicular biopsy

  1. 1. INTERPRETATIONINTERPRETATION OFOF TESTICULAR BIOPSYTESTICULAR BIOPSY By Major Nitu SharmaBy Major Nitu Sharma Guide Lt Col Reena BharadwajGuide Lt Col Reena Bharadwaj
  2. 2. INTRODUCTIONINTRODUCTION Testis is the male gonad & measures 4 x 3Testis is the male gonad & measures 4 x 3 x2.5cms.x2.5cms. It weighs 20 gms, Rt being heavier than left.It weighs 20 gms, Rt being heavier than left. It comprises of 3 layers :T .vaginalisIt comprises of 3 layers :T .vaginalis :T.albuginea:T.albuginea :T.vasculosa:T.vasculosa..
  3. 3. HISTOLOGY OF NORMALHISTOLOGY OF NORMAL TESTISTESTIS It is made up of 250 lobules.It is made up of 250 lobules. Each lobule consists of :4 seminiferous tubules&Each lobule consists of :4 seminiferous tubules& connective tissue stroma with leydig cells.connective tissue stroma with leydig cells. Seminiferous tubuleSeminiferous tubule forms the main structure.forms the main structure. At birth the diameter is 60micron &150At birth the diameter is 60micron &150 inin adults.Theadults.The limiting membrane is madelimiting membrane is made ofof the basal lamina&the basal lamina& alternate layers of smooth muscle cells& collagen.alternate layers of smooth muscle cells& collagen. The sertoli or the sustentacular cells lie with their nucleiThe sertoli or the sustentacular cells lie with their nuclei mostly near the basement membraneof the ST.mostly near the basement membraneof the ST.
  4. 4. SERTOLI CELLS:SERTOLI CELLS: nuclear membrane isnuclear membrane is distinct; chromatin is relatively pale;distinct; chromatin is relatively pale; nucleolus is eosinophilic ,round or oval.nucleolus is eosinophilic ,round or oval. Spermatogonia :Spermatogonia :most immature germ cell;most immature germ cell; located basally in the ST;round to ovallocated basally in the ST;round to oval nucleus with dense chromatin.nucleus with dense chromatin. Primary spermatocytes:Primary spermatocytes:nucleus slightlynucleus slightly large with dark aggregates of chromatin.large with dark aggregates of chromatin.
  5. 5. Sec. spermatocytes:Sec. spermatocytes:nucleus slightly elongatednucleus slightly elongated characteristic of sperm head& tail is elaborated.characteristic of sperm head& tail is elaborated. The normal maturation takes 70 days& finalThe normal maturation takes 70 days& final maturation occurs in thematuration occurs in the epididymis.epididymis. INTERSTITIUMINTERSTITIUM: contains blood vessels: contains blood vessels &lymphatic vessels with testosterone secreting&lymphatic vessels with testosterone secreting leydig cells.leydig cells. Leydig cellsLeydig cells: round to oval nuclei with stainable: round to oval nuclei with stainable lipid, contain eosinophilic Reinke crystals.lipid, contain eosinophilic Reinke crystals.
  6. 6. INDICATIONS OF BIOPSYINDICATIONS OF BIOPSY 1.1. Male infertility investigationsMale infertility investigations 2.2. Role in testicular cancers: controversialRole in testicular cancers: controversial
  7. 7. CAUSES OF INFERTILITYCAUSES OF INFERTILITY PRE TESTICULAR:PRE TESTICULAR: 1.Hypogonadism:1.Hypogonadism: prepubertal:prepubertal:craniopharyngoma ;hypogonadotropiccraniopharyngoma ;hypogonadotropic enuchoidismenuchoidism post pubertalpost pubertal :chromophobe adenoma:chromophobe adenoma 2.Estrogen excess2.Estrogen excess 3. Androgen excess3. Androgen excess 4. Hyperprolactinemia4. Hyperprolactinemia 5.Glucocorticoid excess5.Glucocorticoid excess 6.DM, hypo/hyper thyroidism6.DM, hypo/hyper thyroidism
  8. 8. TESTICULAR:TESTICULAR: 1.Diseases of spermatogenesis1.Diseases of spermatogenesis 2. Klinefelter syndrome2. Klinefelter syndrome 3.Cryptorchidism3.Cryptorchidism 4.Radiation &chemotherapy4.Radiation &chemotherapy 5.Mumps5.Mumps 6.Iatrogenic6.Iatrogenic
  9. 9. POST TESTICULARPOST TESTICULAR:: 1. Anomalies of excretory ducts & accessory1. Anomalies of excretory ducts & accessory glandsglands 2. Impaired sperm motility2. Impaired sperm motility
  10. 10. CLINICAL EVALUATION FORCLINICAL EVALUATION FOR MALE INFERTILITYMALE INFERTILITY 1.History1.History 2.General physical examination & routine2.General physical examination & routine laboratory investigations.laboratory investigations. 3.Semen analysis3.Semen analysis 4.Hormonal studies4.Hormonal studies 55.Testicular biopsy.Testicular biopsy
  11. 11. HISTORYHISTORY h/osurgery in genital area,mumps,STD.h/osurgery in genital area,mumps,STD. h/o viremia of recent onseth/o viremia of recent onset h/ometabolicdisorder,DM,cirrhosis,uremia,h/ometabolicdisorder,DM,cirrhosis,uremia, obesityobesity h/o CT,RT,traumah/o CT,RT,trauma Occupational historyOccupational history
  12. 12. SEMEN ANALYSISSEMEN ANALYSIS Two examinations at leastTwo examinations at least Abstinence for 2 days before examinationAbstinence for 2 days before examination Examined within 2 hours of collectionExamined within 2 hours of collection VOL : 1.5 - 5.0 mlVOL : 1.5 - 5.0 ml COUNT : >50millionCOUNT : >50million MOTILITY : >50%MOTILITY : >50% MORPHOLOGY:head, acrosome, midMORPHOLOGY:head, acrosome, mid piece , tailpiece , tail
  13. 13. CHEMICAL ANALYSIS:CHEMICAL ANALYSIS: 1.1. Fructose: obstructionFructose: obstruction 2.2. Alpha glucosidase:epidydmisAlpha glucosidase:epidydmis 3.3. CK activity: fertilizing potentialCK activity: fertilizing potential
  14. 14. Classification of infertility by semenClassification of infertility by semen analysisanalysis 1.1. Absent ejaculationAbsent ejaculation 2.2. Azospermia:no living spermsAzospermia:no living sperms ST sclerosisST sclerosis germinal aplasiagerminal aplasia maturation arrestmaturation arrest duct obstructduct obstruct endocrinalendocrinal
  15. 15. Oligospermia: counts <20 m/mlOligospermia: counts <20 m/ml conditions :Idiopathicconditions :Idiopathic :cryptorchidism:cryptorchidism :varicocele:varicocele :drugs:drugs Asthenospermia:<50% motilityAsthenospermia:<50% motility conditions :spermatozoa structural defectsconditions :spermatozoa structural defects :prolonged abstinence:prolonged abstinence :antisperm Ab’s:antisperm Ab’s :idiopathic:idiopathic :infection:infection Teratospermia :altered sperm morphologyTeratospermia :altered sperm morphology
  16. 16. HORMONAL STATUSHORMONAL STATUS LHLH FSHFSH PROLACPROLAC TINTIN DIAGNOSISDIAGNOSIS Hypoth/pitHypoth/pit hypogonadismhypogonadism ProlactinomaProlactinoma Testicular failureTesticular failure Prim spermt failurePrim spermt failure idiopathicidiopathic lowlow lowlow lowlow lowlow lowlow highhigh HighHigh HighHigh normalnormal NormalNormal highhigh -- NormalNormal NormalNormal --
  17. 17. TESTICULAR BIOPSYTESTICULAR BIOPSY 1960:11960:1stst by Charneyby Charney 1987:Pesce ;1990: Magid ;1991: Wheeler1987:Pesce ;1990: Magid ;1991: Wheeler INDICATIONSINDICATIONS AbsoluteAbsolute::azospermiaazospermia :oligospermia:oligospermia :teratospermia:teratospermia :atypical cells in ejaculate:atypical cells in ejaculate
  18. 18. Relative:varicoceleRelative:varicocele :cryptorchidism:cryptorchidism :chronic infection:chronic infection :FSH>3 times normal:FSH>3 times normal :hypogonadism:hypogonadism
  19. 19. TECHNIQUETECHNIQUE Open surgical incisional biopsyOpen surgical incisional biopsy Percutaneous testis biopsyPercutaneous testis biopsy Percutaneous testis aspiration.Percutaneous testis aspiration. FIXATIVESFIXATIVES Bouin’s fluid/Zenker fluid/ Stieve’s fluidBouin’s fluid/Zenker fluid/ Stieve’s fluid Formalin Contra Ind:shrinkage of tubulesFormalin Contra Ind:shrinkage of tubules :poor preservation if nuc details:poor preservation if nuc details
  20. 20. StainsStains :: H&EH&E :TRICHROME:TRICHROME :VAN GIESON:VAN GIESON :WEIGERT ELASTIC:WEIGERT ELASTIC :PAS GLYCOGEN:PAS GLYCOGEN Role of electron microscopyRole of electron microscopy
  21. 21. Adequacy of biopsy:Adequacy of biopsy: gross: atleast 3mmsecgross: atleast 3mmsec histo:3-5 lobules with septa ORhisto:3-5 lobules with septa OR :100 profiles of ST:100 profiles of ST
  22. 22. EVALUATIONEVALUATION Overall morphologyOverall morphology Size & structure of STSize & structure of ST Interstitial tissueInterstitial tissue SpermatogenesisSpermatogenesis Quantitative assessmentQuantitative assessment
  23. 23. HISTOLOGICAL PATTERNS OFHISTOLOGICAL PATTERNS OF INFERTILE MALEINFERTILE MALE Normal histologyNormal histology Immature testis in adultImmature testis in adult Sloughing of immature cellsSloughing of immature cells HypospermatogenesisHypospermatogenesis Maturation arrestMaturation arrest Sertoli cell only syndromeSertoli cell only syndrome Peritubular fibrosis & tubular hyalinizationPeritubular fibrosis & tubular hyalinization
  24. 24. NORMAL HISTOLOGYNORMAL HISTOLOGY  Ductal obstructionDuctal obstruction  VaricoceleVaricocele  ST hyper curvatureST hyper curvature  Branching of STBranching of ST  Isolated impaired sperm motilityIsolated impaired sperm motility  Sampling errorSampling error  Toxic, metabolic or infectious agentToxic, metabolic or infectious agent Most commonly in azospermic males with obstr.ofMost commonly in azospermic males with obstr.of excurrent ducts of testisexcurrent ducts of testis
  25. 25. IMMATURE TESTIS INADULTIMMATURE TESTIS INADULT Histo. similar to prepubertal testisHisto. similar to prepubertal testis No peritubular elastic fibresNo peritubular elastic fibres Few spermatogoniaFew spermatogonia Remaining intratubular cells are SertoliRemaining intratubular cells are Sertoli cellscells No mature leydig cellsNo mature leydig cells
  26. 26. Causes of immature testisCauses of immature testis Abnormalities of hypothalamic-pituitaryAbnormalities of hypothalamic-pituitary functionfunction • Prepubertal panhypopituitarismPrepubertal panhypopituitarism  CongenitalCongenital  AcquiredAcquired • Hypogonadotropic enuchoidismHypogonadotropic enuchoidism  Kallmann’s syndromeKallmann’s syndrome • Laurence-Moon-Biedl syndromeLaurence-Moon-Biedl syndrome • Prader-Willi syndromePrader-Willi syndrome Prepubertal androgen excessPrepubertal androgen excess • Androgen-producing tumorAndrogen-producing tumor • Adrenogenital syndromeAdrenogenital syndrome • Exogenous androgen administrationExogenous androgen administration
  27. 27. Sloughing of Immature CellsSloughing of Immature Cells In oligospermic menIn oligospermic men Tubules normal or reduced in diameter withTubules normal or reduced in diameter with central lumina obliterated and containingcentral lumina obliterated and containing sloughed spermatogenic cellssloughed spermatogenic cells Sloughed cells consist of spermatocytes withSloughed cells consist of spermatocytes with mature elementsmature elements Orderly pattern of spermatogenesis is disruptedOrderly pattern of spermatogenesis is disrupted and epithelium has a jumbled disorganizedand epithelium has a jumbled disorganized appearanceappearance Centre of tubules appear cellular than peripheryCentre of tubules appear cellular than periphery and may produce hypocellularity of germinaland may produce hypocellularity of germinal epithelium liningepithelium lining
  28. 28. Scattered tubules with completeScattered tubules with complete spermatogenesis presentspermatogenesis present Mild degree of peritubular fibrosis andMild degree of peritubular fibrosis and collagenous deposits in intertubular areacollagenous deposits in intertubular area Leydig cells normalLeydig cells normal Classify in this group if more than 50%Classify in this group if more than 50% tubules affectedtubules affected Sertoli cells and spermatogonia normal atSertoli cells and spermatogonia normal at peripheryperiphery
  29. 29. Causes of sloughing of immatureCauses of sloughing of immature cellscells VaricoceleVaricocele Prior VasectomyPrior Vasectomy Mumps orchitisMumps orchitis IdiopathicIdiopathic
  30. 30. HypospermatogenesisHypospermatogenesis Also called germinal cell hypoplasiaAlso called germinal cell hypoplasia Seminiferous tubule diameter is within normal limitsSeminiferous tubule diameter is within normal limits Quantitative reduction of spermatogenesisQuantitative reduction of spermatogenesis Overall thinning of the germinal epithelium and lumenOverall thinning of the germinal epithelium and lumen enlargedenlarged Paucity of germinal cell causing sertoli cells to be morePaucity of germinal cell causing sertoli cells to be more conspicuous; thereby resembling sertoli cell onlyconspicuous; thereby resembling sertoli cell only syndromesyndrome Tubules contain sloughed immature spermatogenic cellsTubules contain sloughed immature spermatogenic cells Leydig cells normalLeydig cells normal Patients oligo spermic with normal hormonal levelsPatients oligo spermic with normal hormonal levels
  31. 31. Causes of hypospermatogenesisCauses of hypospermatogenesis MalnutritionMalnutrition Chronic wasting illnessChronic wasting illness Advancing ageAdvancing age Exposure to excessive heatExposure to excessive heat IdiopathicIdiopathic Down’s syndromeDown’s syndrome Klinefelter’s mosaicKlinefelter’s mosaic Ductal obstructionDuctal obstruction Glucocorticoid excessGlucocorticoid excess HypothyroidismHypothyroidism Fertile eunuch syndromeFertile eunuch syndrome ChemotherapyChemotherapy
  32. 32. Spermatogenic mature arrestSpermatogenic mature arrest One of the most prevalent causes of infertilityOne of the most prevalent causes of infertility Failure of spermatogenesis to proceed beyondFailure of spermatogenesis to proceed beyond the primary spermatocyte levelthe primary spermatocyte level Arrested cells increased in number andArrested cells increased in number and sloughed in the tubular luminasloughed in the tubular lumina Tubular diameter, normal sertoli cells, basementTubular diameter, normal sertoli cells, basement membrane,T.propria and leydig cells normalmembrane,T.propria and leydig cells normal Patients oligospermic or azospermic. HormonePatients oligospermic or azospermic. Hormone levels normallevels normal
  33. 33. Causes of SpermatogenicCauses of Spermatogenic Maturation ArrestMaturation Arrest IdiopathicIdiopathic XYYXYY VaricoceleVaricocele Abnormal meiosisAbnormal meiosis Down’s syndromeDown’s syndrome UremiaUremia Cystic fibrosisCystic fibrosis AdrenogenitalAdrenogenital syndromesyndrome Exposure to heatExposure to heat Post pubertalPost pubertal gonadotropin deficiencygonadotropin deficiency Mumps orchitisMumps orchitis Sickle cell diseaseSickle cell disease Glucocorticoid excessGlucocorticoid excess Spinal cord injurySpinal cord injury ChemotherapyChemotherapy
  34. 34. Sertoli Cell only SyndromeSertoli Cell only Syndrome Also calledAlso called germinal aplasiagerminal aplasia oror del Castillo'sdel Castillo's syndromesyndrome, first described in 1947, first described in 1947 11 to 20% of testicular biopsy11 to 20% of testicular biopsy Complete absence of germinal cells from STComplete absence of germinal cells from ST without impairment of sertoli or leydig cellswithout impairment of sertoli or leydig cells ST decreased in diameter and devoid of germST decreased in diameter and devoid of germ cellscells Tubular basement membrane normalTubular basement membrane normal Patients with azospermia and increased FSHPatients with azospermia and increased FSH levelslevels
  35. 35. Causes of Sertoli cell onlyCauses of Sertoli cell only SyndromeSyndrome Idiopathic(congenital)Idiopathic(congenital) ChemotherapyChemotherapy Klinefelter’s mosaicKlinefelter’s mosaic Down’s syndromeDown’s syndrome VaricoceleVaricocele UremiaUremia Irradiation damageIrradiation damage AdrenogenitalAdrenogenital syndromesyndrome MumpsMumps HyperprolactinemiaHyperprolactinemia Isolated FSHIsolated FSH deficiencydeficiency
  36. 36. Peritubular Fibrosis and TubularPeritubular Fibrosis and Tubular HyalinisationHyalinisation Germinal epithelium damaged by increased fibrousGerminal epithelium damaged by increased fibrous tissuestissues May involve tunica propria only with increasedMay involve tunica propria only with increased peritubular myoid cells or hyalinized material betweenperitubular myoid cells or hyalinized material between the basement membrane and myoid cells of T. propriathe basement membrane and myoid cells of T. propria When changes > 10% of tubular fertility is reducedWhen changes > 10% of tubular fertility is reduced With increasing fibrosis and hyalinization germinalWith increasing fibrosis and hyalinization germinal epithelium is progressively lost followed by atrophy ofepithelium is progressively lost followed by atrophy of sertoli cellssertoli cells Tubules reduced in diameterTubules reduced in diameter Leydig cells reduced in numberLeydig cells reduced in number
  37. 37. Causes of peripubular fibrosis andCauses of peripubular fibrosis and tubular hyalinizationtubular hyalinization IdiopathicIdiopathic Klinefelter’s syndromeKlinefelter’s syndrome Adrenogenital syndromeAdrenogenital syndrome XYYXYY Chronic orchitisChronic orchitis Estrogen excessEstrogen excess Irradiation damageIrradiation damage Post pubertal hypopituitarismPost pubertal hypopituitarism Post pubertal androgen excessPost pubertal androgen excess Testicular traumaTesticular trauma Decreased test. vas. supplyDecreased test. vas. supply Myotonic muscular dystrophyMyotonic muscular dystrophy • VaricoceleVaricocele AlcoholismAlcoholism Diabetes mellitusDiabetes mellitus Cystic fibrosisCystic fibrosis Spinal cord injurySpinal cord injury ChemotherapyChemotherapy Androgen insensitivity inAndrogen insensitivity in otherwise normal menotherwise normal men HyperprolactinemiaHyperprolactinemia
  38. 38. QUANTITATION ORQUANTITATION OR ASSESSMENT OF TESTICULARASSESSMENT OF TESTICULAR BIOPSYBIOPSY JOHNSON’S SCORING SYSTEMJOHNSON’S SCORING SYSTEM Score 1 to 10, each ST is examined & scored.Score 1 to 10, each ST is examined & scored. 10- germinal epithelium is multilayered around a open central lumen10- germinal epithelium is multilayered around a open central lumen that count spermatozoa.that count spermatozoa. 9-many spermatozoa but disorganised spermatogenesis9-many spermatozoa but disorganised spermatogenesis 8- few spermatozoa seen8- few spermatozoa seen 7-no spermatozoa but spermatids7-no spermatozoa but spermatids 6-few spermatids seen6-few spermatids seen 5-no spermatozoa,spermatids but spermatocytes seen5-no spermatozoa,spermatids but spermatocytes seen 4-few spermatocytes4-few spermatocytes 3-only spermatogonia3-only spermatogonia 2-No germ cells only sertoli cells2-No germ cells only sertoli cells 1-No cells inside tubule1-No cells inside tubule
  39. 39. Mean score calculatedMean score calculated N: 60% of ST- score of 10N: 60% of ST- score of 10 :<10%- score of 8:<10%- score of 8 Mean: 9.39+/- 0.24Mean: 9.39+/- 0.24 1970- added leydig cell scored1970- added leydig cell scored LS 1- complete absence of leydig cellsLS 1- complete absence of leydig cells LS6 - nodular/diffuse hyperplasia of leydigLS6 - nodular/diffuse hyperplasia of leydig cellscells
  40. 40. Heller: Germ Cell/Sertoli Cell RatioHeller: Germ Cell/Sertoli Cell Ratio Counting at least 30 tubules cross sectionCounting at least 30 tubules cross section Stained- identified all stagesStained- identified all stages  SpermatogoniaSpermatogonia  Pr. SpermatocytePr. Spermatocyte  Sec.spermatocyte and spermatidsSec.spermatocyte and spermatids SCR=SCR= total no of germ cells each typetotal no of germ cells each type total no of sertoli celltotal no of sertoli cell
  41. 41.  NormalNormal Spermatogonia-1.8Spermatogonia-1.8 Spermatocytes- 2.0Spermatocytes- 2.0 Spermatids – 5.2Spermatids – 5.2  OR: 12 Sertoli cell per tubular crossOR: 12 Sertoli cell per tubular cross sectionsection
  42. 42. MaklerMakler Inner diam of tubulesInner diam of tubules  5:150-250 micron5:150-250 micron  1:25-50 micron1:25-50 micron  0:obliterated tubule0:obliterated tubule Thickness of BMThickness of BM  5: 3 micron5: 3 micron  1: 10-13 microns1: 10-13 microns  0:hyalinized0:hyalinized TOTAL SCORE 0-20TOTAL SCORE 0-20 Degree of ST maturationDegree of ST maturation  5: matured to5: matured to spermatozoaspermatozoa  0: sertoli cell only0: sertoli cell only Intra tubular cell layersIntra tubular cell layers  5: >4 cell layers5: >4 cell layers  0: no cells0: no cells
  43. 43. SiggSigg Classified testicular atrophyClassified testicular atrophy  DiffuseDiffuse  Focal : 5 CS tubule atrophyFocal : 5 CS tubule atrophy  MixedMixed Scale 1-5Scale 1-5  1 mild atrophy1 mild atrophy  2 moderate atrophy2 moderate atrophy  3 marked atrophy3 marked atrophy  4 sertoli cell only syndrome4 sertoli cell only syndrome  5 hyalinisation5 hyalinisation
  44. 44. Role in carcinomaRole in carcinoma ControversialControversial Used for staging for disease inUsed for staging for disease in contralateral testiscontralateral testis
  45. 45. ReferencesReferences Steven G Silverberg, Ronald A Delellis, WilliamSteven G Silverberg, Ronald A Delellis, William J Frable. Principles& Practice of SurgicalJ Frable. Principles& Practice of Surgical Pathology& Cytopathology.III rd Edition. Vol III,Pathology& Cytopathology.III rd Edition. Vol III, 2237-51.2237-51. PP Anthony, RNM Mac Sween. RecentPP Anthony, RNM Mac Sween. Recent Advances in Histopathology 11, 135-147.Advances in Histopathology 11, 135-147. Juan rosai.Ackerman’s Text Book of SurgicalJuan rosai.Ackerman’s Text Book of Surgical Pathology,Vol I, Ch18,1257-62.Pathology,Vol I, Ch18,1257-62. Campell Urology VII th Edition Vol II.Campell Urology VII th Edition Vol II. Andersons Text Book of Pathology.Andersons Text Book of Pathology.
  46. 46. THERAPEUTIC ROLETHERAPEUTIC ROLE
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