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Presented by Dr. Jonathan Epstein and prepared by Dr. Katherine Fomchenko
A middle-aged male underwent an orchiectomy for a testis mass.
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1. Question
A middle-aged male underwent an orchiectomy for a testis mass.
mass. Correct
Correct Answer: D. Infarct with necrotizing granulomatous vasculitis
Histological Description: There is a well-demarcated area of testicular parenchymal infarct with residual outlines of necrotic seminiferous tubules. There is an associated polyarteritis nodosa-like (PAN-like) vasculitis with transmural necrotizing inflammation of small to medium-sized arteries. The affected vessels show either focal or circumferential involvement. The inflammatory component within the vasculitis is granulomatous.
Discussion: When presented with a case with necrosis in the testis, it is critical to assess the nature of the necrosis. Caseous necrosis consists of necrotic debris without visible structures native to the testis. In this setting, it is most likely infectious in origin, and the epididymis should also be affected, as that is the site of origin of the testicular infection. Cellular necrosis consists of ghosts of individual cells, where there is no suggestion of pre-existing seminiferous tubules. Often with necrotic seminoma, one can still see adequate cytology to make a definitive diagnosis. In these cases, sometimes OCT3/4 and CD117 may still label the tumor. The presence of germ cell neoplasia in-situ in the surrounding testis may also be helpful in establishing the diagnosis of necrotic germ cell tumor. Torsion is seen either in neonates or in teens/young adults and results in hemorrhagic necrosis of the entire testis. Localized infarcts of the testis taken out from presumed tumor are in the vast majority of times associated with vasculitis. At low power, the brightly eosinophilic fibrinoid necrosis in the vessel walls stand out. The vessels are medium-sized and often at the periphery of the testicle. Non-granulomatous vasculitis, seen in the vast majority of times, represent vasculitis isolated to the testis, although the patient should still be evaluated for systemic disease. Granulomatous vasculitis is much less common and has a higher likelihood of being associated with systemic vasculitis, such as Granulomatosis with Polyangiitis (GPA) or Churg Strauss syndrome.
Incorrect
Correct Answer: D. Infarct with necrotizing granulomatous vasculitis
Histological Description: There is a well-demarcated area of testicular parenchymal infarct with residual outlines of necrotic seminiferous tubules. There is an associated polyarteritis nodosa-like (PAN-like) vasculitis with transmural necrotizing inflammation of small to medium-sized arteries. The affected vessels show either focal or circumferential involvement. The inflammatory component within the vasculitis is granulomatous.
Discussion: When presented with a case with necrosis in the testis, it is critical to assess the nature of the necrosis. Caseous necrosis consists of necrotic debris without visible structures native to the testis. In this setting, it is most likely infectious in origin, and the epididymis should also be affected, as that is the site of origin of the testicular infection. Cellular necrosis consists of ghosts of individual cells, where there is no suggestion of pre-existing seminiferous tubules. Often with necrotic seminoma, one can still see adequate cytology to make a definitive diagnosis. In these cases, sometimes OCT3/4 and CD117 may still label the tumor. The presence of germ cell neoplasia in-situ in the surrounding testis may also be helpful in establishing the diagnosis of necrotic germ cell tumor. Torsion is seen either in neonates or in teens/young adults and results in hemorrhagic necrosis of the entire testis. Localized infarcts of the testis taken out from presumed tumor are in the vast majority of times associated with vasculitis. At low power, the brightly eosinophilic fibrinoid necrosis in the vessel walls stand out. The vessels are medium-sized and often at the periphery of the testicle. Non-granulomatous vasculitis, seen in the vast majority of times, represent vasculitis isolated to the testis, although the patient should still be evaluated for systemic disease. Granulomatous vasculitis is much less common and has a higher likelihood of being associated with systemic vasculitis, such as Granulomatosis with Polyangiitis (GPA) or Churg Strauss syndrome.
