pathology

1. INTERPRETATIONINTERPRETATION OFOF
TESTICULAR BIOPSYTESTICULAR BIOPSY
By Major Nitu SharmaBy Major Nitu Sharma
Guide Lt Col Reena BharadwajGuide Lt Col Reena Bharadwaj

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. 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. 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. 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. INDICATIONS OF BIOPSYINDICATIONS OF BIOPSY
1.1. Male infertility investigationsMale infertility investigations
2.2. Role in testicular cancers: controversialRole in testicular cancers: controversial

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. 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. POST TESTICULARPOST TESTICULAR::
1. Anomalies of excretory ducts & accessory1. Anomalies of excretory ducts & accessory
glandsglands
2. Impaired sperm motility2. Impaired sperm motility

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. 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. 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. 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. 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. 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. 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. 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. Relative:varicoceleRelative:varicocele
:cryptorchidism:cryptorchidism
:chronic infection:chronic infection
:FSH>3 times normal:FSH>3 times normal
:hypogonadism:hypogonadism

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. 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. 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. EVALUATIONEVALUATION
Overall morphologyOverall morphology
Size & structure of STSize & structure of ST
Interstitial tissueInterstitial tissue
SpermatogenesisSpermatogenesis
Quantitative assessmentQuantitative assessment

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. 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. 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. 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. 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. 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

30. Causes of sloughing of immatureCauses of sloughing of immature
cellscells
VaricoceleVaricocele
Prior VasectomyPrior Vasectomy
Mumps orchitisMumps orchitis
IdiopathicIdiopathic

31. 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

33. 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

34. 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

36. 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

37. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45.  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

46. 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

47. 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

48. Role in carcinomaRole in carcinoma
ControversialControversial
Used for staging for disease inUsed for staging for disease in
contralateral testiscontralateral testis

49. 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.

50. THERAPEUTIC ROLETHERAPEUTIC ROLE