Testicular BioPSY

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Interpretation of Testicular Biopsy:

Interpretation of Testicular Biopsy Presented By – Dr. Ravneet Kaur Moderated By – Dr. Manjit S. Bal 10/14/2012 1

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Testis biopsy was first reported by Hotchkiss and Engle at The New York Hospital-Cornell Medical Center, in the late 1930s. Testicular biopsy is generally reserved for men with azoospermia , or absence of sperm from the ejaculate, a finding identified in about 5% to 10% of men evaluated for infertility. 10/14/2012 2

Testicular Biopsy:

Testicular Biopsy Indications Procedure Tissue Handling Complications 10/14/2012 3

Indications :

Indications Obstructive Azoospermia Testicular Sperm Extraction (TSE) Diagnosis of carcinoma In situ Testicular Biopsy during Orchidopexy Contralateral Screening biopsy 10/14/2012 4

Obstructive Azoospermia::

Obstructive Azoospermia : To confirm the presence of normal spermatogenesis , before the surgical correction of the obstruction is planned. Obstruction can be – epididymal (infective cause) Vasectomy Congenital absence of vas 10/14/2012 5

Testicular Sperm Extraction (TSE):

Testicular Sperm Extraction (TSE) An azoospermic patient with an elevated FSH level, especially if it is combined with bilateral small (<15 cm 3 ) testes, usually has non-obstructive azoo-spermia . Should be reserved for patients with nonobstructive azoo-spermia when a physician is actively searching for sperm to be cryo -preserved or used fresh for IVF-ICSI. 10/14/2012 6

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Diagnosis of CIS of the testis:

Diagnosis of CIS of the testis Risk factors for CIS- Male infertility together with a history of cryptorchidism , - Testicular germ cell tumour - Idiopathic testicular atrophy. - Ultrasosnographic abnormalities of the testis especially testicular microlithiasis Testicular lesions of unknown origin warrant an excision biopsy 10/14/2012 8

Testicular biopsy during orchidopexy :

Testicular biopsy during orchidopexy It is recommended in adolescents with cryptorchidism for detection of CIS of the testis. Contralateral screening biopsy - Biopsy of contralateral testis in unilateral testicular cancer is recommended as approx. 5% patients harbour testicular intraepithelial neoplasia in the other testis. Prominent nuclei, abundant cytoplasm, and abnormal spermatogonia . ITGCN stained with OCT3 10/14/2012 9

Histological patterns of Spermatogenesis:

Histological patterns of Spermatogenesis F ive main histological patterns of spermatogenesis: Tubular Sclerosis Sertoli Cell-only Syndrome Spermatogenic / Maturation Arrest Hypospermatogenesis Normal spermatogenesis 10/14/2012 10

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The atrophic tubules have a thickened, convoluted & hyalinized BM. Tubular lumen largely obliterated by fibrous tissue. This is the end stage of a large number of processes causing tubular injury Tubular sclerosis 10/14/2012 11

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Sertoli cell only syndrome The tubules have a reduced diameter, no germ cells, and large mature Sertoli cells. Prominent Leydig cells in the interstitium in this biopsy 10/14/2012 12

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Maturation Arrest Sections show a variation in tubular and luminal diameter. Primary spermatocytes continue to be prominent & absence of mature spermatids . 10/14/2012 13

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-Sections show variably reduced tubular and luminal diameters. -Overall reduction in germ cell elements but all can be identified. Hypospermatogenesis 10/14/2012 14

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Sections show orderly maturation of germ cells from the base to the center of the lumen. Spermatogonia (along the basement membrane), primary & secondary spermatocytes , spermatids , and spermatozoa are seen. Normal spermatogenesis 10/14/2012 15

Technique :

Technique Testicular biopsy can be performed under local and general anaesthesia. Usually, the procedure is performed as day-care surgery in an outpatient clinic setting. For a diagnostic testicular biopsy, a scrotal incision of 2–3 cm could allow enough exposure of the tunica albuginea of the testis. 10/14/2012 16

Types of Testicular Biopsy:

Types of Testicular Biopsy Open testicular biopsy Microsurgical atraumatic testicular biopsy Percutaneous testicular biopsy Testicular fine needle aspiration 10/14/2012 17

Open testicular biopsy:

Open testicular biopsy 10/14/2012 18


1) Tissue is submitted for HPE In Bouin’s Fixative 2) Eppendorf tubes (IVF/ICSI) 3) Imprint Smears 4) Wet preparation 10/14/2012 19

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Wet preparation of testicular tissue Wet preparation from Testicular Tissue readily showing multiple sperm 10/14/2012 20

Microsurgical atraumatic testicular biopsy:

Microsurgical atraumatic testicular biopsy Testis biopsy is performed using an operating microscope (10 X). Many testicular blood vessels can be easily seen and readily avoided. 10/14/2012 21

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The seminiferous tubules of men with Sertoli cell–only syndrome, sclerosis associated with Klinefelter's syndrome, testicular atrophy, cryptorchidism , or prior orchitis are generally smaller than tubules with active spermatogenesis. With use of the operating microscope it is easier to examine the seminiferous tubules, which can be used for sperm retrieval. 10/14/2012 22

Percutaneous testicular biopsy:

Percutaneous testicular biopsy Performed with LA in an office-based setting, and it is generally associated with less pain and morbidity . Disadvantages -Increased risk of injury to the testicular artery or epididymis due to the blind insertion of the biopsy needle. - Needle biopsy offers fewer seminiferous tubules for examination 10/14/2012 23

Testicular fine needle aspiration ( TFNA):

Testicular fine needle aspiration ( TFNA) Fine-needle aspiration of the testis is the least invasive and least painful technique possible for sperm retrieval. This procedure provides only cytological details. It involves insertion of a 21- to 23-gauge needle into the testis and aspiration with a 10- to 20-mL syringe. It is recommended that at least three separate sites be aspirated because of the heterogeneity of the testis. Fine-needle aspiration testis mapping as an adjunct to open testicular biopsy to help locate sperm 10/14/2012 24

Tissue Handling:

Tissue Handling Adequate size of biopsy 3 X 3 X 3 mm The specimen fixation is important as it can influence staining patterns. The European Germ Cell Cancer Consensus Group advocates the use of Stieve's or Bouin's solution for fixation. Bouin's solution allows good fixation of the tissue for histological evaluation of spermatogenesis. 10/14/2012 25


Contd..... Formalin can be used for fixation, but may cause shrinkage artefacts. This can be reduced by using neutral buffered formalin For adequate classification of spermatogenesis, the removed tissue should contain at least 100 seminiferous tubules. Haematoxylin & eosin staining is usually applied for evaluation of spermatogenesis. . 10/14/2012 26


Contd.... For the diagnosis of CIS, two biopsies are taken in each testis to increases the chance of detecting CIS. This applies to normal-size testis and not to atrophic testis. A single testicualr biopsy is recommended for routine diagnostic purposes. 10/14/2012 27


Contd.... Additional staining procedures are recommended. CIS is difficult to identify in testicular biopsies. Several markers- Placental alkaline phosphatase , AP2-gamma c-KIT IHC with OCT 3/4 OCT 3/4 is highly specific for CIS & the best marker for CIS, seminomas and embryonal carcinomas 10/14/2012 28

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OCT 3/4 staining of carcinoma in situ cells in seminiferous tubules of the testis 10/14/2012 29

Complications :

Complications Inadvertent biopsy of the epididymis Significant hematoma formation Infection Testicular atrophy 10/14/2012 30


Conclusions Testicular biopsies can be performed for diagnostic and therapeutic reasons. Retrieved testicular spermatozoa can be successfully used for ICSI. A diagnostic testicular biopsy may be performed in men with azoospermia , normal testicular volume and normal reproductive hormones To differentiate between obstructive and non-obstructive azoospermia . 10/14/2012 31

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Sincere Thanks Dr. Manjit S. Bal 10/14/2012 32 Dr. A S Kalra

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Thanks 10/14/2012 33

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