Glandular inclusions in inguinal hernia sacs: morphologic and immunohistochemical distinction from epididymis and vas deferens

Mullerian Serous Cystadenoma Occurring in the Scrotum Post-Orchidopexy: A Rarely Reported Yet Distinctive Entity

Serous cystadenoma is a rare lesion in the para-testicular tissue, with even rarer reports of this entity occurring in the scrotum post-orchidopexy. We present such an occurrence, adding support for its existence as a distinct entity.

Supernumerary Remnant Vas Deferens Like Wolffian-Derivatives in a Young Child With Abdominal Cocoon Syndrome-A Clinicopathological Novelty

The abdominal cocoon syndrome is a rare cause of recurring intestinal obstruction in children. It refers to encasement of the small bowel by a fibrocollagenous membrane forming a cocoon. We report a nine year old male presenting with abdominal pain, distension, bilious vomiting and inability to pass stool and flatus for two days. In view of a persistently increasing bilious nasogastric output, an urgent exploratory laparotomy was performed. The small bowel loops were matted together forming a cocoon densely adherent to the parietal peritoneum with supra-colic fibrous bands. The bands histologically displayed multiple ductal remnants with epithelium resembling that of ductus deferens. These structures showed immunopositivity for pan-cytokeratin and basal CD10.Workup for tuberculosis and other etiological causes was unremarkable. This is the first documented case of abdominal cocoon in a pediatric subject associated with supernumerary wolffian remnants.

[E-Cadherine and GATA-3 are useful in the confirmation of the vas deferens in vasectomy specimens]

INTRODUCTION AND OBJECTIVES

Urologists often submit the resected tissue from vasectomies for histopathological examination in order to confirm the presence of the vas deferens. Microscopy is simple and based on haematoxylin-eosin staining; however, sample artefacts can sometimes cause confusion and immunohistochemistry can be used to identify the vas deferens.

MATERIALS AND METHODS

We investigated the utility of immunohistochemical analysis using E-cadherin and GATA-3 to confirm the presence of vas deferens epithelium in 110 vasectomy sections with different artefacts, using monoclonal antibodies and a multimer conjugated with peroxidase based technique; 5 renal arteries and 5 renal veins were stained as negative controls.

RESULTS

Membrane staining was observed for E-cadherin, which was moderate (2.7%) or strong (97.3%) in the vas deferens epithelium in all cases: 35 without artefacts, 7 with denuded epithelium, 56 with compressed/distorted epithelium, 8 with detached epithelium and 4 with displaced epithelium. GATA-3 showed moderate (31%) or strong (69%) nuclear staining in all cases, including the 76 with artefacts. In the control group, arteries and veins were negative for both markers in the endothelium, but GATA-3 occasionally stained lymphocytes in the blood vessel wall.

CONCLUSIONS

E-cadherin membrane positivity and GATA-3 nuclear expression are useful for the identification of the vas deferens in vasectomy samples containing artefacts. Vascular endothelium is negative for both markers and any possible GATA-3 staining of the lymphocytes in the blood vessel wall should not be misinterpreted.

Seminal plasma protein networks and enriched functions in varicocele: Effect of smoking

To verify a possible synergistic effect of smoking and varicocele on the seminal plasma proteome and biological functions, a cross-sectional study was performed in 25 smokers and 24 nonsmokers. Samples were used for conventional semen analysis, functional analysis (DNA fragmentation, acrosome integrity and mitochondrial activity) and proteomics by a shotgun approach. Functional enrichment of biological pathways was performed in differentially expressed proteins. Smokers presented lower ejaculate volume (p = .027), percentage of progressively motile spermatozoa (p = .002), total sperm count (p = .039), morphology (p = .001) and higher percentage of immotile spermatozoa (p = .03), round cell (p = .045) and neutrophil count (p = .009). Smokers also presented lower mitochondrial activity and acrosome integrity and higher DNA fragmentation. We identified and quantified 421 proteins in seminal plasma, of which one was exclusive, 21 were overexpressed and 70 were underexpressed in the seminal plasma of smokers. The proteins neprilysin, beta-defensin 106A and histone H4A were capable of predicting the smoker group. Enriched functions were related to immune function and sperm machinery in testis/epididymis. Based on our findings, we can conclude that cigarette smoking leads to the establishment of inflammatory protein pathways in the testis/epididymis in the presence of varicocele that seems to act in synergy with the toxic components of the cigarette.

Ectopic adrenal gland in an adult inguinal hernial sac: A case report

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Ectopic adrenocortical tissue is a rare finding that can be encountered in inguinal hernial sacs of adults.

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Surgeons should be aware of this and are encouraged to resect Ectopic adrenocortical tissue when grossly identified.

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Secondary hyperplasia after adrenalectomy, adrenal insufficiency, and neoplastic transformation should all be considered.

Introduction

A 37-year-old male patient operated for inguinal hernia repair was found to have ectopic adrenocortical tissue in the hernial sac.

Case presentation

A 37-year-old man was admitted for bilateral inguinal hernia. An uneventful open repair was done, and the resected hernial sacs were sent to pathology. Histopathology reported the presence of adrenocortical tissue in the right inguinal hernial sac.

Discussion

Ectopic adrenocortical tissue (EACT) in the groin region is not an unusual finding in children, however, it’s rarely reported in adult patients. Only 9 cases have been reported in English describing EACT in an adult’s inguinal hernia. The finding can be attributed to the close proximity of the developing gonads and adrenal cortex during embryogenesis, and subsequent mechanical translocation of adrenocortical tissue during testicular descent. Some theoretical clinical implications exist for this condition, including secondary hyperplasia after adrenalectomy, adrenal insufficiency in certain situations, and possible neoplastic transformation. Generally, it is recommended that surgeons resect ectopic adrenal glands when identified intra-operatively. However, actively searching for these glands has no known benefit and carries some surgical risks, and is hence not recommended. It is reasonable as well, that clinicians keep the clinical implications of this finding in mind during future follow-ups with such patients.

Conclusion

The presence of ectopic adrenocortical tissue in inguinal hernia sacs is a rare encounter in adults. The condition can have several theoretical clinical implications that need to be considered by surgeons while assessing patients in whom this phenomenon is observed.

Vasitis nodosa and related lesions: a modern immunohistochemical staining profile with special emphasis on novel diagnostic dilemmas

Vasitis nodosa is a benign proliferation of vas deferens epithelium, thought to be a response to trauma or obstruction, usually vasectomy. Although histologic features mimic malignancy, diagnosis is usually straightforward due to the clinical context. We analyzed 21 specimens with vasitis or epididymitis nodosa with antibodies to PAX8, CD10, p63, α-methyl-acyl-coA-racemase (AMACR), GATA3, prostein, NKX3.1, and prostate-specific antigen (PSA). Two diagnostically problematic cases included (1) florid bladder muscle involvement after prostatectomy and (2) involvement of the ampulla and ejaculatory duct in a radical prostatectomy specimen. Vasitis nodosa was excluded in 3 additional histologic mimics (2 post-treatment prostate cancers and 1 bladder cancer). PAX8 yielded consistent positive (100%) nuclear staining in the proliferative glands of vasitis nodosa, often stronger and more uniform than native vas deferens. CD10 labeling was common but also labeled secretions and other structures. Labeling for p63 was often basally located in glands with a multilayered appearance, but often markedly attenuated or lacking in the proliferative glands compared to native epithelium. AMACR positivity was variable but often present (19/21). PSA, prostein, and NKX3.1 were consistently negative. Rare problematic cases of vasitis nodosa include "invasion" of the ejaculatory duct at the prostate and involvement of bladder muscle after prostatectomy. The proliferative vasitis nodosa glands often have a prostate cancer-like staining pattern with variable AMACR positivity and negative or patchy p63. However, reliable positivity for PAX8, patchy GATA3, and negative staining for PSA, NKX3.1, and prostein aid in distinguishing from prostate cancer and tubular variants of bladder cancer.

Epididymis-like Tubules in Adult Renal Hypodysplasia: Immunohistochemical Features Indicate a Mesonephric Origin

We report the presence of epididymis-like tubules in unilateral renal hypodysplasia in 3 adult men. Microscopy showed dilated tubules lined by ciliated columnar epithelium and smaller basal cells, morphologically resembling epididymal tubules. Small tubules lined by cuboidal epithelium were also present in all cases, with glomeruli in 2 cases. The epididymis-like tubules expressed CD10, CK7, PAX8, and AR in the luminal epithelium, while the basal cells were positive for p63, CK7, and focally for CD10. The smooth muscle bundles around the epididymis-like tubules were focally AR and WT1 (cytoplasmic) positive. The epididymis-like tubules were negative for ER, PR, and WT1. CK7 and PAX8 stained all the collecting ducts, with AR staining some. Bowman's capsule, parietal and visceral epithelial cells expressed CD10; WT1 stained the visceral and parietal epithelial cells. Glomerular parietal cells expressed PAX8 and focally, CK7. Proximal tubules were positive for CD10 (luminal membranous and weak cytoplasmic). Distal tubules expressed CK7, PAX8 and AR. An occasional small tubule was ER positive. Scattered stromal cells expressed ER, PR, and AR. The urothelium of the renal pelvis/upper ureter expressed CK7 in all layers, CD10 in the superficial layers, PAX8 in the basal layers and p63 in all layers except the umbrella layer. The epididymis-like tubules replicate the pattern of the mesonephros-derived normal epididymis in expressing CK7, PAX8, CD10, and AR. This supports a mesonephric rather than metanephric origin for these tubules. The aberrant expression of some markers may be a manifestation of the dysplastic nature of the kidneys.

Neutral endopeptidase (CD10) is abundantly expressed in the epididymis and localized to a distinct population of epithelial cells--its relevance for CNP degradation

Neutral endopeptidase (NEP, metallo-endopeptidase EC 3.4.24.11; enkephalinase, neprilysin, CD10, CALLA) represents a major regulator of bioactivity of natriuretic peptides. C-type natriuretic peptide (CNP) is present in high levels in epididymis and seminal plasma. However, detailed expression pattern and CNP-related function of NEP in the epididymis are unknown. Comparison of NEP protein levels in various organs revealed an extremely high expression in human and mouse epididymis. NEP was localized exclusively to apical (luminal) parts of epithelial cells. In man, strong NEP-immunoreactivity was associated with epithelia of efferent ducts and the epididymal duct including stereocilia. Segment-by-segment analysis in mouse revealed a distinct distribution along the epididymal duct. We also found the CNP receptor guanylyl cyclase B (GC-B) in epithelial cells of the epididymal duct. Two different NEP inhibitors decreased CNP degradation and increased CNP/GC-B-induced cGMP production by epididymal membranes, suggesting a functional involvement of NEP. Data indicate an important, previously neglected, role of NEP for regulation of luminal factors in the epididymis and suggest a novel role for CNP/GC-B in the epididymal epithelium, presumably in context of local water balance.

Cystic rete testis with testicular dysplasia in a rabbit

An 8-year-old intact rabbit was presented to a veterinary hospital with a complaint of enlarged left scrotum. Histological examination revealed a single large cyst adjacent to an efferent ductule-like tissue. The cyst wall was composed of monolayer cuboidal cells surrounded by dysplastic testicular tissue, and the seminiferous tubules were not developed at all. The epithelial cells of the cyst possessed the same properties as the epithelial cells of the rete testis that were positive for CD 10 and cytokeratin 18, negative for p63 and lacked desmin-positive muscular layer. The dysplastic testicular tissue was composed of two types of cells: small pleomorphic cells with a condensed nucleus (sex cord-like cells) and large round cells with cytoplasmic lipid droplets (Leydig cells). Both of these cells were positive for vimentin and melan A that are consistent with the staining pattern of Sertoli cells and Leydig cells. This is the first report to demonstrate cystic rete testis with testicular dysplasia in animals.

Aberrant adrenocortical tissue in hernia sac occurring in an adult: case report and review of the literature

Aberrant adrenal tissue is rare, particularly in adults. To the best of our knowledge, only eight cases have been reported in the English literature. Awareness of the possible occurrence of adrenal tissue in hernial sac is crucial, as these rests may have several clinical implications. These potential implications include hyperplasia, adrenal insufficiency, neoplastic transformation and misdiagnosis as metastatic clear cell carcinoma. We report a rare case of aberrant adrenocortical tissue in hernial sac. We review the literature and highlight the clinical implications of this incidental finding.

Use of immunohistochemical markers to confirm the presence of vas deferens in vasectomy specimens

CD10 has recently been described as a marker that can distinguish wolffian duct derivatives from müllerian remnants but has yet to be tested in vasectomy specimens. We sought to determine if CD10 and pankeratin could corroborate the presence of vas deferens (VD). For the study, 103 consecutive vasectomy specimens were immunohistochemically analyzed for CD10, pankeratin, and CD31 expression in luminal and basal layer cells. In all cases with optimal epithelial histologic features (92/103), CD10 demonstrated intense apical membranous expression in all VD and weak basal cytoplasmic staining in about 98% of cases. Pankeratin demonstrated cytoplasmic and membranous expression in apical and basal layers in 99% of VD. In cases with suboptimal epithelial histologic features (11/103), the detection of epithelia was 100% for CD10 and pankeratin. Our data show that CD10 and pankeratin can be used to confirm the presence of VD in vasectomy specimens in which the epithelial histologic features are suboptimal.

Ectopic epididymal tissue in appendix testis

Aberrant epididymal tissue is uncommon and may be associated with an undescended testis. To the best of our knowledge, aberrant epididymal tissue has not been described in a testicular appendix. We report the case of a 7-year-old boy with left cryptorchidism who underwent a homolateral orchidopexy. At operation, the surgeon removed a pedunculated appendix testis containing an epididymal heterotopia. This Wolffian-derivative tissue was confirmed by the diffuse strong CD10 reactivity of the luminal border of the epithelial cells. Awareness of this aberrant tissue avoids misinterpretation as a transected functional reproductive structure.

Intra-abdominal ovarian-type mucinous cystadenoma associated with fallopian tube-like structure and aberrant epididymal tissue in a male patient

Ovarian-type mucinous tumors may occasionally occur in the retroperitoneum, pancreas, and liver exclusively or almost exclusively in women. In men, only few cases of such neoplasms arising within or around the testis have been reported. We describe a unique case of an ovarian-type mucinous cystadenoma occurring in the peritoneal cavity of a 65-year-old male patient with secondary adrenocortical insufficiency and hypogonadism. There was a typical fallopian tube enclosed in the capsule of the tumor. Contiguous to that, accessory ectopic epididymal tissue was found. We have interpreted this case as the result of a minor disorder of embryonic development involving structures of both müllerian and wolffian origin. The disproportion of sexual hormones might have had a role in inducing intra-abdominal müllerian remnants to give rise to the mucinous cystadenoma.

Pure (non-papillary) serous cystadenoma of the epididymis: a histologic and immunohistochemical study

A 44-year-old man presented with painless right scrotal swelling of 2 years duration. A cystic tumor strictly attached to the head of the epididymis was surgically resected. The pathologic examination revealed a unilocular cyst with a thin fibrous capsule, lined by ciliated cubical or cylindrical columnar cells, mostly arranged in a single layer. No papillary projection could be detected. Immunohistochemical staining was positive for epithelial membrane antigen, low- and high molecular weight cytokeratins, progesterone receptor, vimentin, and S-100 protein, but was negative for carcinoembryonic antigen, CD10, p53 protein, and calretinin. Single MIB-1 positive cells were noted. Histologic and immunohistochemical features suggest a Müllerian origin or differentiation. The lesion was diagnosed as pure serous cystadenoma of the epididymis, possibly originating from vestigial remnants of the Müller duct in male. The differential diagnosis to spermatocele and adenomatoid tumor of the epididymis is discussed.

Selected other problematic testicular and paratesticular lesions: rete testis neoplasms and pseudotumors, mesothelial lesions and secondary tumors

The proximity and, in some instances, communication between several structures in the testis and paratestis (rete testis, epididymis, mesothelium, vestigial epithelium and paratesticular soft tissue) result in a plethora of interesting tumors and tumor-like lesions that together pose a formidable diagnostic challenge both because of their morphologic overlap and rarity. The occasional spread of tumors primarily at other sites to this region adds to the potential problem encountered. This review provides an overview of the pathology of nonmesenchymal paratesticular neoplasms and pseudotumors with a focus on the approach to tubulopapillary neoplasms for which diagnostic considerations may include carcinoma of the rete testis, malignant mesothelioma, ovarian-type epithelial tumors, epididymal carcinoma and metastatic carcinomas. The cornerstone of accurate characterization of these lesions is still a comprehensive, traditional clinicopathologic approach, clinical history (of another primary), gross examination (location) and routine light microscopy, but judicious incorporation of contemporary immunohistochemical markers may aid or in some instances be crucial in resolving the problems encountered.