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Pathology Exam Protocol Proposed for Gender-affirming Orchiectomy Specimens

Key findings

  • This study reports histologic features detected at Massachusetts General Hospital in specimens from orchiectomy performed for gender affirmation in male-to-female transgender individuals and proposes a grossing protocol for adequate assessment
  • Although all patients had received hormone therapy, not all had changes consistent with exogenous hormone exposure, such as aspermatogenesis with maturation arrest, diminished/absent Leydig cells, and hyperplasia of the rete testis and/or epididymis
  • Nuclear cytomegaly, which in some cases can mimic germ cell neoplasia in situ (GCNIS), was present in 56% of specimens
  • No specimen displayed GCNIS, evidence of regression, germ cell tumor, sex cord–stromal tumor, or other malignancy
  • Three sections—one of the spermatic cord margin and two of testicular parenchyma to include rete testis/epididymis—should be sufficient to identify relevant pathology, unless a mass or other unusual finding such as regression or GCNIS is seen

Bilateral orchiectomy, a surgical procedure in which one or both testicles are removed, is often an early stage of gender-affirming care for male-to-female transgender people. These procedures are being performed increasingly often.

In Human Pathology, researchers at Massachusetts General Hospital recently reviewed pathologic features identified in gender-affirming orchiectomy specimens and proposed a grossing protocol for adequately assessing these specimens. The authors are Kristine M. Cornejo, MD, a genitourinary pathologist at Mass General and the Mass General Cancer Center, Anton Wintner, MD, a urologic surgeon in the Department of Urology, Chin-Lee Wu, MD, PhD, director of Genitourinary Pathology Services at Mass General and the Cancer Center, and colleagues.


The team identified 23 patients who underwent male-to-female gender-affirming orchiectomy at Mass General between January 2019 and December 2021. All orchiectomies were intrascrotal, and 22 were bilateral; one individual had previously undergone unilateral surgery for an unknown reason.

The average patient age was 39 years. All had received hormone therapy, mean duration of 66 months (range, 12–348 months).

17 control specimens came from patients who had orchiectomy performed for germ cell tumors (n=12), fibrous pseudotumor (n=2), inflammation/ischemia (n=2), or testicular lymphoma (n=1).

Histologic Findings

Key histologic characteristics of the 45 gender-affirming orchiectomy specimens were:

  • Spermatogenesis—Aspermatogenesis with maturation arrest, 71% (controls, 0%); hypospermatogenesis, 18% (controls, 0%); normal spermatogenesis, 11% (controls, 100%). The five normal gender-affirming orchiectomy specimens came from patients who had been on hormone therapy for an average of 108 months
  • Leydig cells—Absent or markedly reduced in quantity in 85% (controls, 0%)
  • Hyperplasia—Epithelial hyperplasia in 53% (controls, 0%); rete testis hyperplasia in 33% (controls, 18%). Hyperplasia in gender-affirming orchiectomy specimens was probably attributable to the presence of estrogen receptors in both tissue types. The three control subjects with rete testis hyperplasia had undergone orchiectomy for germ cell tumor
  • Mean tubular diameter—0.1902 mm versus 0.2482 mm in the control group (P=0.0019)
  • Nuclear cytomegaly (≥3 times the nuclei size of neighboring Sertoli cells)—56% (controls, 0%)
  • Multinucleated stromal cells—13% (controls, 0%). This finding was perhaps a consequence of hormone therapy, as stromal cells in the testes are reportedly reactive to androgen receptors

No specimen displayed germ cell neoplasia in situ (GCNIS) or evidence of regression. All were negative for a germ cell tumor, sex cord–stromal tumor, or other malignancy.

Among patients who underwent bilateral orchiectomy, the histologic findings were similar in both testes except that in one patient, one testis displayed hypospermatogenesis and the other aspermatogenesis.

Slides Reviewed

The average number of slides per orchiectomy was eight (range of 1–11). All findings were identified in the first two slides reviewed per specimen except for three cases in which focal tubular sclerosis would have been missed, overall an inconsequential finding.

Proposed Protocol

Three sections per gender-affirming orchiectomy (spermatic cord margin, n=1; testicular parenchyma with rete testis and epididymis, n=2) should be adequate in most cases. If a mass is seen or regression and/or GCNIS is identified microscopically, an additional section of spermatic cord margin should be submitted. The most important part of the grossing exam is to exclude malignancy.

Nuclear cytomegaly can be misinterpreted as GCNIS. Helpful clues are scattered versus clustered distribution of the cells within the tubules, the presence rather than the absence of spermatogenesis, and especially a lack of prominent nucleoli. As previously reported in Human Pathology, the absence of staining for CD117, organic cation/carnitine transporter 4 (OCT4), and placental alkaline phosphatase (PLAP) excludes GCNIS.

At Mass General, all six specimens with nuclear cytomegaly were tested for OCT4 and were negative.

The pathologic report can include the specific histologic findings identified or make a general statement, such as "testicular parenchyma with features of exogenous hormone therapy."

of specimens from gender-affirming orchiectomy showed absent or markedly reduced Leydig cells

of specimens from gender-affirming orchiectomy showed nuclear cytomegaly

of specimens from gender-affirming orchiectomy showed epithelial hyperplasia

of specimens from gender-affirming orchiectomy showed normal spermatogenesis despite hormone therapy

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