male genitaltract 2

Male Genital Tract Pathology-2

Dr.CSBR.Prasad, M.D.

Testicular tumors

CSBRP-July-2012

Pathologic Classification of Common

Testicular Tumors Germ Cell Tumors

Seminomatous tumors

Seminoma

Spermatocytic seminoma

Non-seminomatous tumors

Embryonal carcinoma,

Yolk sac (endodermal sinus) tumor

Choriocarcinoma

Teratoma

Sex cord-Stromal Tumors

Leydig cell tumor

Sertoli cell tumor

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Figure 22-47 Histogenesis and interrelationships of tumors of germ cell origin.

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Germ cell tumors

Hence germ cell tumors can be divided into:

1-Those that continue to resemble germ cells

ex: Seminoma / Dysgerminoma

2-Those that resemble protions of the embryo

ex: Teratomas

3-Those that resemble portions of the extraembryonic tissue

ex: Yolk sac tumor, Choriocarcinoma CSBRP-July-2012

Pathogenesis – testicular tumors

• Cryptorchidism (10% of testicular tumors)

• Testicular dysgenesis

(testicular feminization, Klinefelter’s)

• Genetic factors

– Low incidence in blacks

– Familial clustering

– Occuring in sibs

– i(12p) CSBRP-July-2012

Seminoma

•Most common type of germ cell tumor

•Peak in 30s

•Types: classic type, spermatocytic type, anaplasitc type.

•Spermatocytic seminoma: distinct both clinically,

histologically,

Uncommon

>60yrs

No metastasis (excellent prognosis)

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Seminoma

Seminoma of the testis. A small rim of remaining normal testis appears at the far

right (arrow). The tumor is composed of lobulated soft tan to brown tissue. CSBRP-July-2012

Seminoma

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Name some RADIOSENSITIVE tumors

• Seminoma

• Medulloblastoma / Myeloma

• Wilms’ tumor

• Lymphomas esp. Hodgkin’s

• Ewing’s tumor

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Pathology Pearls

SMILE

Spermatocytic Seminoma

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Spireme chromatin

Special features of

Spermatocytic Seminoma

• Do not arise from intratubular germ cell neoplasm

• Uncommon 1-2% of all testicular tumors

• Occurs in old age >60yrs

• Slow growing; No mets to regional lymphnodes

• Surgery is the mode of Tx

• No lymphocytic infiltration

• Three types of cells in histology

• Excellent prognosis

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Embryonal carcinoma

•20-30yrs

•More aggressive

•Variegated appearance

•Histologically: ALVEOLAR, TUBULR, &

PAPILLARY patterns

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Here is an embryonal carcinoma of the testis. There is a rim of normal testis superiorly.

The tumor is soft and much more variegated than the seminoma, with red to tan to

brown areas, including prominent hemorrhage and necrosis

Embryonal carcinoma, but there are scattered firmer white areas that

histologically are teratoma. Thus, this testicular neoplasm is mixed embryonal

carcinoma plus teratoma (sometimes called teratocarcinoma).

This is the histologic pattern of embryonal carcinoma. Sheets of blue

cells are trying to form primitive tubules.

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Teratoma • Infants and young children

• In adults pure teratomas are rare

• Gross: Large, heterogenous areas

Cystic and solid areas

• Micro: collection of tissue derived from

different germ layers

Terms:

1. Teratoma with malignant transformation

2. Teratocarcinoma CSBRP-July-2012

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A small testicular carcinoma is shown here. There is a mixture of bluish cartilage (Blue

arrow) with red and white tumor tissue. This neoplasm microscopically contained

mainly teratoma, but areas of embryonal carcinoma were also present.

Here is an embronal carcinoma mixed with teratoma in which islands of bluish white

cartilage from the teratoma component are more prominent. A rim of normal brown

testis appears at the left. CSBRP-July-2012

Here is a testicular neoplasm that is mostly teratoma, but embryonal carcinoma and

seminoma were found microscopically. In contrast with the ovary, pure benign

teratomas of the testis are very rare.

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Immature teratoma

Presence of primitive neuroepithelium

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Immature teratoma

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Immature teratoma

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Teratocarcinoma

Teratoma

+

Embryonal carcinoma

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Teratocarcinoma

At the bottom is a focus of cartilage. Above this is a primitive mesenchymal stroma and

to the left a focus of primitive cells most characteristic for embryonal carcinoma. This is

embryonal carcinoma mixed with teratoma.

Pathology Pearls

“An important point to remember”

Testicular Teratoma

in Pre-pubertal males: Benign

in Post-pubertal males: Malignant

This rule will not apply to OVARIAN teratomas

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Choriocarcinoma

• Highly malignant neoplasm

• Composed of both cyto and

syncytiotrophoblastic cells

• Pure form is rare, most common is mixed

patterns

• Gross: small lesions rarely exceed 5cms,

hemorrhages and necrosis are very common

• HCG can be demonstrated in

syncytiotrophoblasts

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Choriocarcinoma

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Choriocarcinoma

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Choriocarcinoma

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Choriocarcinoma - IHC

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ß-HCG

Yolk sac tumor

• Also known as infantile embryonal carcinoma or endodermal sinus tumor

• It is the most common testicular tumor in infants and children up to 3 years of age

• It has a very good prognosis in infants and young children

• In adults, the pure form of this tumor is rare; instead, yolk sac elements frequently occur in combination with embryonal carcinoma

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Yolk sac tumor

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An endodermal sinus tumor (yolk sac tumor) of the testis is shown composed of primitive germ

cells that form glomeruloid or embryonal-like structures. These tumors are most frequent in

children, but overall they are rare.

YST - Schiller–Duval body

YST - Hyaline globules CSBRP-July-2012

Sex cord-Stromal Tumors

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Leydig cell tumor

• Functional tumor: Androgens, Estrogens, Corticosteroids

• Any age (usually between 20 & 60yrs)

• Presenting feature: Testicular swelling

Gynecomastia

Precocious masculanization

• Morphology: Cicumscribed nodules <5cms

Golden brown cut surface

• Histologically: Leydig cells with Reinke crystals

~10% are malignant

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Reinke’s crystalloids

Van Gieson’s stain

Gynecomastia in a 25yo male. Secondary to Leydig cell tumor of testis.

Gynecomastia - Causes:

1. Cirrhosis of the liver

2. Functioning testicular tumor (leydig cell tumor, sertoli cell tumor)

3. Anabolic steroids

4. Alcoholism

5. Antipsychotic agents

6. Antiretroviral drugs

7. Marijuana / heroin

Pathology Pearls

3 CSBRP-July-2012

LIVER

DRUGS

TESTIS

Pathology Pearls

Name some FUNCTIONAL TUMORS

All hormone secreting tumors are functional

1. Somatostatinoma

2. Glucagonoma

3. Insulinoma

4. Adrenocortical tumors

5. Parathyroid adenoma

1. Leydig cell tumors

2. Sertoli cell tumor

3. Granulosa cell tumors

4. Theca cell tumors

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Sertoli cell tumor

(Androblastoma)

• Functional tumor: may elaborate estrogens or androgens

(precocious masculanization or feminization)

• Occasionally it may induce gynecomastia

• Most of them are benign

• ~10% may pursue malignant course

• Morphology: firm nodules, g/w to yellow

• Histology: cells are arranged in trabaculae and structures

resembling spermatic cord.

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Gonadoblastoma

• Rare

• Tumors composed of

Germ cells + stromal elements

• Arise in dysgenetic gonads (100%)

• In some tumors, germ cell component

may become malignant giving rise to an

invasive Seminoma

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Testicualr Lymphoma

• Most common neoplasm in men >60yrs

• At presentation it’s advanced disease

• It’s almost always NHL – Diffuse large

cell lymphoma

• Prognosis is very poor

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Epidermoid cyst

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Epidermoid cyst of testis

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Mixed germ cell tumors

• ~60% of testicular tumors composed of more

than one pattern

• Prognosis is worsened by the presence of an

aggressive element

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CF of Testicular tumors

• Painless enlargement of the testis

• Spread: Lymphatics: Retroperitoneal para-aortic nodes

Hematogenous: Lungs, brain, liver.

Mets may have different histology

• Tumors are divided in to Seminoma and NSGCT

• Prognosis depends on

--- clinical stage

--- histological type

• Distant mets if present, usually occur within first 2yrs after Tx.

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Differences between Seminoma and NSGCTs

SEMINOMA NSGCT

Presentation 70% in stage-I 60% in stage-II, III.

Mets LN Hematogenous

Tx Extremely

radiosensitive

Radioresistant

Prognosis Less aggressive

Good prognosis

More aggressive

Poor prognosis CSBRP-July-2012

Markers

Molecular:

• OCT3/4 gene

• Inactivation X

chromosome

These can be detected by

immunoperoxidase

and PCR

Biological:

• AFP

• hCG

• PAP

• Placental lactogen

• LDH

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Value of serum markers

(HCG, AFP, LDH)

1. In the evaluation of testicular masses

2. Staging testicular germ cell tumors

3. To assess tumor burden

4. To monitor response to Tx and relapse

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Important practical points to remember

• All testicular masses are neoplastic, unless proven otherwise

• Most of the neoplasms are malignant

• No testicular biopsy if tumor is suspected

• Hence, in case of solid testicular mass, orchiectomy is performed with a presumption of malignancy

• Mets may have different histology: Embryonal carcinoma May present a teratomatous picture in the secondary deposits

Explanation: A. Forward and backward differentiation

B. Primary tumor is mixed and that minor component in the primary lesion, that were unresponsive to chemotherapy survived resulting in the dominant metastatic pattern

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Pathology Pearls

E N D

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Contact:

Dr.CSBR.Prasad, M.D.,

Associate Professor of Pathology,

Sri Devaraj Urs Medical College,

Kolar-563101,

Karnataka,

INDIA.

CSBRPRASAD@REDIFFMAIL.COM