male genitaltract 2
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Designed for UG students.TRANSCRIPT
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.