Testicular tumors

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Testicular tumours and there rare variants with histology

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  • Gross appearance of spermatocytic seminoma. A large tumor of myxoid appearance bulges on the cut surface.
  • Typical chromatin pattern of spermatocytic seminoma.
  • Embryonal carcinoma showing solid nodular cut surface with numerous areas of necrosis and hemorrhage.
  • Embryonal carcinoma. The pattern of growth is diffuse but without the nesting seen in classic seminoma. The high-power view shows the typical large, irregularly shaped, overlapping nuclei with multiple prominent nucleoli.
  • Pleomorphism and hyaline globules in yolk sac tumor of testis
  • Gross appearance of mature (adult) teratoma of testis. There are multiple cystic areas, lobules of mature adipose tissue, and shiny solid nodules corresponding to well-differentiated cartilage.
  • Low-power microscopic view of mature teratoma. Large islands of cartilage are seen surrounding well-differentiated glandular structures.
  • Immature teratoma. B, Microscopic appearance. Hypercellularstroma is seen growing in a concentric fashion around glandular formations.
  • Gross appearance of teratocarcinoma. The solid granular areas correspond to foci of embryonal carcinoma, whereas the pearly nodules correspond to well-differentiated cartilage.
  • Gross appearance of pure choriocarcinoma. The strikingly hemorrhagic appearance is characteristic of this tumor type.
  • Microscopic appearance of testicular choriocarcinoma. There is close intermingling of cytotrophoblast and syncytiotrophoblast, which recapitulates that seen in normal chorionic villi.
  • Gross appearance of Leydig cell tumor. A, The tumor, which has replaced most of the testis, has a granular yellowish appearance.
  • Leydig cell tumor of testis. The neoplasm is characterized by solid growth of polygonal cells with abundant granular acidophilic cytoplasm.
  • MICROSCOPIC :
  • Gross appearance of large cell calcifying Sertoli cell tumor of testis. The tumor is distinctly multinodular. The dark nodules had a prominent component of Leydig cells.
  • MACROSCOPIC :lobulated, firm & uniformly yellow gray massAdult form of granulosa cell tumor involving testis. Note the occasional longitudinal grooves, the oval to spindle shape of the tumor cells, and the high mitotic activity.
  • Gross appearance of malignant lymphoma of large cell type, which completely replaces the testis.
  • Malignant lymphoma of testis. There is diffuse infiltration of the interstitium by neoplastic lymphocytes, which surround and separate atrophic tubules.
  • Microscopic appearance of intratubular germ cell neoplasia in routinely stained section. A row of atypical germ cells with clear cytoplasm is seen against a thickened basement membrane. No spermatogenesis is occurring in this tubule.
  • Testicular tumors

    1. 1. TESTICULAR TUMOUR
    2. 2. TESTICULAR TUMORS WHO CLASSIFICATION  GERM CELL TUMORS  SEX CORD STROMAL TUMORS  Seminoma      Spermatocytic seminoma Embryonal carcinoma Polyembryoma Embryonal carcinoma and teratoma (‘teratocarcinoma’) Teratoma Mature Immature With malignant transformation Choriocarcinoma Yolk sac tumour 1. 2. 3. 4. Leydig cell tumor Sertoli cell tumor Granulosa cell tumor Mixed forms
    3. 3. TESTICULAR TUMORS  1. COMBINED GERM CELL – SEX CORD TUMORS Gonadoblastoma  OTHER TUMORS Malignant lymphoma 2. Rare tumors 1.
    4. 4. Predisposing and accompanying factors        Heredity and genetics. A few cases of testicular germ cell tumor have occurred in a familial setting,suggesting a genetic background. Specifically, trisomy 21 is associated with an increased risk. Elevated estrogens in utero. Gonadal dysgenetic lesions. HIV-infected patients. Environmental factors More common in white than black Klinefelter syndrome.
    5. 5. Age 1. . The peak is 30-40 years - classic seminoma, 2. 60 -65 years - spermatocytic seminoma, 3. The majority of pure yolk sac tumors occur in infants under 2 years of age.
    6. 6. Presentation  Most testicular germ cell tumors present with progressive, painless enlargement of the testis.  They may grow slowly or with appalling speed.  Sometimes, the initial presentation is in the form of a metastatic deposit in the retroperitoneum, lung, or mediastinum.  A small tumor may be found in a testis by palpation or ultrasonography.  The patient may have gynecomastia, large mediastinal and/or pulmonary metastases.
    7. 7.  Cutaneous atypical nevi. It has been claimed that multiple cutaneous atypical nevi occur with increased frequency in patients with testicular germ cell tumors and that they could represent a marker for this disease.
    8. 8. Bilaterality  Bilateral testicular involvement by germ cell tumors is seen in 1.0–2.7% of the cases according to the different series.  The risk of bilaterality rises to 15% if both testes are undescended.  The most common situation is bilateral spermatocytic or classic seminoma.  In the presence of bilateral testicular tumors in an elderly individual, the most likely diagnosis is malignant lymphoma
    9. 9.  Telomerase activity is present in all types of testicular germ cell tumors except for mature teratomas.  Spermatocytic seminoma shows completely different genetic features. Isochromosome 12p is not found.  Numerical chromosomal aberrations are common, and gain of chromosome 9 is characteristic.
    10. 10. SEMINOMA 1. 2. 3. 4. 5. Most common germ cell tumor Mean age is 40 yrs Very rare in children Patients present with painless testicular mass 30 % have metastases at presentation, but only 3% have symptoms related to metastases.
    11. 11. Diagram showing relationships between various types of germ cell tumors
    12. 12. Gross appearance of seminoma. The tumor in A is very small, whereas that in B has replaced most of the testis
    13. 13. Gross appearance of combined tumor of testis. In both instances, the solid homogeneous gray areas correspond to the seminoma, and the variegated foci with hemorrhage to the nonseminomatous component
    14. 14. SEMINOMA  MICROSCOPIC : 1. Cells have round to oval nuclei with one to several nucleoli & clear to eosinophillic cytoplasm 2. Cell borders are well defined 3. Arranged in solid nests separated by fibrous septa 4. Granulomatous infiltrate in 50 % cases
    15. 15. Seminoma associated with marked granulomatous reaction. Only a few tumor cells are visible in this field
    16. 16. This seminoma has increased nuclear pleomorphism and a plasmacytoid appearance
    17. 17. Seminoma with trophoblastic giant cells. (A, Hematoxylin and eosin; B, hCG immunostain
    18. 18. SEMINOMA  IMMUNOHISTO CHEMISTRY  Cells are OCT4+ve,  PLAP +ve, &  c-kit +ve  Contains cytokeratins, although only 36 % cases are +ve  EMA -ve
    19. 19. SEMINOMA Strong reactivity for PLAP
    20. 20. strong nuclear and weaker cytoplasmic reactivity for OCT3/4 in this seminoma
    21. 21. SPERMATOCYTIC SEMINOMA 1. 2. 3. Occurs only in testis & represents 2 % of germ cell tumors Patients are in 50s & present with testicular mass Very rarely metastasize.
    22. 22. SPERMATOCYTIC SEMINOMA  1. 2. MACROSCOPIC Tumors are multinodular & have a yellow edematous appearance Hemorrhage & cystic change can be present
    23. 23. spermatocytic seminoma shows fleshy, gelatinous, and hemorrhagic nodules
    24. 24. SPERMATOCYTIC SEMINOMA  MICROSCOPIC : 1. Characterized by polymorphous cell population composed of small cells to multinucleate giant cells 2. Cells are arranged in sheets & microcysts are present 3. Nests & pseudo glandular structures are also identified 4. Mitotic figures can be numerous 5. Lymphoid & granulomatous infiltrates are absent
    25. 25. Spermatocytic seminoma showing admixture of medium-sized cells (predominating), giant cells, and small lymphocyte-like cells
    26. 26. Typical chromatin pattern of spermatocytic seminoma
    27. 27. SPERMATOCYTIC SEMINOMA  IMMUNOHISTO CHEMISTRY  Cells are PLAP –ve,  vimentin –ve,  muscle marker –ve,  cytokeratin –ve, AFP –ve,  HCG –ve,  EMA –ve  NY-ESO 1 +ve  SCP-1 +ve
    28. 28. Classic seminoma SPERMATOCYTIC SEMINOMA
    29. 29. EMBRYONAL CARCINOMA 1. 2. 3. 4. 2nd most common germ cell tumor, comprising approx. 20 % cases Present in majority of mixed germ cell tumors Most men present in their 20s to 30s with a testicular mass More than 2/3rds of patients have metastases, but only 10 % have symptom related to metastases.
    30. 30. EMBRYONAL CARCINOMA  1. MACROSCOPIC : Fleshy gray white tumor with prominent necrosis & hemorrhage
    31. 31. EMBRYONAL CARCINOMA  MICROSCOPIC : 1. Cells are large with vesicular nuclei, prominent nucleoli, & indistinct cell borders 2. Tumor cells are arranged in sheets, cords & glandular structure 3. Necrosis & hemorrhage may be prominent 4. May be intimately admixed with a yolk sac tumor
    32. 32. Embryonal carcinoma. The pattern of growth is diffuse , The highpower view shows the typical large, irregularly shaped, overlapping nuclei with multiple prominent nucleoli
    33. 33. EMBRYONAL CARCINOMA  IMMUNOHISTO CHEMISTRY  Tumor cells are CD 30 +ve, a finding unique to Embryonal carcinoma, and useful in ruling out solid pattern of Embryonal carcinoma, which can simulate Seminoma .  OCT 4 +ve,  PLAP +ve,  cytokeratin +ve, c-kit –ve, and EMA -ve
    34. 34. CD30 highlights the cytoplasmic membranes of an embryonal carcinoma
    35. 35. YOLK SAC TUMOR  1. 2. 3. 4. CLINICAL : Most common germ cell tumor ( & most common testicular tumor ) in children, where it occurs in its pure form In children, majority of cases are diagnosed before 24 months In adults, it is unusual in pure form, but is found approx. 50 % of mixed germ cell tumors Most adults & children present with a testicular mass
    36. 36. YOLK SAC TUMOR  MACROSCOPIC : white to tan masses, with myxoid & cystic changes
    37. 37. pediatric yolk sac tumor appears as a solid, yellow, myxoid nodule
    38. 38. The cut surface of this adult yolk sac tumor shows areas of hemorrhage and cystic change.
    39. 39. YOLK SAC TUMOR  MICROSCOPIC :  Deposition of basement membrane material & SCHILLER – DUVAL bodies ( central vessel rimmed by loose connective tissue that in turn is lined by malignant epithelium, all within a cystic space ), are characteristic.
    40. 40. YOLK SAC TUMOR
    41. 41. Pleomorphism and hyaline globules in yolk sac tumor of testis.
    42. 42. an embryonal carcinoma may produce structures resembling the endodermal sinus-like formations seen in yolk sac tumor.
    43. 43. YOLK SAC TUMOR, MICROCYSTIC PATTERN
    44. 44. A myxomatous pattern yolk sac tumor has thin cords of cells in an extensively mucoid stroma.
    45. 45. YOLK SAC TUMOR  IMMUNOHISTO CHEMISTRY  AFP + ( focal or patchy ),  cytokeratin +ve,  PLAP variable,  EMA –ve, CD 30 -ve
    46. 46. characteristic patchy distribution of alpha-fetoprotein positivity in this yolk sac tumor
    47. 47. TERATOMA  1. 2. 3. 4. CLINICAL : Adults & children present with testicular mass In children, 2nd most common germ cell tumor Occurs in its pure form with a mean age of diagnosis at 20 months In adults, occur as a component of mixed germ cell tumor & is identified in > 50 % of mixed tumors
    48. 48. TERATOMA MACROSCOPIC :
    49. 49. TERATOMA  MICROSCOPIC : 1. Composed of somatic type of tissues that include enteric type glands, respiratory epithelium, cartilage, muscles etc. 2. Immature Teratomas contain immature neuroepithelium, blastema or cellular stroma
    50. 50. Large islands of cartilage are seen surrounding welldifferentiated glandular structures
    51. 51. IMMATURE TERATOMA, Microscopic appearance. Hypercellular stroma is seen growing in a concentric fashion around glandular formations
    52. 52. TeratocarcinomaThe solid granular areas , pearly nodules
    53. 53. Chorio carcinoma
    54. 54. Microscopic appearance of testicular choriocarcinoma. There is close intermingling of cytotrophoblast and syncytiotrophoblast.
    55. 55. LEYDIG CELL TUMOR  1. 2. 3. CLINICAL : Leydig cell tumors comprises 3 to 5 % of testicular neoplasms Occur in both adults ( majority : 80 % ) & children Children present with endocrinologic symptoms & adults present with testicular mass & some 10-30 % have gynaecomastia
    56. 56. LEYDIG CELL TUMOR  1. 2. 3. MACROSCOPIC : Leydig cells impart a golden brown colour. tumor is solid & lobulated Malignant tumors tend to be larger ( > 5 cm ) than benign tumors Necrosis can be seen in malignant tumors
    57. 57. LEYDIG CELL TUMOR  MICROSCOPIC : 1. Leydig cells vary in size but usually have round nuclei, single prominent nucleoli & abundant eosinophillic cytoplasm or clear cytoplasm 2. Reinke’s crystals are present in 40 to 70 % cases & lipochrome can be abundant in some cases
    58. 58. The neoplasm is characterized by solid growth of polygonal cells with abundant granular acidophilic cytoplasm
    59. 59. The tumor cells have a cytoplasmic clear quality
    60. 60. LEYDIG CELL TUMOR  IMMUNOHISTO CHEMISTRY  Inhibin –+ve,  Mart -1 Tumor shows variable reactivity with  cytokeratins,  S-100 proteins,  synaptophysin, and  estrogens & progesterone receptors
    61. 61. SERTOLI CELL TUMOR  1. 2. 3. CLINICAL : Account for < 1 % of testicular tumors Occur both in children (15 %) & in middle aged adults, & can be malignant ( 10 % cases ) in both Patients present with testicular mass, & estrogen production by tumor can result in gynaecomastia & impotence
    62. 62. SERTOLI CELL TUMOR  1. 2. MACROSCOPIC : Tumors are well circumscribed, solid pale yellow, or white to gray masses Large size & necrosis are worrisome features for malignancy
    63. 63. SERTOLI CELL TUMOR  MICROSCOPIC : 1. Typically composed of solid tubules containing Sertoli cells 2. Cells may be arranged in cords, solid nests & sheets 3. Tubules can contain Lumina
    64. 64. SERTOLI CELL TUMOR  IMMUNOHISTO CHEMISTRY  Inhibin –+ve, but less consistently than in leydig cell tumor & can be +ve with chromogranin,  S-100 proteins, synaptophysin, and cytokeratin AE1/3 & CAM 5.2 in 64-100 % cases  MIS & CD99 +ve
    65. 65. SCLEROSING SERTOLI CELL TUMOR  CLINICAL : 1. Rare variant of Sertoli cell tumor 2. Patients present with a testicular mass & without endocrinologic problems 3. No malignant cases have been reported
    66. 66. SCLEROSING SERTOLI CELL TUMOR Cords, nests & tubules of Sertoli cells are present within a fibrotic stroma
    67. 67. LARGE CELL CALCIFYING SERTOLI CELL TUMOR  1. 2. 3. 4. CLINICAL : Rare variant of sertoli cell tumor Patients are young, with age at diagnosis ranging from 16 to 37 years Occurs as a part of Carney’s complex & in patients with Peutz jegher’s syndrome Malignant tumors ( 17 % cases ) occur, & usually sporadic type
    68. 68. LARGE CELL CALCIFYING SERTOLI CELL TUMOR  MACROSCOPIC :  Benign tumors are small ( usually < 2 cm ) yellow tan or white nodules confined to the testicle  Malignant tumors are larger & may have areas of necrosis
    69. 69. LARGE CELL CALCIFYING SERTOLI CELL TUMOR  1. 2. 3. MICROSCOPIC : Neoplastic cells are arranged in sheets, small nests & cords & are present in a myxoid to fibrous stroma Dystrophic calcifications are present Malignant tumors are large & exhibit extra testicular spread, increased mitotic activity, necrosis, and angiolymphatic invasion
    70. 70. GRANULOSA CELL TUMOR,  1. 2. 3. CLINICAL : Much less common than in adult female ovary Average age = 42 years Often ( 20 % ) associated with Gynaecomastia
    71. 71. GRANULOSA CELL TUMOR,  1. 2. 3. 4. MICROSCOPIC : Micro follicular with a few larger cysts Call – exner bodies may be seen Cells have scant cytoplasm & angular nuclei May have nuclear grooves
    72. 72. GONADOBLASTOMA  1. 2. 3. 4. CLINICAL : Composed of a mixture of Seminoma cells & Sertoli cells Occur in dysgenetic gonads in patients with intersex syndrome Patient karyotype 46 XY or 45X/XY most commonly Invasive germ cell tumors, usually Seminoma arise in Gonadoblastoma
    73. 73. GONADOBLASTOMA  MACROSCOPIC :  Solid yellow to tan tumors in males, testis are cryptoorchid.
    74. 74. GONADOBLASTOMA  MICROSCOPIC : 1. Tumor composed of mainly Seminoma like cells , with admixed sex cord stromal cells 2. Tumor cells form nests with central germ cells & peripheral stromal cells 3. Globules of eosinophillic basement membrane material with peripheral pallisading stromal cells may be present in nests
    75. 75. LYMPHOMA  1. 2. 3. CLINICAL : Lymphoma most often result of secondary spread; occasionally , primary lymphoma may occur Most men are in their 60s Involvement is bilateral in 20 % of all cases
    76. 76. LYMPHOMA MACROSCOPIC : white to tan fleshy tumor
    77. 77. LYMPHOMA  MICROSCOPIC : 1. In adults, most lymphomas are diffuse large cell types with a B cell phenotype 2. May have immunoblastic features 3. In children, small non cleaved lymphoma is most common 4. Has an interstitial growth pattern with sparing of seminiferous tubules
    78. 78. INTRA TUBULAR GERM CELL NEOPLASIA 1. 2. 3. 4. Intra tubular germ cell neoplasia is a precursor lesion for invasive germ cell tumors Identified in almost all testis with invasive germ cell tumors, except testis with spermatocytic seminoma Most patients (> 70 % ) with IGCNU develop invasive germ cell tumor within 7 years Involvement is patchy, & 40 % cases are bilateral
    79. 79. INTRA TUBULAR GERM CELL NEOPLASIA  1.  1. 2. 3. MACROSCOPIC : No alterations MICROSCOPIC : Seminiferous tubules contain seminoma cells that are large with oval nuclei, prominent nucleoli, & clear cytoplasm Cells are confined to basal aspect of tubules Spermatogenesis is absent in involved tubules
    80. 80. Other primary tumors  Carcinoid tumors  Hemangioma  Juvenile xanthogranuloma and myofibroma.  Lipomatosis  Primary sarcoma
    81. 81. Metastatic tumors  Arise for the most part in the lung, prostate, kidney, stomach, or skin (melanoma). Malignant melanoma metastatic to testis
    82. 82. IHC OF TESTICULAR GERM CELL TUMORS Seminoma Spermato. Seminoma Embryonal carcinoma Yolk sac tumor Teratoma Choriocarci noma OCT-4 + - + - - - CD117 + -/+ - - - - CK -/+ - + + + + VIMENTIN + - - + + - PLAP + - + + + + AFP - - + + + + HCG + - + - + + CD30 + - + - - - PAS + - - + - -
    83. 83. Thank you Speaker DR. Narmada Prasad Tiwari

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