This document provides an overview of testicular tumours, including: - Germ cell tumors (GCTs) comprise 95% of testicular cancers and are categorized as seminomas or non-seminomas. - Risk factors include cryptorchidism, family history, prior testicular cancer, and intratubular germ cell neoplasia. - The World Health Organization classifies testicular tumors and includes categories such as seminoma, embryonal carcinoma, teratoma, and sex cord-stromal tumors. - Extragonadal GCTs can occur in sites like the mediastinum and retroperitoneum.

1. PATHOLOGY OF
TESTICULAR TUMOURS
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai 1

2. Moderators:
Professors:
• Prof. Dr.G. Sivasankar,M.S., M.Ch.,
• Prof. Dr.A. Senthilvel,M.S., M.Ch.,
Asst Professors:
• Dr.J. Sivabalan,M.S., M.Ch.,
• Dr. R. Bhargavi,M.S., M.Ch.,
• Dr.S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam,M.S., M.Ch.,
• Dr. D.Tamilselvan,M.S., M.Ch.,
• Dr. K. Senthilkumar,M.S., M.Ch.
Dept of Urology, GRH and KMC,Chennai. 2

3. • Neoplasms of the testis comprise a morphologically and
clinically diverse group of tumors
• In United States
Testicular cancer - most common malignancy among men
aged 20 to 40 years
• Rates are highest in Scandinavia, Germany, Switzerland, and
New Zealand
Intermediate - United States and Great Britain
Lowest - Africa and Asia
3
Dept of Urology, GRH and KMC,Chennai.

4. • Germ cell tumors (GCTs) - 95%
GCTs - broadly categorized
Seminoma
Nonseminoma (NSGCT)
• 90% of GCTs - Arise in the testis
• 2% to 5% - Extragonadal
Retroperitoneum and mediastinum - Most common sites
• Incidence of bilateral GCT
- approximately 2%
4
Dept of Urology, GRH and KMC,Chennai.

5. Risk Factors
• Well -established risk factors
- cryptorchidism
- family history of testicular cancer
- personal history of testicular cancer
- intratubular germ cell neoplasia (ITGCN).
Infertile men - have a higher incidence of testicular
cancer.
5
Dept of Urology, GRH and KMC,Chennai.

6. • Males with cryptorchidism - four to six times more
likely to be diagnosed with testicular cancer
• Meta-analysis - cryptorchidism studies reported that
contralateral descended testis
- slightly increased risk
• Men with first-degree relative with testicular cancer
have - increased risk
6
Dept of Urology, GRH and KMC,Chennai.

7. World Health Organization
Classification of Testicular Tumors
Germ Cell Tumors
Precursor lesions—intratubular malignantgerm cells
(carcinoma In situ)
Seminoma
Variant—seminoma with syncytiotrophoblastic cells
Spermatocytic seminoma
Variant—spermatocytic seminoma with sarcoma
Embryonal carcinoma
Yolk sac tumor
Polyembryoma 7
Dept of Urology, GRH and KMC,Chennai.

8. Trophoblastic tumors
Choriocarcinoma
Choriocarcinoma with other cell types
Placental site trophoblastic tumor
Teratoma
Mature teratoma
Dermoid cyst
Immature teratoma
Teratoma with malignant areas 8
Dept of Urology, GRH and KMC,Chennai.

9. Sex Cord/Gonadal Stromal
Tumors
Pure forms
Leydig cell tumor
Sertoli cell tumor
Large-cell calcifying Sertoli cell tumor
Lipid-rich Sertoli cell tumor
Granulosa cell tumor
Adult-type granulosa cell tumor
Juvenile-type granulosa cell tumor
Tumors of thecoma/fibroma group
Incompletely differentiated sex cord/gonadal stromal tumors
Mixed forms 9
Dept of Urology, GRH and KMC,Chennai.

10. Tumors Containing Both Germ Cell and Sex Cord/Gonadal Stromal
Elements
Gonadoblastoma
Mixed germ cell–sex cord/gonadal stromal tumors, unclassified
Miscellaneous Tumors
Carcinoid tumor
Tumors of ovarian epithelial types
Lymphoid and Hematopoietic Tumors
Lymphoma
Plasmacytoma
Leukemia
10
Dept of Urology, GRH and KMC,Chennai.

11. Tumors of Collecting Ducts and Rete
Adenoma
Carcinoma
Tumors of the Tunica, Epididymis, Spermatic Cord, Supporting Structures, and
Appendices
Adenomatoid tumor
Mesothelioma
Benign
Malignant
Adenoma
Carcinoma
Melanotic neuroectodermal
Desmoplastic small round cell tumor
11
Dept of Urology, GRH and KMC,Chennai.

12. Soft Tissue Tumors
Unclassified Tumors
Secondary Tumors
Tumor-like Lesions
o Nodules of immature tubules
o Testicular lesions of adrenogenital syndrome
o Testicular lesions of androgen-insensitivity syndrome
o Nodular precocious maturation
o Specific orchitis
o Nonspecific orchitis
o Granulomatous orchitis
o Malakoplakia
o Adrenal cortical rest
o Fibromatous peritonitis
o Funiculitis
12
Dept of Urology, GRH and KMC,Chennai.

13. Intratubular Germ Cell Neoplasia
• All adult invasive GCTs arise from ITGCN except
spermatocytic seminoma
• ITGCN - undifferentiated germ cells that have the
appearance of seminoma
• Located basally within the seminiferous tubules
• Tubule - shows decreased or absent spermatogenesis, and
normal constituents are replaced by ITGCN.
• ITGCN - much less frequent in pediatric GCTs
13
Dept of Urology, GRH and KMC,Chennai.

14. • Incidence of CIS in the
male population - 0.8%.
• Testicular CIS develops
from fetal gonocytes
• characterized
histologically by
seminiferous tubules
containing only Sertoli
cells and malignant germ
cells.
14
Dept of Urology, GRH and KMC,Chennai.

15. Seminoma
• Most common type - GCT( 45% )
• Occur - fourth or fifth decade of life
• TYPES
Classic seminoma
Anaplastic seminoma
Atypical seminoma
Spermatocytic seminoma
• Grossly, seminoma - soft tan to white diffuse or multinodular
mass Necrosis may be present but is usually focal
15
Dept of Urology, GRH and KMC,Chennai.

16. • Histologically - consist of a sheetlike arrangement of cells
with polygonal nuclei and clear cytoplasm, with the cells
divided into nests by fibrovascular septa that contain
lymphocytes
• Syncytiotrophoblasts - which stain positive for human
choriogonadotropin
• Lymphocytic infiltrates and granulomatous reactions are
often seen
16
Dept of Urology, GRH and KMC,Chennai.

17. • Large cell sheets with
abundant cytoplasm
• Round hyperchromatic
nuclei with abundant
nucleoli
• Lymphocytic infiltrate
• Trophoblastic giant cells
that produce hCG – 10%
17
Dept of Urology, GRH and KMC,Chennai.

18. • Immunohistochemical staining typically
Negative for CD30
Positive for CD117
Strongly positive for placental alkaline
phosphatase (PLAP).
18
Dept of Urology, GRH and KMC,Chennai.

19. SpermatocyticSeminoma
• Rare & accounts for less than 1% of GCTs.
• Variant of seminoma - represents a distinct
clinicopathologic entity from other GCTs.
• Peak incidence - sixth decade of life
• Does not arise from ITGCN
• Not associated with a history of cryptorchidism or
bilaterality,
• Does not express PLAP and does not occur as part of
mixed GCTs
. 19
Dept of Urology, GRH and KMC,Chennai.

20. Histopathologically
• Nuclei are round, minimal lymphocytic filtration is
present
• Three distinct cell types are present
• Small lymphocyte-like cells, medium-sized cells with
dense eosinophilic cytoplasm and a round nucleus, and
large mononucleated or multinucleated cells
• Benign tumor , always cured with orchiectomy
20
Dept of Urology, GRH and KMC,Chennai.

21. NSGCT
• 55% of GCTs
• Third decade of life
• Most tumor types are mixed including
seminoma
• All have equal prognosis
21
Dept of Urology, GRH and KMC,Chennai.

22. Embryonal Carcinoma
• Consists of undifferentiated
malignant cells resembling
primitive epithelial cells from
early-stage embryos with crowded
pleomorphic nuclei
• Grossly - tan to yellow neoplasm
that often exhibits large areas of
hemorrhage and necrosis.
22
Dept of Urology, GRH and KMC,Chennai.

23. Microscopic appearance
• Grow in solid sheets or in papillary, glandular-alveolar, or
tubular patterns
• Is an aggressive tumor associated with a high rate of
metastasis, with normal serum tumor markers.
• Increased risk of occult metastases
• Typically stains - AE1/AE3, PLAP, and OCT3/4 and does
not stain for c-KIT.
23
Dept of Urology, GRH and KMC,Chennai.

24. Choriocarcinoma
• Rare and aggressive tumor
• Presents as elevated serum hCG levels and
disseminated disease
• Choriocarcinoma commonly spreads by
hematogenous routes
common sites of metastases - lungs and brain, but eye
and skin metastases have also reported
24
Dept of Urology, GRH and KMC,Chennai.

25. Microscopically
• Tumor - composed of
syncytiotrophoblasts and
cytotrophoblasts,
stain positively for hCG
• Areas of hemorrhage and
necrosis - prominent.
25
Dept of Urology, GRH and KMC,Chennai.

26. Yolk SacTumor
• Endodermal sinus tumors
small fraction of adult-type
GCTs
• More common in
mediastinal and pediatric
GCTs.
• Mimics yolk sac of the embryo
• Produces alpha feto protein
26
Dept of Urology, GRH and KMC,Chennai.

27. • Consists reticular network of medium-sized cuboidal cells
with cytoplasmic and extracytoplasmic eosinophilic,
hyaline-like globules
• Hyaline globules - characteristic feature (84% of cases).
• Grow in a glandular, papillary, or microcystic pattern.
• A characteristic feature - Schiller-Duval body, which
resembles endodermal sinuses,
• Yolk sac tumors almost always produce AFP but not
hCG.
27
Dept of Urology, GRH and KMC,Chennai.

28. Teratoma
• Tumors contain well-differentiated or incompletely differentiated
elements of at least two of the three germ cell layers of endoderm,
mesoderm, and ectoderm.
• Derived from a pluripotent malignant precursor
• Characteristically all components are intermixed.
• Well-differentiated tumors - Mature teratomas,
• Whereas incompletely differentiated - called Immature
teratomas.
28
Dept of Urology, GRH and KMC,Chennai.

29. • Mature teratomas include elements
of mature bone, cartilage, teeth,
hair, and squamous epithelium
• Gross appearance - teratoma
depends largely on the elements
within it,
most tumors having solid and
cystic areas.
29
Dept of Urology, GRH and KMC,Chennai.

30. • Teratoma - resistant to chemotherapy
• Teratomas may grow uncontrollably, invade
surrounding structures, and become unresectable
• On rare occasions, teratoma may transform into a
somatic malignancy such as rhabdomyosarcoma,
adenocarcinoma, or primitive neuroectodermal
tumor.
30
Dept of Urology, GRH and KMC,Chennai.

31. • “Teratoma with malignant transformation.”
• Highly aggressive, resistant to conventional
chemotherapy, and associated with a poor
prognosis.
• Teratomas - associated with normal serum tumor
markers, but they may cause mildly elevated serum
AFP levels
31
Dept of Urology, GRH and KMC,Chennai.

32. EXTRA GONADAL GERM CELLTUMORS
• Primary tumors of
extragonadal origin are
rare
• 3-5% of all GCTs are
extragonadal
• Most common sites:
1. Mediastinum
2. Retroperitoneum
3. Sacrococcygeal region
4. Pineal gland
32
Dept of Urology, GRH and KMC,Chennai.

33. EXTRA GONADAL GERM CELLTUMORS
• Histologically all germ cell
types are represented
• Pure seminoma accounting
for nearly half
• May reach large size with
no or relatively few
symptoms
• High potential for local
invasion and distant
metastasis 33
Dept of Urology, GRH and KMC,Chennai.

34. NON–GERM CELLTUMORS
Sex Cord/StromalTumors
34
Dept of Urology, GRH and KMC,Chennai.

35. Leydig CellTumors
• Most common of the sex cord/stromal tumors.
• No association with cryptorchidism.
• Occur in adult males between age 20 and 60 years,
• Painless testicular mass - most common
presentation , frequently with feminizing
characteristics (gynecomastia, impotence, and
decreased libido).
35
Dept of Urology, GRH and KMC,Chennai.

36. • Ninety percent of these tumors -benign
10% are malignant
• Macroscopic - usually small, yellow to brown, well
circumscribed, and without areas of necrosis of hemorrhage.
• Histologically, tumors consist of uniform polygonal cells
with round nuclei.
Reinke crystals - present ( 25% to 40%) appear as densely
eosinophilic needle-like or rhomboid structures within the
cytoplasm.
36
Dept of Urology, GRH and KMC,Chennai.

37. • Most frequent metastatic sites -
Retroperitoneum and lung.
• Metastatic Leydig cell tumors - resistant to
chemotherapy and radiation therapy
• Radical inguinal orchiectomy
- Treatment of choice
37
Dept of Urology, GRH and KMC,Chennai.

38. Sertoli CellTumor
• Comprise less than 1% of testicular neoplasms.
• Can occur in any age group
• No association with cryptorchidism.
• Wel l circumscribed and yellow-white or tan, with
uniform consistency.
• Microscopically - tumors contain epithelial elements
resembling Sertoli cells with varying amounts of
stroma organized into tubules.
38
Dept of Urology, GRH and KMC,Chennai.

39. • Ninety percent of tumors - benign, and 10% are
malignant.
• Treatment - radical inguinal orchiectomy
• RPLND - considered if the suspicion of malignancy is
high or if retroperitoneal adenopathy exists.
• Radiation therapy and chemotherapy are ineffective.
39
Dept of Urology, GRH and KMC,Chennai.

40. Granulosa CellTumors
• Exceedingly rare and resemble adult-type
granulosa cell tumors of the ovary
• Gynecomastia and increased estrogen secretion
are common
• Radical inguinal orchiectomy - curative
because these tumors appear to have limited
metastatic potential.
40
Dept of Urology, GRH and KMC,Chennai.

41. Gonadoblastoma
• Mixed germ cell/sex cord/stromal tumor composed of
seminoma-like germ cells and sex cord cells showing
Sertoli differentiation.
• Occur almost with dysgenic gonads and intersex
syndromes.
• Eighty percent of affected individuals are phenotypic
females, usually presenting with primary amenorrhea
41
Dept of Urology, GRH and KMC,Chennai.

42. • Remainder - phenotypic males, present with
cryptorchidism , hypospadias
• One third of cases - bilateral
• Gonadoblastomas do not metastasize
• Bilateral orchiectomy - required because of
the risk of bilateral tumors.
42
Dept of Urology, GRH and KMC,Chennai.

43. MiscellaneousTesticular Neoplasms
• Adenocarcinoma of the Rete Testis
- Rare but highly malignant neoplasm arising from the collecting
system of the testis.
- Usual presentation is a painless testicular mass with hydrocele.
- More than 50% of patients present with metastatic disease
- RPLND - curative with limited retroperitoneal lymph node
metastasis.
- Chemotherapy and radiation therapy - ineffective.
43
Dept of Urology, GRH and KMC,Chennai.

44. • Primary testicular non-Hodgkin lymphoma - rare
tumor and 1% to 2% of all cases of lymphoma.
• Most commonly - lymphoma involves the testis
through dissemination from extratesticular sites
• Eighty-five percent of cases occur in men older than
age 60.
• SecondaryTumors of theTestis
Lymphoma
44
Dept of Urology, GRH and KMC,Chennai.

45. • Non-Hodgkin lymphoma - most common testicular
neoplasm
• Bilateral testicular involvement - 35% of cases
• Usually presents as painless testicular mass in an older
man. 25% of men have systemic symptoms (fever, night
sweats, weight loss).
• Treatment - radical inguinal orchiectomy.With
chemotherapy
45
Dept of Urology, GRH and KMC,Chennai.

46. Metastases
• Metastases to the testis - rare
• Usually associated with diffuse metastatic disease.
• Bilateral involvement occurs in 15% of patients.
• Most common primary lesions - prostate cancer, lung
cancer, melanoma, colon cancer, and kidney cancer
• Treatment - largely dictated by the primary tumor,
orchiectomy may be considered for palliative reasons.
46
Dept of Urology, GRH and KMC,Chennai.

47. TUMORS OF THE TESTICULAR ADNEXA
AdenomatoidTumor
• Most common paratesticular tumor
• Commonly involving = epididymis
• Most common presentation - small , painless
paratesticular mass ,third or fourth decade
• Microscopic examination -composed of epithelial-like
cells that contain vacuoles and fibrous stroma
• Tumors - benign and managed by inguinal exploration
and surgical excision..
47
Dept of Urology, GRH and KMC,Chennai.

48. Cystadenoma
• Cystadenoma of the epididymis -- corresponds to benign epithelial
hyperplasia.
• Lesions - usually multicystic, the walls of which are studded with
nodules of epithelial cells arranged in a glandular or papillary
configuration.
• One third of cases occur in patients with von Hippel-Lindau
syndrome.
• Lesions - usually small and painless and are detected on routine
examination in a young adult.
48
Dept of Urology, GRH and KMC,Chennai.

49. Mesothelioma
• Paratesticular mesothelioma arises from the tunica
vaginalis
• Presents as a painless scrotal mass in association with a
hydrocele
• Occur in older adults but may be encountered in any age
group.
• Both benign and malignant mesothelioma have been
described, with the distinction based on atypia, mitotic
activity, and invasion
49
Dept of Urology, GRH and KMC,Chennai.

50. • Malignant cases - associated with asbestos
exposure.
• Treatment - Radical inguinal orchiectomy
• RPLND - considered in patients with malignant
tumors withoutwidespread metastaticdisease.
50
Dept of Urology, GRH and KMC,Chennai.

51. Sarcoma
• Sarcomas of the spermatic cord, epididymis,and testis - most common
genitourinarysarcomas in adults.
• Liposarcoma - most common histologic subtype in adults, followed
by rhabdomyosarcoma,leiomyoma,malignant fibrous histiocytoma, and
fibrosarcoma
• Embryonal rhabdomyosarcoma - most common histologic subtype
in men younger than age 30
• Present as a painless, palpablemass, and most are large (>5 cm)
• Ultrasonography - demonstratea solid mass, although it cannot
distinguish between benign and malignantpathology
51
Dept of Urology, GRH and KMC,Chennai.

52. • Sarcomas - inguinal approach with wide excision of the
spermatic cord and testis with high ligation.
• Liposarcomas rarely metastasize but tend to recur
locally
• Postoperative radiation therapy - considered for
tumors or in those in whom the adequacy of local
excision is in doubt
• Systemic chemotherapy should be given to patients with
evidence of retroperitoneal or distant metastases.
52
Dept of Urology, GRH and KMC,Chennai.

53. THANK YOU
53
Dept of Urology, GRH and KMC,Chennai.