Testicular tumours and there rare variants with histology

1. TESTICULAR TUMOUR

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. TESTICULAR TUMORS

1.
COMBINED
GERM CELL –
SEX CORD
TUMORS
Gonadoblastoma

OTHER TUMORS
Malignant lymphoma
2. Rare tumors
1.

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. 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. 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. 
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. 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.  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. 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. Diagram showing relationships between various types of germ cell tumors

13. Gross appearance of seminoma. The tumor in A is very small,
whereas that in B has replaced most of the testis

14. 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

15. 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

16. Seminoma associated with marked granulomatous reaction. Only a few tumor
cells are visible in this field

17. This seminoma has increased nuclear pleomorphism and a
plasmacytoid appearance

18. Seminoma with trophoblastic giant cells. (A, Hematoxylin and eosin; B, hCG
immunostain

19. SEMINOMA
 IMMUNOHISTO CHEMISTRY
 Cells are OCT4+ve,
 PLAP +ve, &
 c-kit +ve
 Contains cytokeratins, although only
36 % cases are +ve
 EMA -ve

20. SEMINOMA Strong
reactivity for PLAP

21. strong nuclear and weaker cytoplasmic reactivity for OCT3/4 in this seminoma

22. 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.

23. SPERMATOCYTIC SEMINOMA

1.
2.
MACROSCOPIC
Tumors are multinodular
& have a yellow
edematous appearance
Hemorrhage & cystic
change can be present

24. spermatocytic seminoma shows fleshy, gelatinous, and hemorrhagic nodules

25. 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

26. Spermatocytic seminoma showing admixture of medium-sized cells
(predominating), giant cells, and small lymphocyte-like cells

27. Typical chromatin pattern of spermatocytic seminoma

28. 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

29. Classic seminoma
SPERMATOCYTIC
SEMINOMA

30. 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.

31. EMBRYONAL CARCINOMA

1.
MACROSCOPIC
:
Fleshy gray white
tumor with
prominent
necrosis &
hemorrhage

32. 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

33. Embryonal carcinoma. The pattern of growth is diffuse , The highpower view shows the typical large, irregularly shaped, overlapping
nuclei with multiple prominent nucleoli

34. 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

35. CD30 highlights the cytoplasmic membranes of an embryonal carcinoma

36. 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

37. YOLK SAC TUMOR
 MACROSCOPIC : white
to tan masses, with
myxoid & cystic changes

38. pediatric yolk sac tumor appears as a solid, yellow, myxoid nodule

39. The cut surface of this adult yolk sac tumor shows areas of hemorrhage and cystic
change.

40. 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.

41. YOLK SAC TUMOR

42. Pleomorphism and hyaline globules in yolk sac tumor of testis.

43. an embryonal carcinoma may produce structures resembling the endodermal
sinus-like formations seen in yolk sac tumor.

44. YOLK SAC TUMOR, MICROCYSTIC
PATTERN

45. A myxomatous pattern yolk sac tumor has thin cords of cells in an
extensively mucoid stroma.

46. YOLK SAC TUMOR
 IMMUNOHISTO CHEMISTRY
 AFP + ( focal or patchy ),
 cytokeratin +ve,
 PLAP variable,
 EMA –ve, CD 30 -ve

47. characteristic patchy distribution of alpha-fetoprotein positivity in this yolk sac
tumor

48. 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

49. TERATOMA
MACROSCOPIC :

50. 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

51. Large islands of cartilage are seen surrounding welldifferentiated glandular structures

52. IMMATURE TERATOMA, Microscopic appearance.
Hypercellular stroma is seen growing in a concentric fashion around
glandular formations

53. TeratocarcinomaThe solid granular areas ,
pearly nodules

54. Chorio carcinoma

55. Microscopic appearance of testicular
choriocarcinoma. There is close intermingling of
cytotrophoblast and syncytiotrophoblast.

56. 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

57. 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

58. 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

59. The neoplasm is characterized by solid growth of
polygonal cells with abundant granular acidophilic
cytoplasm

60. The tumor cells have a cytoplasmic clear quality

61. LEYDIG CELL TUMOR
 IMMUNOHISTO CHEMISTRY
 Inhibin –+ve,
 Mart -1
Tumor shows variable reactivity with
 cytokeratins,
 S-100 proteins,
 synaptophysin, and
 estrogens & progesterone receptors

62. 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

63. 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

64. 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

65. 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

66. 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

67. SCLEROSING
SERTOLI CELL TUMOR
Cords, nests & tubules of Sertoli cells are present within a
fibrotic stroma

68. 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

69. 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

70. 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

71. GRANULOSA CELL TUMOR,

1.
2.
3.
CLINICAL :
Much less common than in adult female ovary
Average age = 42 years
Often ( 20 % ) associated with Gynaecomastia

72. 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

73. 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

74. GONADOBLASTOMA

MACROSCOPIC :

Solid yellow to tan tumors in males, testis are
cryptoorchid.

75. 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

76. 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

77. LYMPHOMA
MACROSCOPIC : white to tan
fleshy tumor

78. 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

79. 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

80. 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

82. Other primary tumors
 Carcinoid tumors
 Hemangioma
 Juvenile xanthogranuloma and myofibroma.
 Lipomatosis
 Primary sarcoma

83. Metastatic tumors
 Arise for the most part in the lung, prostate, kidney,
stomach, or skin (melanoma).
Malignant melanoma metastatic to testis

84. 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
+
-
-
+
-
-

85. Thank you
Speaker
DR. Narmada Prasad Tiwari