Seminomas comprise 50% of all testicular germ cell tumors and are most common at 40 years of age. Patients usually present with testicular swelling and pain. Testicular tumors often have elevated serum hCG (human chorionic gonadotropin) in 10% of patients and elevated serum PLAP (placental-like alkaline phosphatase) in 50% of cases. These tumors typically have a cream to yellow cut surface with a buldging fleshy consistency.
INCIDENCE 50% of all testicular tumors AGE RANGE-MEDIAN Average age 40.5 years
Rare <10 years
EPIDEMIOLOGIC ASSOCIATIONS CHARACTERIZATION Very tall men Increased HLA DR5 and Bw41
DISEASE ASSOCIATIONS CHARACTERIZATION AIDS and immunosuppresion
PATHOGENESIS CHARACTERIZATION Isochromosome 12p Most common abnormality
May lead to K-ras-2 protoncogene activation
CHARACTERIZATION Laboratory Markers Serum hCG 7-25% with mild elevation
10% in stage I patients
25% or more in patients with metastatic disease
Serum LDH Elevated in 82% of patients with metastatic disease Serum PLAP Elevated in 33-91% of stage I patients
Elevated in 40-75% of patients with metastatic disease
Flow cytometry Mean diploid value of 1.6-1.8 times normal
CHARACTERIZATION General Right>Left testis
Tumors average 5 cm
Solid well circumscribed and bulge above the surrounding parenchyma
Cut surface tan to cream colored
VARIANTS Paraneoplastic hypercalcemia Rarely Exophthalmos Sceondary to paraendocrine abnormality Current or surgically corrected cryptorchidism 10-30%
HISTOLOGICAL TYPES CHARACTERIZATION General
There are two cellular elements. There are sheets of seminoma cells with central nuclei, eosinophilic to clear cytoplasm, and large nucleoli. Well defined intercellular borders are present. The second component are numerous lymphocytes occasionally associated with granulomas in 50-60%
About 20% of tumors may have large trophoblast cells, which are immunopositive for HCG. Intermixed with the tumor are broad fibrous bands and septae often infiltrated by lymphocytes.
Necrosis is common
VARIANTS Tubular variant Closely packed solid tubules
CHARACTERIZATION Special stains Glycogen PAS positive Immunoperoxidase
Positive for PLAP, LDH, ferritin, and NSE
hCG positive in 7-25%
Negative for CD30 and EMA
Necrotic Seminoma of the Testis
Establishing the Diagnosis With Masson Trichrome Stain and Immunostains
Barbara D. Florentine, MD, Arno A. Roscher, MD, Jerry Garrett, MD, and Nancy E. Warner, MD
From the Keck School of Medicine, University of Southern California, Los Angeles, Calif (Drs Florentine, Roscher, and Warner); and Henry Mayo Newhall Memorial Hospital, Newhall, Calif (Drs Florentine, Roscher, and Garrett)
Arch Pathol Lab Med 2002;Vol. 126, No. 2, pp. 205206. Abstract quote
We describe an infarcted mass in the testis containing ghost cells suspicious for neoplasm. The entire lesion was necrotic.
A Masson trichrome stain greatly improved nuclear and cytologic detail, confirming the suspicion of neoplasm.
Placental alkaline phosphatase revealed specific membrane staining of the neoplastic cells and established a diagnosis of seminoma. Masson trichrome plus selected immunostains offer a promising approach to the diagnosis of certain necrotic neoplasms.
DIFFERENTIAL DIAGNOSIS KEY DIFFERENTIATING FEATURES
CHARACTERIZATION SPERMATOCYTIC SEMINOMA TYPICAL SEMINOMA Proportion of germ cell tumors 1-2% 40-50% Sites Testis only Testis, ovary, mediastinum, pineal, retroperitoneum Bilaterality 9% 2% Association with other forms of germ cell tumor No Yes Association with IGCNU No Yes Intercellular edema Common Uncommon Composition 3 cell types, with denser cytoplasm, round nuclei 1 cell type, often clear cytoplasm, less regular nuclei Stroma Scanty Prominent Lymphoid reaction Rare to absent Prominent Granulomas Extremely rare Often prominent Sarcomatous transformation Occasional Absent Glycogen Absent to scant Abundant PLAP staining Absent to scant Prominent hCG staining Absent Present in 10% Metastases Extremely rare Common
ADDITIONAL DIFFERENTIAL DIAGNOSIS KEY DIFFERENTIATING FEATURES Solid embryonal carcinoma Solid yolk sac tumor Choriocarcinoma Malignant lymphoma Sertoli cell tumors
PROGNOSIS AND TREATMENT CHARACTERIZATION Prognostic Factors
The tumor stage is the most important prognostic factor for these tumors with tumors limited to the testis having a survival of >95%.
75% present with disease limited to the testis
20% have retroperitoneal involvement
5% have supradiaphragmatic or organ metastases
Poor prognostic factors:
Lacking lymphoid stroma
Elevated serum hCG
Survival >95% survival for tumors confined to testis following orchiectomy and radiation Recurrence Unusual, most occur outside radiated fields in mediastinum, cervical lymph nodes, or lungs Metastasis 2.5% present with metastases Treatment
Seminomas are very radiosensitive and respond well to chemotherapy.
Radiation to ipsilateral inguinal and iliac nodes and periaortic and pericaval lymph nodes
Tumors metastatic to retroperitoneum are treated with radiation and may receive platinum based chemotherapy
Tumors of the Testis, Adnexa, Spermatic cord, and scrotum in Atlas of Tumor Pathology. Third Series. Fascicle 25. 1999.
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