Page 1
The Role of the Surgical Pathologist in Evaluation and
Management of Germ Cell Tumors of the Testis
LASOP SCIENTIFIC PROGRAMTuesday, February 8, 2011
Mahul B. Amin, MDProfessor & Chairman, Department of Pathology
Cedars-Sinai Medical [email protected]
GERM CELL TUMORS OF TESTIS
• Occur in young adults (20 - 50s)• May present with metastasis or develop
extensive metastasis• Most tumors are curable by modern therapies• Histology complex: multiple types each with
numerous patterns• Pathologic diagnosis corner stone of
contemporary management
Pathologic Features that matter in Clinical Practice
GERM CELL TUMORS OF THE
TESTISObjectives:
- Pathologic Features that matter in clinical practice
- Criteria for diagnosis of different components- IHC work up
- Reporting (primary and metastatic sites)
1
Page 2
TUMORS OF THE TESTIS
• Germ cell tumors (90 - 95%)
• Sex-cord stromal tumors (3 - 4%)
• Malignant lymphoma (<1%)
• Metastasis (<1%)
GERM CELL TUMOR•Classic seminoma
•Spermatocytic seminoma
•Pure or Mixed (non-seminomatous) tumor
- Embryonal carcinoma- Yolk sac tumor- Choriocarcinoma- Teratoma
HISTOGENESIS
2
Page 3
CHROMOSOMAL CONSTITUTION OF GERM CELL TUMORS
• Gain in sequences of 12 p (most often i (12p)
• Tumors including ITGCN - aneuploid
• Seen in >95% of germ cell tumors
• Gain chromosome 9 in spermatocytic seminoma
INTRATUBULAR GERM CELL NEOPLASIA
• Edge of invasive tumor
• Infertility (1% - bxs) – approximately 50% progress in 5 years
• Cryptorchid testis (2-8%)
• Contralateral testis cancer (5%)
• Not seen in: Pediatric yolk sac tumorPediatric teratomaSpermatocytic seminoma
GERM CELL TUMORS –Important issues before you look at
slides• Know the serum AFP & HCG levels• Carefully review the gross findings to target
sampling• Take a section of the cord margin• LET THE BISECTED SPECIMEN FIX AFTER
MAKING ADDITIONAL CUTS – architectural and cytologic features are key to the dx of germ cell tumor components
3
Page 4
ITGCN
• Basilar proliferation of clear cells
• Large nuclei
• Vesicular chromatin
• Prominent nucleoli
- Seminoma -like
4
Page 5
ITGCN
ITGCN- Immunomarkers
c-kitOct 3/4Podoplanin PLAP
5
Page 6
OCT3
PLAP
CKIT
INTRATUBULAR GERM CELL NEOPLASIA
• Situations where the diagnosis is clinically relevant
• Seminoma vs sex cord stromal tumor• Seminoma vs Spermatocytic seminoma• Pure teratoma vs. Epidermoid cyst• Biopsies for infertility• Orchiectomies for cryptorchidism
Not everything that is abnormal and intratubular is ITGCN
Pitfall: normal spermatogonia in adult testis
6
Page 7
C KIT false (+)Pitfall: normal spermatogonia in adult testis
Oct 3 more specific for ITGCN
Intratubular embryonal carcinoma
Intratubular spermatocytic seminomaIntratubular seminoma
ITGCN
Intratubular B cell Lymphoma Intratubular Prostate CA
7
Page 8
SEMINOMA - GROSS
8
Page 9
SEMINOMA - MICROSCOPY
SEMINOMA - MICROSCOPY
9
Page 11
SEMINOMA
(+) c-kit
Oct-3/4
Podoplanin
PLAP
(-) CytokeratinCD30AFPβHCG (syncytio-trophoblasts only +)
Immunohistochemistryc-kit
11
Page 12
SEMINOMA
OCT3
PLAP
CKIT
Cytokeratin
SPERMATOCYTIC SEMINOMA
• Older age group (average age 52 yrs)
• Not associated with ITGCN• Not associated with 12p abnormalities• PLAP, keratin, AFP, HCG (-)
• Not associated with other germ cell components
• No ovarian counterpart or extragonadal location
• Clinically benign except if associated with sarcomatous transformation
Unique
12
Page 13
SPERMATOCYTIC SEMINOMA
• Circumscribed
• Mucoid appearance
• Cystic degeneration
Gross
SPERMATOCYTIC SEMINOMA
SPERMATOCYTIC SEMINOMA
• Sheets, nests, lobules
• Variable loose edematous stroma• 3 cell types:
- Small (6-8/µ)- Medium (15-20/µ)- Giant (15-100/µ)
Microscopy
13
Page 14
SPERMATOCYTIC. SEMINOMA
14
Page 15
SPERMATOCYTIC. SEMINOMA
15
Page 16
SPERMATOCYTIC SEMINOMA
SPERMATOCYTIC SEMINOMA
16
Page 17
SPERMATOCYTIC SEMINOMA –INTRTUBULAR GROWTH
• 12 cases reported
• Most cases result in death
SPERMATOCYTIC SEMINOMA – SARCOMATOUS
TRANSFORMATION
TESTIS - IHC
•Germ cell tumor: PLAP (+), EMA (-)
•Sex-cord stromal tumor: Calretinin, Inhibin, CD99, melan-A (+)
•Lymphoma: CD45
•Visceral malignancy: EMA (+)
Screening panel
17
Page 18
GERM CELL TUMORS - IHC•Intratubular germ cell neoplasia
•PLAP (+)•c-kit (+)•Oct 3/4 (+)•Podoplanin (+)
•Classic seminoma•AE1/AE3, CAM 5.2: usually (-) (or focal)•c-kit ,Oct 3/4 & Podoplanin (+)•CD30 (Ber-H2): usually (-) (or focal)•AFP: (-)
•Spermatocytic seminoma•Negative for most markers except c-kit
GERM CELL TUMORS - IHC•Embryonal carcinoma
•AE1/AE3, CAM 5.2: (+)•CD30 (Ber-H2): (+)•Oct 3/4 (+)•AFP(-)•c-kit: (-)
•Endodermal sinus tumor (YST)•AE1/AE3, CAM 5.2: (+)•AFP: (+)•Glypican 3 (+)•CD30 (Ber-H2): (-)•c-kit: (-)•Oct 4 (-)
•Choriocarcinoma•AE1/AE3, CAM 5.2: (+)•ßHCG: (+)•Glypican (+) – mainly syncytiotrophoblasts•Human placental lactogen: (+)•Oct 4 (-)
EMBRYONAL CARCINOMA
• Usually small (average 4 cm)
• Variegated - hemorrhage, necrosis
• Extension into paratestis (20%)
Gross
18
Page 19
EMBRYONAL CARCINOMA
EMBRYONAL CARCINOMAPatterns CellsSolid sheets
Gland formation
Papillary structures
Marked cellular pleomorphism
Nuclear overlap “syncytia”
Irregular chromatin distribution
Prominent nucleoli
Increased mitoses
EMBRYONAL CARCINOMA
19
Page 20
EMBRYONAL CARCINOMA
EMBRYONAL CARCINOMA
EMBRYONAL CARCINOMA
20
Page 21
EMBRYONAL CARCINOMA
• AE1/AE3 (+)• CD30 (+)• Oct 4 (+)• C kit (-)• AFP (-)• Glypican (-)
EMB.Ca
OCT3
PANCK
CD30
YOLK SAC TUMOR - MICROSCOPYPatterns CellsEndodermal sinus
Reticular
Microcystic
Papillary
Glandular
Etc. (+/- 11 patterns)
Cuboidal - in between seminoma and embryonal carcinoma
Spindled
21
Page 22
YST- Endodermal sinus pattern
YOLK SAC TUMOR
Schiller-Duval body Hyaline globules
YST- Glandular & Macrocystic
22
Page 23
YST- solid pattern
23
Page 24
YST- microcystic pattern
Cuboidalcells
YST- myxomatous pattern
Spindlecells
YST- Enteric /endometrioid pattern
24
Page 25
YST- Polyvesicular vitelline pattern
YST- Parietal pattern
YST -Angioblastic pattern
25
Page 26
YST- combination of patterns
THE
RULE!!
YOLK SAC TUMOR
(+) KeratinAFPPLAP
(-) c-kit, Oct3/4CD30 (BerH 2)βHCG (in syncytio-trophoblasts only)
Immunohistochemistry
AFP
26
Page 27
SEM
YST
AFP
OCT3
Glypican-3 expression in testicular germ cell tumors
• Yolk sac tumor 100%• Embryonal carcinoma 0-8%• Choriocarcinoma 30 - 100%
(syncytiotrophoblasts)
• Teratoma 0-40%(immature elements)
• Seminoma 0%• ITGCN 0%
YST Glypican
CC Glypican
27
Page 28
CHORIOCARCINOMA
• Very rare in pure form (<1%)
• Frequently admixed with other germ cell tumor components (7%)
• Frequently present with metastases (hemoptysis, hepatomegaly, CNS dysfunction)
• Symptoms of ↑ βHCG production (gynecomastia, thyrotoxicosis)
CHORIOCARCINOMA
• Usually small hemorrhagic nodule
• Scar
• Clinically/ grossly inapparent
28
Page 29
CHORIOCARCINOMA
• Hemorrhage
• Necrosis
• Vague/ill-formed villiform arrangement
• Biphasic appearance:- Syncytiotrophoblasts – multinucleated cells WRAPPING AROUND
- Cytotrophoblasts – nests, round to polygonal cells
Microscopy
CHORIOCARCINOMA
29
Page 30
CHORIOCARCINOMA
30
Page 31
CHORIOCARCINOMA
EMBRYONAL CARCINOMA WITH “ APPLIQUE FORMATIONS
31
Page 32
SEMINOMA WITH EXTENSIVE SYNCYTIOTROPHOBLASTS
CHORIOCARCINOMA
Keratin (+)βHCG (+)HPL (+)
Immunohistochemistry
TERATOMA• Tumor composed of several tissue types
(endoderm, ectoderm, mesoderm)
• Mature – histologically adult tissue type; ORImmature – fetal/embryonic tissue type
• Age important- Children: Benign (no matter how immature)
- Post-pubertal: Malignant (no matter how mature)
• 65% occur in first 2 yrs of life
• Post-pubertal: young adults, 24% present with metastasis
32
Page 33
Teratoma, predominantly mature
ITGCN
MATURE TERATOMA
• Adult type
• Organoid
• Histologically recognizable as adult tissue
• Ectoderm – Epidermis, neuronal tissue
• Endoderm – GI, respiratory muscosa, mucous glands, etc.
• Mesoderm – Bone, cartilage, muscle, fat, etc.
MATURE TERATOMA
33
Page 34
MATURE TERATOMA
MATURE TERATOMA
MATURE TERATOMA
34
Page 35
MATURE TERATOMA
TERATOMA - EPIDERMOID CYST -BENIGN
Lacks ITGCN
Look for ITGCN
35
Page 37
TERATOMA - DERMOID CYST
Lacks ITGCN
Teratoma, predominantly immature
IMMATURE TERATOMA• Fetal type
• Embryonic tissue
• Immature mesenchyme –cellular spindled
• Immature skeletal muscle –rhabdomyoblasts
• Immature neuroepithelial structures
37
Page 38
IMMATURE TERATOMA
MALIGNANT TRANSFORMATION IN TERATOMA
• Somatic/visceral malignancy in teratoma, i.e.: - Adenocarcinoma
- Squamous cell carcinoma
- Rhabdomyosarcoma
- PNET
• Occurs mostly after chemotherapy –“chemo-selection”
• Size criterion of >4X field
38
Page 39
MIXED GERM CELL TUMOR
MIXED GERM CELL TUMOR
Embryonal Ca + Teratoma - 25-30%
Embryonal Ca + Seminoma - 16%
Embryonal Ca + YST + Teratoma - 11%
Other combinations…
39
Page 40
MIXED GERM CELL TUMOR
EMBRYONAL CA
YST
POLYEMBRYOMA
40
Page 41
DIFFUSE EMBRYOMA
41
Page 42
TESTIS TUMOR - Rule 1
- Germ cell tumor (ITGCN)- Sex-cord stromal tumor (rare)- Lymphoma (interstitial growth)- Metastasis
- Looks different- Vascular-lymphatic invasion- Interstitial growth
•Broad category:
Axiomatic to perform an orchiectomy for a testicular mass
TESTIS IHC: Screening panels• Germ cell tumors- PLAP- SAL4- Oct 3/4- EMA(-)- Vimentin (-)
• Sex cord tumors- SF1- Melan A- Inhibin- Calretinin- CD99- Synaptophysin
•Lymphoma: CD-45, CD3, L26
•Visceral malignancy: EMA (+), vimentin (±)
42
Page 43
LEYDIG CELL TUMOR
INHIBIN
SERTOLI CELL TUMOR
CALRETININ
TESTIS TUMOR – Rule 2
•Seminoma- Surveillance or radiation (Stage I, II)
•Non-Seminomatous (Mixed)- Chemotherapy ± RPLND or
surveillance (Stage I, II)
Seminoma or Non-Seminomatous
43
Page 44
TESTIS TUMOR –Rule 3
-If present: pT 2 tumor-DETERMINES STAGE & THERAPY-Excludes most pts from “surveillance”
Is there vascular-lymphatic invasion?
Use strict criteria- e.g. as in thyroid follicular neoplasms- Preferably peritumoral- Usually more than one focus
44
Page 45
TESTIS TUMOR –Rule 4
Are serum HCG or AFP levels increased? HCG: Syncytiotrophoblasts or
choriocarcinomaAFP: Yolk sac tumor
• DETERMINES SAMPLING
- more extensive & from different appearing areas
- ? entire tumor (in case of pure seminoma and elevated AFP levels)
• MAY INFLUENCE TYPE OF THERAPY
45
Page 46
IHC IN GERM CELL TUMORS - RULE 5
• ITGCN: c- kit, Oct3/4, PLAP, Podoplanin
• Seminoma: c –kit, Oct3/4, Podoplanin
• E Ca: CD-30 (Ber H2), Keratin, Oct3/4
• YST: AFP, Keratin, Glypican 3
• CC: βHCG, HPLCytokeratin AE1/AE3: E Ca, YST, T, CCOct 3/4: Seminoma, E Ca PLAP: Minimal / no value – except in ITGCN
SEM
YST
AFP
OCT3
DIFFUSE EMBRYOMA
46
Page 47
CD30 (Ber H2)
AFP
DIFFUSE EMBRYOMA
GERM CELL TUMOR – Rule 6
• Sample liberally, # cms of size of tumor + 2-3 sections – confirm “pure” histology
• Check AFP, HCG levels
• Check for ITGCN (rule out Sertoli cell tumor & other mimics)
Pure seminoma is a diagnosis of exclusion
GERM CELL TUMORS – RULE 6
• Differential diagnosis• Seminoma with glandular architecture• Seminoma with atypia• Seminoma cells obscured• Absence of mass lesion – exclusive
intertubular growth
Know problems associated with seminoma diagnosis
47
Page 48
CLASSIC SEMINOMA
• Spermatocytic seminoma-Older males-Polymorphic cellular population- Oct 4, Podoplanin (-)
• Sertoli cell tumors: Particularly malignant-Similarity
-Nested, sheet-like growth, occasional hollow tubul es-May have stromal fibrosis and inflammation-Clear cells
-Helpful-Nuclei less pleomorphic; mitoses rare-ITGCN absent-Keratin (+), inhibin, melan-A, calretinin (+)
Differential diagnosis
SERTOLI CELL TUMOR – Solid pattern
48
Page 49
SERTOLI CELL TUMOR – Solid pattern
MALIGNANT SERTOLI CELL TUMOR
49
Page 51
MALIGNANT SERTOLI CELL TUMOR
MALIGNANT SERTOLI CELL TUMOR
SERTOLI CELL TUMORSEMINOMA
51
Page 52
Keratin AE1/AE3MALIGNANT SERTOLI CELL TUMOR
SEMINOMA WITH “GLANDULAR ARCHITECTURE”
• Seminoma involving rete testis• “Tubular”seminoma• Seminoma with “early
carcinomatous transformation”
52
Page 53
PAGETOID INVOL. OF RETE TESTIS
CKIT
TUBULAR SEMINOMA
53
Page 54
TUBULAR SEMINOMA
TUBULAR SEMINOMA
TUBULAR SEMINOMA
54
Page 55
TUBULAR SEMINOMA
TUBULAR SEMINOMA
55
Page 56
SEMINOMA WITH ATYPIA
• Poor fixation and processing – commonest cause• Seminoma with increased mitoses and atypia
• “Anaplastic seminoma”• D/D embryonal ca , YST, lymphoma , Sex cord tumor
• Serum with early carcinomatous transformation• Criteria: Strong keratin or true gland formation• Significance: Depends on institution; some may
treat as non-seminoma
POORLY FIXED SEMINOMA
56
Page 57
POORLY FIXED SEMINOMA
57
Page 58
POORLY FIXED SEMINOMA
POORLY FIXED SEMINOMA
POORLY FIXED SEMINOMA
58
Page 59
OCT 3/4
Solid Emb. Ca Solid YST
Glandular Emb. Ca Glandular YST
59
Page 60
SEMINOMA WITH ECD
STRONG AND DISTINCT KERATIN EXPRESSION
60
Page 61
STRONG AND DISTINCT KERATIN EXPRESSION
AE1/AE3
SEMINOMA CELLS OBSCURED
• Crush artifact• Fibrotic areas• Inflammation, granulomas• Regression
• Cells obscured within inflammationAssociated ITGCN helpful
61
Page 62
Coagulative tumor cell necrosis
62
Page 63
RegressedGerm cell tumor
Intratubular germ cell neoplasia, unclassified
63
Page 64
Intertubular growth pattern of seminoma
Intratubular embryonal carcinoma
Lymphoplasmacytic infiltrate
64
Page 65
Testicular scar
Vascularized scar
Intratubular microlith
65
Page 66
Coarse intratubular calcifications
SEMINOMA WITH ABSENCE OF MASS LESION
• “Interstitial seminoma”- Seminoma obscured by hyperplastic Leydig cells
• ITGCN with focal invasive seminoma
INTERSTITIAL PATTERN OF SEMINOMA
66
Page 67
INTERSTITIAL PATTERN OF SEMINOMA
SEMINOMA CELLS COLONIZING LEYDIG CELLS
67
Page 68
TERATOMA: WHAT REALLY MATTERS? - Rule 7
Mature:- Normal/adult type/organoid elements
Immature:- Embryonic/fetal/undifferentiated/primitive
Age of the patient:- Adult: Malignant, irrespective of maturity- Pediatric: Favorable outcome, in spite of
marked immaturity
SECONDARY MALIGNANCY IN TERATOMA - Rule 8
“Teratoma with malignant transformation”•Rhabdomyosarcoma, PNET, Wilms’, etc.•Squamous cell ca, adenocarcinoma, etc.
Criteria:•“Overgrowth”: 1/2 to entire, 4X objective
Significance:•Primary tumor: No known impact•Secondary tumor: Recurrence, “resistance” to chemotherapy, aggressive course
GERM CELL TUMOR – Rule 9What really matters?•Seminoma
- Pathologic stage- Size- >99% of stage I, IIA, IIB eventually cured
•Mixed germ cell tumor- >80% embryonal carcinoma ( ↓)- >50% teratoma ( ↑)-Advanced tumors: size and number of
metastases
68
Page 69
GERM CELL TUMOR
• Pathologic stage
• Vascular-lymphatic invasion (pT 2 stage)
• Pure or >80% embryonal carcinoma histology – adverse
• >50% mature teratoma – favorable
• Cord margin status
• Tumor size
Histopathologic prognostic factors –primary tumor
GERM CELL TUMOR – Rule 10
•Necrosis, foam cells, fibrosis- Often present- No significance
•Any tumor – S, E Ca, YST, CC, immature teratoma
- Chemotherapy- Hence sample all tissue
•Residual mature teratoma - Controversial
Post-therapy: What really matters?
69
Page 70
GERM CELL TUMOR
• Number of positive lymph nodes
• Size of positive lymph nodes
• Presence of embryonal carcinoma, yolk sac tumor, choriocarcinoma, seminoma
• Presence of somatic malignancy (sarcoma, carcinoma, etc.)
Histopathologic prognostic factors –RPLND specimen
Metastatic colorectal cancer to testis
70
Page 71
CDX2
METASTATIC TUMORS TO TESTIS
Malignant MELANOMA-
the big mimic !
METASTATIC TUMORS – D.DX
MELANOMARENAL CELL CASEMINOMA
71