Genitourinary Pathology
Contributed by Jacob Jerome, MD and Sheldon Bastacky, MD
Clinical History
A male in his 20s presented with low back and left testicular pain. On physical exam, his left testicle was markedly enlarged and a discrete mass was palpated. CT of the abdomen and pelvis demonstrated a 19 cm left testicular mass, 14 cm conglomerate retroperitoneal lymphadenopathy with obstruction of the left ureter, and bilateral basilar pulmonary metastases. At this time, his serum lactate dehydrogenase (LDH) was 741 IU/L, alpha-fetoprotein (AFP) was 31,861 ng/mL, and β-human chorionic gonadotropin (β-hCG) was 29,789 mIU/mL.
Gross Examination
The left radical orchiectomy specimen measured 19.8 x 9.2 x 8.9 cm (Figure 1A), with the mass measuring 19.6 x 9.2 x 8.9 cm and grossly appearing to involve the epididymis, rete testis, spermatic cord, and paratesticular soft tissue. The cut surface of the mass (Figure 1B) was heterogenous and variegated with areas that were tan-white and rubbery, brown and necrotic, cystic, myxoid, and hemorrhagic.
Microscopic Examination
The tumor was heterogenous with multiple components. The majority of the tumor (approximately 85%) was composed of clear to palely eosinophilic tumor cells with vacuolated cytoplasm and mild nuclear atypia in a predominantly microcystic and reticular growth pattern (Figure 2A). Scattered endodermal sinus growth pattern demonstrating Schiller-Duval bodies was also present (Figure 2B). This tumor component was also present as a discrete nodule adjacent to the proximal spermatic cord, representing either a tumor-replaced lymph node or soft tissue metastasis. This portion of the tumor was positive for AE1/AE3 (Figure 2C), AFP (Figure 2D), and glypican-3 (Figure 2E), and negative for CD30 (Figure 2F), and OCT3/4 (Figure 2G). The second largest component (approximately 10%) was composed of large, pleomorphic tumor cells with amphophilic cytoplasm, coarse chromatin, scattered prominent nucleoli, frequent mitoses, and frequent necrosis in a predominantly solid growth pattern (Figure 2H). This portion of tumor was positive for AE1/AE3 (Figure I) and CD30 (Figure 2J), and negative for AFP (Figure 2K) and glypican-3 (Figure 2L). A small portion of the tumor (<5%) had a biphasic appearance and was composed predominantly of mononuclear cells with clear-to-palely eosinophilic cytoplasm, vesicular nuclei, and prominent nucleoli with a much smaller population of large multinucleated cells with dense, smudgy chromatin and abundant dense eosinophilic cytoplasm (Figure 2M). This area was also associated with frequent necrosis. These tumor cells were positive for AE1/AE3 (Figure 2N) and β-hCG (Figure 2O), and negative for CD30 (Figure 2P), AFP (Figure 2Q), and glypican-3 (Figure 2R). The last small portion of the tumor (<5%) was composed of heterologous somatic elements, including mature glandular structures, and a primitive, cellular stroma (not shown). Background germ cell neoplasia in situ (GCNIS) was present, along with multifocal lymphovascular invasion. The tumor also extended into the testicular hilar soft tissue and spermatic cord, and the spermatic cord resection margin was positive.
