Testicular Tumors Flashcards
testicular tumors - epidemiology
*most common tumor of young men
*one of the most curable of all cancers
*no clear etiology, but 10% have history of undescended testis
*bilateral in 2-3%
*>50% of patients present with metastatic disease
*“right goes left, but left stays left” (nodal spread)
*distant mets via blood to lung, liver, brain, bones, kidney
*10% present with epididymitis
testicular malignancies - classifications
-
germ cell tumors
a. seminoma
b. non seminomas (embryonal carcinoma, yolk sac tumor, choriocarcinoma, teratoma) - non-germ cell tumors
a. sex cord stromal tumors (sertoli cell tumors, leydig cell tumors)
b. secondary malignancies (lymphoma, metastases)
general considerations of testicular tumors
*typically present as a firm, painless mass (therefore, CANNOT BE TRANSILLUMINATED on physical exam)
*do NOT biopsy (risk of seeding the scrotum)
*typical age of incidence: 15-40 years
*general risk factors:
-cryptorchidism
-Klinefelter syndrome
-Down syndrome
-testicular dysgenesis syndrome
tumor marker: alpha fetoprotein (AFP)
*elevated in 50-70% of non-seminoma germ cell tumors (NSGCT)
*produced by embryonal carcinoma and yolk sac tumors
*NOT produced in pure choriocarcinoma or seminoma
*half-life of 4-6 days
tumor marker: human chorionic gonadotropin (hCG)
*elevated in all choriocarcinomas
*elevated in 40-60% of embryonal carcinoma
*elevated in 5-10% of seminomas
*half-life of 24 hrs
tumor marker: lactase dehydrogenase (LDH)
*non-specific tumor marker
*elevated in about half of the cases of testicular tumors
*attests to tumor burden
seminoma - overview
*most common germ cell testicular tumor
*originates in the germinal epithelium of the seminiferous tubules
*75% are confined to testis at presentation; 15% involve regional nodes; 10% with distant spread
seminoma - gross pathologic features
*well-demarcated, homogenous, pale mass
*no hemorrhage
*no necrosis
seminoma - microscopic pathologic features
*large cells, clear cytoplasm, central nuclei (“fried egg” appearance)
*placental alkaline phosphatase (PLAP) positive in up to 98% of seminomas
seminoma - 3 types
- classic seminoma (85%)
- anaplastic seminoma (10%) - more aggressive with higher metastatic potential
- spermatocytic seminoma (5%) - classically seen in OLDER patients
seminoma - clinical presentation
*painless testicular mass (some may present with testicular discomfort or swelling)
*mass CANNOT be transilluminated
*relatively slow growing
*mean age at presentation = 40 years
*6-10x higher incidence among white men
*increased PLAP
seminoma - tumor markers
*hCG produced in 5-10% of seminomas
*NO pure seminoma produces AFP
*increased placental alkaline phosphatase (PLAP)
seminoma - therapy considerations
*do NOT perform a biopsy
*discuss sperm banking
*radical inguinal orchiectomy (removal of testicle; confirms diagnosis & helps determine staging)
*management depends on stage
*good prognosis
*does respond to radiation therapy
embryonal carcinoma testicular tumor - overview
*a non-seminoma germ cell testicular cancer
embryonal cell testicular tumor - gross pathologic features
*hemorrhagic mass with necrosis
*usually smaller than seminomas (i.e. does not replace the entire testis)
embryonal cell testicular tumor - microscopic pathologic features
*immature, primitive cells (“embryo-like”) with prominent nucleoli and pleomorphic nuclei
*resemble undifferentiated stem cells
*may form glands
embryonal cell testicular tumor - clinical presentation
*painless testicular mass
*early hematogenous spread: retroperitoneum, lung, liver
*typically positive for placental alkaline phosphatase (PLAP)
embryonal cell testicular tumor - tumor markers
*may secrete alpha fetoprotein (AFP) or beta-hCG, but usually BOTH
embryonal cell testicular tumor - therapy considerations
*do NOT biopsy
*discuss sperm banking
*chemotherapy may lead to differentiation of tumor cell types (resulting in a new, more mature tumor type)
embryonal cell testicular tumor - prognosis
*determined by clinical stage
*aggressive tumors
*highest rate of lymphovascular invasion & extension into the paratesticular tissue
yolk sac testicular tumor - overview
*a non-seminoma germ cell testicular cancer
*most common testicular tumor in children < 3 years old
yolk sac testicular tumor - gross pathologic features
*solid gray-white tumor
*gelatinous surface
*hemorrhage, necrosis, and cystic changes often present
yolk sac testicular tumor - microscopic pathologic features
*classic histology = Schiller-Duval body
-a central vessel surrounded by tumor cells residing in a cystic space
-exhibits a glomerulus-like structure
-present in 50-75% of cases
*most common pattern is a microcytic pattern
yolk sac testicular tumor - clinical presentation
*painless testicular mass
*the most common testicular tumor during childhood (esp. < 3 years old)
*metastases often via hematogenous spread; most commonly spreads to the lungs
*often good prognosis
yolk sac testicular tumor - tumor marker
*alpha fetoprotein (AFP) is typically elevated
choriocarcinoma testicular tumor - overview
*a non-seminoma germ cell testicular cancer
*characterized by disordered syncitiotrophoblastic and cytotrophoblastic elements
choriocarcinoma testicular tumor - gross pathologic features
*hemorrhagic mass with necrosis
choriocarcinoma testicular tumor - microscopic pathologic features
*malignant tumor of syncytiotrophoblasts and cytotrophoblasts
*do NOT get villi (as you would have in placental tissue)
choriocarcinoma testicular tumor - clinical presentation
*painless testicular mass
*rapid hematogenous spread (is placenta-like tissue and “programmed” to find blood vessels)
*may secrete hCG → hyperthyroidism (TSH-like effects) and gynecomastia (LH- and FSH-like effects
*increased risk of brain metastases
*often involves retroperitoneal lymph nodes
*POOR PROGNOSIS due to rapid metastasis
choriocarcinoma testicular tumor - tumor markers
*high hCG ALWAYS present
-alpha subunit of hCG is similar to the alpha subunits of FSH/LH, so may cause gynecomastia and/or hyperthyroidism
*pure forms do NOT make AFP
teratoma testicular tumor - overview
*a non-seminoma germ cell testicular cancer
teratoma testicular tumor - gross pathologic features
*exhibits mature fetal tissue (teeth, hair, etc)
*lesions may be well-circumscribed
teratoma testicular tumor - microscopic pathologic features
*histology may reveal a variety of tissues (organized or unorganized presentation)
*composed of cells derived from at least 2 of the 3 embryonic germ layers (endoderm, mesoderm, ectoderm)
*“immature” teratomas have tissue not seen in adult tissue elements
teratoma testicular tumor - clinical presentation
*painless testicular mass
*MALIGNANT in males (benign in females) but prepubertal are benign and orchiectomy is curative
*prognosis depends on tumor stage
teratoma testicular tumor - tumor markers
*pure teratomas do NOT produce hCG or AFP
*some tumors, however, may be mixed
mixed germ cell tumors
*the majority of germ cell tumors are MIXED (e.g. embryonal carcinoma plus yolk sac tumor plus teratoma)
*combinations with SEMINOMAS are treated as non-seminoma germ-cell tumors (chemotherapy)
*prognosis - based upon the tumor component with the worst prognosis
sex cord stromal tumors - overview
*comprise ~5% of testicular tumors
*can be Leydig Cell tumors and Sertoli Cell tumors
*usually benign
*wide age range (14-87 yrs)
*no known risk factors
Leydig Cell tumor - overview
*a sex cord stromal tumor
*the most common sex cord stromal tumor
*more frequently presents in adults (40-50yrs) but can present at any age
Leydig Cell tumor - pathologic features
*gross: golden brown to yellow cut surface
*micro: Leydig cells with abundant pink cytoplasm and REINKE CRYSTALS (pink-staining rod-like cytoplasmic inclusions)
Leydig Cell tumor - clinical presentation
*painless testicular mass
*Leydig cells produce androgens and estrogen, so can result in precocious puberty (children) or gynecomastia (adults)
Leydig Cell tumor - management
*radical inguinal orchiectomy preferred
*prognosis dependent on tumor stage (most are benign)
Sertoli Cell tumor - overview
*a sex cord stromal tumor
*composed of the cells that line the seminiferous tubules
*can present at any age (avg. age = 45 yrs)
Sertoli Cell tumor - microscopic pathologic features
*tumor forms tubules
*uniform cuboidal or columnar cells with moderate pale or lightly pink cytoplasm
*often with prominent cytoplasmic lipid vacuoles
Sertoli Cell tumor - clinical presentation
*painless testicular mass
*rarely exhibit gynecomastia or precocious puberty
*may be seen in patients with:
-Peutz-Jeghers syndrome
-Carney syndrome
-androgen insensitivity syndrome
-testicular feminization syndrome
Sertoli Cell tumor - management
*radical inguinal orchiectomy
*prognosis based on tumor stage (only 10% are malignant)
lymphoma testicular cancer - overview
*a non-germ cell testicular cancer
*comprise 5% of all testicular tumors
*may be primary or secondary
lymphoma testicular cancer - microscopic pathologic features
*sheets of malignant lymphoid cells infiltrate between normal testicular structures
*most common = diffuse large B cell lymphoma
*others include: MALT lymphoma, follicular lymphoma, T cell lymphoma, Burkitt lymphoma (in children)
lymphoma testicular cancer - clinical presentation
*painless testicular mass
*most common cause of a testicular mass in older men over 60 yrs
*usually BILATERAL
*commonly also presents with B symptoms (fever, night sweats, weight loss)
*prognosis generally POOR
