Testis & paratestis
Germ cell tumors
Seminoma
Author: Michelle R. Downes, M.D.
Editor-in-Chief: Debra L. Zynger, M.D.
Last author update: 7 January 2020
Last staff update: 4 August 2023
Copyright: 2012-2024, PathologyOutlines.com, Inc.
PubMed Search: Seminoma testis
Table of Contents
Definition / general | Essential features | Terminology | ICD coding | Epidemiology | Sites | Pathophysiology | Etiology | Clinical features | Diagnosis | Laboratory | Radiology description | Radiology images | Prognostic factors | Case reports | Treatment | Gross description | Gross images | Frozen section description | Frozen section images | Microscopic (histologic) description | Microscopic (histologic) images | Cytology description | Cytology images | Positive stains | Negative stains | Molecular / cytogenetics description | Sample pathology report | Differential diagnosis | Board review style question #1 | Board review style answer #1 | Board review style question #2 | Board review style answer #2Cite this page: Downes M. Seminoma. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/testisseminomas.html. Accessed December 3rd, 2024.
Definition / general
- Most common type of testicular germ cell tumor (up to 50%) and may occur as component of mixed germ cell tumor
- Derived from transformed gonocytes
- Consists of cells with well defined borders, (usually) clear cytoplasm, round to polygonal nuclei and prominent nucleolus
Essential features
- Most frequent germ cell tumor of the testis
- Presents in young men (30 - 49) with unilateral palpable mass
- Typically a well demarcated, uniform neoplasm with characteristic cytological features and background of fibrous septae and lymphocytes
- Germ cell markers (OCT 3/4, CD117) are useful in the diagnosis
- Prognosis is stage dependent with excellent 5 year survival when clinical stage 1
Terminology
- Seminoma: testicular primary (or mediastinal primary)
- Dysgerminoma: same tumor but primary to the ovary
- Germinoma: same tumor but primary to extragonadal sites (such as pineal gland)
ICD coding
Epidemiology
- Male, age 30 - 49
- Rare in > 70 or < 20 years
Sites
- Testicle
Pathophysiology
- Arises from germ cell neoplasia in situ (GCNIS)
- GCNIS cells are proposed to arise from delayed maturation of primordial germ cells / gonocytes with polyploidization resulting in a transformed germ cell
- This progresses post puberty into seminoma (most likely GCNIS evolves into intratubular seminoma and then invasive seminoma) (J Urol 1996;155:1938)
Etiology
- Risk factors include: family history, previous germ cell tumor, cryptorchidism, subfertility, immunodeficiency disorders (Br J Urol 1989;64:78, J Urol 1996;155:1938)
Clinical features
- Usual presentation is with a mass
- < 5% present with metastatic symptoms
- Paraneoplastic symptoms are rare (limbic encephalopathy, hypercalcemia, polycythemia, exophthalmus) (BMJ Case Rep 2014;2014:bcr2014206893)
- Metastases are initially retroperitoneal and then progress to mediastinal and cervical nodes; visceral metastases develop late
Diagnosis
- Testicular ultrasound
- Serum LDH, AFP and hCG performed
- Chest Xray or CT of abdomen and chest (Cancer Treat Res 2018;175:273)
Laboratory
- Serum LDH and PLAP may be elevated
- hCG levels are increased in up to 20% of cases but elevation is modest (Pathol Annu 1991;26:59)
- AFP should not be increased, if elevated think liver disease or nonseminoma component
Radiology description
- Uniform, well delineated and hypoechoic mass on ultrasound
- May be microlithiasis
Radiology images
Images hosted on other servers:
Ultrasound with testicle mass
Parietal metastasis
Prognostic factors
- Clinical stage 1 has 95 - 98% 5 year survival
- > 40 years and advanced stage are poor prognostic features (nonpulmonary metastases)
Case reports
- 27 year old man with neoplastic meningitis from testicular seminoma (Oncologist 2018;23:1385)
- 30 year old man with hemoperitoneum from ruptures intra-abdominal testis (BMJ Case Rep 2018;2018:224898)
- 34 year old man with mediastinal seminoma presenting as a neck mass (Diagn Cytopathol 2019;47:334)
- 40 year old man with intra-abdominal seminoma arising in cryptorchid testis (J Med Case Rep 2019;13:2)
- 44 year old man with limbic encephalitis from metastatic “burned out” seminoma (Front Neurol 2018;9:20)
Treatment
- Surgery (radical orchiectomy) for primary
- Surveillance protocols used for stage 1 disease
- Radiation (very radiosensitive tumor) and chemotherapy (platinum based) used in higher stage disease
- Retroperitoneal lymph node dissection used for residual post chemotherapy disease (J Natl Compr Canc Netw 2012;10:502)
Gross description
- Well demarcated, homogeneous, solid cream or grey tumors; surface nodularity and lobulation; may be multiple nodules
- Necrosis or hemorrhage usually minimal
- If regressed, only a scar may be visible
- Usually confined to testis (90%)
Gross images
Contributed by Debra L. Zynger, M.D.
pT1a
pT1b
pT2
Images hosted on other servers:
Very large seminoma
Seminoma
Lobulated soft tan to brown tissue
Frozen section description
- Fibrous bands with lymphocytes and clear cells
- Intra-operative smear / touch prep preparation will show large cells with abundant cytoplasm and admixed lymphocytes; tigroid type pattern (dense and light stripes) in air dried Giemsa smear
Frozen section images
Contributed by Michelle Downes, M.D. and Debra L. Zynger, M.D.
Intraoperative frozen section
Pale, foamy cytoplasm
Microscopic (histologic) description
- Sheets or lobular configuration of tumor with fibrous septae
- Cells are typically pale (glycogen) but may be eosinophilic
- Cell membranes are well defined with distinct cell boundaries
- Nuclei are polygonal and may have a flat edge giving a squared off appearance; they contain one or more prominent central nucleoli; no nuclear overlap if well fixed tissue
- A lymphocytic infiltrate is present (T lymphocytes) with plasma cells; germinal centers may occur
- Granulomas noted in up to 50% of cases
- Intercellular edema with microcystic spaces and coagulative type necrosis can be present
- Multinucleated syncytiotrophoblasts can be seen in 20% of tumors and can produce hCG
- Intratubular seminoma may be adjacent to invasive seminoma (30% cases)
- Less frequent growth patterns include intertubular pattern (may not form a mass), corded growth, microcystic, tubular, signet ring appearance
- Anaplasia referring to increased mitoses and pleomorphism within a seminoma is no longer reported (no correlation with outcome) (J Urol 1996;155:1938)
- Fibrosis and sclerosis can indicate regressed or burnt out seminoma
- Lymphovascular invasion is uncommon, especially in tumors under 4 cm, and should be differentiated from artifactual carry over (Am J Clin Pathol 2016;145:341)
- Invasion of rete testis can be direct stromal invasion or pagetoid invasion; direct stromal invasion carries prognostic significance in seminoma (Am J Surg Pathol 2017;41:e22)
Microscopic (histologic) images
Contributed by Michelle Downes, M.D. and Debra L. Zynger, M.D.
Fibrous septae
Admixed lymphocytes
Large cells with clear cytoplasm
Coagulative necrosis
OCT 3/4
CD117
Granulomatous inflammation
Granuloma
Intratubular seminoma
Rete testis invasion
Rete testis pagetoid spread
Hilar fat invasion
Epididymal invasion
Syncytiotrophoblasts
hCG
Discontinuous spermatic cord invasion
Cytology description
- Discohesive population of large cells with moderate cytoplasm, round slightly irregular nuclei and one or more prominent nucleoli
- Background population of small, mature lymphocytes
- Classic “tigroid smear” seen mostly in hypercellular aspirates (J Cytol 2011;28:39)
Cytology images
Contributed by Michelle Downes, M.D. and Debra L. Zynger, M.D.
Intraoperative touch prep
Large cells with prominent nucleoli
Tigroid pattern
Negative stains
Molecular / cytogenetics description
- Isochromosome from the short arm of chromosome 12, i(12p) present
- KIT mutations (Cancer Res 2005;65:8085)
Sample pathology report
- Right testis, mass, radical orchiectomy:
- Seminoma, 3.6 cm (see synoptic report)
- Comment: Immunohistochemistry was performed and the tumor expresses OCT 3/4 and CD117. The cells are negative with CD30 and AFP. The immunoprofile supports the morphologic interpretation of seminoma.
Differential diagnosis
- Embryonal carcinoma, solid pattern:
- Significantly greater atypia with lack of distinct cell borders
- Nuclei overlap and increased mitotic activity
- May have additional growth patterns present
- CD30 and cytokeratin positive
- Spermatocytic tumor:
- Yolk sac, solid pattern:
- Usually some variability in growth patterns present
- Lacks distinct fibrous septae and abundant lymphocytes
- May have Schiller-Duval bodies and hyaline globules
- Glypican 3 and alpha-fetoprotein (AFP) positive
- Sertoli cell tumor:
- Lymphoma:
- Granulomatous orchitis:
Board review style question #1
- Which of the following stains is appropriate for differentiating between seminoma and embryonal carcinoma?
- AFP
- CD30
- hCG
- OCT 3/4
- SALL4
Board review style answer #1
Board review style question #2
- A 38 year old man presents with a unilateral, painless palpable mass in the left testis. His serum AFP and hCG are normal with mild LDH elevation. The histology of his orchiectomy specimen is shown. Where would be the most typical first site for metastasis?
- Bone
- Brain
- Groin nodes
- Lung
- Retroperitoneal nodes
Board review style answer #2
