Testis & paratestis

• Tumor originating from germ cells with more than one embryonic germ layer

• Ultrasound is used to help exclude benign pathology
• Imaging may demonstrate calcifications or predominantly cystic lesions
• Computed tomography of the chest and abdomen used for staging purposes

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• The International Germ Cell Consensus Classification guides prognosis and risk of recurrence for testicular germ cell malignancies (IGCCCG) (J Clin Oncol 1997;15:594, J Clin Oncol 2007;25:1033)
• Presence of teratoma is associated with better prognosis and therefore histologic recognition and documentation is required (Eur J Cancer 2001;37:576)
  • Germ cell tumors with > 50% teratoma have fewer metastases (J Clin Oncol 1988;6:1467)
  • Germ cell tumors with > 25% teratoma have less lymphovascular invasion (pT1) (Am J Clin Pathol 2016;145:341)

• Radical orchiectomy is first line therapy for testicular mass in an adult
• Increasing rate of testis sparing surgery for prepubertal tumors (Rev Urol 2004;6:11)
• Retroperitoneal lymph node dissection and platinum based chemotherapy are adjunctive therapies for testicular germ cell tumor
• Treatment guidelines are based on postorchiectomy TNM stage (NCCN guidelines: Testicular Cancer)
• Consider sperm preservation options

Contributed by Debra L. Zynger, M.D.

• Postpubertal type
  • Recognition is important as the percentage of teratoma must be documented in orchiectomy specimens and metastatic lesions
  • Demonstrate varying degrees of atypia
  • Any type of tissue may be present, such as gastrointestinal glands, respiratory epithelium, cartilage, squamous epithelium with keratinization, primitive undifferentiated spindle cells, or neuroepithelium
  • Will have GCNIS (Med Surg Urol 2014;3:1)
  • Associated with atrophic testis with sclerosis and microliths (Ulbright: Atlas of Tumor Pathology, 4th Series - Tumors of the Testis and Adjacent Structures, First Edition, 2013)
• Prepubertal type
  • More likely to have tissue arrangements mimicking organs (organoid morphology with tissue layers visible such as epithelium, lamina propria and muscularis propria) but any tissue type may be present (Moch: WHO Classification of Tumours of the Urinary System and Male Genital Organs (IARC WHO Classification of Tumours), Fourth Edition, 2016)
  • Hair follicles may be seen (not in postpubertal type)
  • No cytologic atypia, GCNIS or necrosis; minimal mitoses (Ulbright: Atlas of Tumor Pathology, 4th Series - Tumors of the Testis and Adjacent Structures, First Edition, 2013)
• Teratoma with somatic type malignancy
  • Sarcoma is most prevalent somatic type malignancy but other tumor types occur, including adenocarcinoma, squamous cell carcinoma and primitive neuroectodermal tumor (PNET) (Moch: WHO Classification of Tumours of the Urinary System and Male Genital Organs (IARC WHO Classification of Tumours), Fourth Edition, 2016, J Urol 1998;159:133, Ulbright: Atlas of Tumor Pathology, 4th Series - Tumors of the Testis and Adjacent Structures, First Edition, 2013)

Contributed by Debra L. Zynger, M.D.

A 27 year old man presents with a painless enlarging testicular mass. He undergoes appropriate workup and orchiectomy confirms diagnosis of a pure postpubertal teratoma. Which of the following is likely to be true?

1. AFP is likely elevated
2. Cytogenetic analysis will reveal chromosomal abnormalities
3. Few mitotic figures will be identified microscopically
4. Hair follicles are likely to be seen microscopically
5. He has a poor prognosis

B. Cytogenetic analysis will reveal chromosomal abnormalities

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Reference: Teratoma

A 37 year old woman gives birth to a male baby who is diagnosed with an undescended testicle. Further workup reveals a large intra abdominal mass, which is resected. Pathology is consistent with a pure teratoma. Which of the following is most likely present on microscopic examination?

1. Adjacent areas of germ cell neoplasia in situ
2. Areas with organoid morphology
3. Many mitotic figures and cytologic atypia
4. Sarcomatous elements
5. Significant areas of testicular tubular atrophy

B. Areas with organoid morphology

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Reference: Teratoma