A distinctive gonadal neoplasm related to gonadoblastoma

Mixed germ cell-sex cord stromal tumour of the testis and ovary: comparison and contrast

Mixed germ cell-sex cord stromal tumours (MGC-SCSTs) of the testis and ovary differ significantly in their histological appearance, clinical behaviour, and molecular genetics. Until recently, the germ cells of testicular MGC-SCST were considered to be invariably histologically bland, whereas those from neoplasms that arise in the ovary have histological features characteristic of premalignancy. However, a recent histological and molecular genetic study demonstrated histological abnormalities and multiple chromosomal losses and gains in a small subset of testicular cases, thus providing the first evidence that testicular MGC-SCSTs can exceptionally show histological and molecular abnormalities. All cases of testicular MGC-SCST reported to date have been clinically benign, whereas ovarian examples are sometimes the precursor of a malignant germ cell neoplasm that can be clinically aggressive. Both genetic and epigenetic influences likely account for dissimilarities in these uncommon gonadal neoplasms.

Novel insights into the mixed germ cell-sex cord stromal tumor of the testis: detection of chromosomal aneuploidy and further morphological evidence supporting the neoplastic nature of the germ cell component

The existence of a true mixed germ cell-sex cord stromal tumor (MGSCT) of the testis remains controversial. Based on our experience with rare testicular tumors in this spectrum, we sought to perform a detailed clinicopathologic and molecular study of MGCSCT. Eight cases of testicular MGSCT were morphologically reviewed, screened for chromosomal aberrations (using array comparative genomic hybridization (aCGH) and low pass genomic sequencing), and analyzed by next generation sequencing (The Illumina TruSight Tumor 170). Immunohistochemistry for OCT3/4, Nanog, SALL4, DMRT1, and inhibin was performed on the cohort. Clinical data and follow-up were assessed by medical record review. All patients were karyotypically normal men aged 27-74 years (median 41). All tumors had a similar biphasic morphology characterized by various proportions of the sex cord component resembling granulosa cell tumor of adult type and the germ cell component cytomorphologically akin to spermatocytic tumor. Germ cells were haphazardly scattered throughout the tumor or arranged in larger groups, without tubular formation. In 4 cases, atypical mitoses were found within the germ cells. Additionally, in 2 cases there was invasion into the spermatic cord, adjacent hilar soft tissue and into the tumor capsule, which contained both tumor components. Immunohistochemically, focal nuclear expression of DMRT1 was found in the germ cell component in 7/7 analyzable tumors, while SALL4 was positive in 6 cases and negative in one case. All tumors were negative with OCT3/4 and Nanog. The sex cord stromal component had immunoreactivity for inhibin in 7/7 analyzable cases. Four of 8 cases were cytogenetically analyzable: 4/8 by low pass genomic sequencing and 2/8 by aCGH. The results of both methods correlated well, revealing mostly multiple chromosomal losses and gains. One case revealed loss of chromosome 21; 1 case had loss of chromosomes 21 and 22 and partial gain of 22; 1 case had loss of chromosomes 22 and Y, partial loss of X, and gain of chromosomes 20, 5, 8, 9, 12, and 13; and the remaining one gain of chromosomes 20, 3, 6, 8, 2x(9), 11, 2x(12), 13, 14, 18, and 19. Three cases were analyzable by NGS; clinically significant activating mutations of either FGFR3 or HRAS were not detected in any case. Follow-up was available for 4 patients (12, 24, 84, and 288 months) and was uneventful in all 4 cases. The identification of extratesticular invasion of both the germ cell and sex cord stromal components, the DMRT1 expression, and the presence of atypical mitoses in germ cells argue for the neoplastic nature of the germ cell component. The molecular genetic study revealing multiple chromosomal losses and gains in a subset of the cases provides the first evidence that molecular abnormalities occur in testicular MGSCT. Multiple chromosomal aneuploidies, namely, recurrent losses of chromosomes 21 and 22 and gains of 8, 9, 12, 13, and 20, indicate that the germ cell component might be related to the morphologically similar spermatocytic tumor, which is characterized by extensive aneuploidies including recurrent gains of chromosomes 9 and 20 and loss of chromosome 7. In summary, our data support that rare examples of true MGSCT of the testis do exist and they represent a distinct tumor entity with admixed adult-type granulosa cell tumor and spermatocytic tumor components.

Protein expression of the transcription factors DMRT1, TCLF5, and OCT4 in selected germ cell neoplasms of the testis

In the present study, we investigated protein expression of the transcription factors mammalian doublesex and mab-3 related transcription factor 1 (DMRT1), basic helix-loop-helix transcription factor-like 5 (TCLF5), and octamer-binding transcription factor 4 (OCT4) in normal human spermatogenesis, testicular mixed germ cell-sex cord stromal tumor (MGC-SCST), spermatocytic tumor, and seminoma. In normal human spermatogenesis, DMRT1 is expressed in the nuclei of spermatogonia but not in those of more mature germ cells. By way of contrast, TCLF5 is expressed in the nuclei of some clusters of primary spermatocytes that have entered meiosis 1, in secondary spermatocytes, and in round (early) spermatids in the seminiferous tubules of adults during the reproductive years. OCT4 is expressed in primordial germ cells but not in the seminiferous tubules of the normal adult testis during the reproductive years. DMRT1 is expressed in the germ cells of both testicular MGC-SCST and spermatocytic tumor, whereas TCLF5 is not expressed in either neoplasm. These low-grade neoplasms, however, differ histologically in that all the germ cell nuclei of testicular MGC-SCST resemble spermatogonia, whereas in spermatocytic tumor, the nuclei of the medium-sized and large cells resemble those of primary spermatocytes. Both neoplasms lack expression of OCT4. By way of contrast, in seminoma, a fully malignant testicular germ cell tumor, the germ cell nuclei express OCT4 but do not express either DMRT1 or TCLF5.

Gonadoblastoma with Coexistent Features of Mixed Germ Cell-Sex Cord Stroma Tumor: A Case Report

Gonadoblastoma and mixed germ cell-sex cord stroma tumor have been widely recognized as two separate entities on the basis of both clinical and pathological features. The typical morphological pattern of both tumor types was found by us to coexist in the same gonadal tumor in a 14-year-old 46,XY phenotypically female subject who also had a contralateral dysgerminoma. A subserous implant showing the mixed germ cell-sex cord pattern of the primary tumor was detected in the uterine body. Following therapy the patient is alive and well after a 7-year follow-up. The distinction between gonadoblastoma and mixed germ cell-sex cord stroma tumor requires discussion.

Recent Advances in the Pathology and Classification of Gonadal Neoplasms Composed of Germ Cells and Sex Cord Derivatives

In recent years, our understanding of neoplasms composed of germ cells and sex cord derivatives has increased. In this review, advances in the classification and pathology of ovarian germ cell-sex cord-stromal tumors are discussed. Only 2 neoplasms, each with a distinctive pathogenesis and clinicopathologic features, are included in this category. Gonadoblastoma is a tumor that usually occurs in the dysgenetic gonads of intersex patients that have a Y chromosome, whereas mixed germ cell-sex cord-stromal tumor arises in normal gonads in patients without sex chromosomal abnormalities. Ovarian mixed germ cell-sex cord-stromal tumors differ from their testicular counterparts in their histological appearance, immunohistochemical staining reactions, and biological behavior probably because the latter show a greater degree of maturity of their germ cell component. The introduction of cisplatin-based chemotherapy and the application of tumor markers have dramatically improved the clinical outlook for those patients who develop secondary malignant germ cell neoplasms.

Mixed germ cell sex cord–stromal tumors of the testis and ovary. Morphological, immunohistochemical, and molecular genetic study of seven cases

We present the morphological, immunohistochemical, and molecular genetic features of three cases of testicular and four cases of ovarian mixed germ cell sex cord-stromal tumors (MGSCT). The germ cells in the testicular MGSCTs morphologically differed from those in classical seminomas by lacking the typical "square off" quality of the nuclei. In contrast to the nuclei in classical seminomas, their size in testicular MGSCTs was smaller and nucleoli were inconspicuous and the cytoplasm was Periodic Acid-Schiff (PAS) negative. Quite on the contrary, the variability in the size of the nuclei of the germ cells in the testicular MGSCTs was more similar to that seen in the germ cells of spermatocytic seminomas. Immunohistochemically, the germ cells of MGSCTs in one case reacted positively with antibody to AE1-AE3 by paranuclear dot-like or rodlike positivity. All three testicular MGSCTs had a negative reaction with the rest of antibodies, including placental alkaline phosphatase (PLAP), OCT4, and c-kit protein. Ovarian MGSCT in our series differed from the testicular lesions in both the germ cell component and the sex cord component. The germ cells in all four ovarian cases had cytomorphological and immunohistochemical features identical to those in classical seminomas/dysgerminomas. They possessed the typical "square off" quality of the nuclei, which were much more blastic, with more mitoses compared with the testicular tumors in our series, and they were PLAP (4/4), OCT4 (4/4) and c-kit protein (3/4) positive immunohistochemically. The cytoplasm of the germ cells in ovarian neoplasms contained PAS positive glycogen. Germ cells in one ovarian MGSCTs showed amplification of 12p. All other germ cells were negative for amplification of 12p. All five successfully analyzed cases showed no mutation in all studied exons and exon-intron junctions in c-kit and PDFGRA genes.

A clinicopathologic, histologic, and immunohistochemical study of mixed germ cell-stromal tumors of the testis in 16 dogs

In a review of 262 neoplasms in 225 dogs, 18 tumors in 16 dogs were mixed germ cell-stromal tumors containing intimately admixed germ cells and Sertoli cells in tubular structures of various sizes. Seven of the 18 neoplasms were predominantly composed of germ cells, and 11 were predominantly composed of Sertoli cells. In 15 neoplasms, the germ cells were more anaplastic than the Sertoli cells, and in three neoplasms, both cell types were anaplastic. Five of the seven mixed-cell tumors with predominantly germ cells had germ cells infiltrating the adjoining tissues. Immunocytochemical studies of all 18 mixed-cell tumors, testes from five clinically normal dogs, six seminomas, and six Sertoli cell tumors revealed that neuron specific enolase (NSE) and vimentin were useful in demonstrating the dual population of the mixed cell tumors by differential staining of the germ cells and Sertoli cells. Half of the tumors stained differentially with desmin. In the normal testes, seminomas, and Sertoli cell tumors, parallel staining of germ cells and Sertoli cells by NSE and vimentin was seen, but only the appropriate tissues stained with desmin. The mixed-cell tumors in this study had morphologic features in common with mixed germ cell-sex cord stromal tumors and gonadoblastomas of human beings; clinically, they had more in common with the former. These mixed cell tumors in dogs should be classified separately.

Non-germ cell tumors of testis

Testicular tumors of non-germ cell origin represent from 5 percent to 10 percent of all testicular neoplasms. Included in this group are sex cord/gonadal stromal tumors, most originating from Leydig or Sertoli cells, mixed tumors, and tumors of mesenchymal or hematopoietic origin. In addition, various miscellaneous lesions, tumor-like conditions, and secondary testicular tumors may be classified as non-germ cell tumors. This review covers the presentation, diagnosis, and treatment of these rare lesions.

Gonadoblastoma in an anatomically normal man: a case report and literature review

Gonadoblastoma, a rare gonadal neoplasm, presents most frequently in phenotypic female or phenotypically male patients with dysgenetic gonads or undescended testes. To date, only 2 cases of gonadoblastoma have been reported in anatomically normal male patients with scrotal testes. Both of these patients presented with testicular masses and germ cell tumors. We report a case of a genotypically and phenotypically normal, fertile man with descended testes who on evaluation for chronic orchialgia had a gonadoblastoma unaccompanied by a germ cell neoplasm. The tumor was nonpalpable and was initially discovered on scrotal ultrasound.

Hormone-producing tumors of the ovary

The ovary is an endocrine organ that gives rise to a wide variety of neoplastic and tumorlike nonneoplastic conditions, some of which are associated with endocrine activity. The hormones produced may be steroidal or nonsteroidal. The ovary is unique among endocrine organs in reacting to the presence of nonendocrine tumors within it by abnormal or inappropriate production of sex steroidal hormones. A classification of hormone-producing ovarian lesions is proposed based on the World Health Organization's histologicai typing of ovarian tumors.

Mixed germ cell-sex cord stroma tumor of the testis. A report with ultrastructural findings

The case of a 41-year-old man with testicular mixed germ cell-sex cord stroma tumor is reported. The patient noticed a gradual, painless, right-sided testicular enlargement 4 years before being treated by radical orchiectomy. The testis contained a centrally located tumor. There was no evidence of metastases. An histologic examination and an ultrastructural study showed that the tumor was composed of germ cells and sex cord derivatives; the typical features of mixed germ cell-sex cord stroma tumor were present. The patient is well and disease-free 2 years after the operation. Currently, none of the testicular tumors of this type has been associated with metastases or was overgrown by malignant germ cell tumors, and radical orchiectomy resulted in complete cure. The literature regarding this entity is reviewed, the differential diagnosis is discussed, and the importance of making the correct diagnosis is emphasized.

Ovarian Sertoli-Leydig cell tumor with elevated serum alpha-fetoprotein

An 18-year-old girl with virilization and an elevated level of serum alpha-fetoprotein (AFP) was found to have a Sertoli-Leydig cell tumor (SLCT) of the ovary. The tumor had a heterologous element of gastrointestinal type epithelium, retiform pattern, and multilocular cysts, many of which were lined by Sertoli-like cells. Alpha-fetoprotein was detected immunohistochemically in cells with the histologic appearance of Sertoli cells, and testosterone was detected in the Leydig cells. Results of lectin affinity chromatography indicated that AFP produced by this tumor was different from the AFP to be found in the liver.

Malignant mixed germ-cell-sex cord-stromal tumors of the ovary associated with isosexual precocious puberty

Two cases of hormonally active, metastasizing malignant mixed germ cell-sex cord-stromal tumors are described in otherwise normal prepubertal girls. Isosexual precocity was noted 5 months and 1 month before surgery. One child died 1 year after presentation, and the other was alive, with no apparent tumor, 1 year after diagnosis. These two cases represent the first recorded instance of a unique tumor in which metastases of several cell types were encountered.

Gonadoblastoma presenting as isosexual precocious puberty in a genetic female

A 6 1/2-year-old female with pseudoprecocious puberty was found to have a gonadoblastoma. Her karyotype was 46, XX; serum estradiol level was markedly elevated; and androgens were within the range of normal. The importance of the Y chromosome and dysgenetic gonad in the predisposition to development of a gonadoblastoma is reviewed. A further categorization of gonadoblastomas based on the presence or absence of the Y chromosome is suggested.

Coexistence of a gonadoblastoma and mixed germ cell-sex cord stroma tumor

A 46 XY woman with a dysgerminoma and gonadoblastoma is described. Both dysgerminoma-gonadoblastoma and mixed germ cell-sex cord stromal tissue was present upon microscopic examination. This case exemplifies the transition that can exist between these two distinctly separate tumors.

Simultaneous occurrence of a granulosa cell tumour and a serous papillary cystadenocarcinoma in the same ovary. A case report

This report describes a previously unreported collision of a papillary serous cystadenocarcinoma and a granulosa cell tumour with a sarcomatoid growth pattern in the same ovary of a seventy-five year old woman with no endocrinological abnormality. The patient died from widespread dissemination of the adenocarcinoma.

Ovarian sex cord tumor with annular tubules: review of 74 cases including 27 with Peutz-Jeghers syndrome and four with adenoma malignum of the cervix

The sex cord tumor with annular tubules (SCTAT) is a distinctive ovarian neoplasm the predominant component of which has morphologic features intermediate between those of the granulosa cell tumor and those of the Sertoli cell tumor; focal differentiation into either granulosa cell or Sertoli cell tumor may occur. Of the 74 cases that form the basis of this investigation 27 were associated with the Peutz-Jeghers syndrome; these tumors were all benign and were typically multifocal, bilateral, very small or even microscopical in size and calcified. Twelve of the 27 patients had symptoms suggestive of hyperestrinism attributable to the SCTAT; menstrual irregularity had occurred in eleven cases and postmenopausal bleeding in one. Four of the 27 patients had "adenoma malignum" of the cervix and two of them died of it. The 47 tumors from patients without evidence of the Peutz-Jeghers syndrome were unilateral and usually large. Twenty-five of them were accompanied by symptoms suggestive of hyperestrinism, such as menstrual irregularity, postmenopausal bleeding or sexual precocity; seven were malignant and four of these were fatal.

Mixed germ cell-sex cord stroma tumor of the ovary associated with isosexual precocious puberty in a normal girl

A case of mixed germ cell-sex cord stroma tumor occurring in a normal 8-year-old girl with 46XX karyotype is reported. The child presented with evidence of isosexual precocious puberty 3 years prior to the excision of the tumor. Although the tumor was known to be present at least 2 years prior to its excision and weighed more than 1 kg, there was no evidence of involvement of the adjacent organs or metastases at the time of excision. The contralateral ovary was normal. The endocrine activity abated following the excision of the tumor and the patient is well and free of disease 2 years after the operation. The literature concerning this entity is discussed and reviewed.

Gonadoblastoma: ultrastructural evidence for testicular origin

A gonadoblastoma arising in the dysgenetic gonad of a virilized 17-year-old Caucasian with a female phenotype and with a 45,X0/46, X-ring-Y genotype was studied by light microscopic histochemistry, electron microscopy, and ultrastructural histochemistry. The gonadoblastoma was composed of nests of cells containg large germ cells and small "granulosa-Sertoli-like cells," and stromal tissue containing "Leydig-like cells." The germ cells were identical to those found in normal fetal gonads and in germ cell tumors. Charcot-Böttcher crystalloids present in the "granulosa-Sertoli-like cells" strongly suggest that they are, in fact, Sertoli cells. Multilayered basal laminae located in the periphery of the tumor nests and in "hyaline bodies" were identical to those surrounding the seminiferous tubules of the adult testis. The "Leydig-like cells" present in the stroma contained occasional dense bodies and crystalloids which characterize the Leydig cells of the fetal testis. Delta 5-3 beta hydroxysteroid dehydrogenase activity was demonstrated in the periphery of lipid droplets and lysosome-like dense bodies of the Leydig cells, and in some Sertoli cells. The findings support the theory that gonadoblastoma arises in a dysgenetic testis rather than in a dysgenetic ovary.