Tubular seminoma of the testis

An overview of testicular germ cell tumors

CONTEXT

More than 90% of testicular neoplasms originate from germ cells. Testicular germ cell tumors (GCTs) are a heterogeneous group of neoplasms with diverse histopathology and clinical behavior.

OBJECTIVE

To help the readers distinguish various subtypes of GCTs, to highlight the clinical manifestations and pathologic features of these tumors, and to review several newly developed immunohistochemical markers for GCTs.

DATA SOURCES

Review of the pertinent literature and our experience.

CONCLUSIONS

The etiology of GCTs is largely unknown. Cytogenetic studies suggest a different pathogenesis for each group of infantile/prepubertal GCTs, postpubertal GCTs, and spermatocytic seminoma. Unclassified intratubular germ cell neoplasia is the precursor of all GCTs, excluding spermatocytic seminoma and infantile/prepubertal GCTs. Seminoma, the most common GCT in adults, does not occur before 5 years of age. Spermatocytic seminoma, a tumor of elderly men, typically has an indolent clinical behavior, but rarely it undergoes sarcomatous transformation associated with an aggressive behavior. Embryonal carcinoma is the most common component in mixed GCTs. Eighty percent or more of embryonal carcinoma component and vascular invasion are recognized predictors of occult metastasis for clinical stage I mixed GCTs. Most patients with prepubertal yolk sac tumor, the most common pediatric GCT, have stage I disease at presentation. Most choriocarcinomas present with metastatic symptoms because of the propensity for rapid hematogenous dissemination. Teratomas in children regardless of maturity and dermoid cysts in adults are benign; in contrast, teratomas in adults have a malignant behavior. With appropriate therapy, the majority of testicular GCTs are curable.

From carcinoma in situ to testicular germ cell tumour

The mechanisms of invasive tumour development from pre-invasive CIS are unknown. We examined changes in functional parameters of the tubular wall according to the increase in CIS cells and tubular size. Immunohistochemistry was performed on 37 testicular specimens from 25 patients with carcinoma in situ and/or malignant germ cell tumour for the detection of actin/myosin in myocytes, and laminin/integrin alpha 6 in the basement membrane of seminiferous tubules. Tumour cells were detected by PlAP, Sertoli cells by inhibin alpha and vimentin and by cytokeratin 18/connexin 26 immunoreactivity, which is selectively expressed together with CIS. Areas showing clusters of tumour cells surrounded by a fibrous sheet could be identified as enlarged tubules because of focal Sertoli cell-specific co-expression of inhibin alpha, vimentin, cytokeratin 18, and connexin 26 immunoreaction. These clusters exhibited an intact basement membrane shown by a persistent laminin/integrin alpha 6 immunoreactivity, but myocytes had lost their contractility indicated by the loss of myosin/actin immunoreactivity. They often showed septa originating from the fibrous sheet containing numerous capillaries. Focal areas of syncytiotrophoblastic cells within classical seminoma also expressing inhibin alpha, cytokeratin 18, and connexin 26 could be differentiated from single Sertoli cells within tumor cell clusters by typical hCG but absence of vimentin immunoreactivity. In contrast to the current concept of CIS cells passing the tubular wall, these data provide evidence for an additional theory, i.e. that the switch from pre-invasive CIS to invasive tumour takes place in situ by tubular enlargement due to tumour cell proliferation followed by Sertoli cell degeneration and conversion of the tubular wall into connective tissue.