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Presented by Jonathan Epstein, M.D. and prepared by Wang (Steve) Cheung, M.D., Ph.D.
Case 5: A 20 year old male was noted to have a testicular mass and underwent orchiectomy.
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Week 311: Case 5
A 20 year old male was noted to have a testicular mass and underwent orchiectomy.
Answer: Choriocarcinoma and Teratoma
Histology: Some of the tumor is characterized by tubules lined by cuboidal epithelium as well as epithelium with columnar cells showing subnuclear vacuoles. Elsewhere there are areas of necrosis and hemorrhage surrounded by very pleomorphic cells. In areas a dimorphic population may be recognized consisting of multinucleated cells with abundant amphophilic cytoplasm and very pleomorphic nuclei adjacent to cells with smaller yet still recognizably malignant nuclei with slightly grayer cytoplasm.
Discussion: This case is a nice example of choriocarcinoma in a malignant mixed germ cell tumor. It is relatively rare to see choriocarcinoma as a component of a mixed germ cell tumor. More frequently, one can see scattered syncytiotrophoblastic giant cells in a setting of seminoma or less frequently embryonal carcinoma or teratoma. The distinction between isolated syncytiotrophoblastic giant cells and choriocarcinoma is the presence of cytotrophoblasts in choriocarcinoma. In cases with only isolated syncytiotrophoblastic giant cells the giant cells tend to cluster around blood lakes and dilated blood vessels further mimicking choriocarcinoma. However in choriocarcinoma one tends to see not only tumor surrounding areas of hemorrhage but areas of frank necrosis as well. Although pathologists tend to worry about missing small foci of choriocarcinoma in a malignant mixed germ cell tumor, this is not a critical issue in terms of treatment or prognosis. In a non seminomatous germ cell tumor, the prognosis is based more on serum markers than on the histological findings. This includes levels of alpha fetoprotein, HCG, and LDH. In addition whether there are non-pulmonary visceral metastases is also of prognostic significance. As it relates to trophoblastic cells, the presence of a HCG level less than 5000 IU/L is of good prognosis as compared to an intermediate prognosis with HCG levels between 5000 and 50,000 and a poor prognosis with HCG levels greater than 50,000. Consequently, cases with scattered syncytiotrophoblastic giant cells or even small foci of choriocarcinoma will typically have HCG levels of less than 5000 with a good prognosis regardless whether there is choriocarcinoma present or absent. In cases with a more significant choriocarcinoma component, there will be more markedly elevated HCG levels in the serum with a correspondingly worse prognosis.