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Presented by Jonathan Epstein, M.D. and prepared by Hillary Ross, M.D.
Case 6: A 23 year old male had a history of embryonal carcinoma on the right testis.
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Week 409: Case 6
A 23 year old male had a history of embryonal carcinoma on the right testis. The left testis on follow-up showed a radiologic abnormality and a left testicular biopsy was performed.images/1alex/09282009case6image1.jpg
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images/1alex/09282009case6image3.jpgCorrect
Answer: Intratubular germ cell neoplasia
Histology: Approximately 40% of the seminiferous tubules are histologically unremarkable with adequate spermatogenesis. The remaining tubules show a lack of spermatogenesis. The tubules are lined along the basement membrane by cells with abundant clear cytoplasm. In many of the nuclei it is difficult to appreciate cytologic features yet in others the nuclei are enlarged with prominent red nucleoli. The submitted stain for PLAP shows strong membranous staining within the atypical cells lining the seminiferous tubules lacking spermatogenesis.
Discussion: In some cases it may be difficult to diagnosis intratubular germ cell neoplasia and to separate them out from Sertoli cells. In contrast to the small nucleoli seen within Sertoli cells, intratubular germ cell neoplasia has cells with similar cytology to those of seminoma. Intratubular embryonal carcinoma typically does not consist of merely a single cell layer along the basement membrane but is composed of solid nests within tubules having significant pleomorphism often with very eosinophilic necrosis. In cases where there is a need for verification of the diagnosis of intratubular germ cell neoplasia, stains for PLAP, as done in this case, c-kit, or OCT4 may be performed which will label the neoplastic germ cells. I have seen cases where
c-kit has not been entirely specific for germ cell neoplasia such that I prefer either PLAP or OCT4. Approximately 5% of the testes contralateral to a germ cell tumor contain intratubular germ cell neoplasia as seen in the current case. In this country, routine biopsy of the contralateral testis looking for intratubular germ cell neoplasia is typically not performed. Rather, the testis is followed closely and if a tumor arises, it is typically diagnosed early and associated with a good prognosis. If the intratubular germ cell neoplasia is identified, it is associated with approximately a 50% risk of progressing to invasive carcinoma over a 5 year period of time. Treatment is typically performed with radiation at a low enough dose that leydig cells are preserved yet the intratubular germ cell neoplasia is destroyed.Incorrect
Answer: Intratubular germ cell neoplasia
Histology: Approximately 40% of the seminiferous tubules are histologically unremarkable with adequate spermatogenesis. The remaining tubules show a lack of spermatogenesis. The tubules are lined along the basement membrane by cells with abundant clear cytoplasm. In many of the nuclei it is difficult to appreciate cytologic features yet in others the nuclei are enlarged with prominent red nucleoli. The submitted stain for PLAP shows strong membranous staining within the atypical cells lining the seminiferous tubules lacking spermatogenesis.
Discussion: In some cases it may be difficult to diagnosis intratubular germ cell neoplasia and to separate them out from Sertoli cells. In contrast to the small nucleoli seen within Sertoli cells, intratubular germ cell neoplasia has cells with similar cytology to those of seminoma. Intratubular embryonal carcinoma typically does not consist of merely a single cell layer along the basement membrane but is composed of solid nests within tubules having significant pleomorphism often with very eosinophilic necrosis. In cases where there is a need for verification of the diagnosis of intratubular germ cell neoplasia, stains for PLAP, as done in this case, c-kit, or OCT4 may be performed which will label the neoplastic germ cells. I have seen cases where
c-kit has not been entirely specific for germ cell neoplasia such that I prefer either PLAP or OCT4. Approximately 5% of the testes contralateral to a germ cell tumor contain intratubular germ cell neoplasia as seen in the current case. In this country, routine biopsy of the contralateral testis looking for intratubular germ cell neoplasia is typically not performed. Rather, the testis is followed closely and if a tumor arises, it is typically diagnosed early and associated with a good prognosis. If the intratubular germ cell neoplasia is identified, it is associated with approximately a 50% risk of progressing to invasive carcinoma over a 5 year period of time. Treatment is typically performed with radiation at a low enough dose that leydig cells are preserved yet the intratubular germ cell neoplasia is destroyed.
