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Presented by Dr. Jonathan Epstein and prepared by Dr. Jennifer Bynum
Case 3: A 52 year old man underwent an orchiectomy for a 1.2 cm testicular mass.
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1. Question
Week (624): Case 3
A 52 year old man underwent an orchiectomy for a 1.2 cm testicular mass.
Correct
Answer: Sertoli cell tumor of indeterminant malignant potential
Histology: The lesion in the testis is composed of nests and tubules which infiltrates between seminiferous tubules in the surrounding non-neoplastic testis. In areas the tumor cells demonstrate a spindled morphology. The nuclei are slightly variable in size and shape and have delicate euchromatin with a single small central nucleolus. Up to 7 mitoses per 10 HPF were identified. The lesion lacked necrosis and vascular invasion.
Discussion: In assessing a testicular neoplasm, one first considers could this be a germ cell tumor. After deciding that this lesion does not resemble any germ cell tumor, next one should evaluate whether it is consistent with a sex cord stromal tumor. The architecture in this case where tubules are formed lined by relatively bland cells with a central small nucleolus is consistent with Sertoli cell differentiation, recapitulating normal Sertoli cells. One could verify sex cord stromal differentiation with immunohistochemistry for inhibin and SF-1 with some cases also staining for calretinin, and synaptophysin. However, a minority of sex cord stromal tumors are negative for all these markers and must be diagnosed on the H&E morphology. Malignant Sertoli cell tumors are distinguished from benign tumors by lack of nuclear atypia, under 5 cm., less than 3 mitoses per 10HPF, no vascular invasion, more circumscribed, and lack of necrosis. In this case there is somewhat more atypia than benign lesions yet not overtly so. It has an elevated mitotic rate and is infiltrative. Given it has some but not a majority of atypical features it would be best considered as having borderline malignancy. Even if it was a malignant Sertoli cell tumor, there is no adjuvant therapy so either for malignant or borderline lesions patients are merely followed for the potential of metastatic disease, with a worse prognosis for malignant tumors.
Incorrect
Answer: Sertoli cell tumor of indeterminant malignant potential
Histology: The lesion in the testis is composed of nests and tubules which infiltrates between seminiferous tubules in the surrounding non-neoplastic testis. In areas the tumor cells demonstrate a spindled morphology. The nuclei are slightly variable in size and shape and have delicate euchromatin with a single small central nucleolus. Up to 7 mitoses per 10 HPF were identified. The lesion lacked necrosis and vascular invasion.
Discussion: In assessing a testicular neoplasm, one first considers could this be a germ cell tumor. After deciding that this lesion does not resemble any germ cell tumor, next one should evaluate whether it is consistent with a sex cord stromal tumor. The architecture in this case where tubules are formed lined by relatively bland cells with a central small nucleolus is consistent with Sertoli cell differentiation, recapitulating normal Sertoli cells. One could verify sex cord stromal differentiation with immunohistochemistry for inhibin and SF-1 with some cases also staining for calretinin, and synaptophysin. However, a minority of sex cord stromal tumors are negative for all these markers and must be diagnosed on the H&E morphology. Malignant Sertoli cell tumors are distinguished from benign tumors by lack of nuclear atypia, under 5 cm., less than 3 mitoses per 10HPF, no vascular invasion, more circumscribed, and lack of necrosis. In this case there is somewhat more atypia than benign lesions yet not overtly so. It has an elevated mitotic rate and is infiltrative. Given it has some but not a majority of atypical features it would be best considered as having borderline malignancy. Even if it was a malignant Sertoli cell tumor, there is no adjuvant therapy so either for malignant or borderline lesions patients are merely followed for the potential of metastatic disease, with a worse prognosis for malignant tumors.
