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Presented by Dr. Epstein and prepared by Dr. J. David Peske.
A 45 year old man presented with a 3 cm testicular mass and an orchiectomy was performed.
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Clinical History: A 45 year old man presented with a 3 cm testicular mass and an orchiectomy was performed. At our institution, an extensive study was performed which was negative for multiple keratins, STAT6, desmin, and myogenin. FISH showed no evidence of X:18 translocation. SF-1, inhibin, and ER were diffusely positive.
Choose the correct diagnosis:
Correct
Histological Description: There was predominantly extratesticular tumor but it also had an intratesticular component. Microscopically, it was composed of a mixed storiform and short fascicular growth pattern. The lesion was very hypercellular with focal areas of a looser background. Nuclei were either plump-ovoid or spindled with small central nucleoli. Nuclear pleomorphism was absent. Mitotic figures were not frequent but readily identifiable. At our institution, an immunohistochemical stain for SF-1 was performed.
Answer: C
Discussion: Paratesticular synovial sarcoma and SFT exceedingly rarely affect the paratesticular region. Paratesticular embryonal rhabdomyosarcoma is the most common paratesticular tumor in childhood but would be uncommon in an older age group. The microscopic appearance of the tumor in this case is typical of fibrothecoma of the testis in that it is composed of a mixture of either storiform pattern and/or short fascicles. One half of the testicular fibrothecomas are very hypercellular. Cases are equally split between having plumper ovoid as opposed to spindled pointed nuclei, with all cases lacking prominent nucleoli. In the largest study to date, 11 testicular fibrothecomas had 0 to 2 mitoses per 10 HPF, 3 had 4 to 5 mitoses per 10 HPF, and 2 had 9 to 10 mitoses per 10 HPF. Collagen deposition either in bands or investing single cells ranged from none to extensive. The average size was 1.8 cm but ranged up to 7.6 cm. Given that some testicular fibrothecomas can be large, hypercellular, with increased mitotic activity, they can be confused with a malignant spindle cell tumor. Despite some worrisome histologic features, they appear uniformly benign in their behavior. The current case was unique in that the majority of the tumor protruded outside of the testis where the differential diagnosis had to expand to include paratesticular tumors. Testicular fibrothecomas typically abut the tunica albuginea such that it is not totally unexpected that in a rare case the tumor could expand outward to mimic a paratesticular tumor.Incorrect
Histological Description: There was predominantly extratesticular tumor but it also had an intratesticular component. Microscopically, it was composed of a mixed storiform and short fascicular growth pattern. The lesion was very hypercellular with focal areas of a looser background. Nuclei were either plump-ovoid or spindled with small central nucleoli. Nuclear pleomorphism was absent. Mitotic figures were not frequent but readily identifiable. At our institution, an immunohistochemical stain for SF-1 was performed.
Answer: C
Discussion: Paratesticular synovial sarcoma and SFT exceedingly rarely affect the paratesticular region. Paratesticular embryonal rhabdomyosarcoma is the most common paratesticular tumor in childhood but would be uncommon in an older age group. The microscopic appearance of the tumor in this case is typical of fibrothecoma of the testis in that it is composed of a mixture of either storiform pattern and/or short fascicles. One half of the testicular fibrothecomas are very hypercellular. Cases are equally split between having plumper ovoid as opposed to spindled pointed nuclei, with all cases lacking prominent nucleoli. In the largest study to date, 11 testicular fibrothecomas had 0 to 2 mitoses per 10 HPF, 3 had 4 to 5 mitoses per 10 HPF, and 2 had 9 to 10 mitoses per 10 HPF. Collagen deposition either in bands or investing single cells ranged from none to extensive. The average size was 1.8 cm but ranged up to 7.6 cm. Given that some testicular fibrothecomas can be large, hypercellular, with increased mitotic activity, they can be confused with a malignant spindle cell tumor. Despite some worrisome histologic features, they appear uniformly benign in their behavior. The current case was unique in that the majority of the tumor protruded outside of the testis where the differential diagnosis had to expand to include paratesticular tumors. Testicular fibrothecomas typically abut the tunica albuginea such that it is not totally unexpected that in a rare case the tumor could expand outward to mimic a paratesticular tumor.
