Eble JN, Sauter G., Epstein JI, Sesterhenn IA - iarc

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senting symptom: back or abdominal pain, gastrointestinal problems, cough or dyspnoea. Gynecomastia may also be seen in about 5% of cases. Occasionally, extensive work ups have resulted without an adequate examination of the genitalia. Imaging Ultrasound (US) is the primary imaging modality for evaluating scrotal pathology. It is easily performed and has been shown to be nearly 100% sensitive for identifying scrotal masses. Intratesticular versus extratesticular pathology can be differentiated with 98-100% sensitivity {211,378,2194}. The normal testis has a homogeneous, medium level, granular echo texture. The epididymis is isoechoic to slightly hyperechoic compared to the testis. The head of the epididymis is approximately 10-12 mm in diameter and is best seen in the longitudinal plane, appearing as a slightly rounded or triangular structure on the superior pole of the testis. Visualization of the epididymis is often easier when a hydrocele is present. When evaluating a palpable mass by ultrasound, the primary goal is localization of the mass (intratesticular versus extratesticular) and further characterization of the lesion (cystic or solid). With rare exception, solid intratesticular masses should be considered malignant. While most extratesticular masses are benign, a thorough evaluation must be performed. If an extratesticular mass has any features suspicious of malignancy it must be removed. The sonographic appearance of testicular tumours reflects their gross morphology and underlying histology. Most tumours are hypoechoic compared to the surrounding parenchyma. Other tumours can be heterogeneous with areas of increased echogenecity, calcifications, and cyst formation {211,378,927,1007, 2194,2347}. Although larger tumours tend to be more vascular than smaller tumours, colour Doppler is not of particular use in tumour characterization but does confirm the mass is solid {1126}. Epididymal masses are more commonly benign. It can, however, be difficult to differentiate an epididymal mass from one originating in the spermatic cord or other paratesticular tissues. This is especially true in the region of the epididymal body and tail where normal structures can be difficult to visualize. Since ultrasound is easily performed, inexpensive, and highly accurate, magnetic resonance (MR) imaging is seldom needed for diagnostic purposes. MR imaging can, however, be a useful problem solving tool and is particularly helpful in better characterizing extratesticular solid masses {507,2362}. Computed tomography (CT) is not generally useful for differentiating scrotal pathology but is Table 4.02 Overview of the three different subgroups of testicular germ cell tumours, characterized by age at clinical presentation, histology of the tumour, clinical behaviour and genetic changes. Age of the patient at clinical presentation (years) Adolescents and young adults (i.p. 15-45) Elderly (i.p. over 50) Histology of the tumour 0-5 Teratoma and/or yolk sac tumour Seminoma Non-seminoma (embryonal carcinoma, teratoma, yolk sac tumour, choriocarcinoma) Spermatocytic Seminoma * found in all invasive TGCTs, regardless of histology. Clinical behaviour Benign Malignant Malignant Malignant Benign, although can be associated with sarcoma Chromosomal imbalances Not found Loss: 6q Gain: 1q , 20q, 22 Aneuploid, and Loss: 11, 13, 18, Y Gain: 12p*, 7, 8, X Gain: 9 the primary imaging modality used for tumour staging. Tumour markers There are two principal serum tumour markers, alpha fetoprotein (AFP) and the beta subunit of human chorionic gonadotropin (ßhCG). The former is seen in patients with yolk sac tumours and teratomas, while the latter may be seen in any patients whose tumours include syncytiotrophoblastic cells. AFP is normally synthesized by fetal yolk sac and also the liver and intestine. It is elevated in 50-70% of testicular germ cell tumours and has a serum half life of 4.5 days {305,1333}. hCG is secreted by placental trophoblastic cells. There are two subunits, alpha and beta, but it is the beta subunit with a half life of 24-36 hours that is elevated in 50% of patients with germ cell tumours. Patients with seminoma may have an elevation of this tumour marker in 10-25% of cases, and all those with choriocarcinoma have elevated ßhCG {1333}. If postorchiectomy levels do not decline as predicted by their half lives to appropriate levels residual disease should be suspected. Also a normal level of each marker does not necessarily imply the absence of disease. Lactate dehydrogenase (LDH) may also be elevated, and there is a direct relationship between LDH and tumour burden. However, this test is nonspecific although its degree of elevation correlates with bulk of disease. Tumour spread and staging The lymphatic vessels from the right testis drain into lymph nodes lateral, anterior, and medial to the vena cava. The left testis drains into lymph nodes distal, lateral and anterior to the aorta, above the level of the inferior mesenteric artery. These retroperitoneal nodes drain from the thoracic duct into the left supraclavicular lymph nodes and the subclavian vein. Somatic genetics Epidemiology, clinical behaviour, histology, and chromosomal constitution define three entities of germ cell tumours (GCTs) in the testis {1540,1541,1965}: teratomas and yolk sac tumours of neonates and infants, seminomas and non-seminomas of adolescents and young adults, the so called TGCTs, and the spermatocytic seminomas of elderly. Germ cell tumours 223
Similar tumours as those of group 1 and 2 can be found in the ovary and extragonadal sites, in particular along the midline of the body. Relatively little is known on the genomic changes of these GCTs. Supposedly the findings in the GCTs of the testis are also relevant for classification and understanding of the pathogenesis of ovarian and extragonadal GCTs. Genetic susceptibility (familial tumours) Familial testicular germ cell tumours of adolescents and adults (TGCTs), account for 1.5-2% of all germ cell tumours of adults. The familial risks of TGCTs increase 3.8-fold for fathers, 8.3 for brothers and 3.9 for sons indicating that genetic predisposition is a contributor to testicular cancer {532}. Earlier age of onset, a higher frequency of bilaterality and an increased severity of disease suggest that genetic anticipation is responsible for many father-son TGCTs {1014}. Recently, environmental and heritable causes of cancer have been analysed by structural equation modelling {532}. The estimate of proportion of cancer susceptibility due to genetic effects was 25% in adult TGCTs. The childhood shared environmental effects were also important in testicular cancer (17%). Numerous groups have attempted to identify candidate regions for a TGCT susceptibility gene or genes {1386,1457, 2148,2435}. No differences were detected between familial/bilateral and sporadic TGCT in chromosomal changes {2435}. However, a TGCT susceptibility gene on chromosome Xq27, that also predisposes to undescended testis, has been proposed by the International Testicular Cancer Linkage Consortium {2148}. Although the role of genetic factors in the etiology of TGCTs appears to be established, the existence of a single susceptibility gene is doubtful. Most probably genetic predisposition shared with intrauterine or childhood environmental Table 4.03 Tumour suppressor genes involved in the pathogenesis of testicular germ cell tumours (TGCTs). (Putative) Pathway Gene Chromosomal mapping Cell cycle control Cell survival/ Apoptosis Transcription Signaling Methylation Proteolysis Protein interaction Unknown CDKN2C CDKN1A CDKN2B CDKN2A CDKN1B RB1 CDKN2D BCL10 FHIT TP53 MXI1 WT1 APC MCC NME1,2 DCC SMAD4 1p32 6p21 9p21 9p21 12p12-13 13q14 19p13 1p22 3p14 17p13 10q24 11p13 5q21-22 5q21-22 17q23 18q21 18q21 RNF4 4p16.2 {2055} hH-Rev107 11q12-13 {2407} {175} {175} {1053} {417,1041,1053} {175} {2519} {176} {740,2703,2829} {1384} {1301} (for review) {2436} {1536} {2045} {2045} {161} {1856,2516} {299} DNMT2 10p15.1 {2436} Testisin KALK13 NES1/KLK10 16p13 19q13 19q13 Reference(s) {1116} {409} {1577} effects are involved in the molecular pathogenesis of TGCTs. Inter-sex individuals Persons with 46,XY or 45,X/46,XY gonadal dysgenesis are at very high risk of gonadal germ cell tumour. The absolute risk is reported to be as high as 10-50% {2267,2728}. Genomic imprinting Genomic imprinting refers to the unique phenomenon in mammals of the different functionality of a number of genes due to their parental origin. This difference is generated during passage through the germ cell lineage. The pattern of genomic imprinting has significant effects on the developmental potential of cells {2459}. TGCTs show a consistent biallelic expression of multiple imprinted genes {882,1537,1544,1742,1914,2129,2697,2 726} as do mouse embryonic germ cells {2548}. This suggests that biallelic expression of imprinted genes in TGCTs is not the result of loss of imprinting (LOI) but is intrinsic to the cell of origin. This could also explain the presence of telomerase activity in TGCTs, except in (mature) teratomas {53}. The teratomas and yolk sac tumours of infants show a slightly different pattern of genomic imprinting {2243,2334}, supporting the model that these tumours originate from an earlier stage of germ cell development than TGCTs. Although little is known about the pattern of genomic imprinting of spermatocytic seminomas {2726} the available data indicate that these tumours have already undergone paternal imprinting. Testicular germ cell tumours of adolescents and adults: Seminomas and non-seminomas Chromosomal constitution All TGCTs, including their precursor, intratubular germ cell neoplasia unclassified (IGCNU) are aneuploid [{567,676, 1962}, for review]. Seminoma and IGCNU cells are hypertriploid, while the tumour cells of non-seminoma, irrespective of their histological type are hypotriploid. This suggests that polyploidization is the initial event, leading to a tetraploid IGCNU, followed by net loss of chromosomal material {1962}. Aneuploidy of TGCTs has been related to the presence of centrosome amplification {1653}. 224 Tumours of the testis and paratesticular tissue
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World Health Organization Classific
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This volume was produced in collabo
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Contents 1 Tumours of the kidney 9
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CHAPTER 1 Tumours of the Kidney Can
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TNM classification of renal cell ca
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one quarter of kidney cancers in bo
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Familial renal cell carcinoma M.J.
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Table 1.02 Genotype - phenotype cor
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A B Fig. 1.11 A Multiple cutaneous
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A B Fig. 1.14 Birt-Hogg-Dubé syndr
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Clear cell renal cell carcinoma D.J
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Fig. 1.20 Clear cell renal cell car
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Papillary renal cell carcinoma B. D
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A B Fig. 1.29 Papillary renal cell
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Fig. 1.33 Chromophobe RCC with sarc
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Carcinoma of the collecting ducts o
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Renal medullary carcinoma C.J. Davi
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Renal carcinomas associated with Xp
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Renal cell carcinoma associated wit
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Papillary adenoma of the kidney J.N
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of this tumour. Microscopic extensi
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A B Fig. 1.59 Metanephric adenoma.
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esults in intratumoral aneurysms. O
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peritumoural fibrous pseudocapsule.
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increases in prevalence to approxim
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Nephrogenic rests and nephroblastom
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Cystic partially differentiated nep
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A B Fig. 1.80 Clear cell sarcoma of
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A B Fig. 1.85 Rhabdoid tumour of th
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transcription factor is fused to th
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Leiomyosarcoma S.M. Bonsib Definiti
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Angiomyolipoma G. Martignoni M.B. A
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melanocytic and smooth muscle marke
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Multinucleated and enlarged ganglio
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Haemangioma P. Tamboli Definition H
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Fig. 1.107 Juxtaglomerular cell tum
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Intrarenal schwannoma I. Alvarado-C
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Mixed epithelial and stromal tumour
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Synovial sarcoma of the kidney J.Y.
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Renal carcinoid tumour L.R. Bégin
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Primitive neuroectodermal tumour (E
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Paraganglioma / Phaeochromocytoma P
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Leukaemia A. Orazi Interstitial inf
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WHO histological classification of
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TNM classification of carcinomas of
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The risk of bladder cancer goes dow
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Tumour spread and staging Urinary b
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feature in such patients undergoing
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A Fig. 2.12 Infiltrative urothelial
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A Fig. 2.15 A Infiltrating urotheli
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A B Fig. 2.19 A Infiltrative urothe
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Fig. 2.23 Infiltrative urothelial c
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ing systems have been proposed on t
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Non-invasive urothelial tumours G.
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chronically inflamed urothelium and
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Inverted papilloma G. Sauter Defini
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muscle invasive disease, but there
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Fig. 2.42 Non-invasive urothelial n
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A Fig. 2.45 Non-invasive urothelial
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for DBCCR1 silencing {984,2476}. Th
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Squamous cell carcinoma D.J. Grigno
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Fig. 2.51 Squamous cell carcinoma.
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Adenocarcinoma A.G. Ayala P. Tambol
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A B Fig. 2.61 A Adenocarcinoma in s
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A B Fig. 2.65 Intramural urachal ca
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Müllerian origin is postulated for
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A Fig. 2.69 Small cell carcinoma. A
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Carcinoid L. Cheng Definition Carci
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Leiomyosarcoma J. Cheville Definiti
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Osteosarcoma L. Guillou Definition
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Leiomyoma J. Cheville Definition A
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Haemangioma L. Cheng Definition Hae
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Metastatic tumours and secondary ex
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Tumours of the renal pelvis and ure
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nodular, ulcerative or infiltrative
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Tumours of the urethra F. Hofstädt
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usually show enteric, colloid or si
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CHAPTER 3X Tumours of of the the Pr
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TNM classification of carcinomas of
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contrast, mortality among migrants
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Fig. 3.06 Transrectal ultrasound of
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PSA-related diagnostic strategies.
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A B C Fig. 3.10 A,B Section of pros
Page 167 and 168: pale-clear, similar to benign gland
Page 169 and 170: A B Fig. 3.20 A, B Adenocarcinoma w
Page 171 and 172: prostate adenocarcinomas exhibit AR
Page 173 and 174: A Fig. 3.27 A, B Foamy gland adenoc
Page 175 and 176: A B Fig. 3.32 A Sarcomatoid carcino
Page 177 and 178: A B Fig. 3.37 A Gleason score 1+1=2
Page 179 and 180: A B Fig. 3.43 A Prostate cancer Gle
Page 181 and 182: Fig. 3.48 Heat map-nature. From S.M
Page 183 and 184: Fig. 3.51 Prostate cancer. Major su
Page 185 and 186: many stage T1b cancers. Stage T2 Mo
Page 187 and 188: Fig. 3.58 Patterns of seminal vesic
Page 189 and 190: Prostatic intraepithelial neoplasia
Page 191 and 192: A B Fig. 3.63 A Micropapillary high
Page 193 and 194: A B Fig. 3.68 A Ductal carcinoma in
Page 195 and 196: Ductal adenocarcinoma X.J. Yang L.
Page 197 and 198: Papillary pattern can be seen in bo
Page 199 and 200: A B Fig. 3.74 A Inflammation withou
Page 201 and 202: Squamous neoplasms T.H. Van der Kwa
Page 203 and 204: Neuroendocrine tumours P.A. di Sant
Page 205 and 206: Mesenchymal tumours J. Cheville F.
Page 207 and 208: Fig. 3.89 Sarcoma of the prostate.
Page 209 and 210: Miscellaneous tumours P.H. Tan L. C
Page 211 and 212: A Fig. 3.96 A Adenocarcinoma of the
Page 213 and 214: WHO histological classification of
Page 215 and 216: Introduction F.K. Mostofi I.A. Sest
Page 217: wartime birth cohorts illustrate th
Page 221 and 222: crucial for the development of this
Page 223 and 224: A B Fig. 4.09 Spermatocytic seminom
Page 225 and 226: A B Fig. 4.14 Intratubular germ cel
Page 227 and 228: A B Fig. 4.19 Seminoma. A Typical s
Page 229 and 230: Fig. 4.24 Seminoma. Vascular invasi
Page 231 and 232: Fig. 4.28 Spermatocytic seminoma wi
Page 233 and 234: A B Fig. 4.33 Embryonal carcinoma.
Page 235 and 236: A B Fig. 4.38 Yolk sac tumour. A En
Page 237 and 238: have cytoplasmic lacunae that conta
Page 239 and 240: A Fig. 4.46 Teratoma. A Longitudina
Page 241 and 242: A B Fig. 4.51 A Cut surface of derm
Page 243 and 244: Fig. 4.54 Mixed germ cell tumour. L
Page 245 and 246: Sex cord / gonadal stromal tumours
Page 247 and 248: A B C Fig. 4.67 Malignant Leydig ce
Page 249 and 250: A Fig. 4.73 A Sertoli cell tumour.
Page 251 and 252: ICD-O codes Granulosa cell tumour 8
Page 253 and 254: ICD-O code 8592/1 Clinical features
Page 255 and 256: A B Fig. 4.83 Germ cell-sex cord/go
Page 257 and 258: A Fig. 4.85 A, B Brenner tumour of
Page 259 and 260: typical grade III follicular morpho
Page 261 and 262: testicular parenchyma and tumour te
Page 263 and 264: A B the surgical scar and adjacent
Page 265 and 266: Immunoprofile Ordóñez and associa
Page 267 and 268: often have a grey-white cut surface
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Fig. 4.111 Angiomyofibroblastoma-li
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A B Fig. 4.119 Embryonal rhabdomyos
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Table 4.05 Secondary tumours of the
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WHO histological classification of
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A Fig. 5.04 A, B Squamous cell carc
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deformed by an exophytic mass. In s
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A B C Fig. 5.12 A Warty (condylomat
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A Fig. 5.20 Bowenoid papulosis. A,
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three had been circumcized by 9 yea
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Mesenchymal tumours J.F. Fetsch M.
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Fig. 5.31 Neurofibroma of the penis
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oectodermal tumour/Ewing sarcoma [p
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Secondary tumours of the penis C.J.
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Dr John N. EBLE* Dept. of Pathology
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Dr Ricardo PANIAGUA Department of C
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Source of charts and photographs 1.
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References 1. Anon. (1955). Case re
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115. Ariel I, Sughayer M, Fellig Y,
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246. Birt AR, Hogg GR, Dube WJ (197
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374. Cardone G, Malventi M, Roffi M
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502. Corti B, Carella R, Gabusi E,
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633. Donhuijsen K, Schmidt U, Richt
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768. Fischer J, Palmedo G, von Knob
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900. Goedert JJ, Cote TR, Virgo P,
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1028. Hartmann A, Dietmaier W, Hofs
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1162. Iezzoni JC, Fechner RE, Wong
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2937. Zhuang Z, Park WS, Pack S, Sc
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CCNB, 226 CCND1, 105, 108 CCND2, 22
Page 351 and 352:
J Juvenile type granulosa cell tumo
Page 353 and 354:
Promoter methylation, 21 Prostate s
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