CHAPTER X CHAPTER 4 - Cancer et environnement

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A B Fig. 4.33 Embryonal carcinoma. A Embryonal carcinoma composed of blastocyst-like vesicles. B Solid type of embryonal carcinoma. A B Fig. 4.34 Embryonal carcinoma. A Papillary type of embryonal carcinoma. B Intratubular embryonal carcinoma. Note the tumour necrosis. 1490} and may be more common in Orientals when compared to Caucasians {1276}. In adults, it usually occurs as a component of a mixed germ cell tumour and is seen in approximately 40% of NSGCTs. In adults, it is much more common in Caucasians than in other races. The age incidence corresponds to the age incidence of testicular malignant mixed germ cell tumours {2564}. Fig. 4.35 Embryonal carcinoma. Vascular invasion of embryonal carcinoma. Clinical features Signs and symptoms In children, the median age at the presentation is 16-17 months but may extend to 11 years {1274,2244}. There is a right sided preponderance {1274}. Almost ninety percent of cases present with an otherwise asymptomatic scrotal mass {1274}. Seven percent of cases present with a history of trauma or acute onset pain and 1 percent present with a hydrocele {1274}. Alpha fetoprotein levels are elevated in 90 percent of cases {1274, 2595}. Ultrasound examination reveals a solid intratesticular lesion with a different echo texture from that of the testis. Tumour spread Ten to twenty percent of children have metastases at presentation {1274,2078}. The nodal spread is to the retroperitoneum {1274,2244}. In children there appears to be a predilection for haematogenous spread, 40% presenting with haematogenous spread alone {326}. In 20-26 percent of cases the first site of clinical involvement is the lungs {326, 1274}. Although it is not clear if retroperitoneal nodes are also involved in those cases, in adults, the pattern of spread is similar to that seen in other NSGCTs. Macroscopy Macroscopically pure yolk sac tumours are solid, soft, and the cut surface is typically pale grey or grey-white and somewhat gelatinous or mucoid {1021,1274}. Large tumours show haemorrhage and necrosis {2564}. Histopathology The histopathological appearance is the same, regardless of patient age {1021, 1274,2564}. Several different patterns are usually admixed, and may be present in equal amounts, although not infrequently one pattern may predominate {1201}. Tumours composed entirely of a single histologic pattern are rare {2564}. 238 Tumours of the testis and paratesticular tissue
Histologic patterns Microcystic or reticular pattern The microcystic pattern consists of a meshwork of vacuolated cells producing a honeycomb appearance. The tumour cells are small and may be compressed by the vacuoles, which may contain pale eosinophilic secretion. The nuclei vary in size, but generally are small. Mitotic activity is typically brisk. Hyaline globules are often present {1201,2593}. This pattern is the most common one. Macrocystic pattern The macrocystic pattern consists of collections of thin-walled spaces of varying sizes. They may be adjacent to each other, or separated by other histologic patterns. Solid pattern The solid pattern consists of nodular collections or aggregates of medium sized polygonal tumour cells with clear cytoplasm, prominent nuclei, and usually showing brisk mitotic activity. It is often associated with a peripheral microcystic pattern which helps distinguish it from typical seminoma and embryonal carcinoma. Sometimes the cells may show greater pleomorphism and giant cells may be present. Glandular-alveolar pattern This pattern consists of collections of irregular alveoli, gland-like spaces and tubular structures lined by cells varying from flattened to cuboidal or polygonal. The glandlike spaces or clefts form a meshwork of cavities and channels, sometimes interspersed with myxomatous tissue. Endodermal sinus pattern This pattern consists of structures composed of a stalk of connective tissue containing a thin walled blood vessel and lined on the surface by a layer of cuboidal cells with clear cytoplasm and prominent nuclei. Mitotic activity is usually present and may be brisk. These structures, also known as Schiller-Duval bodies, are considered a hallmark of YST {2593}. They are seen scattered within the tumour in varying numbers. Their absence does not preclude the diagnosis. Papillary pattern This pattern has numerous, usually fine papillae consisting of connective tissue cores lined by cells with prominent nuclei and often showing brisk mitotic activity. The connective tissue cores vary from loose and oedematous to fibrous and hyalinized. Sometimes there may be considerable deposits of hyaline material forming wider and more solid brightly eosinophilic and amorphous papillae. Myxomatous pattern This pattern consists of collections of myxomatous tissue containing sparse cords, strands or collections of individual cells showing prominent nuclei and mitotic activity {1201}. Polyvesicular vitelline pattern This pattern consists of collections of vesicles or cysts varying in shape and size surrounded by connective tissue which may vary from cellular and oedematous to dense and fibrous. The vesicles are lined by columnar to flattened cells. Sometimes the vesicles are small and adhere to each other, and some may Fig. 4.36 Yolk sac tumour in the testis of a one year old. be hourglass shaped {2593}. This pattern is uncommon. Hepatoid pattern Collections of hepatoid cells are present in some tumours, and is more frequently seen in tumours from postpubertal patients. Hyaline globules are frequently seen {1197,2669}. Sometimes, collections of such cells may be numerous and of considerable size, although usually they are small. Enteric pattern Individual or collections of immature glands are not uncommon {1201,2669}. They usually resemble allantois, enteric or endometrioid glands. They are similar to some glands in teratomas, but the association with other yolk sac tumour patterns and absence of a muscular component aid in their distinction. Hyaline globules may be present and numerous. Immunoprofile Positive staining for AFP is helpful in diagnosis but the reaction is variable and sometimes weak. Negative staining does not exclude a diagnosis of YST. YST shows strong positive immunocyto- A B Fig. 4.37 Yolk sac tumour. A Microcystic pattern of yolk sac tumour. B Glandular-alveolar pattern of yolk sac tumour. Germ cell tumours 239
Page 1 and 2: CHAPTER 4X Tumours of the of the Te
Page 3 and 4: TNM classification of germ cell tum
Page 5 and 6: Germ cell tumours P.J. Woodward A.
Page 7 and 8: senting symptom: back or abdominal
Page 9 and 10: A B Fig. 4.03 Germ cell tumours gen
Page 11 and 12: process at all {1524}. In addition,
Page 13 and 14: A B Fig. 4.12 Comparison of morphol
Page 15 and 16: small tumour insufficient to produc
Page 17 and 18: A B C Fig. 4.22 Seminoma. A Pseudog
Page 19 and 20: A B Fig. 4.27 Spermatocytic seminom
Page 21: Differential diagnoses Differential
Page 25 and 26: A Fig. 4.40 Yolk sac tumour. A Pleo
Page 27 and 28: Teratoma Teratomas are generally we
Page 29 and 30: A B C Fig. 4.49 Teratoma. A Teratom
Page 31 and 32: A B Fig. 4.52 Teratoma with somatic
Page 33 and 34: A B Fig. 4.59 Mixed germ cell tumou
Page 35 and 36: A B C Fig. 4.64 Leydig cell tumour.
Page 37 and 38: A Fig. 4.69 Androgen insensitivity
Page 39 and 40: tinguished from Sertoli cell nodule
Page 41 and 42: ound and have spherical, regularly
Page 43 and 44: Tumours containing both germ cell a
Page 45 and 46: Miscellaneous tumours of the testis
Page 47 and 48: Lymphoma and plasmacytoma of the te
Page 49 and 50: Tumours of collecting ducts and ret
Page 51 and 52: Tumours of paratesticular structure
Page 53 and 54: Epidemiology Nodular mesothelial hy
Page 55 and 56: A B Fig. 4.104 Papillary cystadenom
Page 57 and 58: Fig. 4.109 Desmoplastic small round
Page 59 and 60: Fig. 4.115 Leiomyosarcoma. Coronal,
Page 61 and 62: Secondary tumours C.J. Davis Defini

CHAPTER X CHAPTER 4 - Cancer et environnement

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