CHAPTER X CHAPTER 4 - Cancer et environnement

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A B Fig. 4.38 Yolk sac tumour. A Endodermal sinus pattern. B Endodermal sinus structure (Schiller-Duval body). chemical staining with low molecular weight cytokeratin. Other proteins present in fetal liver such as alpha-1 antitrypsin, albumin, ferritin, and others, may also be present {1201}. Genetics Recurrent anomalies have been detected in the infantile yolk sac tumours of the testis, including loss of the short arm of chromosome 1 (in particular the p36 region), the long arm of chromosome 6, and gain of the long arm of chromosomes 1, and 20, and the complete chromosome 22 {1792,2054,2693}. High level amplification of the 12q13-q14 region (of which MDM2 might be the target), and to a lesser extent the 17q12-q21 region, has been demonstrated in one tumour. However, no gene or genes involved in the yolk sac tumour of neonates and infants have been identified yet. The yolk sac tumours of adults, being a pure or a part of a mixed TGCTs are also aneuploid {1543}. Interestingly, loss of 6q also seems to be a recurrent change, which might indicate that it is related to the histology of the tumour. Prognosis and predictive factors Clinical criteria Age does not appear to be prognostically important {1274,2244}. Clinical stage and degree of AFP elevation are of prognostic value {1274,2244,2595}. Morphologic criteria Except for lymphovascular invasion, there are no established morphologic prognostic criteria. Trophoblastic tumours Choriocarcinoma Definition Choriocarcinoma is a malignant neoplasm composed of syncytiotrophoblastic, cytotrophoblastic, and intermediate trophoblastic cells. ICD-O codes Choriocarcinoma 9100/3 Trophoblastic neoplasms other than choriocarcinoma Monophasic choriocarcinoma Placental site trophoblastic tumour 9104/1 Epidemiology Pure choriocarcinoma represents less than 1% (0.19%) of testicular germ cell tumours; choriocarcinoma is admixed with other germ cell tumour elements in 8% of testicular germ cell tumours {1382}. Its estimated incidence, occurring either as a pure tumour or as a component of a mixed germ cell tumour, is approximately 0.8 cases per year per 100,000 male population in those countries with the highest frequency of testicular cancer. A Fig. 4.39 Yolk sac tumour. A Hepatoid pattern. B Enteric pattern. B 240 Tumours of the testis and paratesticular tissue
A Fig. 4.40 Yolk sac tumour. A Pleomorphic cell type. B Polyvesicular vitelline pattern. B Fig. 4.41 Yolk sac tumour. AFP positive staining. Clinical features Signs and symptoms Patients with choriocarcinoma are young, averaging 25-30 years of age. They most commonly present with symptoms referable to metastases. The haematogenous distribution of metastases explains the common presenting symptoms: haemoptysis, dyspnoea, central nervous system dysfunction, haematemesis, melena, hypotension, and anaemia. Haemorrhage in multiple visceral sites represents the hallmark of a “choriocarcinoma syndrome” {1529}. Patients typically have very high levels of circulating human chorionic gonadotropin (hCG) (commonly greater than 100,000 mIU/ml). Because of the cross reactivity of hCG with luteinizing hormone, the consequent Leydig cell hyperplasia causes some patients (about 10%) to present with gynecomastia. Occasional patients develop hyperthyroidism because of the cross reactivity of hCG with thyroid stimulating hormone. Clinical examination of the testes may or may not disclose a mass. This is because the primary site may be quite small, or even totally regressed, despite widespread metastatic involvement. be surrounded by a discernible rim of white to tan tumour. In some cases with marked regression, a white/grey scar is the only identifiable abnormality. Tumour spread Choriocarcinoma disseminates by both haematogenous and lymphatic pathways. Retroperitoneal lymph nodes are commonly involved, although some patients with visceral metastases may lack lymph node involvement. Additionally, autopsy studies have shown common involvement of the lungs (100%), liver (86%), gastrointestinal tract (71%), and spleen, brain, and adrenal glands (56%) {1800}. Histopathology Choriocarcinoma has an admixture, in varying proportions, of syncytiotrophoblastic, cytotrophoblastic and intermediate trophoblastic cells. These cellular components are arranged in varying patterns, usually in an extensively haemorrhagic and necrotic background. In some examples, the syncytiotrophoblasts "cap" nests of cytotrophoblasts in a pattern that is reminiscent of the architecture seen in immature placental villi. Most commonly, they are admixed in a more or less random fashion, usually at the periphery of a nodule that has a central zone of haemorrhage and necrosis. In occasional cases, which have been descriptively termed "monophasic" {2672}, the syncytiotrophoblastic cell component is inconspicuous, leaving a marked preponderance of cytotrophoblastic and intermediate trophoblastic cells. Blood vessel invasion is commonly identified in all of the patterns. The syncytiotrophoblastic cells are usually multinucleated with deeply staining, eosinophilic to amphophilic cytoplasm; they typically have several, large, irregularly shaped, hyperchromatic and often smudged appearing nuclei. They often Imaging Choriocarcinomas do not have distinctive imaging characteristics to differentiate them from other non-seminomatous tumours. Their appearance varies from hypoechoic to hyperechoic. They may invade the tunica albuginea. Macroscopy Choriocarcinoma most commonly presents as a haemorrhagic nodule that may A Fig. 4.42 Choriocarcinoma. A Longitudinal ultrasound image of the testis shows a small, slightly heterogeneous mass, which is almost isoechoic compared to the normal parenchyma (arrow). B Chest radiograph shows multiple lung metastases. The patient presented with hemoptysis. B Germ cell tumours 241
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 and 22: Differential diagnoses Differential
Page 23: Histologic patterns Microcystic or
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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