547047

research-article2014

IJSXXX10.1177/1066896914547047International Journal of Surgical PathologyChander et al

Images in Pathology International Journal of Surgical Pathology 2015, Vol. 23(1) 30­–31 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1066896914547047 ijs.sagepub.com

Pure Glandular Endometrioid-Like Yolk Sac Tumor of the Testis Ankush Chander, MD1, Christopher N. Otis, MD1, and Lisa L. Cole, MD1

A 43-year-old male with a past medical history of a right undescended testis status post orchidopexy at the age of 10 presented to his general practitioner with complaints of a dull aching pain and swelling in the right groin region. Physical examination demonstrated a firm, mobile, right inguinal mass and an absent right testis within the scrotum. A subsequent ultrasound revealed the inguinal mass to be the undescended testis, within which there was a heterogeneous mass with multiloculated hypoechoic regions. α-Fetoprotein (AFP) and β-HCG serum levels were within normal limits. A right radical orchiectomy was performed due to concerns of malignancy. A firm 2.3-cm heterogeneous mass with hemorrhagic cystic foci located at the lower pole of the testis was present in the resected specimen. The mass was confined to the testicular parenchyma (Figure 1A). A well-circumscribed mass microscopically contained multiple cystic and hemorrhagic areas with tubulopapillary glands lined by columnar cells with prominent suband supranuclear vacuolization, enlarged, atypical nuclei, and abundant mitoses (Figure 1B and C). The tumor cells were negative for the following immunohistochemical studies: AFP, CD30, Oct3/4, renal cell carcinoma antigen, and PAX8; in addition, epithelial membrane antigen was focally positive. This staining pattern does not support a yolk sac tumor (YST), embryonal carcinoma, seminoma, or metastatic renal cell carcinoma. However, due to the unique glandular architectural and cytologic features of the tumor, an endometrioid-like variant of yolk sac origin was still considered even though the tumor cells lacked AFP. To further classify the tumor type, a Gypican3 immunohistochemical study demonstrated diffuse cytoplasmic immunoreactivity in tumor cells (Figure 1D) and negative cytokeratin7 immunoreactivity. Taken together, the immunohistochemical results support the diagnosis of a primitive adenocarcinoma of yolk sac lineage over a conventional adenocarcinoma.

YSTs may display diverse histological patterns and in adult males are common components of mixed germ cell tumors with the pure form being extremely rare. YST can be mistaken for other germ cell tumor subtypes or in this case an adenocarcinoma. YSTs are immunoreactive for AFP 55% to 100% of cases. Therefore, an absence of AFP by immunohistochemistry does not exclude an YST.1-3 Glypican3 immunoreactivity has been reported to be more sensitivity than AFP for testicular and ovarian YSTs.4-6 Glypican3 is especially useful for YSTs with unusual or rare morphological patterns. One study reported glypican3 immunoreactivity in 100% of all YSTs versus only 58% for AFP.7 Rarely, a pure glandular pattern of YST with prominent subnuclear vacuolization resembling secretory endometrioid carcinoma (endometrioid-like YST) occurs in the ovary. In males, similar histological patterns are usually only seen in metastatic deposits of YSTs rather than in the primary tumor itself. In such an instance, the differential diagnosis includes that of a pure glandular testicular YST or a rare adenocarcinoma that has developed from a preexisting teratoma.8 This case presents a primary testicular neoplasm with a pure secretory endometrioid-like morphology immunoreactive for glypican3, rare immunoreactivity for epithelial membrane antigen, and negative results for Oct3/4, AFP, and cytokeratin7. This case demonstrates the applicability of glypican3 immunohistochemistry in an unusual variant of a testicular non-seminomatous germ cell tumor.

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Baystate Medical Center, Tufts University School of Medicine, Springfield, MA, USA Corresponding Author: Lisa L. Cole, Department of Pathology, Baystate Medical Center, Springfield, MA 01199, USA. Email: [email protected]

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Figure 1.  (A) Bivalved testis with well-circumscribed tumor nodule. (B) Secretory endometrioid-like pattern (hematoxylin– eosin, 200× magnification). (C) Columnar cells with prominent sub- and supranuclear vacuolization (hematoxylin–eosin, 400× magnification). (D) Glypican3 immunohistochemical stain.

References 1.  Niehans GA, Manivel JC, Copland GT, Scheithauer BW, Wick MR. Immunohistochemistry of germ cell and trophoblastic neoplasms. Cancer. 1988;62:1113-1123. 2.   Eglen DE, Ulbright TM. The differential diagnosis of yolk sac tumor and seminoma. Usefulness of cytokeratin, alphafetoprotein, and alpha-1-antitrypsin immunoperoxidase reactions. Am J Clin Pathol.1987;88:328-332. 3.   Morinaga S, Ojima M, Sasano N. Human chorionic gonadotropin and alpha-fetoprotein in testicular germ cell tumors. An immunohistochemical study in comparison with tissue concentrations. Cancer. 1983;52:1281-1289. 4.   Zynger DL, Dimov ND, Luan C, Teh BT, Yang XJ. Glypican 3: a novel marker in testicular germ cell tumors. Am J Surg Pathol. 2006;30:1570-1575.

5.  Ota S, Hishinuma M, Yamauchi N, et al. Oncofetal protein glypican-3 in testicular germ-cell tumor. Virchows Arch. 2006;449:308-314. 6.  Esheba GE, Pate LL, Longacre TA. Oncofetal protein glypican-3 distinguishes yolk sac tumor from clear cell carcinoma of the ovary. Am J Surg Pathol. 2008;32:600-607. 7. Zynger DL, McCallum JC, Luan C, Chou PM, Yang XJ. Glypican 3 has a higher sensitivity than alpha-fetoprotein for testicular and ovarian yolk sac tumour: immunohistochemical investigation with analysis of histological growth patterns. Histopathology. 2010;56:750-757. 8.  Ulbright TM. Germ cell tumors of the gonads: a selective review emphasizing problems in differential diagnosis, newly appreciated, and controversial issues. Mod Pathol. 2005;18:S61-S79.

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Pure glandular endometrioid-like yolk sac tumor of the testis.

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