- Email: [email protected]
Serous papillary cystic tumor of borderline malignancy with focal carcinoma arising in testis: Case report with immunohistochemical and ultrastructural observations
CASE STUDIES
SEROUS PAPILLARY ARISING IN TESTIS: OBSERVATIONS
CYSTIC TUMOR OF BORDERLINE MALIGNANCY WITH FOCAL CARCINOMA CASE REPORT WITH IMMUNOHISTOCHEMICAL AND ULTRASTRUCTURAL
Asiotis” md Mtxistcl- et al.” N’e J~rescnt anothw exanlple of tllis grouJ) of’tuux~rs that may he c.lassitiCcl as uliillerian berou~ IxqAu~); c~ystadrnoma of tmrderlinc rnaligmnq with li~,11 tlrv~lopment of invasivr cauc~. The tumor has hrrn examined 1)~ light micr-osc-opv, illlrrlurlohistc,~hrnlistr~, and rlwtron mi-
(-t’osu’p\
(:.4SP: REI’OK’I The palient tcmsillrc~toiii\~ history of asyinl~tou~atic tvilargenwit of the right testis “siiic-c sew~A dwade~.” On adnlission. the right testis was l’ound to 1x2enlarged to about double the normal sizr ar~tl of hrm UHsistrim. The swelling was entireI\; paiulrus. I’aiiJxition failed to scJxuxte the totis Lr-ortl the epididw~ia. I~~~mwarkat~le laborator); findings resulted fi-oui urc&~, c011~putrd toIiwgrapt~v ol’lhc abrlo~r~ri~ and pelvis. hone xxi, at)domial.~l honography. C~nd hipedal lytl,J~ll;ln#ioa~;ipli~ I’or lymph node ~~wtxt;~st~. Tc.sticwIar sc,nograph) revcalcd a l;ir~c i~~tio~iro~~~ioi~s mx+s with foc,il liquefaction within the right htmiac rotunl. Again, the testis xrd cpididyulis could not be seJ)arat4 from eac+i other. On sut-gcy. Ihe right testis J)t-ovcd to h;~vc a fuw and, irl pi-l. 1)(m) cx~i~sislrrit~~. containing sot~lt vyrlic ;i~eab with Illilk> fluid. Thr tunica albuginea J~roved IO I,& unrelnarkahle without evidence of hydroccle or tumor- growtll. The coIltents 01‘ the right henlisc~rotuni (testis. rpidid~niis. and funic~ulus sJ’t.rmaticwS) wc’rc I-~~II~owI. -rllv patient I’0ll0wcd ,311 unvIlr;u-k;tt)lv po$tsurgic-A ~oursc. 011e wan. xflcr surgery. thew i\ 110 witltnc c 01’ tu1ii01 Ic’currenw 01 nlctaataw~. 01
75
HUMAN PATHOLOGY
TABLE 1.
Volume 23, No. 1 (January
Results of lmmunohistochemistry
k~ATEKIAI,S
+++ +++ Foe ally +
+/++' t/t+
+t t;+t +tt tt+ ++/+tt tt + +
IO +t
+ I~‘r~c;lll~(t,
1992)
AND METHODS
The twnor was fixed in 10% fornddehycle and bec.tions were stained with heniatoxylin-cosin, Elastica-van (;ieson, Giemsa, Goniori silver staining, and periodic acid-Schiff‘. Inriirrnoliistochemistr~ was perforniecl using the peroxiclase-antiperoxiclase technique and a Iwgc number. of antibodies (Table 1). tdectron microscopy was perfornied on the formalin-fixed niatcrial following postfixation with 1% oslniuni tetroxicle and embedding in aralclite.
Gross Findings
The surgical stwcimcn IMI a size of 15 X ti X 5 CIII and presenred s&rat large c,ystic spaces measuring up to 4.5 X 4.5 X 1.5 cm The cysts hatl a wall of firm, yellowish-whitr connective tissue with fir4 wc’roses a11t1tirmmhagrs. ‘Ihc inner bvatl of Ihc c ycts showed t);it~iltoriiato~~~ formatiom of varying size. measuring up 10 Y X 2 X 2 (XI. The epiclidytnis was grossly urireniarkal~Ic. The rc1c testis could not be tletinilelv iclenlifird. Sonir residual tcsticul;u- Iissue was visible. Microscopy
Ttle cyslic walls c‘onsis(rtl of‘tlense fibrous collneclivr tis5116’with pronout~wd fc~al hyalinization, hemorrhage, hrniosiclei-iu tlcposits, rctnol~ ncc‘roscs. ;intl ac.cumul;itio~is of fo;url cells. together with bonie li)reign body giant cells ai~d notispccific ifillaniniatory itifill12~es. Occ;tsion~ll~. calciuttt de-
FIGURE 1. Wall of a cyst. Papillary proliferation consistent with the diagnosis of a papillary cystadenoma of borderline malignancy. Hyalinization of a cystic wall is seen at the bottom right; necrosis with numerous clefts following removal of cholesterol crystals is seen at the bottom left. (Hematoxylin-eosin stain; magnification ‘T77.)
FIGURE 2. and tubular thelial cells. tumor cells.
Focal invasion of the cystic wall by irregular nests formations composed of atypical columnar epiFocal deposits of calcium are seen between the (Hematoxylin-eosin stain: magnification X123.)
CASE STUDIES
FIGURE 3. Electron microscopy of the bmor cells. See text for explanation. (Magnification x5,450: inset magnification I 46.000 )
HUMAN PATHOLOGY TABLE 2.
hlei\tel- et aIs
Volume 23, No. 1 (January 1992)
Review of Miillerian
Testicular
High-columnar
Tumors of Ovarian Type
epithrlial
the papillae.
pseudostratifict!. hearing
sometimes
cilia; no wnarkahle
or mitotir hodics;
activity;
no invasive
inlr,lunohistoctlelniarrv Illat
I’t-esent studv
atvpid
few psammonu gt-cwth. identical
10
of fwst case
Cuhoklal
z\li\e and Mdl
to c~~!umna~- cells. ~-are cilia
and mitotic lining
cells lining
in part
figures
papillae;
infiltmtic>u
I \I
of the cells
focal stromal
-
the cliagnostician to rule out MT with a high degree of probability.“.’ Moreover. the strongly positive reaction for HEA125 in our case favors the diagnosis of OST since HEA- I25 is found to be only weakly positive in some cells of a minorit! of MTs (Miiller- K-M, personal corrlmllnication. IWO). The positive reaction for HMFG-2 is of no practical value for the differential diagnosis since it may be found in both OST and MT.” CA-1 25 has not been used for the differential diagnosis’; however. to our hnowledge, no studies have been published concerning its possible occurrence in MT. The antimesothelial cell antibody (courtesy of Professor Donna) has been fi)~lnd to be positive in mesotheliomas of the pleura, peritoncut~l. and tunica vaginalis testis, in adenomatoid tumors, and in serous cystadenomas and cystadenocarcinoIrlas of the ovary.‘,” Hence, it camlot be used for the differential diagnosis. Electron microscopy is of only minor value in ditierentiating OS?‘ from MT.“’ Although not conclusive, the presence of epithelial cells bearing cilia supports the diagnosis of OST.
tunica vaginalis testis (MT). A history of longstanding, painless testicular swelling as observed in our patient may be found in both types of tumors. The subtotal destruction of the testis, the missing connection with the tunica vaginalis testis, and the lack of a hydrocele, all of which are frequent findings in MT (24 of 33 cases’) support the diagnosis of OST. I.ight microscopy may be similar in both tumors, including the occurrence of psammoma bodies, and therefore does not permit a definite conclusion. Immunohistochemist~ gave a strongly positive result for cytokeratin KL-1, EMA, HEA- 25, CA-1 25, HMFG2. and BRST-3, and a moderately positive result for CEA, protein S-l 00, and HPLAP (polyclonal). The reactions fo1 HPLAP (monoclonal), I.eu-Ml , and antimesothelial cell antibody (courtesy of Professor Donna) were weakly positive. Although the value of immunohistochemistry for the differential dia~iosis between OST and MT is still a matter of debate, it is now widely accepted that a positive reaction for Leu-Ml, CEA, and BRST-3 (B72.3) will point to OST and will allow
78
CASE
Miiller-ian
“pt-i1narv” “t’rimq” tiliitlg
tu1110rs
01
miitlerkm
C'IIK'I.~C
of thr
~ht ov;trian
0rigin;de either fronl epitheliunl and stronu.”
arise
from
v;cgirialis
t);irri( surfke)
iil;uly
cwibrvonat
ntiilteri:un
“Seumdnry”
ct,irheliulr~,~~hich
Imiica
twl\-ic mrsotllr~liuln, t.ririg
tumors
tiut,I5.
tniillrrian
l'ron~
twu~lhelium
may
rniitlerian
nic31i’r that the IIIc.
testis
01' the
"src~o~~ia~~"
develops
testis
from
1.1.OIII
(in women. the
cells
tumors the
II-0111 the
meso~lirliur~~
coy-
1)~ mcfqdasia.
The first group umt)i-isrs c;ircinoiii;i of ihr appendix testis together wilti qstad~~1~01n;is drisi1ig fi-om wmimts of 1niilleriari epithcliuni wit bin ttic tcstic-uldi tissue itself. ‘l&r sec.ond group cwntains serous. IIILIC inorb 01 c~ntlometrioict cystic tumors of rhe ovarian type. Summing ;mlinarioii.
up
1tir prcsrril
0\2ri;iri
t~b~~,rt tratisilion
of
tkfinitety
primal-v
Furthw
tvpe,
or
diagnosk
1i(.113;11.at~d t);~rat~sti(~ular ;tptwldix I)v
testis,
;hIc.
Lo lhr
mic~rosuot)i(~ pic.(urv
mic rowopic
p;lttrrli
Brief Review of Testicular Common Epi~!helial r’pe
‘1’0 0111‘I~ilo~~trtlge. of d wrom
as
testis.
the
tes-
of the coultl
Llt~WIniid-
;mct the tlit+erent tumors.
of Mdlerian
cdsc is the ninth
rrstwclivcly. Origin,
in rtie literacurc
type, and tht fir51 scrokis tqGll;iry ( ~sladerio~arc,inoma of w&an type cte5~rihcd in ttir tvhlis. ‘I‘able 2 briefly summarizes thrse seven (.d\c’c. Ihe p~ienrs wew between i I and 60 years old: onI\ two
01
ttieni
I)elongecl
IO Ihc ;qe
of 0vari;in
group
uncler
’ “0 _ yrxrs.
and
cddcr
th;in -14 years. Clinical follow-iit) unwed ,I yImI of I IO I1 years withour eviclenc-e of recul-renq 01 tiw13s(;isc’s,. with ltic excrption of one patient who died front 1nc~r;islaric luilg wnwrf: no mrtaslases of thr lestic.utat~ (111nor No inforniation was ;~vail;ihlv in three \\?I t’ torlntl to ;lLlq’w.‘~’ ttw
0~tier.s
c vslic tumor
I are
‘I‘hese tumors
strurrures,
Tumors
orhe
c.;u-vinonu
course,
tww3ponding
our
01 rnuc~inoris
such
dinkrl
of thosc
of’the
tumors.
considered
01. wtr
regard
c‘ys-
with
xid
In our opinion. it c~anlicb( the (urnor belongs 10 the
tumors.
rpitiidymis,
rlllrd 0111with
papillary
malignancy
miitterian
scco~idarv
ex-
mic roscopy,
as a serous
borderline
wherhel-
tliff&n~i:d
pathologic
and electron
iiiro invasive cancer.
deter-n,incd
g~orip of
of- c.cmventional
rlitnor ~nay be classified
1;3dtwom;i, Iw
the rcsul~s
iilirniulotiisto~tieniistr~.
w-t.1 e
DESMOPLASTIC A DIAGNOSTIC I‘IIOMAS
I%. C:KOI
MALIGNANT DILEMMA 11’. \lR.
MK(:Pl,
MESOTHELIOMA THOMAS
V.
COLUY,
MASQUERADING MD, PF.I~K (:. (L\Y. VI).
AS SCLEROSING FCCP,
MEDIASTINITIS:
ANI) KICH.WD.J.
I’Is.\sI,
MD, FCCP
SEROUS PAPILLARY ARISING IN TESTIS: OBSERVATIONS
CYSTIC TUMOR OF BORDERLINE MALIGNANCY WITH FOCAL CARCINOMA CASE REPORT WITH IMMUNOHISTOCHEMICAL AND ULTRASTRUCTURAL
Asiotis” md Mtxistcl- et al.” N’e J~rescnt anothw exanlple of tllis grouJ) of’tuux~rs that may he c.lassitiCcl as uliillerian berou~ IxqAu~); c~ystadrnoma of tmrderlinc rnaligmnq with li~,11 tlrv~lopment of invasivr cauc~. The tumor has hrrn examined 1)~ light micr-osc-opv, illlrrlurlohistc,~hrnlistr~, and rlwtron mi-
(-t’osu’p\
(:.4SP: REI’OK’I The palient tcmsillrc~toiii\~ history of asyinl~tou~atic tvilargenwit of the right testis “siiic-c sew~A dwade~.” On adnlission. the right testis was l’ound to 1x2enlarged to about double the normal sizr ar~tl of hrm UHsistrim. The swelling was entireI\; paiulrus. I’aiiJxition failed to scJxuxte the totis Lr-ortl the epididw~ia. I~~~mwarkat~le laborator); findings resulted fi-oui urc&~, c011~putrd toIiwgrapt~v ol’lhc abrlo~r~ri~ and pelvis. hone xxi, at)domial.~l honography. C~nd hipedal lytl,J~ll;ln#ioa~;ipli~ I’or lymph node ~~wtxt;~st~. Tc.sticwIar sc,nograph) revcalcd a l;ir~c i~~tio~iro~~~ioi~s mx+s with foc,il liquefaction within the right htmiac rotunl. Again, the testis xrd cpididyulis could not be seJ)arat4 from eac+i other. On sut-gcy. Ihe right testis J)t-ovcd to h;~vc a fuw and, irl pi-l. 1)(m) cx~i~sislrrit~~. containing sot~lt vyrlic ;i~eab with Illilk> fluid. Thr tunica albuginea J~roved IO I,& unrelnarkahle without evidence of hydroccle or tumor- growtll. The coIltents 01‘ the right henlisc~rotuni (testis. rpidid~niis. and funic~ulus sJ’t.rmaticwS) wc’rc I-~~II~owI. -rllv patient I’0ll0wcd ,311 unvIlr;u-k;tt)lv po$tsurgic-A ~oursc. 011e wan. xflcr surgery. thew i\ 110 witltnc c 01’ tu1ii01 Ic’currenw 01 nlctaataw~. 01
75
HUMAN PATHOLOGY
TABLE 1.
Volume 23, No. 1 (January
Results of lmmunohistochemistry
k~ATEKIAI,S
+++ +++ Foe ally +
+/++' t/t+
+t t;+t +tt tt+ ++/+tt tt + +
IO +t
+ I~‘r~c;lll~(t,
1992)
AND METHODS
The twnor was fixed in 10% fornddehycle and bec.tions were stained with heniatoxylin-cosin, Elastica-van (;ieson, Giemsa, Goniori silver staining, and periodic acid-Schiff‘. Inriirrnoliistochemistr~ was perforniecl using the peroxiclase-antiperoxiclase technique and a Iwgc number. of antibodies (Table 1). tdectron microscopy was perfornied on the formalin-fixed niatcrial following postfixation with 1% oslniuni tetroxicle and embedding in aralclite.
Gross Findings
The surgical stwcimcn IMI a size of 15 X ti X 5 CIII and presenred s&rat large c,ystic spaces measuring up to 4.5 X 4.5 X 1.5 cm The cysts hatl a wall of firm, yellowish-whitr connective tissue with fir4 wc’roses a11t1tirmmhagrs. ‘Ihc inner bvatl of Ihc c ycts showed t);it~iltoriiato~~~ formatiom of varying size. measuring up 10 Y X 2 X 2 (XI. The epiclidytnis was grossly urireniarkal~Ic. The rc1c testis could not be tletinilelv iclenlifird. Sonir residual tcsticul;u- Iissue was visible. Microscopy
Ttle cyslic walls c‘onsis(rtl of‘tlense fibrous collneclivr tis5116’with pronout~wd fc~al hyalinization, hemorrhage, hrniosiclei-iu tlcposits, rctnol~ ncc‘roscs. ;intl ac.cumul;itio~is of fo;url cells. together with bonie li)reign body giant cells ai~d notispccific ifillaniniatory itifill12~es. Occ;tsion~ll~. calciuttt de-
FIGURE 1. Wall of a cyst. Papillary proliferation consistent with the diagnosis of a papillary cystadenoma of borderline malignancy. Hyalinization of a cystic wall is seen at the bottom right; necrosis with numerous clefts following removal of cholesterol crystals is seen at the bottom left. (Hematoxylin-eosin stain; magnification ‘T77.)
FIGURE 2. and tubular thelial cells. tumor cells.
Focal invasion of the cystic wall by irregular nests formations composed of atypical columnar epiFocal deposits of calcium are seen between the (Hematoxylin-eosin stain: magnification X123.)
CASE STUDIES
FIGURE 3. Electron microscopy of the bmor cells. See text for explanation. (Magnification x5,450: inset magnification I 46.000 )
HUMAN PATHOLOGY TABLE 2.
hlei\tel- et aIs
Volume 23, No. 1 (January 1992)
Review of Miillerian
Testicular
High-columnar
Tumors of Ovarian Type
epithrlial
the papillae.
pseudostratifict!. hearing
sometimes
cilia; no wnarkahle
or mitotir hodics;
activity;
no invasive
inlr,lunohistoctlelniarrv Illat
I’t-esent studv
atvpid
few psammonu gt-cwth. identical
10
of fwst case
Cuhoklal
z\li\e and Mdl
to c~~!umna~- cells. ~-are cilia
and mitotic lining
cells lining
in part
figures
papillae;
infiltmtic>u
I \I
of the cells
focal stromal
-
the cliagnostician to rule out MT with a high degree of probability.“.’ Moreover. the strongly positive reaction for HEA125 in our case favors the diagnosis of OST since HEA- I25 is found to be only weakly positive in some cells of a minorit! of MTs (Miiller- K-M, personal corrlmllnication. IWO). The positive reaction for HMFG-2 is of no practical value for the differential diagnosis since it may be found in both OST and MT.” CA-1 25 has not been used for the differential diagnosis’; however. to our hnowledge, no studies have been published concerning its possible occurrence in MT. The antimesothelial cell antibody (courtesy of Professor Donna) has been fi)~lnd to be positive in mesotheliomas of the pleura, peritoncut~l. and tunica vaginalis testis, in adenomatoid tumors, and in serous cystadenomas and cystadenocarcinoIrlas of the ovary.‘,” Hence, it camlot be used for the differential diagnosis. Electron microscopy is of only minor value in ditierentiating OS?‘ from MT.“’ Although not conclusive, the presence of epithelial cells bearing cilia supports the diagnosis of OST.
tunica vaginalis testis (MT). A history of longstanding, painless testicular swelling as observed in our patient may be found in both types of tumors. The subtotal destruction of the testis, the missing connection with the tunica vaginalis testis, and the lack of a hydrocele, all of which are frequent findings in MT (24 of 33 cases’) support the diagnosis of OST. I.ight microscopy may be similar in both tumors, including the occurrence of psammoma bodies, and therefore does not permit a definite conclusion. Immunohistochemist~ gave a strongly positive result for cytokeratin KL-1, EMA, HEA- 25, CA-1 25, HMFG2. and BRST-3, and a moderately positive result for CEA, protein S-l 00, and HPLAP (polyclonal). The reactions fo1 HPLAP (monoclonal), I.eu-Ml , and antimesothelial cell antibody (courtesy of Professor Donna) were weakly positive. Although the value of immunohistochemistry for the differential dia~iosis between OST and MT is still a matter of debate, it is now widely accepted that a positive reaction for Leu-Ml, CEA, and BRST-3 (B72.3) will point to OST and will allow
78
CASE
Miiller-ian
“pt-i1narv” “t’rimq” tiliitlg
tu1110rs
01
miitlerkm
C'IIK'I.~C
of thr
~ht ov;trian
0rigin;de either fronl epitheliunl and stronu.”
arise
from
v;cgirialis
t);irri( surfke)
iil;uly
cwibrvonat
ntiilteri:un
“Seumdnry”
ct,irheliulr~,~~hich
Imiica
twl\-ic mrsotllr~liuln, t.ririg
tumors
tiut,I5.
tniillrrian
l'ron~
twu~lhelium
may
rniitlerian
nic31i’r that the IIIc.
testis
01' the
"src~o~~ia~~"
develops
testis
from
1.1.OIII
(in women. the
cells
tumors the
II-0111 the
meso~lirliur~~
coy-
1)~ mcfqdasia.
The first group umt)i-isrs c;ircinoiii;i of ihr appendix testis together wilti qstad~~1~01n;is drisi1ig fi-om wmimts of 1niilleriari epithcliuni wit bin ttic tcstic-uldi tissue itself. ‘l&r sec.ond group cwntains serous. IIILIC inorb 01 c~ntlometrioict cystic tumors of rhe ovarian type. Summing ;mlinarioii.
up
1tir prcsrril
0\2ri;iri
t~b~~,rt tratisilion
of
tkfinitety
primal-v
Furthw
tvpe,
or
diagnosk
1i(.113;11.at~d t);~rat~sti(~ular ;tptwldix I)v
testis,
;hIc.
Lo lhr
mic~rosuot)i(~ pic.(urv
mic rowopic
p;lttrrli
Brief Review of Testicular Common Epi~!helial r’pe
‘1’0 0111‘I~ilo~~trtlge. of d wrom
as
testis.
the
tes-
of the coultl
Llt~WIniid-
;mct the tlit+erent tumors.
of Mdlerian
cdsc is the ninth
rrstwclivcly. Origin,
in rtie literacurc
type, and tht fir51 scrokis tqGll;iry ( ~sladerio~arc,inoma of w&an type cte5~rihcd in ttir tvhlis. ‘I‘able 2 briefly summarizes thrse seven (.d\c’c. Ihe p~ienrs wew between i I and 60 years old: onI\ two
01
ttieni
I)elongecl
IO Ihc ;qe
of 0vari;in
group
uncler
’ “0 _ yrxrs.
and
cddcr
th;in -14 years. Clinical follow-iit) unwed ,I yImI of I IO I1 years withour eviclenc-e of recul-renq 01 tiw13s(;isc’s,. with ltic excrption of one patient who died front 1nc~r;islaric luilg wnwrf: no mrtaslases of thr lestic.utat~ (111nor No inforniation was ;~vail;ihlv in three \\?I t’ torlntl to ;lLlq’w.‘~’ ttw
0~tier.s
c vslic tumor
I are
‘I‘hese tumors
strurrures,
Tumors
orhe
c.;u-vinonu
course,
tww3ponding
our
01 rnuc~inoris
such
dinkrl
of thosc
of’the
tumors.
considered
01. wtr
regard
c‘ys-
with
xid
In our opinion. it c~anlicb( the (urnor belongs 10 the
tumors.
rpitiidymis,
rlllrd 0111with
papillary
malignancy
miitterian
scco~idarv
ex-
mic roscopy,
as a serous
borderline
wherhel-
tliff&n~i:d
pathologic
and electron
iiiro invasive cancer.
deter-n,incd
g~orip of
of- c.cmventional
rlitnor ~nay be classified
1;3dtwom;i, Iw
the rcsul~s
iilirniulotiisto~tieniistr~.
w-t.1 e
DESMOPLASTIC A DIAGNOSTIC I‘IIOMAS
I%. C:KOI
MALIGNANT DILEMMA 11’. \lR.
MK(:Pl,
MESOTHELIOMA THOMAS
V.
COLUY,
MASQUERADING MD, PF.I~K (:. (L\Y. VI).
AS SCLEROSING FCCP,
MEDIASTINITIS:
ANI) KICH.WD.J.
I’Is.\sI,
MD, FCCP