Article By:

Manjula R., M.B.B.S. Postgraduate student
Email: manjular98@yahoo.com

Durva Prabhugaonkar, M.B.B.S.
Email: prabhudurva88@gmail.com

Adora Fernandes, M.B.B.S. Postgraduate student
Email: adora90@gmail.com

R. G. Wiseman Pinto, MD, DNB,
MNAMS, MIAC
Professor and Head,
Department of Pathology
Goa Medical College,
Bambolim, Goa 403202
Email: wisemanpinto@gmail.com

Abstract

A cryptorchid testis is more likely to develop a germ cell tumor than is a normally placed organ. The incidence is greater when the testis is intra-abdominal as compared with an inguinal testis. Seminoma is the most common type, but other germ cell tumors also occur. Seminomas account for about 50% of all testicular tumors. They are divided into two major categories: classic and spermatocytic. Here, we report five cases of seminoma developing in undescended testes, four of which were intra-abdominal and one was inguinal.

Introduction:
Seminoma is a germ cell tumor of the testicles or rarely, the extra-gonadal location. Seminomas makeup 50% of germ cell tumors, although it accounts for only 1% of cancers in men. It is most commonly seen in the 4th decade of life (35-45 years). There are also well-described racial and geographic differences that play a role in the incidence of seminoma, overall the incidence of seminoma is 6-10-fold higher in Caucasians, which is observed across all age groups. Cryptorchidism represents the strongest risk factor for seminoma with an increased risk not only in the affected testis but also in the contralateral testis. Other risk factors include family history of germ cell tumors, certain intersex conditions and a previous history of a germ cell tumor. Histopathologically, two types of pure seminoma have been described: classic and spermatocytic.

Material & Methods:
This article comprises of a study of five patients with undescended testis that presented with an intra-abdominal mass or inguinal swellings in the outpatient department at Goa Medical College. These cases presented during the period of 1995 to 2017 (22 years). Biopsy samples were received by the Department of Pathology of Goa Medical College.

The age group varied from 20-45 years. Out of five patients, four were male and one was hermaphrodite (intersex). In four of the cases, the testes were intra-abdominal and in one case it was inguinal.

On microscopy, all the cases were classical seminomas with typical histological features of groups of large germ cells separated by fibrous stroma containing lymphocytes (Figure 1).

TC-Apr2017-009 - histopathology of seminomaFigure 1. Histopathology of seminoma arising in an undescended testis; note the large germinal cells in group, clusters separated by fibrous tissue containing lymphocytes and histiocytes. (Hematoxylin & Eosin Stain (H&E) x 100).

Periodic acid-Schiff (PAS) stain was also done depicting glycogen (Figure 2).

TC-Apr2017-010 - PAS stain of seminomaFigure 2. PAS stain of seminoma; note the glycogen positivity (red in colour) seen in the cytoplasm of the cells (PAS stain x 400).

Discussion:
Cryptorchidism is a known cause of testicular tumors. The position of the undescended testis is related to the likelihood of carcinogenesis, with the intra-abdominal location having the highest risk of malignancy. The incidence of developing a testicular tumor is 10 times higher in an inguinal testis and 50 times higher in an intra-abdominal testis[1].

The cause of carcinogenesis is still debatable. A high intra-abdominal temperature has been incriminated as the cause of carcinogenesis in the testis. There may be a decrease in the spermatogenesis, Leydig cell abnormality and delay in the development of the Sertoli cells in the testis leading to infertility[2].

Painless enlargement of the testis or an abdominal mass (Figures 3 and 4) are the common modes of presentation. Rarely, an abdominal testicular tumor can cause an acute abdomen, pain, and haematuria because of adjacent visceral infiltration[3].

TC-Apr2017-011 - protruded abdomen due to an intra-abdominal massFigure 3. Clinical photograph of a 20-yearold patient showing protruding abdomen due to an intra-abdominal mass.

TC-Apr2017-012 - CT scan showing an large abdominal mass

Figure 4. Computed Tomography (CT) scan showing a large intra-abdominal mass in a 20-year-old male patient.

The undescended testis carries a 20-48 times higher potential for malignant transformation than the normally undescended testis.

Classical seminoma is the most common single histologic type of germinal testicular neoplasms.Seminoma is a common pure germ cell tumor of testis. It is the most prevalent solid malignancy affecting young male adults in the age group of 35-45 years[4].

Fine needle aspiration cytology (FNAC) smears from the lesion show discohesive, large tumor cells, dispersed in singles with granular cytoplasm, enlarged nuclei and many with prominent nucleoli. The background is tigroid with variable amounts of lymphocytes (Figures 5 and 6).

Microscopically, sheets of relatively uniform tumor cells are divided into poorly demarcated lobules by delicate fibrous septa with T lymphocytes and plasma cells (Figure1). Cells are large, round to polyhedral, with distinct cell membranes, abundant clear/watery cytoplasm (glycogen), large central nuclei, and 1-2 prominent, often elongated, and irregular nucleoli. Usually, minimal mitotic figures are seen. Tubular preservation may occur at the periphery of the tumor[5].

TC-Apr2017-013 - fine needle aspiration cytology (FNAC) of the seminomaFigure 5. Fine needle aspiration cytology (FNAC) of the seminoma arising from an intra – abdominal undescended testis.(Hematoxylin & Eosin (H & E) x 100).

TC-Apr2017-014 - High power view of the FNAC of seminoma

Figure 6. High power view of the FNAC of seminoma; note the large germinal cells having clear cytoplasm seen with May-
Grünwald-Giemsa (MGG) stain x 400).

 

IMMUNOHISTOCHEMISTRY:
Markers positive in seminoma are as follows:

  • Placental alkaline phosphatase (PLAP)
  • PAS
  • ANGIOTENSIN 1 CONVERTING ENZYME
  • CD117/c-KIT
  • OCT3/4
  • SALLA
  • SOX17
  • DL-40
  • NANOG

Conclusion:
We have presented five cases of undescended  testis of patients in the age group of 20-45 years of age, of which four out of five cases were intraabdominal testis and only one was inguinal. Histopathologically, all were classical seminomas. Our findings were concurrent with existing risk factor statistics and typical presentations.

References:
1. Haque MM, Siddique AB, Rabbani ABMG, Quasem MA, Rahman AKMG, Rahman MM Seminoma in undescended intraabdominal testis: a case report. TAJ. December 2005;18 (2)

2. Alawad AAM, Younis FH Giant seminoma in an undescended testis present in gas a mass in the right iliac fossa .J. of Surgery. 2015; 11(3): 111-112.

3. Palma CC, Cristobal B., Maccioni R. Seminoma in an adult cryptorchid testis (intra-abdominal): a case report. Act as Urol
Esp. 2007; 31(2):160-163

4. Wood HM, Elder JS Cryptorchidism and testicular cancer: separating fact from fiction. J. of Urol. Feb 2009;181(2):452-61

5. Alshyarba MH. A giant intra-abdominal testicular seminoma. Biomed Research.2010;21(3):227-229