Prof. Dr. med. Beata BODE-LESNIEWSKA Institute of Pathology and Molecular Pathology University Hospital; Zurich

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Lambert Butler
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1 Prof. Dr. med. Beata BODE-LESNIEWSKA Institute of Pathology and Molecular Pathology University Hospital; Zurich 32 year old man 2 months history of growing left supraclavicular lymph nodes Antibiotic treatment was not successful Thoraco-abdominal staging (at first CT, than PET-CT)

2 PET-CT performed prior to the FNAC of the leftsupraclavicular mass Aug 18th

3 32 year old man 2 months history of growing left supraclavicular lymph nodes Antibiotic treatment was not successful Thoraco-abdominal staging (at first CT, than PET- CT) showed large retroperitoneal, mediastinal and left supraclavicular tumor masses based on imaging the strong clinical suspicion of a lymphoma has been rendered. Sonographically guided FNAC of the left supraclavicular lymph node

4 Sonographically guided FNAC of the pathologic lymph nodes (pln) pln pln Aug 18th

5 Direct smear PAP stain; 100x

6 Direct smear PAP stain; 50x

7 Direct smear PAP stain; 200x

8 Direct smear PAP stain; 200x

9 Direct smear PAP stain; 200x

10 Direct smear PAP stain; 400x

11 Direct smear PAP stain; 400x

12 Cell block HE stain; 100x

13 Cell block Mib1; 200x

14 Differential diagnosis Carcinoma Melanoma Lymphoma Hodgkin Non-Hodgkin (anaplastic) Sarcoma (e.g. epithelioid sarcoma, angiosarcoma, etc ) Germ cell tumor (Mesothelioma)

15 Cell block Cytokeratin (AE1/AE3); 200x

16 FNAC lymph node Cell block; 200x CD20 CD3

17 FNAC lymph node Cell block; 400x CD45 CD30 Alk1 S100, ERG, CD34, CD31 INI1 expression present

18 Differential diagnosis Carcinoma Melanoma Lymphoma Hodgkin Non-Hodgkin Sarcoma Germ cell tumor Mesothelioma

19 Cell block OCT3/4; 400x

20 Cell block PLAP; 400x

21 FNAC lymph node Cell block; 200x SALL4 bhcg

22 Direct smear PAP stain; 400x Germ cell tumor (seminoma) (19.8.)

23 Aug 19th

24 Urology consult

25 Semicastration

27 PLAP Germ cell neoplasia in situ (GCNIS)

28 Final diagnosis Metastatic (at presentation) seminoma Extensive metastases retroperitoneal and left cervical Initial manifestation as supraclavicular lymphadenopathy «Burnt out» (regressed) germ cell tumor of the right testis Semicastration with focal scaring Advanced atrophy of the tubuli Germ cell neoplasia in situ (GCNIS) present

29 Post 4 months chemotherapy Initial PET-C (at presentation)

30 Follow up Recurrent tumor 6 month after initial presentation High dose chemotherapy with autologous bone marrow transplantation successful Local lumbal spine radiotherapy for residual tumor 6 years after initial presentation no further tumor manifestations declared as cured

31 Germ cell Tumors (GCT) Rare (1% of male malignancy) Incidence / (higher in industrialiezed countries) Ethnicity / genetic susceptibility Enviromental factors however - most common cancer among young male patients (puberty to 40-ies) in industrialized countries High metastatic potential Accompanied by tumor markers in blood (AFP, bhcg) Curable with modern combined therapy regimens (most important chemotherapy)

32 Usual presentation as a testicular mass Some 3-10% of seminomas and embryonal carcinomas present as a metastatic disease Practically all choriocarcinomas are metastatic at presentation «Burnt out» (regressed) testicular tumors May cause bulky metastatic diesease Should not be confused with (rare) extragonadal primaries (retroperitoneum, mediastinum)

33 GCT - Subtypes Seminoma Non-seminomatous GCT Embryonal carcinoma Yolk sac tumor Choriocarcinoma Teratomas Mixed GCT

Cytologic diagnosis of GCT Not on primary tumors Possible in metastatic setting First diagnosis, if testicular primary not obvious Recurrent tumor Advantage: rapid turn

34 Cytologic diagnosis of GCT Not on primary tumors Possible in metastatic setting First diagnosis, if testicular primary not obvious Recurrent tumor Advantage: rapid turn over time final pathologic tissue diagnosis within 2 days No excisional biopsy neccessary Semicastration on the 4th day Disease specific diagnosis chemotherapy prompty started

35 Facit Metastatic germ cell tumor (GCT) may cause cervial lymphydenopathy (not only retroperitoneal / mediastinal) Cytologic diagnosis of GCT is well feasible GCT should be considered as a differential diagnosis especially in young male patients with rapidly progressive lymphadenopathy

Disclosure of Relevant Financial Relationships

Evening Specialty Conference - Genitourinary Pathology Case 2 Disclosure of Relevant Financial Relationships Sean R Williamson, MD Henry Ford Health System, Detroit, MI @Williamson_SR USCAP requires that