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

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)

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

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

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

Direct smear PAP stain; 100x

Direct smear PAP stain; 50x

Direct smear PAP stain; 200x

Direct smear PAP stain; 400x

Cell block HE stain; 100x

Cell block Mib1; 200x

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

Cell block Cytokeratin (AE1/AE3); 200x

FNAC lymph node Cell block; 200x CD20 CD3

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

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

Cell block OCT3/4; 400x

Cell block PLAP; 400x

FNAC lymph node Cell block; 200x SALL4 bhcg

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

Aug 19th

Urology consult

Semicastration

PLAP Germ cell neoplasia in situ (GCNIS)

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

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

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

Germ cell Tumors (GCT) Rare (1% of male malignancy) Incidence 1.5-12 / 100 000 (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)

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)

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 over time final pathologic tissue diagnosis within 2 days No excisional biopsy neccessary Semicastration on the 4th day Disease specific diagnosis chemotherapy prompty started

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