ORIGINAL ARTICLE
Adult Granulosa Cell Tumors of the Testis A Report of 32 Cases Kristine M. Cornejo, MD*w and Robert H. Young, MD*w
Abstract: The clinicopathologic features of 32 adult granulosa cell tumors (AGCT) of the testis are presented. The patients were from 14 to 87 years of age (mean 40.0 y) and underwent orchiectomy (n = 30) or wedge excision (n = 2). None had endocrine-related symptoms. The tumors measured 0.5 to 6.0 cm (mean 2.8 cm) and were predominantly well circumscribed and yellow-tan, except for 1, which had infiltrative borders. The predominant pattern was diffuse, but insular, spindled, microfollicular (Call-Exner bodies), trabecular, corded, watered-silk, palisading, and pseudopapillary patterns were also present. The cells contained round to ovoid nuclei with frequent longitudinal nuclear grooves, indistinct cell borders, and varying amounts of eosinophilic cytoplasm. Most tumors contained limited amounts of fibrocollagenous stroma. The mitotic count ranged from 0 to 18/10 high-power fields (HPF) (mean 4.9/10 HPF, 400). Two tumors had prominent necrosis, and 1 had vessel invasion. Follow-up information was available for 19 patients, with a mean of 51.0 months (range, 1 to 169 mo). All were without evidence of disease except 1 who had lung metastasis at 24 months. Our findings indicate that the morphologic spectrum of testicular AGCT is similar to that of ovarian AGCT. The majority of testicular examples have a good prognosis (compared with a malignant behavior in 2 of 7 cases in 1 prior series). Lymphovascular invasion, infiltrative borders, and size >4 cm may help in identifying cases with aggressive behavior, as these features were present in the one case with metastasis in our series. Mitotic counts varied and do not appear to be of prognostic significance on the basis of our experience. Key Words: testis, adult granulosa cell tumor, sex cord-stromal tumor, prognosis
of the remainder are Sertoli cell tumors.4,5 Recent studies have added to our knowledge of the clinical and pathologic features of these tumors. The well-known granulosa cell tumor (GCT) is much more common in the ovary, and experience with testicular examples is limited. In the testis, as in the ovary, GCTs are divided into adult and juvenile forms. Only 1 series focusing on the adult form has been published.6 We have seen a relatively large number of examples of this rare neoplasm and report our experience with 32 examples herein.
MATERIALS AND METHODS A search of the consultation files at the Massachusetts General Hospital uncovered 32 cases of adult granulosa cell tumors (AGCT) of the testis (Table 1). The one case from our routine hospital material (previously reported)3,7 is not included in this series, as the slides are no longer present for review, but the tumor is depicted as it is typical of a subset of the cases overall (Fig. 1A). Hematoxylin and eosin–stained sections available for review ranged from 1 to 14 slides (mean 3.8 slides/case). Immunohistochemical stains were reviewed if performed, or results were documented per the original pathology report. Clinical data including presentation, serum markers, gross description, and treatment were recorded, as were gross characteristics. The neoplasms were evaluated for histologic patterns, cytologic features including mitotic count, the presence of lymphovascular invasion (LVI), hemorrhage, necrosis, and nature of the stroma.
(Am J Surg Pathol 2014;38:1242–1250)
RESULTS Clinical Data
S
ex cord-stromal tumors comprise about 5% of testicular tumors in adults but about 30% of those from children.1–3 Most are Leydig cell tumors, and the majority
From the *James Homer Wright Pathology Laboratories, Massachusetts General Hospital; and wDepartment of Pathology, Harvard Medical School, Boston, MA. Conflicts of Interest and Source of Funding: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Kristine M. Cornejo, MD, Department of Pathology, Massachusetts General Hospital, Warren Building 225, 55 Fruit Street, Boston, MA 02114 (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
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The results are summarized in Table 1. The patients were from 14 and 87 years of age (mean 40.0 y). None had endocrine-related symptoms or elevated serum markers. Of the 25 that reported a presenting symptom, 23 patients had a testicular mass or swelling. The remaining 2 patients presented with a prior history of a repaired undescended testis and a presumed testicular torsion, respectively. The tumor was located slightly more often on the right (left, n = 12; right, n = 19). The patients underwent orchiectomy (n = 30) or wedge excision (n = 2). None underwent lymph node dissection or received adjuvant therapy. Follow-up information was available for 19 patients. The mean follow-up interval Am J Surg Pathol
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TABLE 1. Clinicopathologic Data of Testicular AGCT Cases Case Age (y) Laterality Size (cm) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
37 49 22 50 — 27 87 47 51 47 55 25 45 74 27 32 18 60 23 20 52 14 21 17 64 14 28 51 63 25 44 50
Left Right Left Left Left Right — Right Right Left Left Right Right Left Right Right Left Right Right Left Right Right Right Right Right Right Left Right Left Right Left Right
2.8 3.0 3.3 0.9 3.0 1.8 — 4.5 2.1 0.5 2.1 2.0 1.4 3.5 1.4 4.2 3.2 6.0 1.4 4.5 4.3 0.8 3.0 1.5 2.4 3.5 2.6 3.0 1.0 5.5 1.2 4.7
Treatment Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Wedge excision Orchiectomy Orchiectomy Wedge excision Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy
Mitotic Count (per HPF) Presence of LVI or Necrosis 14/10 1/10 0/10 2/10 0/10 3/10 4/10 6/10 4/10 0/10 2/10 0/10 8/10 11/10 7/10 2/10 3/10 1/10 6/10 8/10 8/10 1/10 1/10 18/10 8/10 8/10 11/10 1/10 6/10 4/10 2/10 6/10
None None None None Necrosis None None None None None None None None None None None None None None Necrosis LVI None None None None None None None None None None None
Follow-up LTF DOOD at 137 mo NED at 48 mo NED at 59 mo LTF NED at 60 mo NED at 169 mo LTF NED at 58 mo LTF NED at 80 mo LTF LTF NED at 104 mo NED at 36 mo LTF LTF LTF NED at 65 mo NED at 1 mo Metastasis to lung at 24 mo LTF NED at 37 mo LTF NED at 28 mo NED at 35 mo LTF LTF NED at 25 mo NED at 1 mo NED at 1 mo NED at 1 mo
DOOD indicates died of other disease; LTF, lost to follow-up; NED, no evidence of disease.
was 51.0 months (range, 1 to 169 mo). All patients were without evidence of disease except 1 who had lung metastasis at 24 months.
inantly solid, with 2 being both solid and cystic. The cut surface was typically lobulated and yellow-tan (Fig. 1A), or tan to white (Fig. 1B), but 1 was red-pink and spongy.
Gross Features
Microscopic Features
The tumors measured 0.5 to 6.0 cm (mean 2.8 cm) in maximum dimension and were well circumscribed, except for 1, which had infiltrative borders. They were predom-
On low-power examination, all but 1 of the tumors was well circumscribed. They often exhibited a nodular low-power appearance, and within the nodules the cells
FIGURE 1. Macroscopic images of testicular AGCTs. A, Lobular yellow neoplasm with a few cysts and foci of hemorrhage. B, Neoplasm with a uniform white to yellow sectioned surface. r
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FIGURE 2. Low-power view showing prominent cellular lobules intersected by scant nonspecific fibrous stroma (hematoxylin and eosin stain).
predominantly grew diffusely (Fig. 2). However, spindled, insular, microfollicular, trabecular, corded, watered-silkgyriform, palisading, and pseudopapillary patterns were also present to varying degrees (Figs. 3–6) (Table 2). The diffuse and spindled patterns were seen as sheets of rounded or fusiform cells, respectively. The microfollicular pattern comprised numerous small spaces (Call-Exner bodies), which often contained hyalinized basement membrane material or eosinophilic fluid. The corded and trabecular patterns exhibited regular to irregularly arranged thin cords or thick columns of tumor cells. The watered-silk or gyriform patterns were defined by interweaving cords and undulating columns of cells, whereas the insular pattern was characterized by nests of tumor cells surrounded by stroma. The palisading pattern was characterized by tumor cells arranged parallel to each other, resembling a fence. The pseudopapillary pattern was characterized by tumor cells surrounding fibrovascular cores, forming papillary-like architecture. The tumor cells contained uniformly round to ovoid nuclei with conspicuous longitudinal nuclear grooves, indistinct cell borders, and variable amounts of eosinophilic cytoplasm, the latter usually being scant and barely perceptible, but it was moderately conspicuous in 3 (Fig. 7). The granulosa cells were luteinized in 3 cases, containing more abundant clear to eosinophilic cytoplasm with rounded nuclei (Fig. 8A). The tumors contained limited amounts of fibrocollagenous stroma except for 5, in which the stroma was more abundant and often intermixed with spindled granulosa cells forming a herringbone and/or fascicular pattern (Figs. 8B, C). None of the cases had luteinized stromal cells. The mitotic count ranged from 0 to 18/10 high-power fields (HPF) (mean 4.9/10 HPF, 400). Two cases had necrosis, 8 cases had hemorrhage and/or hemosiderin deposition, and LVI was noted in only 1 case. All of the tumors were unencapsulated, except 1, which had a fibrous pseudocapsule. The tumor infiltrated
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FIGURE 3. Histologic patterns of AGCT. A, Diffuse pattern (H&E stain). B, Spindled pattern (H&E stain). H&E indicates hematoxylin and eosin.
between the seminiferous tubules in 14 cases and the rete testis in 12 cases and invaded the tunica albuginea in 6 cases. Only 1 tumor involved the paratesticular tissue and showed lymphatic invasion (T2). The immunohistochemical results are summarized in Table 3. The tumor cells were strongly positive for inhibin, vimentin, and calretinin and negative for EMA and desmin. Most tumors were negative for cytokeratin, and in the few cases that showed immunoreactivity, it was weak and patchy or in a paranuclear dot-like pattern. Variable staining was observed with smooth muscle actin, S-100, and Melan-A.
DISCUSSION GCTs are much more common in the ovary than in the testis.8 In the ovary, AGCTs are much more common than their juvenile counterpart. Given the rarity of both AGCT and juvenile GCTs (JGCT), it is not possible to accurately assess their relative frequency, but the information r
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FIGURE 4. Histologic patterns of AGCT. A, Corded pattern (H&E stain). B, Gyriform or watered-silk pattern (H&E stain). H&E indicates hematoxylin and eosin.
at hand suggests a more balanced distribution of the 2 in male than in female individuals. Although we acknowledge a bias, as the majority of material comes from consult cases, we have seen almost as many AGCTs as JGCTs of the testis. The first description of a testicular GCT was by Laskowski in 1952.9 Since then, a small number of cases have been reported, mostly singly, with only 1 series of 7 patients.3,6,7,10–20 The present series is the largest study of AGCTs of the testis reported. Patients with this neoplasm have typically presented with a painless testicular mass or swelling at an average age of 44 years, which is similar to our series of 40 years.1 Although none of our patients had such findings, endocrine manifestations such as gynecomastia or decreased libido have been present in up to 25% of cases in the literature.1,8 Tumors have reported to range from microscopic to 13.0 cm in maximum dimension and are well circumscribed and tan to yellow.1 Teilum21 was the first to emphasize the homology between GCTs in the ovary and testis. Our findings indicate that the morphologic spectrum of testicular AGCTs is indeed similar to that of ovarian AGCTs. r
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FIGURE 5. Histologic patterns of AGCT. A, Microfollicular pattern (Call-Exner bodies) (H&E stain). B, Insular pattern (H&E stain). H&E indicates hematoxylin and eosin.
The overall differential diagnosis of AGCT of the testis is narrower than pertains to the similar tumor of the ovary because of the rarity, in the testis, of some of its well-known mimics in the ovary, such as, for example, metastatic lobular carcinoma from the breast. Nonetheless, a number of issues may arise. JGCTs differ from the adult form as they occur in the first 6 months of life and are rare after the first year.1,8,22,23 They may be associated with ambiguous external genitalia and abnormal karyotypes, which are not present in AGCTs.1,8,22,23 Microscopically, the predominant patterns in JGCTs are follicular and solid or a combination of both. The follicles are often irregular in size and shape in comparison with the uniformly sized follicles in AGCTs and frequently contain mucinous material. Call-Exner bodies are usually absent in the JGCT. The follicles are lined by granulosa cells with an outer layer of theca cells, which are not commonly found in AGCT. The granulosa cells have more abundant eosinophilic or vacuolated cytoplasm with round nuclei that www.ajsp.com |
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FIGURE 7. Granulosa cells with uniformly round to ovoid nuclei, frequent longitudinal nuclear grooves, indistinct cell borders, and scant cytoplasm (hematoxylin and eosin stain).
FIGURE 6. Histologic patterns of AGCT. A, Palisading pattern (H&E stain). B, Pseudopapillary pattern (H&E stain). H&E indicates hematoxylin and eosin.
lack grooves. A prominent fibrous stroma is more common in the AGCT.8,22,23 Leydig and Sertoli cell tumors also present at a similar age of 46.5 and 45 years, respectively.1,4,5,8 Histologically, Leydig cell tumors can easily be distinguished
TABLE 2. Pathologic Data of Testicular AGCT Cases Morphologic Feature Patterns Diffuse/solid Insular Spindled Cords/trabecular/gyriform Microfollicular/Call-Exner bodies Herringbone/fascicular Pseudopapillary/palisading Luteinized granulosa cells Mitotic count/10 HPF r4/10 HPF Z5-10/10 HPF > 10/10 HPF
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N (%) 27 17 16 13 7 5 4 3
(84) (53) (50) (41) (22) (16) (13) (9)
18 (56) 10 (31) 4 (13)
from AGCTs as they contain sheets or lobular aggregates of neoplastic cells with round, centrally located nuclei and abundant eosinophilic cytoplasm arranged with variable amounts of fibrous stroma. The cells may occasionally appear vacuolated and contain crystals of Reinke, which are not identified in AGCTs.4 Sertoli cell tumors contain polygonal tumor cells with abundant pale to lightly eosinophilic cytoplasm and may also be vacuolated. They can contain trabecular, corded, or diffuse patterns, making them occasionally difficult to differentiate from AGCTs. However, distinguishing features are the presence of well-formed tubules, albeit in varying amounts, and the lack of the typical microfollicular pattern of AGCTs. Although nuclear grooves may be seen in Sertoli cell tumors, they are generally inconspicuous and histologically are much more characteristic of AGCTs.5,8 In addition, Sertoli cell tumors are sometimes vascular, not a feature of the AGCTs of this series, and may have a hyalinized stroma.5 Having discussed the differential diagnosis with Sertoli cell tumor, it is pertinent to note that in the ovary, the differential for AGCT is less commonly an issue, the Sertoli-Leydig cell tumor being more often a consideration. In the testis, however, the Sertoli-Leydig cell tumor is, compared with the ovary, remarkably uncommon such that this is almost never a realistic consideration, and, if it should be, criteria used for the ovary would pertain. The differential diagnosis of the AGCT also includes a fibrothecoma, which similarly occurs at an average age of 44 years.24 Testicular fibrothecomas are comprised of ovoid and/or spindled cells in varying amounts of collagenous stroma and may mimic AGCTs containing a spindled and/ or fibrosarcoma-like pattern.24 The various architectural patterns and distinct cytologic features help differentiate AGCTs from fibrothecomas. Zhang et al24 recently described inhibin positivity in 11 of 13 (85%) cases in a patchy to diffuse pattern, making immunohistochemistry unreliable in differentiating these 2 neoplasms. r
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TABLE 3. Immunoreactivity of Testicular AGCT Cases IHC Stains Inhibin Vimentin Calretinin Smooth muscle actin S-100 Cytokeratin Melan-A Desmin HMB45 EMA
FIGURE 8. Additional histologic features of AGCTs of the testis. A, Luteinization of granulosa cells with abundant clear to eosinophilic cytoplasm (H&E stain). B, Abundant fibrocollagenous stroma intermixed with spindled granulosa cells (H&E stain). C, Spindled granulosa cells with fibrocollagenous stroma imparting a herringbone pattern (H&E stain). H&E indicates hematoxylin and eosin.
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No. Cases Stained 11 5 7 6 7 7 4 4 2 4
Positive Cases (N [%]) 9 5 6 4 4 3 1 0 0 0
(82) (100) (86) (67) (57) (43) (weak or dot-like) (25) (0) (0) (0)
Finally, in the testis, compared with the ovary, a greater percentage of sex cord-stromal tumors defy confident subclassification into the specific groupings such as granulosa and Sertoli cell tumor and are placed in the sex cord-stromal tumor unclassified group. These may have foci, in isolation, consistent with AGCT, but by definition the tumors have other features that are indeterminate or even of Sertoli nature. All our tumors had dominant foci of clear cut granulosa cell neoplasia. Overall, the role of immunohistochemistry in establishing the diagnosis of AGCT is limited as they contain similar staining patterns to other sex cord-stromal tumors of the testis. The majority of AGCT cases showed positivity for vimentin, inhibin, and calretinin and negativity for EMA. Other immunohistochemical markers such as SMA, S-100, cytokeratin, and Melan-A had more inconsistent results. A paranuclear dot-like pattern seen with cytokeratin staining has been previously reported in GCTs and was identified in one of our cases.25 The CD99 and antimullerian immunostains have also been rarely reported to be positive in AGCTs but was not performed in any of our cases.10,26,27 GCTs are considered to be low-grade malignant neoplasms as they are slow growing with metastasis in up to 20% of cases.1,28 The majority of AGCTs of the testis have a good prognosis. A literature review revealed 7 cases with metastatic disease among 30 reported cases (23%) (Table 4).6,14,15,18–20 Combining these with our 19 cases containing follow-up, there is a total of 8 of 49 (16%) cases with metastases. It is difficult to predict which neoplasms will potentially metastasize based on clinicopathologic features. Pathologic features that were thought to predict malignant potential included tumor size >5 cm, moderate or marked nuclear atypia, necrosis, LVI, an infiltrative border or paratesticular invasion, and >5 mitotic figures/ 10 HPF.2,6,19 Hanson and Ambaye16 identified tumor size as the only feature significantly associated with malignant behavior and excluded tumor necrosis, mitotic count, age, and presence of gynecomastia. Features such as LVI, infiltrative borders, and size >4 cm may help in identifying cases with more aggressive behavior, as these 3 features were present in the one case with metastases in our series. In addition, 3 of the 7 cases from the literature review also noted LVI, and all 7 cases were >4 cm in size. Mitotic counts varied and did not appear to be prognostic. www.ajsp.com |
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TABLE 4. Summary of Testicular AGCTs With Metastasis (n = 8)
Age (y)
Endocrine-related Symptoms, Laboratories
JimenezQuintero et al6
60
JimenezQuintero et al6
Case
Presentation
Size (cm)
None
Mass slowly growing for years
7.0
29
None
Incidental finding
7.5
Matoska et al14
26
Gynecomastia
Harrison et al15
65
None
Suppiah et al18
51
Hammerich et al19
55
Mostofi et al20
41
—
This study
52
None
Mass slowly growing for 7 mo
10.0
Testicular swelling for 9 mo
5.0
Serum AFP and HCG WNL
Testicular swelling
—
Serum AFP and HCG WNL
Incidental finding
10.5
Mass slowly growing for 8 y —
10.5 4.3
Gross and Pathologic Features Circumscribed, yellow, friable, and necrotic with thick capsule 2/50 HPF Circumscribed, heterogenous, partly cystic, hemorrhagic 3/50 HPF LVI present Partly solid and cystic, gray, rubbery 9/10 HPF Suggestion of vascular spread Paratesticular tumor arising from the epididymis
— Homogenous surface with calcifications 13/10 HPF LVI present Lobulated, tan-pink Red-pink, spongy soft mass with infiltrative borders LVI present
Follow-up DOD at 134 m, liver and RLN metastases at 121 mo s/p CT AWD at 14 mo, RLN metastasis at diagnosis, right ILN metastasis at 12 mo, s/p RLND and CT NED at 168 mo, metastases to RLN s/p RLND, and RT
DOD at 32 mo, metastasis to RLN s/p RLND at 8 mo, metastasis to left retroperitoneum at 15 mo s/p excision, recurrence with peritoneal metastasis at 17 mo s/p CT for 6 mo, with progression with iliac and RLN adenopathy, s/p pazopanib for 4 mo with partial response and resolution of RLN adenopathy NED at 76 mo, metastasis to left tibia at 72 mo s/p amputation NED at 39 mo, multiple pulmonary metastases at diagnosis s/p metastasectomy and CT DOD at 5 mo, multiple metastases AWD at 24 mo, metastasis to lung
AFP indicates alpha-fetoprotein; AWD, alive with disease; CT, chemotherapy; DOD, died of disease; HCG, human chorionic gonadotropin; HPF, high power field; ILN, inguinal lymph nodes; LVI, lymphovascular invasion; NED, no evidence of disease; RLN, retroperitoneal lymph nodes; RLND, retroperitoneal lymph node dissection; RT, radiotherapy; s/p, status post; WNL, within normal limits.
The mainstay of treatment for organ-confined disease is surgical, usually orchiectomy. However, treatment in advanced disease is less clear as there is no consensus on therapeutic recommendations because of the rarity of the neoplasm. Patients are often kept under extended surveillance with annual imaging because of the possibility of metastasis, which can occur years after diagnosis.6,18 Retroperitoneal lymph node dissection (RLND) may have some utility as 4 of 13 patients with stage I testicular sex cord-stromal tumors (Leydig cell tumor, n = 3; sex cord-stromal tumor, n = 1) who underwent RLND were upstaged as a result of the surgery.29 Therefore, RLND may have some utility in cases with malignant features or small-volume metastatic disease.29 It appears from the review of the literature that the patients with lymph node and/or distant metastases
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treated successfully with surgical resection have a better outcome, as 3 patients are alive without disease at 39, 76, and 168 months, respectively, and 1 patient is alive with disease at 14 months. The remaining cases treated with neoadjuvant therapy alone or were not surgical candidates for resection died of disease. Similar results have been reported by Gohji et al30 in malignant gonadal stromal tumors. Overall, the primary role of chemotherapy and/or radiotherapy is less clear, as AGCT of the testis appears to be somewhat chemoresistant.15,30 One patient had a partial response to pazopanib, an oral multitargeted tyrosine kinase inhibitor, which has antiangiogenic effects after treatment failure with chemotherapy.15 In addition, the patient had complete resolution of their retroperitoneal lymphadenopathy. Targeted therapy using tyrosine kinase inhibitors may r
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provide a sensible option in patients with metastatic disease, particularly in cases in which surgical resection is not feasible. Little is understood about the pathogenesis of testicular AGCTs. Recently, a single somatic mutation of the FOXL2 gene (C134W) has been identified in up to 97% of AGCTs of the ovary.31,32 FOXL2, also called forkhead box L2, is a transcription factor involved in ovarian differentiation and is required for normal granulosa cell development.31,33 The FOXL2 nuclear protein was consistently immunoexpressed in 93% to 100% of AGCTs of the ovary that harbored a FOXL2 mutation.32,34 Conversely, the results within testicular AGCTs have varied. Hes et al35 analyzed 4 AGCTs of the testis for FOXL2 by both immunohistochemistry and sequencing analysis. Interestingly, all 4 tumors were positive by immunohistochemistry but were negative for the mutation in the 3 tumors tested. A second study by Lima et al33 identified 2 of 5 (40%) testicular AGCTs harbored the FOX2 mutation. In addition, FOXL2 immunoreactivity has been identified in 3 (100%) testicular JGCTs.36 Therefore, the mutational status of FOXL2 in testicular GCTs is unclear, but they appear to aberrantly express FOXL2 by immunohistochemistry and may serve as an additional diagnostic ancillary tool. Although FOXL2 immunohistochemical and mutational studies have not been performed on other sex cord-stromal tumors of the testis, besides GCTs, they have been performed in a number of tumors in the ovary. FOXL2 immunoreactivity has been identified in 58% of sex cord-stromal tumors tested such as in Sertoli cell tumors and thecoma-fibroma tumors but not in other non– sex cord-stromal tumors.32 Leydig cell tumors, which may also enter the differential diagnosis, have been negative for FOX2L. Therefore, immunopositivity for FOXL2 supports a tumor of sex cord-stromal origin but is not specific for GCTs. In addition, although the FOX2L mutation is specific for AGCTs, it has been reported in rare cases of thecomas, Sertoli-Leydig cell tumors, and sex cord-stromal tumors unclassified.32 Studies have also shown that sustained activation of the WNT/CTNNB1 pathway leads to the development of GCTs in mice.37 A recent study revealed that CTNNB1 mutant mice with loss of phosphatase and tensin homolog (PTEN) expression in their Sertoli cells developed testicular GCTs.38 An additional study confirmed that in addition to PTEN loss, KRAS activation in Sertoli cells of CTNNB1 mutant mice also produces GCTs.39 Therefore, CTNNB1 activation with loss of PTEN or activation of KRAS may also play a role in tumorigenesis. In addition, CTNNB1 mutations have also been identified in testicular Sertoli cell tumors and do not appear to be specific to GCTs.40 These new insights into the molecular pathways involved in the development of AGCTs appear promising and may help identify targets for therapy. In conclusion, our large series and review of the literature highlights the clinicopathologic features and prognosis of these rare neoplasms, as well as the difficulty in determining optimal management for these patients. r
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Although most AGCTs of the testis behave in a benign manner, a small subset has the capability to metastasize, often years after diagnosis. Therefore, long-term followup in these patients is important. Furthermore, on-going research into the molecular pathogenesis of GCTs may provide new diagnostic tools and goals for targeted therapy, which may improve the outcome in the few patients with metastatic disease. REFERENCES 1. Sesterhenn IA, Cheville J, Woodward PJ, et al. Sex cord/gonadal stromal tumours. In: Eble JN, Sauter G, Epstein JI, Sesterhenn IA, eds. WHO Classification of Tumours: Pathology and Genetics of Tumours of the Urinary System and Male Genital Organs. Lyon, France: International Agency for Research on Cancer (IARC); 2004:250–258. 2. Cheville JC. Classification and pathology of testicular germ cell and sex cord-stromal tumors. Urol Clin North Am. 1999;26:595–609. 3. Marshall FF, Kerr WS Jr, Kliman B, et al. Sex cord-stromal (gonadal stromal) tumors of the testis: a report of 5 cases. J Urol. 1977;117:180–184. 4. Kim I, Young RH, Scully RE. Leydig cell tumors of the testis. A clinicopathological analysis of 40 cases and review of the literature. Am J Surg Pathol. 1985;9:177–192. 5. Young RH, Koelliker DD, Scully RE. Sertoli cell tumors of the testis, not otherwise specified: a clinicopathologic analysis of 60 cases. Am J Surg Pathol. 1998;22:709–721. 6. Jimenez-Quintero LP, Ro JY, Zavala-Pompa A, et al. Granulosa cell tumor of the adult testis: a clinicopathologic study of seven cases and a review of the literature. Hum Pathol. 1993;24:1120–1125. 7. Case records of the Massachusetts General Hospital: case 41471. N Engl J Med. 1955;253:926–931. 8. Young RH. Sex cord-stromal tumors of the ovary and testis: their similarities and differences with consideration of selected problems. Mod Pathol. 2005;18(suppl 2):S81–S98. 9. Laskowski J. Feminizing tumours of testis; general review with case report of granulosa cell tumour of testis. Endokrynol Pol. 1952; 3:337–343. 10. Al-Bozom IA, El-Faqih SR, Hassan SH, et al. Granulosa cell tumor of the adult type: a case report and review of the literature of a very rare testicular tumor. Arch Pathol Lab Med. 2000;124:1525–1528. 11. Miliaras D, Anagnostou E, Moysides I. Adult type granulosa cell tumor: a very rare case of sex-cord tumor of the testis with review of the literature. Case Rep Pathol. 2013;2013:932086. DOI: 10.1155/ 2013/932086. 12. Hisano M, Souza FM, Malheiros DM, et al. Granulosa cell tumor of the adult testis: report of a case and review of the literature. Clinics (Sao Paulo). 2006;61:77–78. 13. Song Z, Vaughn DJ, Bing Z. Adult type granulosa cell tumor in adult testis: report of a case and review of the literature. Rare Tumors. 2011;3:e37; 117–119. 14. Matoska J, Ondrus D, Talerman A. Malignant granulosa cell tumor of the testis associated with gynecomastia and long survival. Cancer. 1992;69:1769–1772. 15. Harrison MR, Huang W, Liu G, et al. Response to antiangiogenesis therapy in a patient with advanced adult-type testicular granulosa cell tumor. Oncology (Huntingt). 2009;23:792–795. 16. Hanson JA, Ambaye AB. Adult testicular granulosa cell tumor: a review of the literature for clinicopathologic predictors of malignancy. Arch Pathol Lab Med. 2011;135:143–146. 17. Gupta A, Mathur SK, Reddy CP, et al. Testicular granulosa cell tumor, adult type. Indian J Pathol Microbiol. 2008;51:405–406. 18. Suppiah A, Musa MM, Morgan DR, et al. Adult granulosa cell tumour of the testis and bony metastasis. A report of the first case of granulosa cell tumour of the testicle metastasising to bone. Urol Int. 2005;75:91–93. 19. Hammerich KH, Hille S, Ayala GE, et al. Malignant advanced granulosa cell tumor of the adult testis: case report and review of the literature. Hum Pathol. 2008;39:701–709.
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20. Mostofi FK, Theiss EA, Ashley DJ. Tumors of specialized gonadal stroma in human male patients. Androblastoma, Sertoli cell tumor, granulosa-theca cell tumor of the testis, and gonadal stromal tumor. Cancer. 1959;12:944–957. 21. Teilum G. Classification of testicular and ovarian androblastoma and Sertoli cell tumors; a survey of comparative studies with consideration of histogenesis, endocrinology, and embryological theories. Cancer. 1958;11:769–782. 22. Lawrence WD, Young RH, Scully RE. Juvenile granulosa cell tumor of the infantile testis. A report of 14 cases. Am J Surg Pathol. 1985;9:87–94. 23. Young RH, Lawrence WD, Scully RE. Juvenile granulosa cell tumor—another neoplasm associated with abnormal chromosomes and ambiguous genitalia. A report of three cases. Am J Surg Pathol. 1985;9:737–743. 24. Zhang M, Kao CS, Ulbright TM, et al. Testicular fibrothecoma: a morphologic and immunohistochemical study of 16 cases. Am J Surg Pathol. 2013;37:1208–1214. 25. Otis CN, Powell JL, Barbuto D, et al. Intermediate filamentous proteins in adult granulosa cell tumors. An immunohistochemical study of 25 cases. Am J Surg Pathol. 1992;16:962–968. 26. Guzzo T, Gerstein M, Mydlo JH. Granulosa cell tumor of the contralateral testis in a man with a history of cryptorchism. Urol Int. 2004;72:85–87. 27. Rey R, Sabourin JC, Venara M, et al. Anti-Mullerian hormone is a specific marker of sertoli- and granulosa-cell origin in gonadal tumors. Hum Pathol. 2000;31:1202–1208. 28. Talerman A. Pure granulosa cell tumour of the testis. Report of a case and review of the literature. Appl Pathol. 1985;3: 117–122. 29. Mosharafa AA, Foster RS, Bihrle R, et al. Does retroperitoneal lymph node dissection have a curative role for patients with sex cord-stromal testicular tumors? Cancer. 2003;98:753–757.
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30. Gohji K, Higuchi A, Fujii A, et al. Malignant gonadal stromal tumor. Urology. 1994;43:244–247. 31. Shah SP, Kobel M, Senz J, et al. Mutation of FOXL2 in granulosacell tumors of the ovary. N Engl J Med. 2009;360:2719–2729. 32. Al-Agha OM, Huwait HF, Chow C, et al. FOXL2 is a sensitive and specific marker for sex cord-stromal tumors of the ovary. Am J Surg Pathol. 2011;35:484–494. 33. Lima JF, Jin L, de Araujo AR, et al. FOXL2 mutations in granulosa cell tumors occurring in males. Arch Pathol Lab Med. 2012;136:825–828. 34. Schrader KA, Gorbatcheva B, Senz J, et al. The specificity of the FOXL2 c.402C > G somatic mutation: a survey of solid tumors. PLoS One. 2009;4:e7988. 35. Hes O, Vanecek T, Petersson F, et al. Mutational analysis (c.402C > G) of the FOXL2 gene and immunohistochemical expression of the FOXL2 protein in testicular adult type granulosa cell tumors and incompletely differentiated sex cord stromal tumors. Appl Immunohistochem Mol Morphol. 2011;19:347–351. 36. Kalfa N, Fellous M, Boizet-Bonhoure B, et al. Aberrant expression of ovary determining gene FOXL2 in the testis and juvenile granulosa cell tumor in children. J Urol. 2008;180:1810–1813. 37. Boerboom D, Paquet M, Hsieh M, et al. Misregulated Wnt/betacatenin signaling leads to ovarian granulosa cell tumor development. Cancer Res. 2005;65:9206–9215. 38. Boyer A, Paquet M, Lague MN, et al. Dysregulation of WNT/ CTNNB1 and PI3K/AKT signaling in testicular stromal cells causes granulosa cell tumor of the testis. Carcinogenesis. 2009;30:869–878. 39. Richards JS, Fan HY, Liu Z, et al. Either Kras activation or Pten loss similarly enhance the dominant-stable CTNNB1-induced genetic program to promote granulosa cell tumor development in the ovary and testis. Oncogene. 2012;31:1504–1520. 40. Perrone F, Bertolotti A, Montemurro G, et al. Frequent mutation and nuclear localization of beta-catenin in sertoli cell tumors of the testis. Am J Surg Pathol. 2014;38:66–71.
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Adult Granulosa Cell Tumors of the Testis A Report of 32 Cases Kristine M. Cornejo, MD*w and Robert H. Young, MD*w
Abstract: The clinicopathologic features of 32 adult granulosa cell tumors (AGCT) of the testis are presented. The patients were from 14 to 87 years of age (mean 40.0 y) and underwent orchiectomy (n = 30) or wedge excision (n = 2). None had endocrine-related symptoms. The tumors measured 0.5 to 6.0 cm (mean 2.8 cm) and were predominantly well circumscribed and yellow-tan, except for 1, which had infiltrative borders. The predominant pattern was diffuse, but insular, spindled, microfollicular (Call-Exner bodies), trabecular, corded, watered-silk, palisading, and pseudopapillary patterns were also present. The cells contained round to ovoid nuclei with frequent longitudinal nuclear grooves, indistinct cell borders, and varying amounts of eosinophilic cytoplasm. Most tumors contained limited amounts of fibrocollagenous stroma. The mitotic count ranged from 0 to 18/10 high-power fields (HPF) (mean 4.9/10 HPF, 400). Two tumors had prominent necrosis, and 1 had vessel invasion. Follow-up information was available for 19 patients, with a mean of 51.0 months (range, 1 to 169 mo). All were without evidence of disease except 1 who had lung metastasis at 24 months. Our findings indicate that the morphologic spectrum of testicular AGCT is similar to that of ovarian AGCT. The majority of testicular examples have a good prognosis (compared with a malignant behavior in 2 of 7 cases in 1 prior series). Lymphovascular invasion, infiltrative borders, and size >4 cm may help in identifying cases with aggressive behavior, as these features were present in the one case with metastasis in our series. Mitotic counts varied and do not appear to be of prognostic significance on the basis of our experience. Key Words: testis, adult granulosa cell tumor, sex cord-stromal tumor, prognosis
of the remainder are Sertoli cell tumors.4,5 Recent studies have added to our knowledge of the clinical and pathologic features of these tumors. The well-known granulosa cell tumor (GCT) is much more common in the ovary, and experience with testicular examples is limited. In the testis, as in the ovary, GCTs are divided into adult and juvenile forms. Only 1 series focusing on the adult form has been published.6 We have seen a relatively large number of examples of this rare neoplasm and report our experience with 32 examples herein.
MATERIALS AND METHODS A search of the consultation files at the Massachusetts General Hospital uncovered 32 cases of adult granulosa cell tumors (AGCT) of the testis (Table 1). The one case from our routine hospital material (previously reported)3,7 is not included in this series, as the slides are no longer present for review, but the tumor is depicted as it is typical of a subset of the cases overall (Fig. 1A). Hematoxylin and eosin–stained sections available for review ranged from 1 to 14 slides (mean 3.8 slides/case). Immunohistochemical stains were reviewed if performed, or results were documented per the original pathology report. Clinical data including presentation, serum markers, gross description, and treatment were recorded, as were gross characteristics. The neoplasms were evaluated for histologic patterns, cytologic features including mitotic count, the presence of lymphovascular invasion (LVI), hemorrhage, necrosis, and nature of the stroma.
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RESULTS Clinical Data
S
ex cord-stromal tumors comprise about 5% of testicular tumors in adults but about 30% of those from children.1–3 Most are Leydig cell tumors, and the majority
From the *James Homer Wright Pathology Laboratories, Massachusetts General Hospital; and wDepartment of Pathology, Harvard Medical School, Boston, MA. Conflicts of Interest and Source of Funding: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Kristine M. Cornejo, MD, Department of Pathology, Massachusetts General Hospital, Warren Building 225, 55 Fruit Street, Boston, MA 02114 (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
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The results are summarized in Table 1. The patients were from 14 and 87 years of age (mean 40.0 y). None had endocrine-related symptoms or elevated serum markers. Of the 25 that reported a presenting symptom, 23 patients had a testicular mass or swelling. The remaining 2 patients presented with a prior history of a repaired undescended testis and a presumed testicular torsion, respectively. The tumor was located slightly more often on the right (left, n = 12; right, n = 19). The patients underwent orchiectomy (n = 30) or wedge excision (n = 2). None underwent lymph node dissection or received adjuvant therapy. Follow-up information was available for 19 patients. The mean follow-up interval Am J Surg Pathol
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TABLE 1. Clinicopathologic Data of Testicular AGCT Cases Case Age (y) Laterality Size (cm) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
37 49 22 50 — 27 87 47 51 47 55 25 45 74 27 32 18 60 23 20 52 14 21 17 64 14 28 51 63 25 44 50
Left Right Left Left Left Right — Right Right Left Left Right Right Left Right Right Left Right Right Left Right Right Right Right Right Right Left Right Left Right Left Right
2.8 3.0 3.3 0.9 3.0 1.8 — 4.5 2.1 0.5 2.1 2.0 1.4 3.5 1.4 4.2 3.2 6.0 1.4 4.5 4.3 0.8 3.0 1.5 2.4 3.5 2.6 3.0 1.0 5.5 1.2 4.7
Treatment Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Wedge excision Orchiectomy Orchiectomy Wedge excision Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy Orchiectomy
Mitotic Count (per HPF) Presence of LVI or Necrosis 14/10 1/10 0/10 2/10 0/10 3/10 4/10 6/10 4/10 0/10 2/10 0/10 8/10 11/10 7/10 2/10 3/10 1/10 6/10 8/10 8/10 1/10 1/10 18/10 8/10 8/10 11/10 1/10 6/10 4/10 2/10 6/10
None None None None Necrosis None None None None None None None None None None None None None None Necrosis LVI None None None None None None None None None None None
Follow-up LTF DOOD at 137 mo NED at 48 mo NED at 59 mo LTF NED at 60 mo NED at 169 mo LTF NED at 58 mo LTF NED at 80 mo LTF LTF NED at 104 mo NED at 36 mo LTF LTF LTF NED at 65 mo NED at 1 mo Metastasis to lung at 24 mo LTF NED at 37 mo LTF NED at 28 mo NED at 35 mo LTF LTF NED at 25 mo NED at 1 mo NED at 1 mo NED at 1 mo
DOOD indicates died of other disease; LTF, lost to follow-up; NED, no evidence of disease.
was 51.0 months (range, 1 to 169 mo). All patients were without evidence of disease except 1 who had lung metastasis at 24 months.
inantly solid, with 2 being both solid and cystic. The cut surface was typically lobulated and yellow-tan (Fig. 1A), or tan to white (Fig. 1B), but 1 was red-pink and spongy.
Gross Features
Microscopic Features
The tumors measured 0.5 to 6.0 cm (mean 2.8 cm) in maximum dimension and were well circumscribed, except for 1, which had infiltrative borders. They were predom-
On low-power examination, all but 1 of the tumors was well circumscribed. They often exhibited a nodular low-power appearance, and within the nodules the cells
FIGURE 1. Macroscopic images of testicular AGCTs. A, Lobular yellow neoplasm with a few cysts and foci of hemorrhage. B, Neoplasm with a uniform white to yellow sectioned surface. r
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FIGURE 2. Low-power view showing prominent cellular lobules intersected by scant nonspecific fibrous stroma (hematoxylin and eosin stain).
predominantly grew diffusely (Fig. 2). However, spindled, insular, microfollicular, trabecular, corded, watered-silkgyriform, palisading, and pseudopapillary patterns were also present to varying degrees (Figs. 3–6) (Table 2). The diffuse and spindled patterns were seen as sheets of rounded or fusiform cells, respectively. The microfollicular pattern comprised numerous small spaces (Call-Exner bodies), which often contained hyalinized basement membrane material or eosinophilic fluid. The corded and trabecular patterns exhibited regular to irregularly arranged thin cords or thick columns of tumor cells. The watered-silk or gyriform patterns were defined by interweaving cords and undulating columns of cells, whereas the insular pattern was characterized by nests of tumor cells surrounded by stroma. The palisading pattern was characterized by tumor cells arranged parallel to each other, resembling a fence. The pseudopapillary pattern was characterized by tumor cells surrounding fibrovascular cores, forming papillary-like architecture. The tumor cells contained uniformly round to ovoid nuclei with conspicuous longitudinal nuclear grooves, indistinct cell borders, and variable amounts of eosinophilic cytoplasm, the latter usually being scant and barely perceptible, but it was moderately conspicuous in 3 (Fig. 7). The granulosa cells were luteinized in 3 cases, containing more abundant clear to eosinophilic cytoplasm with rounded nuclei (Fig. 8A). The tumors contained limited amounts of fibrocollagenous stroma except for 5, in which the stroma was more abundant and often intermixed with spindled granulosa cells forming a herringbone and/or fascicular pattern (Figs. 8B, C). None of the cases had luteinized stromal cells. The mitotic count ranged from 0 to 18/10 high-power fields (HPF) (mean 4.9/10 HPF, 400). Two cases had necrosis, 8 cases had hemorrhage and/or hemosiderin deposition, and LVI was noted in only 1 case. All of the tumors were unencapsulated, except 1, which had a fibrous pseudocapsule. The tumor infiltrated
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FIGURE 3. Histologic patterns of AGCT. A, Diffuse pattern (H&E stain). B, Spindled pattern (H&E stain). H&E indicates hematoxylin and eosin.
between the seminiferous tubules in 14 cases and the rete testis in 12 cases and invaded the tunica albuginea in 6 cases. Only 1 tumor involved the paratesticular tissue and showed lymphatic invasion (T2). The immunohistochemical results are summarized in Table 3. The tumor cells were strongly positive for inhibin, vimentin, and calretinin and negative for EMA and desmin. Most tumors were negative for cytokeratin, and in the few cases that showed immunoreactivity, it was weak and patchy or in a paranuclear dot-like pattern. Variable staining was observed with smooth muscle actin, S-100, and Melan-A.
DISCUSSION GCTs are much more common in the ovary than in the testis.8 In the ovary, AGCTs are much more common than their juvenile counterpart. Given the rarity of both AGCT and juvenile GCTs (JGCT), it is not possible to accurately assess their relative frequency, but the information r
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FIGURE 4. Histologic patterns of AGCT. A, Corded pattern (H&E stain). B, Gyriform or watered-silk pattern (H&E stain). H&E indicates hematoxylin and eosin.
at hand suggests a more balanced distribution of the 2 in male than in female individuals. Although we acknowledge a bias, as the majority of material comes from consult cases, we have seen almost as many AGCTs as JGCTs of the testis. The first description of a testicular GCT was by Laskowski in 1952.9 Since then, a small number of cases have been reported, mostly singly, with only 1 series of 7 patients.3,6,7,10–20 The present series is the largest study of AGCTs of the testis reported. Patients with this neoplasm have typically presented with a painless testicular mass or swelling at an average age of 44 years, which is similar to our series of 40 years.1 Although none of our patients had such findings, endocrine manifestations such as gynecomastia or decreased libido have been present in up to 25% of cases in the literature.1,8 Tumors have reported to range from microscopic to 13.0 cm in maximum dimension and are well circumscribed and tan to yellow.1 Teilum21 was the first to emphasize the homology between GCTs in the ovary and testis. Our findings indicate that the morphologic spectrum of testicular AGCTs is indeed similar to that of ovarian AGCTs. r
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FIGURE 5. Histologic patterns of AGCT. A, Microfollicular pattern (Call-Exner bodies) (H&E stain). B, Insular pattern (H&E stain). H&E indicates hematoxylin and eosin.
The overall differential diagnosis of AGCT of the testis is narrower than pertains to the similar tumor of the ovary because of the rarity, in the testis, of some of its well-known mimics in the ovary, such as, for example, metastatic lobular carcinoma from the breast. Nonetheless, a number of issues may arise. JGCTs differ from the adult form as they occur in the first 6 months of life and are rare after the first year.1,8,22,23 They may be associated with ambiguous external genitalia and abnormal karyotypes, which are not present in AGCTs.1,8,22,23 Microscopically, the predominant patterns in JGCTs are follicular and solid or a combination of both. The follicles are often irregular in size and shape in comparison with the uniformly sized follicles in AGCTs and frequently contain mucinous material. Call-Exner bodies are usually absent in the JGCT. The follicles are lined by granulosa cells with an outer layer of theca cells, which are not commonly found in AGCT. The granulosa cells have more abundant eosinophilic or vacuolated cytoplasm with round nuclei that www.ajsp.com |
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FIGURE 7. Granulosa cells with uniformly round to ovoid nuclei, frequent longitudinal nuclear grooves, indistinct cell borders, and scant cytoplasm (hematoxylin and eosin stain).
FIGURE 6. Histologic patterns of AGCT. A, Palisading pattern (H&E stain). B, Pseudopapillary pattern (H&E stain). H&E indicates hematoxylin and eosin.
lack grooves. A prominent fibrous stroma is more common in the AGCT.8,22,23 Leydig and Sertoli cell tumors also present at a similar age of 46.5 and 45 years, respectively.1,4,5,8 Histologically, Leydig cell tumors can easily be distinguished
TABLE 2. Pathologic Data of Testicular AGCT Cases Morphologic Feature Patterns Diffuse/solid Insular Spindled Cords/trabecular/gyriform Microfollicular/Call-Exner bodies Herringbone/fascicular Pseudopapillary/palisading Luteinized granulosa cells Mitotic count/10 HPF r4/10 HPF Z5-10/10 HPF > 10/10 HPF
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N (%) 27 17 16 13 7 5 4 3
(84) (53) (50) (41) (22) (16) (13) (9)
18 (56) 10 (31) 4 (13)
from AGCTs as they contain sheets or lobular aggregates of neoplastic cells with round, centrally located nuclei and abundant eosinophilic cytoplasm arranged with variable amounts of fibrous stroma. The cells may occasionally appear vacuolated and contain crystals of Reinke, which are not identified in AGCTs.4 Sertoli cell tumors contain polygonal tumor cells with abundant pale to lightly eosinophilic cytoplasm and may also be vacuolated. They can contain trabecular, corded, or diffuse patterns, making them occasionally difficult to differentiate from AGCTs. However, distinguishing features are the presence of well-formed tubules, albeit in varying amounts, and the lack of the typical microfollicular pattern of AGCTs. Although nuclear grooves may be seen in Sertoli cell tumors, they are generally inconspicuous and histologically are much more characteristic of AGCTs.5,8 In addition, Sertoli cell tumors are sometimes vascular, not a feature of the AGCTs of this series, and may have a hyalinized stroma.5 Having discussed the differential diagnosis with Sertoli cell tumor, it is pertinent to note that in the ovary, the differential for AGCT is less commonly an issue, the Sertoli-Leydig cell tumor being more often a consideration. In the testis, however, the Sertoli-Leydig cell tumor is, compared with the ovary, remarkably uncommon such that this is almost never a realistic consideration, and, if it should be, criteria used for the ovary would pertain. The differential diagnosis of the AGCT also includes a fibrothecoma, which similarly occurs at an average age of 44 years.24 Testicular fibrothecomas are comprised of ovoid and/or spindled cells in varying amounts of collagenous stroma and may mimic AGCTs containing a spindled and/ or fibrosarcoma-like pattern.24 The various architectural patterns and distinct cytologic features help differentiate AGCTs from fibrothecomas. Zhang et al24 recently described inhibin positivity in 11 of 13 (85%) cases in a patchy to diffuse pattern, making immunohistochemistry unreliable in differentiating these 2 neoplasms. r
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TABLE 3. Immunoreactivity of Testicular AGCT Cases IHC Stains Inhibin Vimentin Calretinin Smooth muscle actin S-100 Cytokeratin Melan-A Desmin HMB45 EMA
FIGURE 8. Additional histologic features of AGCTs of the testis. A, Luteinization of granulosa cells with abundant clear to eosinophilic cytoplasm (H&E stain). B, Abundant fibrocollagenous stroma intermixed with spindled granulosa cells (H&E stain). C, Spindled granulosa cells with fibrocollagenous stroma imparting a herringbone pattern (H&E stain). H&E indicates hematoxylin and eosin.
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No. Cases Stained 11 5 7 6 7 7 4 4 2 4
Positive Cases (N [%]) 9 5 6 4 4 3 1 0 0 0
(82) (100) (86) (67) (57) (43) (weak or dot-like) (25) (0) (0) (0)
Finally, in the testis, compared with the ovary, a greater percentage of sex cord-stromal tumors defy confident subclassification into the specific groupings such as granulosa and Sertoli cell tumor and are placed in the sex cord-stromal tumor unclassified group. These may have foci, in isolation, consistent with AGCT, but by definition the tumors have other features that are indeterminate or even of Sertoli nature. All our tumors had dominant foci of clear cut granulosa cell neoplasia. Overall, the role of immunohistochemistry in establishing the diagnosis of AGCT is limited as they contain similar staining patterns to other sex cord-stromal tumors of the testis. The majority of AGCT cases showed positivity for vimentin, inhibin, and calretinin and negativity for EMA. Other immunohistochemical markers such as SMA, S-100, cytokeratin, and Melan-A had more inconsistent results. A paranuclear dot-like pattern seen with cytokeratin staining has been previously reported in GCTs and was identified in one of our cases.25 The CD99 and antimullerian immunostains have also been rarely reported to be positive in AGCTs but was not performed in any of our cases.10,26,27 GCTs are considered to be low-grade malignant neoplasms as they are slow growing with metastasis in up to 20% of cases.1,28 The majority of AGCTs of the testis have a good prognosis. A literature review revealed 7 cases with metastatic disease among 30 reported cases (23%) (Table 4).6,14,15,18–20 Combining these with our 19 cases containing follow-up, there is a total of 8 of 49 (16%) cases with metastases. It is difficult to predict which neoplasms will potentially metastasize based on clinicopathologic features. Pathologic features that were thought to predict malignant potential included tumor size >5 cm, moderate or marked nuclear atypia, necrosis, LVI, an infiltrative border or paratesticular invasion, and >5 mitotic figures/ 10 HPF.2,6,19 Hanson and Ambaye16 identified tumor size as the only feature significantly associated with malignant behavior and excluded tumor necrosis, mitotic count, age, and presence of gynecomastia. Features such as LVI, infiltrative borders, and size >4 cm may help in identifying cases with more aggressive behavior, as these 3 features were present in the one case with metastases in our series. In addition, 3 of the 7 cases from the literature review also noted LVI, and all 7 cases were >4 cm in size. Mitotic counts varied and did not appear to be prognostic. www.ajsp.com |
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TABLE 4. Summary of Testicular AGCTs With Metastasis (n = 8)
Age (y)
Endocrine-related Symptoms, Laboratories
JimenezQuintero et al6
60
JimenezQuintero et al6
Case
Presentation
Size (cm)
None
Mass slowly growing for years
7.0
29
None
Incidental finding
7.5
Matoska et al14
26
Gynecomastia
Harrison et al15
65
None
Suppiah et al18
51
Hammerich et al19
55
Mostofi et al20
41
—
This study
52
None
Mass slowly growing for 7 mo
10.0
Testicular swelling for 9 mo
5.0
Serum AFP and HCG WNL
Testicular swelling
—
Serum AFP and HCG WNL
Incidental finding
10.5
Mass slowly growing for 8 y —
10.5 4.3
Gross and Pathologic Features Circumscribed, yellow, friable, and necrotic with thick capsule 2/50 HPF Circumscribed, heterogenous, partly cystic, hemorrhagic 3/50 HPF LVI present Partly solid and cystic, gray, rubbery 9/10 HPF Suggestion of vascular spread Paratesticular tumor arising from the epididymis
— Homogenous surface with calcifications 13/10 HPF LVI present Lobulated, tan-pink Red-pink, spongy soft mass with infiltrative borders LVI present
Follow-up DOD at 134 m, liver and RLN metastases at 121 mo s/p CT AWD at 14 mo, RLN metastasis at diagnosis, right ILN metastasis at 12 mo, s/p RLND and CT NED at 168 mo, metastases to RLN s/p RLND, and RT
DOD at 32 mo, metastasis to RLN s/p RLND at 8 mo, metastasis to left retroperitoneum at 15 mo s/p excision, recurrence with peritoneal metastasis at 17 mo s/p CT for 6 mo, with progression with iliac and RLN adenopathy, s/p pazopanib for 4 mo with partial response and resolution of RLN adenopathy NED at 76 mo, metastasis to left tibia at 72 mo s/p amputation NED at 39 mo, multiple pulmonary metastases at diagnosis s/p metastasectomy and CT DOD at 5 mo, multiple metastases AWD at 24 mo, metastasis to lung
AFP indicates alpha-fetoprotein; AWD, alive with disease; CT, chemotherapy; DOD, died of disease; HCG, human chorionic gonadotropin; HPF, high power field; ILN, inguinal lymph nodes; LVI, lymphovascular invasion; NED, no evidence of disease; RLN, retroperitoneal lymph nodes; RLND, retroperitoneal lymph node dissection; RT, radiotherapy; s/p, status post; WNL, within normal limits.
The mainstay of treatment for organ-confined disease is surgical, usually orchiectomy. However, treatment in advanced disease is less clear as there is no consensus on therapeutic recommendations because of the rarity of the neoplasm. Patients are often kept under extended surveillance with annual imaging because of the possibility of metastasis, which can occur years after diagnosis.6,18 Retroperitoneal lymph node dissection (RLND) may have some utility as 4 of 13 patients with stage I testicular sex cord-stromal tumors (Leydig cell tumor, n = 3; sex cord-stromal tumor, n = 1) who underwent RLND were upstaged as a result of the surgery.29 Therefore, RLND may have some utility in cases with malignant features or small-volume metastatic disease.29 It appears from the review of the literature that the patients with lymph node and/or distant metastases
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treated successfully with surgical resection have a better outcome, as 3 patients are alive without disease at 39, 76, and 168 months, respectively, and 1 patient is alive with disease at 14 months. The remaining cases treated with neoadjuvant therapy alone or were not surgical candidates for resection died of disease. Similar results have been reported by Gohji et al30 in malignant gonadal stromal tumors. Overall, the primary role of chemotherapy and/or radiotherapy is less clear, as AGCT of the testis appears to be somewhat chemoresistant.15,30 One patient had a partial response to pazopanib, an oral multitargeted tyrosine kinase inhibitor, which has antiangiogenic effects after treatment failure with chemotherapy.15 In addition, the patient had complete resolution of their retroperitoneal lymphadenopathy. Targeted therapy using tyrosine kinase inhibitors may r
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provide a sensible option in patients with metastatic disease, particularly in cases in which surgical resection is not feasible. Little is understood about the pathogenesis of testicular AGCTs. Recently, a single somatic mutation of the FOXL2 gene (C134W) has been identified in up to 97% of AGCTs of the ovary.31,32 FOXL2, also called forkhead box L2, is a transcription factor involved in ovarian differentiation and is required for normal granulosa cell development.31,33 The FOXL2 nuclear protein was consistently immunoexpressed in 93% to 100% of AGCTs of the ovary that harbored a FOXL2 mutation.32,34 Conversely, the results within testicular AGCTs have varied. Hes et al35 analyzed 4 AGCTs of the testis for FOXL2 by both immunohistochemistry and sequencing analysis. Interestingly, all 4 tumors were positive by immunohistochemistry but were negative for the mutation in the 3 tumors tested. A second study by Lima et al33 identified 2 of 5 (40%) testicular AGCTs harbored the FOX2 mutation. In addition, FOXL2 immunoreactivity has been identified in 3 (100%) testicular JGCTs.36 Therefore, the mutational status of FOXL2 in testicular GCTs is unclear, but they appear to aberrantly express FOXL2 by immunohistochemistry and may serve as an additional diagnostic ancillary tool. Although FOXL2 immunohistochemical and mutational studies have not been performed on other sex cord-stromal tumors of the testis, besides GCTs, they have been performed in a number of tumors in the ovary. FOXL2 immunoreactivity has been identified in 58% of sex cord-stromal tumors tested such as in Sertoli cell tumors and thecoma-fibroma tumors but not in other non– sex cord-stromal tumors.32 Leydig cell tumors, which may also enter the differential diagnosis, have been negative for FOX2L. Therefore, immunopositivity for FOXL2 supports a tumor of sex cord-stromal origin but is not specific for GCTs. In addition, although the FOX2L mutation is specific for AGCTs, it has been reported in rare cases of thecomas, Sertoli-Leydig cell tumors, and sex cord-stromal tumors unclassified.32 Studies have also shown that sustained activation of the WNT/CTNNB1 pathway leads to the development of GCTs in mice.37 A recent study revealed that CTNNB1 mutant mice with loss of phosphatase and tensin homolog (PTEN) expression in their Sertoli cells developed testicular GCTs.38 An additional study confirmed that in addition to PTEN loss, KRAS activation in Sertoli cells of CTNNB1 mutant mice also produces GCTs.39 Therefore, CTNNB1 activation with loss of PTEN or activation of KRAS may also play a role in tumorigenesis. In addition, CTNNB1 mutations have also been identified in testicular Sertoli cell tumors and do not appear to be specific to GCTs.40 These new insights into the molecular pathways involved in the development of AGCTs appear promising and may help identify targets for therapy. In conclusion, our large series and review of the literature highlights the clinicopathologic features and prognosis of these rare neoplasms, as well as the difficulty in determining optimal management for these patients. r
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Adult Granulosa Cell Tumors of the Testis
Although most AGCTs of the testis behave in a benign manner, a small subset has the capability to metastasize, often years after diagnosis. Therefore, long-term followup in these patients is important. Furthermore, on-going research into the molecular pathogenesis of GCTs may provide new diagnostic tools and goals for targeted therapy, which may improve the outcome in the few patients with metastatic disease. REFERENCES 1. Sesterhenn IA, Cheville J, Woodward PJ, et al. Sex cord/gonadal stromal tumours. In: Eble JN, Sauter G, Epstein JI, Sesterhenn IA, eds. WHO Classification of Tumours: Pathology and Genetics of Tumours of the Urinary System and Male Genital Organs. Lyon, France: International Agency for Research on Cancer (IARC); 2004:250–258. 2. Cheville JC. Classification and pathology of testicular germ cell and sex cord-stromal tumors. Urol Clin North Am. 1999;26:595–609. 3. Marshall FF, Kerr WS Jr, Kliman B, et al. Sex cord-stromal (gonadal stromal) tumors of the testis: a report of 5 cases. J Urol. 1977;117:180–184. 4. Kim I, Young RH, Scully RE. Leydig cell tumors of the testis. A clinicopathological analysis of 40 cases and review of the literature. Am J Surg Pathol. 1985;9:177–192. 5. Young RH, Koelliker DD, Scully RE. Sertoli cell tumors of the testis, not otherwise specified: a clinicopathologic analysis of 60 cases. Am J Surg Pathol. 1998;22:709–721. 6. Jimenez-Quintero LP, Ro JY, Zavala-Pompa A, et al. Granulosa cell tumor of the adult testis: a clinicopathologic study of seven cases and a review of the literature. Hum Pathol. 1993;24:1120–1125. 7. Case records of the Massachusetts General Hospital: case 41471. N Engl J Med. 1955;253:926–931. 8. Young RH. Sex cord-stromal tumors of the ovary and testis: their similarities and differences with consideration of selected problems. Mod Pathol. 2005;18(suppl 2):S81–S98. 9. Laskowski J. Feminizing tumours of testis; general review with case report of granulosa cell tumour of testis. Endokrynol Pol. 1952; 3:337–343. 10. Al-Bozom IA, El-Faqih SR, Hassan SH, et al. Granulosa cell tumor of the adult type: a case report and review of the literature of a very rare testicular tumor. Arch Pathol Lab Med. 2000;124:1525–1528. 11. Miliaras D, Anagnostou E, Moysides I. Adult type granulosa cell tumor: a very rare case of sex-cord tumor of the testis with review of the literature. Case Rep Pathol. 2013;2013:932086. DOI: 10.1155/ 2013/932086. 12. Hisano M, Souza FM, Malheiros DM, et al. Granulosa cell tumor of the adult testis: report of a case and review of the literature. Clinics (Sao Paulo). 2006;61:77–78. 13. Song Z, Vaughn DJ, Bing Z. Adult type granulosa cell tumor in adult testis: report of a case and review of the literature. Rare Tumors. 2011;3:e37; 117–119. 14. Matoska J, Ondrus D, Talerman A. Malignant granulosa cell tumor of the testis associated with gynecomastia and long survival. Cancer. 1992;69:1769–1772. 15. Harrison MR, Huang W, Liu G, et al. Response to antiangiogenesis therapy in a patient with advanced adult-type testicular granulosa cell tumor. Oncology (Huntingt). 2009;23:792–795. 16. Hanson JA, Ambaye AB. Adult testicular granulosa cell tumor: a review of the literature for clinicopathologic predictors of malignancy. Arch Pathol Lab Med. 2011;135:143–146. 17. Gupta A, Mathur SK, Reddy CP, et al. Testicular granulosa cell tumor, adult type. Indian J Pathol Microbiol. 2008;51:405–406. 18. Suppiah A, Musa MM, Morgan DR, et al. Adult granulosa cell tumour of the testis and bony metastasis. A report of the first case of granulosa cell tumour of the testicle metastasising to bone. Urol Int. 2005;75:91–93. 19. Hammerich KH, Hille S, Ayala GE, et al. Malignant advanced granulosa cell tumor of the adult testis: case report and review of the literature. Hum Pathol. 2008;39:701–709.
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20. Mostofi FK, Theiss EA, Ashley DJ. Tumors of specialized gonadal stroma in human male patients. Androblastoma, Sertoli cell tumor, granulosa-theca cell tumor of the testis, and gonadal stromal tumor. Cancer. 1959;12:944–957. 21. Teilum G. Classification of testicular and ovarian androblastoma and Sertoli cell tumors; a survey of comparative studies with consideration of histogenesis, endocrinology, and embryological theories. Cancer. 1958;11:769–782. 22. Lawrence WD, Young RH, Scully RE. Juvenile granulosa cell tumor of the infantile testis. A report of 14 cases. Am J Surg Pathol. 1985;9:87–94. 23. Young RH, Lawrence WD, Scully RE. Juvenile granulosa cell tumor—another neoplasm associated with abnormal chromosomes and ambiguous genitalia. A report of three cases. Am J Surg Pathol. 1985;9:737–743. 24. Zhang M, Kao CS, Ulbright TM, et al. Testicular fibrothecoma: a morphologic and immunohistochemical study of 16 cases. Am J Surg Pathol. 2013;37:1208–1214. 25. Otis CN, Powell JL, Barbuto D, et al. Intermediate filamentous proteins in adult granulosa cell tumors. An immunohistochemical study of 25 cases. Am J Surg Pathol. 1992;16:962–968. 26. Guzzo T, Gerstein M, Mydlo JH. Granulosa cell tumor of the contralateral testis in a man with a history of cryptorchism. Urol Int. 2004;72:85–87. 27. Rey R, Sabourin JC, Venara M, et al. Anti-Mullerian hormone is a specific marker of sertoli- and granulosa-cell origin in gonadal tumors. Hum Pathol. 2000;31:1202–1208. 28. Talerman A. Pure granulosa cell tumour of the testis. Report of a case and review of the literature. Appl Pathol. 1985;3: 117–122. 29. Mosharafa AA, Foster RS, Bihrle R, et al. Does retroperitoneal lymph node dissection have a curative role for patients with sex cord-stromal testicular tumors? Cancer. 2003;98:753–757.
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30. Gohji K, Higuchi A, Fujii A, et al. Malignant gonadal stromal tumor. Urology. 1994;43:244–247. 31. Shah SP, Kobel M, Senz J, et al. Mutation of FOXL2 in granulosacell tumors of the ovary. N Engl J Med. 2009;360:2719–2729. 32. Al-Agha OM, Huwait HF, Chow C, et al. FOXL2 is a sensitive and specific marker for sex cord-stromal tumors of the ovary. Am J Surg Pathol. 2011;35:484–494. 33. Lima JF, Jin L, de Araujo AR, et al. FOXL2 mutations in granulosa cell tumors occurring in males. Arch Pathol Lab Med. 2012;136:825–828. 34. Schrader KA, Gorbatcheva B, Senz J, et al. The specificity of the FOXL2 c.402C > G somatic mutation: a survey of solid tumors. PLoS One. 2009;4:e7988. 35. Hes O, Vanecek T, Petersson F, et al. Mutational analysis (c.402C > G) of the FOXL2 gene and immunohistochemical expression of the FOXL2 protein in testicular adult type granulosa cell tumors and incompletely differentiated sex cord stromal tumors. Appl Immunohistochem Mol Morphol. 2011;19:347–351. 36. Kalfa N, Fellous M, Boizet-Bonhoure B, et al. Aberrant expression of ovary determining gene FOXL2 in the testis and juvenile granulosa cell tumor in children. J Urol. 2008;180:1810–1813. 37. Boerboom D, Paquet M, Hsieh M, et al. Misregulated Wnt/betacatenin signaling leads to ovarian granulosa cell tumor development. Cancer Res. 2005;65:9206–9215. 38. Boyer A, Paquet M, Lague MN, et al. Dysregulation of WNT/ CTNNB1 and PI3K/AKT signaling in testicular stromal cells causes granulosa cell tumor of the testis. Carcinogenesis. 2009;30:869–878. 39. Richards JS, Fan HY, Liu Z, et al. Either Kras activation or Pten loss similarly enhance the dominant-stable CTNNB1-induced genetic program to promote granulosa cell tumor development in the ovary and testis. Oncogene. 2012;31:1504–1520. 40. Perrone F, Bertolotti A, Montemurro G, et al. Frequent mutation and nuclear localization of beta-catenin in sertoli cell tumors of the testis. Am J Surg Pathol. 2014;38:66–71.
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2014 Lippincott Williams & Wilkins
