Path. Res. Pract. 164,423-435 (1979)
Teaching Case
Department of Pathology, University of Basel, Switzerland
Testicular Nodule in an Elderly Man Editor: H. U. ZOLLINGER Prepared by: H. OHNACKER This 77 year old man had noticed a painless swelling in the right scrotal region for 5 weeks. Right-sided orchidectomy was performed because of suspicion of a testicular tumor. The patient was in good general condition and showed no other signs of diseaseother than his testicular mass. A longitudinal section through the right testis revealed an ill-defined nodule, 2 em in diameter, grayish-white, firm, and homogeneous. The microscopic features of the testicular lesion are shown in Figs. I and 2.
For the diagnosis and some typical features of this disease, please see next page.
4 24 • H. Ohnacker
Diagnosis: Malignant lymphoma of the testis (reticulum cell or histiocytic type)
Fig. 3. Malignant lymphoma of the testis (BN 17639/78): Concentric separation of peritubular reticulin layers. Novotny's modification of Gomori's reticulin stain, X 180. Fig. 4. Seminoma (BN 22868/78): Condensed peritubular reticulin layers. Novotny's modification of Gomori's reticulin stain, X 180.
The characteristic histologic features which allow differentiation from other testicular tumors, especially seminomas, are as follows: 1. Diffuse intertubular growth of the tumor (Fig. I) leaving tubules or tubular remnants discernable even in the central parts of the tumor. 2. Characteristic pattern of reticulin fibers in silver stains. Concentric or onion-skin-like separation of peritubular reticulin layers (Fig. 3). Seminomas may show small areas of intertubular growth (mostly in marginal regions), but in contrast to lymphoma there is no concentric splitting of peritubular reticulin layers (Fig. 4). The peritubular reticulin in seminoma seems to be even more condensed rather than being split apart. 3. Increase of reticulin fibers (in histiocytic lymphoma, which is by far the most frequent type of testicular lymphoma).
Testicular Nodule in an Elderly Man· 425
4. Cellular features (Fig. 2): Lymphoma cells are smaller, show less cytoplasm 'and absence of demonstrable cytoplasmic glycogen as compared to seminoma cells. The nuclear-cytoplasmic ratio is increased. 5. Diffuse infiltration of vein walls by lymphoma cells especially when the spermatic cord is affected. 6. Absence of intratubular spread of tumor cells in the surrounding noninfiltrated testicular parenchyma. This "intratubular spread" (represented by atypical spermatogonia or seminoma cells) is a very characteristic feature of seminoma.
Clinical features of testicular malignant lymphoma Frequency: About 3-8% of all testicular tumors. Age incidence: This tumor may occur at any age, but there is a pronounced peak incidence in the 7th and 8th decades. (This is in sharp contrast to seminoma, which shows its peak incidence in the 4th and 5th decades.) Location: The initial lesion seems to prefer the right testis. There is a definite tendency of the tumor to involve both sides (about 25% of the cases), either successively (more often) or simultaneously (less frequent). Systemic disease: Most cases of testicular malignant lymphoma must be regarded as metastatic disease in the course of otherwise disseminated malignant lymphoma. Generalized lymphoma may be present before, at the time of, or after orchidectomy. Prognosis: Very poor (60-80% of the patients die of disseminated disease within 2 years after orchidectomy). A few cases, however, show a more favorable prognosis, with tumor-free survival five or more years after orchidectomy and no signs of generalized lymphoma. These cases can be regarded as 'primary' lymphomas of testis, a diagnosis which only can be made retrospectively by the course of the disease.
References Gowing, N. F. c.: Malignant
lymphoma of the testis. In "Pathology of the testis", R.C.P. Pugh (ed.), pp. 334-355. Blackwell Scientific Publications, Oxford (1976) Hamlin,]. A., Kagan, A. R., and Friedman, N. B.: Lymphomas of the testicle. Cancer 29, 1352- 1356 (197 2) Raute, M., and Wurster, K.: Das maligne Lymphom des Hodens. Virchows Arch. A Path. Anat. Histol. 363, 259-272 (1974) Sussmann, E. B., Hajdu, S. I., Lieberman, P. H., and Whitmore, W. F.: Malignant lymphoma of the tests: A clinico-pathologic study of 37 cases. J. Uro!. IIB, 1004-1007 (1977) ( 1977) Dr. H. Ohnacker, Institut fur Pathologic der Universitat Basel, Sdionbeinstr. 40, CH-4056 Basel, Switzerland
Teaching Case
Department of Pathology, University of Basel, Switzerland
Testicular Nodule in an Elderly Man Editor: H. U. ZOLLINGER Prepared by: H. OHNACKER This 77 year old man had noticed a painless swelling in the right scrotal region for 5 weeks. Right-sided orchidectomy was performed because of suspicion of a testicular tumor. The patient was in good general condition and showed no other signs of diseaseother than his testicular mass. A longitudinal section through the right testis revealed an ill-defined nodule, 2 em in diameter, grayish-white, firm, and homogeneous. The microscopic features of the testicular lesion are shown in Figs. I and 2.
For the diagnosis and some typical features of this disease, please see next page.
4 24 • H. Ohnacker
Diagnosis: Malignant lymphoma of the testis (reticulum cell or histiocytic type)
Fig. 3. Malignant lymphoma of the testis (BN 17639/78): Concentric separation of peritubular reticulin layers. Novotny's modification of Gomori's reticulin stain, X 180. Fig. 4. Seminoma (BN 22868/78): Condensed peritubular reticulin layers. Novotny's modification of Gomori's reticulin stain, X 180.
The characteristic histologic features which allow differentiation from other testicular tumors, especially seminomas, are as follows: 1. Diffuse intertubular growth of the tumor (Fig. I) leaving tubules or tubular remnants discernable even in the central parts of the tumor. 2. Characteristic pattern of reticulin fibers in silver stains. Concentric or onion-skin-like separation of peritubular reticulin layers (Fig. 3). Seminomas may show small areas of intertubular growth (mostly in marginal regions), but in contrast to lymphoma there is no concentric splitting of peritubular reticulin layers (Fig. 4). The peritubular reticulin in seminoma seems to be even more condensed rather than being split apart. 3. Increase of reticulin fibers (in histiocytic lymphoma, which is by far the most frequent type of testicular lymphoma).
Testicular Nodule in an Elderly Man· 425
4. Cellular features (Fig. 2): Lymphoma cells are smaller, show less cytoplasm 'and absence of demonstrable cytoplasmic glycogen as compared to seminoma cells. The nuclear-cytoplasmic ratio is increased. 5. Diffuse infiltration of vein walls by lymphoma cells especially when the spermatic cord is affected. 6. Absence of intratubular spread of tumor cells in the surrounding noninfiltrated testicular parenchyma. This "intratubular spread" (represented by atypical spermatogonia or seminoma cells) is a very characteristic feature of seminoma.
Clinical features of testicular malignant lymphoma Frequency: About 3-8% of all testicular tumors. Age incidence: This tumor may occur at any age, but there is a pronounced peak incidence in the 7th and 8th decades. (This is in sharp contrast to seminoma, which shows its peak incidence in the 4th and 5th decades.) Location: The initial lesion seems to prefer the right testis. There is a definite tendency of the tumor to involve both sides (about 25% of the cases), either successively (more often) or simultaneously (less frequent). Systemic disease: Most cases of testicular malignant lymphoma must be regarded as metastatic disease in the course of otherwise disseminated malignant lymphoma. Generalized lymphoma may be present before, at the time of, or after orchidectomy. Prognosis: Very poor (60-80% of the patients die of disseminated disease within 2 years after orchidectomy). A few cases, however, show a more favorable prognosis, with tumor-free survival five or more years after orchidectomy and no signs of generalized lymphoma. These cases can be regarded as 'primary' lymphomas of testis, a diagnosis which only can be made retrospectively by the course of the disease.
References Gowing, N. F. c.: Malignant
lymphoma of the testis. In "Pathology of the testis", R.C.P. Pugh (ed.), pp. 334-355. Blackwell Scientific Publications, Oxford (1976) Hamlin,]. A., Kagan, A. R., and Friedman, N. B.: Lymphomas of the testicle. Cancer 29, 1352- 1356 (197 2) Raute, M., and Wurster, K.: Das maligne Lymphom des Hodens. Virchows Arch. A Path. Anat. Histol. 363, 259-272 (1974) Sussmann, E. B., Hajdu, S. I., Lieberman, P. H., and Whitmore, W. F.: Malignant lymphoma of the tests: A clinico-pathologic study of 37 cases. J. Uro!. IIB, 1004-1007 (1977) ( 1977) Dr. H. Ohnacker, Institut fur Pathologic der Universitat Basel, Sdionbeinstr. 40, CH-4056 Basel, Switzerland
