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  Table of Contents    
CASE REPORT  
Year : 2017  |  Volume : 60  |  Issue : 3  |  Page : 415-417
Bilateral seminomas coexisting with adenomatoid tumor: An unusual occurrence


1 Department of Pathology, Sir Ganga Ram Hospital, New Delhi, India
2 Department of General and Laparoscopic Surgery, Sir Ganga Ram Hospital, New Delhi, India

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Date of Web Publication22-Sep-2017
 

   Abstract 

Coexistence of bilateral seminomas and adenomatoid tumor is rare. We encountered an interesting case of bilateral testicular seminomas along with a paratesticular nodule which was diagnosed as an adenomatoid tumor on histology. Although seminomas and adenomatoid tumor are frequent neoplasms, bilaterality and their coexistence have been rarely described and can pose diagnostic difficulties. Herein, we describe a case of a 53-year-old man who presented with bilateral testicular swellings which were diagnosed as bilateral seminomas with an adenomatoid tumor in the left paratesticular region on histopathology. The pathological findings of these coexistent tumors and the utility of immunohistochemistry in establishing a correct diagnosis in such scenarios are discussed.

Keywords: Adenomatoid tumor, immunohistochemistry, seminoma

How to cite this article:
Mittal S, Sarangi R, Jain S. Bilateral seminomas coexisting with adenomatoid tumor: An unusual occurrence. Indian J Pathol Microbiol 2017;60:415-7

How to cite this URL:
Mittal S, Sarangi R, Jain S. Bilateral seminomas coexisting with adenomatoid tumor: An unusual occurrence. Indian J Pathol Microbiol [serial online] 2017 [cited 2019 Dec 11];60:415-7. Available from: http://www.ijpmonline.org/text.asp?2017/60/3/415/215401



   Introduction Top


Seminomas are one of the most common tumors of the testis. Bilateral involvement is however uncommon. Coexistence of bilateral seminomas with an adenomatoid tumor has been documented rarely. Epididymal tumors can be picked up on ultrasonography, but the coexisting tumors can pose difficulties and may be missed. Adenomatoid tumors, being benign, can mimic the epididymal spread of testicular tumor clinicoradiologically as well as on histopathology affecting the line of treatment. In the present case, the two tumors could not be separately identified on ultrasonography.

Coexistence of two malignancies is not commonly described in the literature. At times, they can lead to diagnostic dilemma and finally lead to change of treatment regimens accordingly.


   Case Report Top


A 53-year-old man presented with bilateral painless testicular swellings which were slowly increasing in size over the past 6 months. There was no other significant medical or surgical history. On clinical examination, both sides, testes were enlarged. Ultrasound of the scrotum revealed enlarged bilateral testes with large hypo echoic lesion and intact capsules [Figure 1]a. Serum beta-human chorionic gonadotropin and alpha-fetoprotein levels were within normal limits. With clinicoradiological diagnosis of seminomas, the patient underwent bilateral high orchiectomy with the removal of left iliac lymph node. Grossly, the left testis was enlarged measuring 9.5 cm × 7 cm × 5 cm and showed a tumor replacing the testicular parenchyma with only a thin rim of normal testicular tissue at the periphery. Right orchiectomy specimen measured 6 cm × 4 cm × 3 cm. There was a tumor in the upper pole, measuring 4.5 cm × 3.5 cm. Normal testicular tissue was identified in the lower pole. Cut surface of both tumors was gray-white, lobulated, and homogenous [Figure 1]b. Microscopic examination of both testicular tumors showed classical findings of seminoma composed of cells arranged in nests and lobules surrounded by dense lymphocytic infiltrate. The cells were round to polygonal with a distinct cell membrane, clear to pale eosinophilic cytoplasm, and prominent nucleoli [Figure 2]a. In addition, the left testis showed a tumor nodule in the paratesticular region adjacent to the seminomatous component. It was composed of two elements: epithelial-like cells and other fibrous stroma. The cells were large, polyhedral having abundant cytoplasm and were arranged in strands and tubules separated by fibromuscular stroma [Figure 3]a. On immunohistochemistry, the tumor cells of seminomas showed diffuse membranous staining with placental alkaline phosphatase (PLAP) [Figure 2]b and were negative for calretinin, epithelial membrane antigen (EMA), and HBME-1. The cells in the paratesticular tumor nodule were positive for calretinin [Figure 3]b, EMA, and HBME-1 suggesting a mesothelial origin. They were negative for PLAP, inhibin, and carcinoembryonic antigen (CEA). Epididymis and spermatic cord of both sides were unremarkable. The left iliac lymph node was free of tumor. The findings were consistent with diagnosis of classic seminoma of bilateral testes (pT1 pN0 pMx) with adenomatoid tumor of the left paratesticular tissue. No adjuvant chemotherapy or radiotherapy was given. Following surgery, the patient was put on hormonal replacement therapy. He had an uneventful recovery and showed no evidence of tumor recurrence or metastasis at 2-year follow-up.
Figure 1: (a and b) Ultrasonography of the scrotum showing bilateral testicular enlargement with a hypoechoic lesion in both testes. Gross specimen Left testis - Enlarged and replaced by a tumor. Cut surface is gray-white and homogenous. Right testis - Similar tumor in the upper pole with normal testicular tissue in the lower pole

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Figure 2: (a and b) Microscopic examination from testicular masses showing a tumor of round to polygonal cells surrounded by fibrous stroma with chronic inflammatory infiltrate (H and E, ×400). Tumor cells from testicular mass are positive for Placental alkaline phosphatase (IHC, ×400)

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Figure 3: (a and b) Photomicrograph from the paratesticular region of left testis showing tumor composed of large polyhedral cells with abundant cytoplasm arranged in strands and tubules separated by fibromuscular stroma (H and E, ×400). Tumor cells of paratesticular region are positive for calretinin (IHC, ×200)

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   Discussion Top


Seminoma is the most common pure germ cell tumor of the testis accounting for 35%–50% of all germ cell tumors, with an average age of diagnosis between 15 and 35 years.[1] Bilateral germinative testicular tumors are uncommon, and their synchronous occurrence is even rarer.[2] The diagnosis of classical seminoma is usually straightforward. Variants of seminoma or when it is present as a component of the mixed tumor may pose diagnostic difficulties. Tumor staging has important treatment implications. On the other hand, an adenomatoid tumor is the most common tumor of epididymis, located mostly at its lower pole. They occur usually in the third to fifth decades of life and accounts for 30% of all paratesticular tumors.[3] They have also been reported in spermatic cord, ejaculatory duct,  Fallopian tube More Details, and uterus. The clinical presentation may vary from asymptomatic to painful nodules. Grossly, they are circumscribed firm, gray-white masses up to 5 cm and may be cystic. Majority of them are readily diagnosed, based on their several typical locations and characteristic microscopic features.[4] The imaging modality of choice for diagnosing scrotal pathologies is ultrasonography. In some lesions originating from tunica of testis, this may pose diagnostic difficulties.[5]

In the present case, although tumor morphology of paratesticular nodule was different from seminoma, the proximity to seminoma capsule made it difficult to exclude the possibility of extratesticular spread. On immunohistochemistry, adenomatoid tumors are positive for cytokeratin (CK) and EMA and are negative for CEA. At times, they need to be differentiated from epithelioid hemangioma which is positive for CD34 and negative for keratin. The mesothelial origin of these tumors is proved by its positivity for thrombomodulin, HBME-1, CK 5/6, OC125, and calretinin.[6] Coexistence of these tumors with seminomas has not been described in literature. There is only one case report on Google search that describes the accompaniment of seminoma with adenomatoid tumor.[7] Differentiating adenomatoid tumor in paratestis from extratesticular spread of seminoma can be diagnostically challenging and carries significant diagnostic and therapeutic implications. Although the presence of desmoplastic stroma is one of the characteristic inherent features of adenomatoid tumor, it may be difficult to differentiate it from desmoplastic stroma of infiltrating malignant tumor. Immunohistochemistry is useful as seminomas will be positive for PLAP and negative for CK, EMA, HBME-1, and calretinin.

Awareness of this concurrence is important to establish the correct diagnosis. The knowledge of tumor location and ancillary immunohistochemical studies is helpful in resolving differentials in this situation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Woodward PJ, Sohaey R, O'Donoghue MJ, Green DE. From the archives of the AFIP: Tumors and tumorlike lesions of the testis: Radiologic-pathologic correlation. Radiographics 2002;22:189-216.  Back to cited text no. 1
    
2.
Schmitz A. Bilateral and synchronic seminomatous testicular neoplasia. Int Braz J Urol 2003;29:330-1.  Back to cited text no. 2
    
3.
Samad AA, Pereiro B, Badiola A, Gallego C, Zungri E. Adenomatoid tumor of intratesticular localization. Eur Urol 1996;30:127-8.  Back to cited text no. 3
    
4.
de Klerk DP, Nime F. Adenomatoid tumors (mesothelioma) of testicular and paratesticular tissue. Urology 1975;6:635-41.  Back to cited text no. 4
    
5.
Monappa V, Rao AC, Krishnanand G, Mathew M, Garg S. Adenomatoid tumor of tunica albuginea mimicking seminoma on fine needle aspiration cytology: A case report. Acta Cytol 2009;53:349-52.  Back to cited text no. 5
    
6.
Delahunt B, Eble JN, King D, Bethwaite PB, Nacey JN, Thornton A. Immunohistochemical evidence for mesothelial origin of paratesticular adenomatoid tumour. Histopathology 2000;36:109-15.  Back to cited text no. 6
    
7.
Uzunlar AK, Yaldiz M, Ozdemir E, Yilmaz F, Ozaydin M. A case report of adenomatoid tumor accompanying with seminoma. Nagoya Med J 2000;44:59.  Back to cited text no. 7
    

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Correspondence Address:
Sunila Jain
Department of Pathology, Sir Ganga Ram Hospital, New Delhi - 110 060
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_871_15

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