The impact of histological review on clinical management of testicular cancer

Testicular cancer: The usage of central review for pathology diagnosis of orchiectomy specimens

BACKGROUND

Radical orchiectomy specimens present a unique set of challenges for pathology assessment owing to their rarity and complexity. This study compares second opinion pathology reports generated at a single, large academic institution to primary reports from outside hospitals.

METHODS

A database search was conducted for orchiectomy cases that were sent to our institution for management of testicular cancer from 2014 to 2015. Cases sent for consultation without a finalized diagnosis from the outside hospitals were excluded. A total of 221 consecutive cases were evaluated for comparison of final diagnoses between the outside institution and central pathology review.

RESULTS

This study revealed significant discrepancy involving multiple parameters between original and second opinion pathology reports. Of 221 cases of germ cell tumors assessed, 31% showed some discrepancy of histologic subtype. Overall, reporting of lymphovascular invasion changed in 22% of cases; of those, initially called positive 23% were changed to negative and of those initially called negative 12% were changed to positive. Although the overall discrepancy for spermatic cord invasion was 9%, an initial positive diagnosis was negated 35% of the time. The pathologic stage was altered in 23% of cases, mostly secondary to differences interpreting lymphovascular and spermatic cord invasion.

CONCLUSION

Pathologists evaluating orchiectomy specimens should be aware of the major pitfalls in classification and staging, many of which may affect patient management.

HMGA2 expression distinguishes between different types of postpubertal testicular germ cell tumour

The group of postpubertal testicular germ cell tumours encompasses lesions with highly diverse differentiation – seminomas, embryonal carcinomas, yolk sac tumours, teratomas and choriocarcinomas. Heterogeneous differentiation is often present within individual tumours and the correct identification of the components is of clinical relevance. HMGA2 re‐expression has been reported in many tumours, including testicular germ cell tumours. This is the first study investigating HMGA2 expression in a representative group of testicular germ cell tumours with the highly sensitive method of quantitative real‐time PCR as well as with immunohistochemistry. The expression of HMGA2 and HPRT was measured using quantitative real‐time PCR in 59 postpubertal testicular germ cell tumours. Thirty specimens contained only one type of tumour and 29 were mixed neoplasms. With the exception of choriocarcinomas, at least two pure specimens from each subgroup of testicular germ cell tumour were included. In order to validate the quantitative real‐time PCR data and gather information about the localisation of the protein, additional immunohistochemical analysis with an antibody specific for HMGA2 was performed in 23 cases. Expression of HMGA2 in testicular germ cell tumours depended on the histological differentiation. Seminomas and embryonal carcinomas showed no or very little expression, whereas yolk sac tumours strongly expressed HMGA2 at the transcriptome as well as the protein level. In teratomas, the expression varied and in choriocarcinomas the expression was moderate. In part, these results contradict data from previous studies but HMGA2 seems to represent a novel marker to assist pathological subtyping of testicular germ cell tumours. The results indicate a critical role in yolk sac tumours and some forms of teratoma.

Disparities in Interpretation of Primary Testicular Germ Cell Tumor Pathology

OBJECTIVES

Accurate pathologic interpretation of testicular germ cell tumors (GCTs) can be problematic due to low incidence and variation in histologic patterns. By analyzing changes in the diagnosis of testicular specimens after secondary review, we hoped to determine how these can affect prognosis and treatment.

METHODS

From 1999 to 2013, a total of 235 patients underwent radical orchiectomy at a referring facility and had pathology specimens reanalyzed by our center's pathologists with expertise in genitourinary malignancies. We identified discrepancies in pathologic reporting.

RESULTS

Fifty (21.3%) patients had variations in interpretation of their orchiectomy specimens. A clinically significant alteration was identified in 16 (6.8%) patients, most commonly due to recognition (or misrecognition) of lymphovascular invasion (LVI) associated with nonseminomatous germ cell tumors (NSGCTs). Changes in LVI status resulted in upstaging or downstaging from clinical stage 1A to stage 1B or vice versa in six patients with NSGCTs, with a subsequent change in therapeutic strategy. In addition, one patient with stage 1 pure seminoma had been misclassified with nonseminoma.

CONCLUSIONS

Inaccurate interpretation of orchiectomy specimens is not uncommon and may lead to incorrect tumor staging, imprecise assignment of progression risk, and inappropriate management recommendations. Secondary opinions of primary GCT orchiectomy specimens potentially facilitate appropriate counseling and therapeutic strategies.

Lymphovascular invasion in testicular germ cell tumors: clinicopathological correlates

Introduction

We assessed clinical–pathological correlates of lymphovascular invasion in testicular germ–cell tumors.

Material and methods

Archived pathology specimens from 145 patients treated by radical orchiectomy for testicular germ cell tumors at our institution in 1995–2006 were reanalyzed by a dedicated urologic pathologist, and the corresponding medical records were reviewed. The association of lymphovascular invasion with clinical and pathological parameters was tested using stepwise logistic regression analysis.

Results

Lymphovascular invasion was identified in 38 (26%) patients and was associated with younger age, testicular pain at presentation, elevated serum tumor markers, nonseminoma histology, and advanced clinical stage. Orchalgia was indicated as the impetus for referral in 67 (46%) patients and characterized as a dull aching sensation, persistent or intermittent in nature. Among the 98 men diagnosed with clinical stage I, those presenting with testicular pain had a 1.8X–higher likelihood of lymphovascular invasion than those without pain (95% CI 1.13–14.9, p = 0.02), and patients with elevated serum tumor markers had an 8.5–fold increased probability of lymphovascular invasion than those presenting with normal tumor markers (CI 1.1–54.2, p = 0.05). Among men with nonseminoma histology, elevated tumor markers was the strongest predictor of lymphovascular invasion in both univariate and multivariate analyses (OR 5.05, 95% CI 1.16–21.8, p = 0.03).

Conclusion

Providing pathologists with information on pre–orchiectomy tumor marker levels and, possibly, testicular pain at presentation may increase their vigilance in searching for lymphovascular invasion, potentially improving their diagnostic accuracy. Whether it may also translate into improved oncological outcomes needs further evaluation.

Concordance and prediction ability of original and reviewed vascular invasion and other prognostic parameters of clinical stage I nonseminomatous germ cell testicular tumors after retroperitoneal lymph node dissection

PURPOSE

We reviewed the slides of patients with clinical stage I nonseminomatous germ cell testicular tumors who underwent retroperitoneal lymph node dissection to evaluate the concordance between original and reviewed vascular invasion status, and other histological correlates.

MATERIALS AND METHODS

Between 2002 and 2007 at our institution 202 consecutive patients underwent retroperitoneal lymph node dissection. We requested the slides of 183 patients who underwent orchiectomy elsewhere. The risk of nodal metastasis was considered high in those with vascular invasion and/or greater than 90% embryonal carcinoma, and low in those with no vascular invasion and embryonal carcinoma less than 90%. Using Cohen's κ we assessed the concordance index between original and reviewed parameters (vascular invasion and risk category). Using the chi-square test we also evaluated the association between nodal status at retroperitoneal lymph node dissection and original vs reviewed parameters.

RESULTS

The original report did not contain vascular invasion information on 98 of 183 cases (53.4%). A total of 164 patients were evaluable since we had no slides for 19. Vascular invasion absence and presence were confirmed in 27 (73.0%) and 30 (78.9%) of 37 patients, respectively (Cohen's κ = 0.16). Low and high risk status was confirmed in 20 of 28 patients (71.4%) and in 47 of 64 (50.6%), respectively (Cohen's κ = 0.22). Reviewed vascular invasion and risk category were significantly associated with nodal status at retroperitoneal lymph node dissection (chi-square test p = 0.03 and 0.01, respectively), although the original parameters were not.

CONCLUSIONS

In half of the patients no information was available on vascular invasion in the original reports. Concordance between original and reviewed reports was generally poor. Reviewed parameters better predicted nodal status at retroperitoneal lymph node dissection. These findings may have important implications in clinical practice.

TCL1 protein expression in testicular germ cell tumors

We immunohistochemically studied TCL1 protein expression in different histologic types of 63 testicular germ cell tumors: 23 seminomas, 14 embryonal carcinomas, 4 teratomas, 2 yolk sac tumors, and 20 mixed germ cell tumors. The 20 mixed germ cell tumors contained components of seminoma (n = 10), embryonal carcinoma (n = 18), teratoma (n = 16), yolk sac tumor (n = 7), and choriocarcinoma (n = 3). We also examined 40 cases of intratubular germ cell neoplasia, unclassified type (IGCNU). Positive immunoreactivity for TCL1 was observed in 91% of the seminoma samples (30/33) and all IGCNU cases. In contrast, no TCL1 expression was detected among the nonseminomatous germ cell tumors. In the context of testicular germ cell neoplasia, the presence of TCL1 protein appears restricted to IGCNU and seminoma, suggesting association with an undifferentiated state and loss of protein expression with tumor differentiation. Immunohistochemical evaluation of TCL1 expression may have usefulness in substantiating a diagnosis of IGCNU or seminoma and in the separation of seminoma from nonseminomatous germ cell tumors.

Second opinion pathology in tertiary care of patients with urologic malignancies

OBJECTIVES

The purpose of this study is to evaluate the utility of second opinion pathology in patients who are seen in consultation for urologic malignancy.

METHODS

We retrospectively reviewed the records of all patients who were seen at our institution in consultation for urologic malignancy from August 2002 to April 2008. All available pathologic slides were reviewed by the urologist and pathologist at the time of consultation and compared with the original diagnosis. Discrepant diagnoses were reviewed by at least 2 pathologists. Diagnostic disagreements were graded as minor or major according to the significance of their effect on treatment or prognosis. We report the proportion and types of diagnostic discrepancies and their impact on patient care.

RESULTS

A total of 264 patients were seen in consultation. Of these, 213 had pathologic material available for review: prostate cancer 117 (55%), bladder cancer 83 (39%), testis cancer 5 (2%), renal pelvis or ureteral cancer 5 (2%), retroperitoneal tumor 2 (1%), and kidney cancer 1 (0.5%). Disagreement with the original diagnosis was found in 22 cases (10%), of which 18 (8%) were classified as major, and 4 (2%) were classified as minor. Interventions avoided or delayed, as a direct result of second opinion pathology, were a prostate biopsy in 1 patient, management of metastatic prostate cancer in 1 patient, partial nephrectomy in 1 patient, management of urothelial carcinoma in situ (CIS) in 1 patient, and radical cystectomy in 5 patients. Interventions recommended or performed were radical prostatectomy in 1 patient, and radical cystectomy in another. Additional pathology from subsequent biopsy or surgery was available in 12 of the 22 patients, and the second opinion pathologic diagnosis was supported in all patients.

CONCLUSIONS

A second opinion review of surgical pathology for urologic malignancy can result in major therapeutic and prognostic changes, which can impact patient care. Our results support the review of all pathology by the urologist and pathologist as part of the consultation in patients with urologic malignancy.

D2-40 immunohistochemistry in the differential diagnosis of seminoma and embryonal carcinoma: a comparative immunohistochemical study with KIT (CD117) and CD30

The distinction between seminoma and embryonal carcinoma based on morphology alone can sometimes be problematic, requiring the use of immunohistochemistry to facilitate diagnosis. D2-40 is a monoclonal antibody that reacts with an oncofetal antigen expressed by fetal germ cells and testicular germ cell tumors. The diagnostic value of D2-40 immunohistochemistry in distinguishing seminoma from embryonal carcinoma has not been determined. D2-40 immunoreactivity was evaluated in a series of testicular germ cell tumors and compared with that of KIT (CD117) and CD30, to assess the relative utility of this marker in discriminating between seminoma and embryonal carcinoma. Forty testicular germ cell neoplasms were examined, which included 19 seminomas, three embryonal carcinomas, three teratomas, one yolk sac tumor, and 14 mixed germ cell tumors. The 14 cases of mixed germ cell tumors contained components of seminoma (n=7), embryonal carcinoma (n=11), teratoma (n=10), yolk sac tumor (n=2), and choriocarcinoma (n=1). All cases of pure seminoma and the seminomatous components of mixed germ cell tumors exhibited positive immunoreactivity for D2-40. Focal positivity for D2-40 was also observed in 29% of the embryonal carcinoma samples. D2-40 immunoreactivity in seminomas was characterized by diffuse membrane staining, whereas for embryonal carcinomas, staining was focal and distributed along the apical surfaces of the neoplastic cells. Immunohistochemical staining for KIT was observed in 92% of the seminoma samples and in none of the embryonal carcinomas. Conversely, CD30 expression was identified in 93% of the embryonal carcinoma samples and in none of the seminomas. Other germ cell components showed no immunoreactivity for D2-40, KIT, or CD30. KIT and CD30 are effective immunohistochemical markers in separating seminoma from embryonal carcinoma. Although a highly sensitive marker for seminomas, D2-40 positivity was also observed in a subset of embryonal carcinomas, thus limiting the utility of this antibody for discriminating between these two malignancies.

The continued value of central histopathological review of testicular tumours

AIMS

Central histopathological review of testicular tumours prior to definitive treatment can have an important impact on patient management. This study was designed to assess the continued value of central review in the light of increasing subspecialization and increased numbers of consultant histopathologists.

MATERIALS AND RESULTS

The original and review reports of 291 testicular cancer specimens from 1998 to 2002 were analysed, looking particularly at major diagnosis, vascular invasion and the tumour elements within non-seminomatous germ cell tumours (NSGCT). When a diagnosis was altered any effect on subsequent patient management was assessed. There was a discrepancy in tumour type in 11 cases (4%) compared with 6% in 1992-1997. The commonest change was from seminoma to NSGCT or combined germ cell tumour (5/11). There was also diagnostic difficulty with spermatocytic seminoma (3/11). The clinical management of all 11 cases was influenced as a result of the review diagnosis. Discrepancies in vascular invasion were noted in 13 of the 126 NSGCTs (10%) compared with 20% in 1992-1997. Differences in NSGCT tumour elements, though clinically less important, were frequent in both groups.

CONCLUSIONS

There continues to be a small number of significant and clinically important errors identified following central histopathological review of testicular tumours. This study highlights the value of central review and supports its continued practice in the management of testicular tumours.

The role of the histopathologist in the management of testicular germ cell tumour in adults

In the last 20--30 years the availability of effective chemotherapy and more accurate clinical staging has greatly improved the prognosis for patients with testicular germ cell tumours. Initially, such treatment appeared to diminish the role of histopathology to the distinction between seminoma and nonseminomatous germ cell tumour (NSGCT) in the primary specimen. However, histopathology has evolved as a prognostic tool indicating the risk of relapse in various defined clinical contexts thereby facilitating therapeutic decisions. The clinical emphasis has been on quality of life and reduction of therapy both in terms of the number of patients treated and the number of chemotherapy courses given to each patient. The treatment of adult testicular germ cell tumours may differ between countries but protocols are established. Therefore it is appropriate to discuss the role of histopathology during this era of relative therapeutic stability.

An analysis of the impact of pathology review in gynecologic cancer

PURPOSE

To analyze the impact of pathology review in gynecologic malignancies.

METHODS AND MATERIALS

For all new gynecologic patients seen between December 2, 1993 and January 4, 1996, we conducted a retrospective chart review to determine if a pathology review by the institute's consultant pathologist changed the diagnosis, and if so whether the change altered patient management. A total of 514 patients were seen, of whom 120 had cervical cancer, 226 had endometrial cancer, 122 had a primary ovarian or peritoneal malignancy, 9 had a vaginal malignancy, 28 had vulvar cancer, and 9 had a miscellaneous gynecologic malignancy.

RESULTS

On pathology review the diagnosis changed for 200 of 599 specimens (33%). This altered management for 63 of 514 patients (12%). For patients with cervical cancer, the grade of tumor was the main change in pathologic diagnosis, with occasional change in the presence of lymph vascular invasion. These did not translate into patient management alterations. Eight patients (1.5%) had management alterations. The changes in depth of invasion and vascular invasion altered management for 3 patients. Changes in pap smears resulted in two management alterations, and changes in histologic diagnoses altered management for 3 cases. For endometrial primaries the changes in pathologic diagnosis included grade, depth of invasion, and the presence of cervical involvement. This did alter management in 40 cases (8%). For the ovarian malignancies, the main changes were grade, extent of disease, or histologic classification, some of which (10 patients, 2%) resulted in altered management. One patient with a vaginal lesion had the diagnosis changed, which did alter management. Of the patients diagnosed with vulvar cancer, the pathologic diagnosis changed for 11 patients. This included changes in grade and depth of invasion. This altered management of 2 patients. The remaining miscellaneous gynecologic malignancies had only two diagnosis changes that altered management.

CONCLUSIONS

Pathologic review of gynecologic malignancies is justified as it can alter patient management. In addition, the process facilitates cooperation of the multidisciplinary team and provides a valuable educational forum to enhance patient care.

The value of central histopathological review of testicular tumours before treatment

OBJECTIVE

To assess the value of central histopathological review of testicular tumours.

MATERIALS AND METHODS

The histopathology reports of the referring hospital and central review were compared for all referred testicular specimens (201 orchidectomies and seven testicular biopsies) from 11 hospitals in one region, between 1992 and 1997.

RESULTS

There were two main findings: First, there was a major discrepancy of tumour type in 12 specimens (6%). The most frequent change (in five cases) was from seminoma to nonseminomatous germ cell tumour (NSGCT). There were also difficulties with uncommon tumours such as spermatocytic seminoma, lymphoma and adenocarcinoma. Treatment was changed as result of the altered diagnosis in eight of these 12 patients. Second, there were discrepancies of interpretation of vascular invasion in 12 of 59 NSGCTs (20%). Differences of tumour elements recognized in NSGCTs were frequent.

CONCLUSIONS

The errors discovered on central histopathological review of testicular tumours were significant, though small in number. This supports the idea of central review and is consistent with the specialization recommended in the Calman-Hine cancer arrangements.

The need for specialist review of pathology in paediatric cancer

A retrospective histopathological review of 2104 cases of solid tumour was carried out to assess the variability in diagnosis of childhood cancer. Cases were subject to three independent, concurrent opinions from a national panel of specialist pathologists. The conformity between them was analysed using the percentage of agreement and the kappa statistic (kappa), a measure of the level of agreement beyond that which could occur by chance alone, and weighted kappa (w kappa), which demonstrates the degree of variation between opinions. The major groupings of the Birch-Marsden classification were used within which tumours were assigned for kappa analysis according to the clinical significance of the differential diagnoses. The mean agreement for all tumours together was 90%; kappa = 0.82, w kappa = 0.82. Retinoblastoma achieved the highest kappa value (1.0) and lymphoma the lowest (0.66). Of the cases, 16.5% had their original diagnoses amended and the panel confirmed the original diagnosis of paediatric pathologists in 89% of cases compared with 78% for general pathologists. The varying levels of agreement between experts confirm the difficulty of diagnosis in some tumour types, suggesting justification for specialist review in most diagnoses. Specialist training in paediatric pathology is also recommended.

Primary intratesticular sarcoma. Immunohistochemical ultrastructural and DNA flow cytometric study of three cases with a review of the literature

BACKGROUND

Fourteen cases of testicular sarcoma have been reported in the contemporary era. These included 7 cases of rhabdomyosarcoma, 2 spindle cell sarcoma, 2 osteosarcoma, 1 leiomyosarcoma, 1 fibrosarcoma, and 1 chondrosarcoma coma.

METHODS

In this report, immunohistochemical stains, electron microscopy, and DNA flow cytometric analysis were performed on primary testicular sarcomas from three patients.

RESULTS

The patients were age 47, 40, and 33 years. Each presented initially with a testicular mass. The tumors measured 4.8, 4.0, and 4.0 cm in greatest dimension. There was no associated germ cell elements nor elevated alpha-fetoprotein or beta-human chorionic gonadotropin. Case 1 was positive for actin, vimentin, and alpha-1-chymotrypsin. Case 2 was positive for vimentin but not desmin. Case 3 was positive for desmin and S-100. Smooth muscle differentiation was identified by electron microscopy. Flow cytometric analysis revealed DNA aneuploidy in all cases: 1.27, 1.29, and 1.71. The 3 patients were alive and well without recurrent disease at 7, 6, and 4 years after diagnosis. Inguinal orchiectomy was the initial treatment in all 17 patients, there was 1 death from metastatic disease and 2 patients with distant metastases.

CONCLUSION

Primary testicular sarcoma is a rare indolent tumor with potential for distant metastases. Two cases of primary testicular leiomyosarcoma and one of unclassified sarcoma of the testis are reported.