Elsevier

Human Pathology

Volume 36, Issue 6, June 2005, Pages 640-645
Human Pathology

Original contribution
Intertubular growth in pure seminomas: associations with poor prognostic parameters

https://doi.org/10.1016/j.humpath.2005.03.011Get rights and content

Summary

Clinical stage I seminomas are effectively treated with surgery raising concerns as to when to give adjuvant radiation therapy given the risk of secondary malignancies. A recent randomized trial found tumor size and rete testis invasion to be the strongest predictors of relapse in clinical stage I seminomas. These 2 parameters may be surrogate measures of tumor volume. Intertubular seminoma (ITS) of the testis describes the presence of neoplastic germ cells within the interstitium of the testis. These cells are detected away from the main macroscopic mass. Because ITS can infiltrate in a 3-dimensional fashion, it may also represent a measure of tumor volume not usually noted in standard pathology reporting. The goal of this study was to determine the incidence of ITS in pure seminomas and its association with other prognostic parameters. One hundred twenty consecutive pure seminomas surgically removed between 1998 and 2003 were evaluated. ITS was defined as the presence of an interstitial or intertubular growth pattern of tumor cells, which was noncontiguous with the main tumor and present at least 3 high-power fields away from the tumor mass. The average tumor size was 3.4 cm. Of the entire cohort of patients, which included pathological stages T1 through T3, 11% had invasion through the tunica albuginea, 51% had rete testis invasion, 51% had lymphovascular invasion, 93% had associated intratubular germ-cell neoplasia, and 36% had ITS. ITS was significantly associated with rete testis invasion (P = .001). Logistic regression analysis looking at ITS, tumor size, patient age, and lymphovascular invasion revealed that only ITS was associated with rete testis invasion (RR, 4.1, P < .0001). ITS is present in a significant proportion of pure seminomas and has a significant association with rete testis invasion. The presence of ITS may therefore be an important prognostic factor, not only because it alters the calculated size of the tumor but also because it has an association with rete testis invasion.

Introduction

Standard treatment of clinical stage I seminomas includes orchidectomy and external beam radiation. Because of their sensitivity to radiation, most seminomas have a good prognosis, irrespective of their presenting stage. Clinicians are now rethinking the standard treatment strategies for early stage disease especially because the risk of second malignancies in postradiation patients is a real concern, particularly given the early age of diagnosis in many of these patients [1].

Over the last 20 years, postorchidectomy surveillance programs have been introduced as an alternative treatment to adjuvant therapy for clinical stage I seminomas. Recently, a large randomized trial found, by multivariate analysis, that tumor size of more than 4 cm and rete testis invasion were the strongest predictors of relapse in patients with clinical stage I seminoma managed by surveillance only [2]. Seminomas are usually nodular and well circumscribed, facilitating gross measurement. Macroscopic measurement, akin to that in lobular carcinoma of the breast, may become more difficult especially when the pattern of invasion is more diffuse. An intertubular growth pattern, although often present at the periphery of a grossly discernable mass, can be identified microscopically away from the main mass. In this instance, the cells typically do not form a macroscopic mass, and therefore, it is difficult to give an accurate assessment of the true size of the tumor. This type of growth pattern, which we have called intertubular seminoma (ITS), may alter the estimated size of the mass and, when infiltrating in 3 dimensions, may represent a measure of tumor volume not usually noted in standard pathology reports. We set out to determine the incidence of ITS in pure seminomas and assess its associations with other prognostic parameters including rete testis involvement.

Section snippets

Methods

A retrospective computer search of the pathology records at the Brigham and Women's Hospital, Boston, Mass, from January 1988 to January 2003 identified 120 consecutive orchidectomy specimens that contained pure seminomas. All the hematoxylin and eosin slides from each case were reviewed to confirm the diagnosis. All the tumors were staged according to the American Joint Committee on Cancer pathological classification for testicular tumors (sixth edition) [3]. In addition, they were assessed

Results

We reviewed 120 cases of pure seminoma. The mean age of the patients was 35.1 years (age range, 20-68 years) and the average gross size of the tumors was 3.4 cm (size range, 1-9 cm). According to the American Joint Committee on Cancer pathological staging system (sixth addition) [3], 47.5% were T1, 41.5% were T2, and 11% were classified as T3 tumors. When looking at tumor size by stage, the 95% confidence interval for mean stage T1 was 2.57 (range, 2.167-2.966), stage T2 was 3.96 (range,

Discussion

Only a small percentage (10%-20%) of clinical stage I seminomas harbor occult retroperitoneal lymph node metastases [6], [7]. As a consequence, surveillance-only protocols were established a number of years ago as an alternative treatment strategy for clinical stage I seminomas. The reported relapse rates for patients managed by surveillance only range from 15% to 19% [2], [8], [9], [10], [11]. Numerous studies over the last number of years have addressed the question of stage I seminomas

References (17)

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