• 32 year old man• 2 months history of growing left supraclavicular lymph nodes• Antibiotic treatment was not successful• Thoraco-abdominal staging (at first CT, than PET-CT)

Prof. Dr. med. Beata BODE-LESNIEWSKAInstitute of Pathology and Molecular PathologyUniversity Hospital; Zurich

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Aug 18th

• 32 year old man• 2 months history of growing left supraclavicular

lymph nodes• Antibiotic treatment was not successful• Thoraco-abdominal staging (at first CT, than PET-

CT) showed large retroperitoneal, mediastinal and left supraclavicular tumor masses – based on imaging the strong clinical suspicion of a lymphoma has been rendered.

• Sonographically guided FNAC of the leftsupraclavicular lymph node

pLN

pLN

Sonographically guided FNAC of the pathologic lymph nodes (pLN)

Aug 18th

Direct smearPAP stain; 100x

Direct smearPAP stain; 50x

Direct smearPAP stain; 200x

Direct smearPAP stain; 200x

Direct smearPAP stain; 200x

Direct smearPAP stain; 400x

Direct smearPAP stain; 400x

Cell block HE stain; 100x

Cell block Mib1; 200x

Differential diagnosis

• Carcinoma• Melanoma• Lymphoma

– Hodgkin– Non-Hodgkin (anaplastic)

• Sarcoma (e.g. epithelioid sarcoma, angiosarcoma, etc…)

• Germ cell tumor

• (Mesothelioma)

Cell block Cytokeratin (AE1/AE3); 200x

CD3CD20

Cell block; 200xFNAC lymph node

Cell block; 400xFNAC lymph node

CD45CD30Alk1

S100, ERG, CD34, CD31

INI1 expression present

Differential diagnosis

• Carcinoma• Melanoma• Lymphoma

– Hodgkin– Non-Hodgkin

• Sarcoma• Germ cell tumor

• Mesothelioma

Cell block OCT3/4; 400x

Cell block PLAP; 400x

SALL4 bHCGCell block; 200xFNAC lymph node

Direct smearPAP stain; 400x

Germ cell tumor (seminoma)(19.8.)

Aug 19th

Urology consult

Semicastration

PLAP

Germ cell neoplasia in situ (GCNIS)

Final diagnosis• Metastatic (at presentation) seminoma

– Extensive metastases retroperitoneal and leftcervical

– Initial manifestation as supraclavicularlymphadenopathy

• «Burnt out» (regressed) germ cell tumor of the right testis– Semicastration with focal scaring– Advanced atrophy of the tubuli– Germ cell neoplasia in situ (GCNIS) present

Post 4 monthschemotherapy

Initial PET-C(at presentation)

Follow up• Recurrent tumor 6 month after initial

presentation• High dose chemotherapy with autologous

bone marrow transplantation – successful• Local lumbal spine radiotherapy for residual

tumor

• 6 years after initial presentation no furthertumor manifestations – declared as cured

Germ cell Tumors (GCT)• Rare (1% of male malignancy)• Incidence 1.5 -12 / 100 000 (higher in industrialiezed

countries)– Ethnicity / genetic susceptibility– Enviromental factors

• … however - most common cancer among young male patients (puberty to 40-ies) in industrialized countries

• High metastatic potential• Accompanied by tumor markers in blood (AFP, bHCG)

• Curable with modern combined therapy regimens(most important chemotherapy)

• Usual presentation as a testicular mass• Some 3-10% of seminomas and embryonal

carcinomas present as a metastatic disease• Practically all choriocarcinomas are metastatic

at presentation

• «Burnt out» (regressed) testicular tumors– May cause bulky metastatic diesease– Should not be confused with (rare) extragonadal

primaries (retroperitoneum, mediastinum)

GCT - Subtypes

• Seminoma• Non-seminomatous GCT

– Embryonal carcinoma– Yolk sac tumor– Choriocarcinoma– Teratomas

• Mixed GCT

Cytologic diagnosis of GCT• Not on primary tumors• Possible in metastatic setting

– First diagnosis, if testicular primary not obvious– Recurrent tumor– Advantage: rapid turn over time

• final pathologic tissue diagnosis within 2 days• No excisional biopsy neccessary• Semicastration on the 4th day• Disease specific diagnosis chemotherapy prompty started

Facit

• Metastatic germ cell tumor (GCT) may causecervial lymphydenopathy (not onlyretroperitoneal / mediastinal)

• Cytologic diagnosis of GCT is well feasible

• GCT should be considered as a differential diagnosis especially in young male patientswith rapidly progressive lymphadenopathy

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