Necrotic
testicular tumors are relatively frequent and can present a significant diagnostic challenge. Because of differing treatments for
seminomas versus nonseminomas, accurate diagnosis is critical. Eleven totally (n=9) or almost totally (n=2) necrotic
testicular tumors were retrieved from our consult files. The submitting pathologists favored benign processes in 4 cases,
Leydig cell tumor in 1, and
lymphoma in 1. The cases were evaluated for histologic features and, when material was available, by immunostaining with 7
antibodies:
keratin (AE1/AE3), OCT4,
placental alkaline phosphatase,
alpha-fetoprotein (AFP), CD117, CD30, and S100. Only distinct reactivity in a cellular distribution in the necrotic zone was considered positive; nuclear reactivity alone was scored for OCT4 and membrane reactivity for CD117 and CD30. Mean patient age was 35 years (range 16-63). Mean
tumor size was 19 mm (range 7-53). All patients presented with unilateral testicular masses (6 right, 5 left); 2 also had
acute pain. The combination of histologic features, immunostains and, in 1 case, serum AFP permitted classification of 8
tumors (4
seminomas, 3
embryonal carcinomas, 1
yolk sac tumor). Three were not classifiable. The necrotic
seminomas lacked associated coarse intratubular calcifications and were positive for OCT4 (4/4) and CD117 (3/3) but negative for
keratin (0/4) and CD30 (0/4). The necrotic
embryonal carcinomas had associated coarse intratubular calcifications and were positive for
keratin (2/3), OCT4 (2/2), and CD30 (3/3). OCT4 stained 1 unclassifiable
tumor, which lacked other specific markers. We did not find
placental alkaline phosphatase, AFP, and S100 stains useful, although S100 did highlight
tumor "ghost" cells in 1 case. Other features in most cases included intratubular germ cell
neoplasia (6/11), tubular
atrophy/hyalinization (10/11),
tumor "ghost" cells (10/11),
scar (9/11), and
inflammation (10/11). Of the 5 patients with available follow-up, 3 were free of disease at 1, 5, and 8 years after
orchiectomy (2 necrotic
seminomas and 1
germ cell tumor, unclassified). One patient with
yolk sac tumor (age 63 y) developed widespread
metastases after 15 months and died of disease. The final case was initially misinterpreted as "testicular
infarction, no
malignancy" and 16 months later the patient developed a large retroperitoneal
seminoma. Most totally necrotic
testicular tumors can be placed into clinically important groups by assessment for coarse intratubular calcifications and staining reactions for
keratin, OCT4, CD117, and CD30.