The differential diagnosis of testicular germ cell tumors in theory and practice

A critical analysis of two major systems of classification and review of 389 cases

Summary

To better appreciate the conflicts and controversy surrounding the classification of testicular tumors, and to reappraise their morphologic substrate under the advent of tumor markers, 389 of our own cases are reviewed, classified according to the systems advocated by the World Health Organization (WHO) and the Testicular Tumour Panel and Registry (TTPR) of Great Britain, and evaluated statistically.

While many cases fit easily into either classification, the following difficulties were manifest: 1) Discrepancies in definitions and diagnostic criteria are the reason that considerably more germ cell tumors could be classified as mixed choriocarcinomas (WHO) than as trophoblastic teratomas (TTPR). It was found that tumor markers supply histochemical data that often conflict with rather than supplement morphologic ones in diagnosis and differential diagnosis. Similarly, the incidence of yolk sac structures, as yet not recorded separately by the TTPR, varies as either morphologic or histochemical criteria are applied. 2) The division of the morphologic spectrum of teratomatous differentiation by criteria of distinction that are unequal in the two systems yield comparable but non-congruent tumor entities. Consequently, borderline cases may undergo shifts to noncorresponding groups as they are translated from one system to the other. 3) Criteria separating teratoma with malignant transformation and polyembryoma (WHO) from closely allied lesions proved impractical. 4) Diagnostic labels that incorporate not only a morphologic pattern but a definite level in the histogenetic hierarchy generate a climate of incompatibility between systems whose histogenetic perspectives differ. Embryonal carcinoma's claim to totipotence, in particular, leads to a conceptual split with the teratomas and brings the WHO system by itself into theoretic difficulties. Moreover, as the morphologic criteria for embryonal carcinoma are not in keeping with its histogenetic premise, the rigid separation is difficult to enforce in practice.

Once the air is cleared, a resolution is easily reached. In the combined use of both classifications their real difference, splitting vs lumping, becomes a true asset.

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von Hochstetter, A.R., Hedinger, C.E. The differential diagnosis of testicular germ cell tumors in theory and practice. Virchows Arch. A Path. Anat. and Histol. 396, 247–277 (1982). https://doi.org/10.1007/BF00431386

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Key words

  • Testicular tumors
  • Germ cell tumors
  • Classifications