2014, Volume 30, Number 1, Page(s) 069-072
Seminoma Presenting as a Polypoid Bladder Mass: A Case Report
Afaf ALSOLAMİ1, Mohammed ALOTAİBİ2, Shouki BAZARBASHİ3, Abdulmonem ALMUTAWA4, Mohammed AKHTAR4
1Department of Pathology and Laboratory Medicine, King Khalid University Hospital, RIYADH, KINGDOM of SAUDI ARABIA
2Departments of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, KINGDOM of SAUDI ARABIA
3Departments of Medical Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, KINGDOM of SAUDI ARABIA
4 Departments of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, KINGDOM of SAUDI ARABIA
Keywords: Seminoma, Urinary bladder, Germ cell tumors, Hematuria
We report a case of extragonadal seminoma presenting as a polypoid
mass in the urinary bladder. The patient presented with two months
history of hematuria. Evaluation by CT scan and cystoscopic
examination revealed a polypoid mass in the base of the bladder.
Biopsy of the mass revealed a classical type of seminoma. The
diagnosis of seminoma was supported by strong immunostaining
of the tumor cells for C-Kit and placental alkaline phosphatase.
Thorough physical examination and radiologic imaging of other
organ systems failed to reveal any other tumor. Both testes were
found to be normal on examination and on ultrasound imaging.
Patient responded well to chemotherapy. This case is unique because
to the best of our knowledge there are no previously reported cases in
the literature with seminoma presenting as a bladder mass.
Extragonadal germ cell tumors (GCTs) in adults are
uncommon and are mostly encountered in men.
Mediastinum is the most common site of these tumors
followed by retroperitoneum and central nervous system.
Many of the extragonadal germ cell tumors are seminomas,
although other types of germ cell tumors including
embryonal carcinoma, yolk sac tumor, teratoma and mixed
germ cell tumor may also be seen1,2
. We hereby present
a unique case of extragonadal seminoma which presented
with a large polypoid intravesical mass.
A 51-year-old man presented with a history of gross
hematuria for two months. The patient was obese and a heavy smoker (2 packs per day) for the last twenty
years. Patient’s past medical history was unremarkable
and physical examination did not reveal any significant
abnormality. A computed tomography scan (CT) showed
a polypoid enhancing mass measuring 35x43 mm arising
from the posterior basal aspect of the urinary bladder near
the trigon, highly suggestive of urinary bladder carcinoma
). The mass extended up to the base of the prostate
but no definite intraprostatic extension was seen. Cystoscopy
revealed a large polypoid mass with areas of ulceration at
the bladder neck extending to the trigone. A cystoscopic
biopsy was obtained, which revealed a seminoma. In view
of the unusual nature of the tumor, a second cystoscopic
examination was performed and additional biopsy material
was obtained in order to confirm the pathologic diagnosis.
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|Figure 1: CT scan of the pelvic cavity showing a polypoid mass
within the urinary bladder (arrow).
Both biopsies represented bladder mucosa, in which lamina
propria was extensively replaced by a cellular malignant
neoplasm. The overlying urothelium was focally ulcerated
but otherwise uninvolved. The tumor in the lamina propria
was composed of uniform round to polygonal cells with
moderate to abundant partly clear cytoplasm and large
nuclei with prominent nucleoli. Interspersed with the
tumor cells were variable numbers of lymphocytes (Figure
2, 3). The tumor cells were strongly immunoreactive for
placental alkaline phosphatase and C-Kit (CD117) with a
strong membrane staining pattern (Figure 4). There was
patchy dot-like pattern of staining for CK8/18 within some
of the tumor cells. The tumor cells were non-reactive for
prostate specific antigen (PSA), prostatic specific acid
phosphatase, CK7, CK20, CD45, CK (AE1/AE3), HMB45,
S100, CD34, high molecular weight cytokeratin, epithelial
membrane antigen, p63, and CD34. The tumor was diagnosed as classical seminoma. No other germ cell tumor
elements were noted.
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|Figure 2: Bladder biopsy featuring a cellular neoplasm within the
lamina propria. The tumor cells are intermixed with lymphocytes.
The overlying urothelium is unremarkable (H&E x20).
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|Figure 3: Higher magnification photomicrograph of the tumor
depicting tumor cells with abundant partly clear cytoplasm, large
nuclei and prominent nucleoli. Scattered lymphocytes are present
in the background (H&E x40).
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|Figure 4: The tumor cells featuring strong immunohistochemical
staining for C-kit (CD117) with a prominent membrane pattern
Following the diagnosis of seminoma involving the urinary
bladder, the patient was further evaluated for the presence
of a primary tumor and for detection of tumor in other
locations. A careful examination of both testes including
ultrasound evaluation, failed to reveal any abnormal
masses or calcifications. Examination by CT scan failed
to reveal any masses in mediastinal or retroperitoneal
spaces, abdomen and pelvis. Tumor markers including
serum alpha-fetoprotein (4.9 μg/L), human chorionic
gonadotropin (2.0 IU/L) and lactate dehydrogenase (165 U/L) were all in normal limits. Prostate specific antigen
was 1.0μg/L. The patient was treated by four cycles of
chemotherapy consisting of bleomycin, etoposide and
cisplatin. There was a significant response with the mass
shrinking to <50% of the original size. The patient however
refused further chemotherapy. A CT scan two years later
revealed the bladder mass to be unchanged. There was no
evidence of any metastatic focus within the abdomen, lungs
Extragonadal germ cell tumors are uncommon,
representing 1-5% of germ cell tumors. Their morphology
varies widely and includes mature teratoma, immature
teratoma, seminoma, yolk sac tumor, embryonal carcinoma
and mixed germ cell tumor. Approximately 30-40% of
these tumors are seminomas. Extragonadal germ cell
tumors can be found anywhere on the midline, particularly
the retroperitoneum, the anterior mediastinum, the
sacrococcyx, and the pineal gland. The orbit, suprasellar
area, palate, thyroid, submandibular region, anterior
abdominal wall, stomach, liver, vagina, and prostate are the
other reported less common sites (1,2).
To the best of our knowledge, no cases of extragonadal
germ cell tumors with presumed origin in urinary bladder
have been reported. On the other hand five cases of
seminoma with possible primary origin in the prostate have
been documented3-7. In all cases the tumor was a pure
classical seminoma except for one case reported by Han
et al5. In that patient the tumor was a mixed germ cell
tumor with predominant pattern of yolk sac tumor, while
seminoma represented only a minor component. In two
of the reported cases the major bulk of the tumor was in
the prostate but there was extension into the bladder neck3,7. None of the tumors presented as intravesical mass.
A few cases of metastatic seminoma to the prostate or
bladder have been reported8-11. In the present case the
main component of the tumor was present as a polypoid
intravesical mass, however the base of the tumor was
adjacent to the base of the prostate without clear evidence
of prostatic involvement.
Controversy remains regarding the origin of extragonadal
germ cell tumors. The classical theory suggests that
extra gonadal germ cell tumors are derived from local
transformation of primordial germ cells misplaced during
gonadal embryogenesis. The more restricted anatomical
distribution of the GCTs primarily in the midline locations
can probably be explained by the fact that generally the germ cells cannot survive outside the specialized niches
present in testis and ovary. The occurrence of GCTs in the
thymus and the midline of the brain suggest the presence
of niches at those sites, which presumably offer the same
support to germ cell and their neoplastic counterparts as
provided by the gonads. Thymic epithelium may behave as
feeder of the seminoma cells in thymus as sex cord stromal
cells in the gonads12.
An alternative theory suggests that extragonadal tumors
represent migration of malignant cells from occult in situ
lesions in the gonad; hence, they may be gonadal in origin.
There are several reports of patients with extragonadal
germ cell tumor with synchronous and metachronous
germ cell tumors within the gonad13-15. These reports
emphasize the point that extragonadal germ cell tumors
should be accepted as primary tumor only after a thorough
evaluation of the patient to rule out a gonadal primary
neoplasm. Furthermore, a prolonged follow up may also
be necessary to unmask a hidden primary gonadal tumor.
This indeed was the case in several reported cases in which
an extragonadal tumor was initially thought to be primary,
only to discover several years later that there was a gonadal
germ cell tumor, which was not clinically apparent earlier13-15. In our case, although a search for a primary tumor
within the gonads has yielded negative results, such a
possibility cannot be completely excluded until the patient
has been followed for several years without any evidence
of gonadal neoplasm or the testes have been examined for
an occult or regressed germ cell tumor. Germ cell tumors
in the testis are known to undergo spontaneous regression
leaving only a scar as evidence of preexisting tumor14,16.
In summary, a unique case of classical seminoma presenting
as a large intravesical mass is presented.
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