Topic: CPC 3

Transcriber: Nais
Editor: Reyia

3rd CLINICOPATHOLOGIC CONFERENCE – TERATOMA and CHORIOCARCINOMA

GENERAL DATA

• 35 y/o male from Batangas

• CC: chest pain
• 4 months history of right-sided chest pain
• Alcoholic and chronic smoker
• Severe chest pain, admission and was discharged
• Gradual enlargement of the right breast
• Non-productive cough and low-grade fever, 25% weight loss, hence admission
• CXR: Right Pulmonary Mass
• Complete autopsy was done

AUTOPSY FINDINGS
EXTERNAL EXAMINATION:

• Body is that of an adult male

• Nutrition is at par with age
• Thoracostomy incision site over the 6th ICS RAAL
• CVP line incision site over the left cubital fossa
• Bilateral gynecomastia
• SUBCUTANEOUS FAT: 0.8 cm
• NECK ORGANS: thyroid weighs 30 gm and is unremarkable. Parathyroids are not
located

MEDIASTINUM

• Trachea and large bronchi contain no aspirated material nor blood

• Lymph nodes are not enlarged.
• An ill-defined, hemorrhagic, soft to friable mass is seen involving the right supero-
anterior mediastinum and SVC

PLEURAL CAVITIES

• The right cavity contains 1800 ml of clotted blood

• The left contains 500 ml of serous clear fluid

LUNGS

• A 10 x 9 x 2 cm, ill-defined, lobulated, soft to firm, reddish-blue mass, involving RU

and middle lobe
• CSS: soft to friable, variegated, cream-red parenchyma. Focal irregular pale yellow,
solid, firm areas also seen.
• The right lower lobe and the left lung are cyanotic, wrinkled, rubbery and airless

PERICARDIAL CAVITY

• Hemorrhagic, soft, friable tumor tissue is loosely adherent to the right lateral and
posterior aspects of the pericardium
• The sac contains the same tumor tissue
• There are loose tumor tissue adhesions between the two layers of pericardium

HEART

• Weighs 240 gm

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 • Epicardial surface of the posterior and lateral wall of the right ventricle is shaggy with
hemorrhagic, soft, friable parenchyma
• Myocardium, endocardium, valves and coronary arteries are unremarkable

LIVER

o Weight: 1,350 gms

o 32 x 22 x 10 cm (enlarged)
o Doughy
 yellowish-brown
o CSS: yellowish and greasy parenchyma
*

MICROSCOPIC DIAGNOSIS
• LUNGS
– Sections of the solid yellow areas show mature tissues derived from the 3
germ layers
– Some of the cartilagenous foci are immature with basophilic cells with large
and dark nuclei
– In addition, there are foci of small dark-staining cells with scanty cytoplasm
with a tendency to form rosettes
– Sections taken from the hemorrhagic, soft, friable areas show alternating
sheets of pale, regular cytotrophoblasts and eosinophilic, irregular
syncitiotrophoblasts
– The same trophoblasts are found inside some pulmonary blood vessels
– Sections fro the rest of the right and the left lung show collapse of alveoli
– The remaining patent alveoli contain lightly eosinophilic, homogenous
material

DIAGNOSIS
TERATOMA WITH IMMATURE ELEMENTS AND CHORIOCARCINOMATOUS COMPONENT; TUMOR
EMBOLI, PULMONARY VESSELS; ATELECTASIS; PULMONARY EDEMA.

MICROSCOPIC DIAGNOSIS
• PERICARDIUM AND HEART

– Hemorrhagic areas with cytotrophoblasts and syncitiotrophoblasts involving

the parietal and visceral pericardium
– Myocardium is not involved
– Mature teratomatous elements not seen

DIAGNOSIS
CHORIOCARCINOMA

MICROSCOPIC DIAGNOSIS
• LIVER
– Areas with polygonal cells with a central vesicular nucleus and abundant pink
cytoplasm (normal hepaticytes)
– Areas with numerous tiny fat vesicles (fatty liver)
• BREAST
• - Ductal and connective tissue proliferation with periductal edema

DIAGNOSIS
GYNECOMASTIA

MICROSCOPIC DIAGNOSIS
• KIDNEYS

– Dilatation of proximal convoluted tubules

– Epithelial cells are finely granular with desquamation
– Patchy loss of epithelial cells

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 – Tubular dilatation
– Patchy necrosis

DIAGNOSIS
• ACUTE TUBULAR NECROSIS, BOTH KIDNEYS.

FINAL ANATOMIC DIAGNOSIS

I. MEDIASTINAL TERATOMA WITH MATURE AND IMMATURE ELEMENTS AND

CHORIOCARCINOMATOUS COMPONENT, WITH INFILTRATION INTO THE RIGHT LUNG AND
PERICARDIUM.
A. RESIDUAL HEMOTHORAX, 1800 ML, RIGHT.
B. HYDROTHORAX, 500 ML, LEFT.
C. COMPRESSION ATELECTASIS, BOTH LUNGS.
D. ACUTE TUBULAR NECROSIS, BOTH KIDNEYS.
E. HYPOXIC CHANGES, BRAIN.
F. GYNECOMASTIA, BILATERAL.
II. S/P TUBE THORACOSTOMY FOR EVACUATION OF HEMOTHORAX.

CAUSE OF DEATH

HYPOVOLEMIC SHOCK SECONDARY TO TUMOR BLEED (MEDIASTINAL TERATOMA WITH

MATURE AND IMMATURE ELEMENTS AND CHORIOCARCINOMATOUS COMPONENT, WITH
INFILTRATION INTO THE RIGHT LUNG AND PERICARDIUM).

DISCUSSION ( this discussion was already lifted from the book)

TERATOMAS

• congenital tumors containing derivatives of all three germ layers and arise from
pluripotent embryonal cells
• commonly occur in ovaries, testes, retroperitoneum and the sacro-coccygeal region
• Superior mediastinal teratomas: usually asymptomatic till late, often discovered
incidentally on CXR
• Symptoms such as chest pain, dyspnea or cough: result of compression of nearby
structures
• Definitive diagnosis: histology
• Rarely, not all three germ layers are identifiable
• teratomas have been reported to contain hair, teeth, bone and very rarely more
complex organs such as eyeball, torso, and hand
• Usually, however, a teratoma will contain no organs but rather one or more tissues
normally found in organs such as the brain, thyroid, liver, and lung
• Known to secrete exocrine and endocrine products of their tissue components
• In a very small %, a malignant transformation or malignant component is seen (e.g.
sq. cell ca, adenoca and choriocarcinoma); the mass usually has a long history and is
seen in older patients.
• Thought to be present at birth, but often they are not diagnosed until much later in
life.
• It is predominantly diagnosed between the 2nd and 4th decade and the incidence is:
M=F
• Mature teratomas:most common histological type of germ cell tumors, followed by
seminomas
• Germ cell tumors are predominantly found in gonads, while the anterior mediastinum
is the most common extragonadal site
• Mediastinal teratomas are the most common tumor of the anterior compartment

CLASSIFIED INTO:
• MATURE TERATOMA (BENIGN)
– are commonly cystic
– aka Dermoid Cyst
– presumably derived from the ectodermal differentiation of totipotential cells
– Bilateral in 10 to 15%
– Unilocular cyst containing hair and cheesy sebaceous material
– Hx: cyst wall: strat. sq. epithelium with underlying sebaceous glands, hair
shafts and other skin adenxal structures

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 – Can also be seen: cartilage, bone, thyroid tissue and other organoid
formations
– 1% undergo malignant transformation

• IMMATURE TERATOMA (MALIGNANT)

– Rare tumors
– Component tissue resembles that observed in the fetus or embryo rather than
in adult
– Found chiefly in prepubertal adolescents and young women (mean age= 18
y/o)
– Grow rapidly and frequently penetrate the capsule with local spread or
metastasis
– High-grade tumors have poor prognosis
– Recurrences may develop after 2 years
– Hx: varying amounts of immature tissue differentiating toward cartilage,
glands, bone, muscle, nerve, etc.

• MONODERMAL TERATOMAS

– A remarkable, rare group of tumors

– Struma ovarii and carcinoid: most common
– Always unilateral; although a contralateral teratoma may be present

MEDIASTINAL TERATOMA

• The mediastinal germ cell tumors comprise 15% of anterior mediastinal tumors in
adults and 25% in children
• Benign tumors include mature teratomas and mature teratomas with an immature
component of <50%
• Mediastinum: 3rd most common location next to sacrococcygeal and retroperitoneal
sites
• Teratomas are the 2nd most common tumor of all the compartments of the
mediastinum next to neurogenic tumors
• Are believed to arise fro the 3rd pharyngeal pouch, the thymus anlage
• About 65% of the mediastinal teratomas are mature.
• Usually, mediastinal teratomas are the most frequent mediastinal germ cell tumors,
while immature teratomas are very rare

CHORIOCARCINOMA

• Most aggressive form of gestational trophoblastic disease

• mixture of cytotrophoblast and syncytiotrophoblast in plexiform pattern
• Rapidly invasive and metastasizing; may present with metastases but have small or
necrotic primary tumor
• Choriocarcinomas often have large areas of hemorrhage and necrosis and consist of
large pleomorphic, multinucleated cells with ample eosinophilic cytoplasm known as
syncytiocytotrophoblasts and cytotrophoblasts, which are polygonal cells with a clear
cytoplasm, round nuclei, and conspicuous nucleoli.
• elevated B-HCG

Hemothorax
• escape of blood in the pleural cavity
• large clots that accompany the fluid component of blood
• non inflammatory

Hydrothorax
• collection of serous fluid within the pleural cavities
• fluid is clear and straw colored
• may be unilateral or bilateral
• most common cause is cardiac failure, accompanied by pulmo congestion and edema
• fluid collects basally  causes compression and atelectasis of the regions of the lung
surrounded by the fluid

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Compression atelectasis
• results when pleural cavity is partially or completely covered by fluid exudates,
tumor, blood or air
• mediastinum shifts away from the affected lung
• occurs when local or generalized fibrotic changes in the lung or pleura prevent full
expansion
• reduces oxygenation and predisposes to infection
• reversible disorder

Acute tubular necrosis

• Destruction of tubular epithelial cells
• Acute diminution or loss of renal function
• Most common cause of ARF
• Causes tubular cell injury and disturbances in blood flow
o Microscopic
 Necrotic & detached tubular epithelial cells
 Swollen, vacuolated epithelial cells
 Distal tubules and collecting ducts contain casts
 Recovery phase shows epithelial regeneration (flattened tubular cells,
mitotic figures)

o Grossly
 Swollen kidneys
 Pale cortex
• Tubular damage is a primary event leading to:
o Arteriolar vasoconstriction
o Tubular obstruction by casts derived from necrotic and apoptotic epithelial
cells
o Back leak of tubular fluids
o Altered glomerular ultrafiltration

Stages:
 Initiation – inciting event; involves the first 36 hours
- slight ↓ in urine output
- ↑ BUN

 Maintenance
- oliguria (40-400 ml/day)
- salt & water overload
- ↑ BUN, hyperkalaemia, metabolic acidosis

 Recovery Phase
- increasing urine output (diuresis; 3 L/day) with loss of sodium & potassium
(hypokalemia)
- BUN & creatinine return to normal

Gynecomastia
-enlargement of male breast
• Unilateral or bilateral
• Button like subareolar enlargement
• Indicator of hyperestrenism  suggest liver cirrhosis or testicular tumor
• Imbalance between estrogens which stimulate breast tissue and androgens
Morphology:
- Proliferation of dense collagenous connective tissue
- Marked micropapillary hyperplasiaof ductal linings
- Cells are fairly regular, columnar to cuboidal cells with regular nuclei.