Ovarian Dysgerminomas Pathology Overview of Ovarian

Dysgerminomas

Author: Florette K Gray Hazard, MD; Chief Editor: Ramya Masand, MD more...
Updated: Oct 20, 2015

Overview of Ovarian Dysgerminomas

Differentiating Ovarian Dysgerminomas

Laboratory Markers
Gross and Microscopic Features
Immunohistochemistry
Molecular and Genetic Features
Prognosis of Ovarian Dysgerminomas
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References

Overview of Ovarian Dysgerminomas

A dysgerminoma is a tumor of the ovary that is composed of primitive, undifferentiated germ cells. Germ cell
tumors arise from primordial germ cells of the ovary and the testis; however, pathogenesis of the ovarian germ
cell tumors is unknown. Of the ovarian lesions, 97% are benign proliferations (ie, matureteratomas; the
remaining 3% are malignant.[1]
Germ cell tumors may be distinguished by their line of differentiation. Primitive, unipotential germ cells are the
precursors to ovarian dysgerminomas and their testicular analogue, the seminoma. However, pleuripotential
germ cells diverge along several lines of differentiation: trophoblasts, choriocarcinoma; embryonic cells,
embryonal carcinoma; extraembryonic components (endoderm, mesoderm, ectoderm), teratoma; presomite
embryoid bodies, polyembryoma; and yolk sac, yolk sac (endodermal sinus) tumor.
Dysgerminomas are the most common malignant germ cell tumor occurring in theovary (see the following
image), and these lesions are found most commonly in adolescents and young adults; in fact, approximately
60% of cases are diagnosed in patients younger than 20 years. [2] Common signs and symptoms of ovarian
dysgerminomas include abdominal/pelvic pain (55-85%), abdominal mass (35%), fever (10-25%), vaginal
bleeding (10%), and, occasionally, ascites. Unlike other germ cell tumors, dysgerminomas often occur
bilaterally (approximately 10-20% of cases).

and percentages of malignant germ cell tumors.

Extraovarian tumor spread of dysgerminomas often involves the retroperitoneal and pelvic lymph nodes; these
tumors are highly susceptible to radiotherapy.[1] In addition, hematogenous spread may occur; common sites of
involvement are the lungs, liver, and bone.[2]

Go to Ovarian Cancer and Borderline Ovarian Cancer for complete information on these topics.

Differentiating Ovarian Dysgerminomas

The chief disorders in the differential diagnosis of dysgerminoma are lymphoma/leukemia, yolk sac
tumor, embryonal carcinoma, and Sertoli cell tumor. Large-cell lymphoma typically occurs bilaterally; it is
recognized on positive staining of markers for CD45 (LCA) but not for OCT3/4, PLAP, or SALL4. [3]
Yolk sac tumor may exhibit a solid pattern, simulating dysgerminoma, but other classic architectural patterns of
yolk sac tumor (ie, reticular, microcystic, glandular, or Schiller-Duvall bodies) are also invariably present.
Pure embryonal carcinoma is rare in the ovary. However, mixed germ cell tumors occur in approximately 5% of
cases. When present, embryonal cell carcinoma exhibits more nuclear hyperchromasia and nuclear
pleomorphism, amphophilic cytoplasm, high mitotic index, and necrosis. Often, a glandular or papillary
architecture is present. The cells of embryonal carcinoma express CD30 and cytokeratin (strong, diffuse),
whereas those of dysgerminoma do not.
A study investigated nuclear protein in the testis (NUT) expression in ovarian germ cell tumors (GCTs). The
study found that most malignant ovarian GCTs express NUT protein, albeit focally, and this should be
considered when evaluating immunostaining in the differential diagnosis of poorly differentiated malignancies,
particularly NUT midline carcinoma. The study further advised that since NUT protein appears to play a role in
normal germ cell maturation it may influence intestinal or hepatoid differentiation within malignant GCTs. [4]
Sertoli cell tumors may be mistaken for dysgerminoma when tubules are indistinct and/or solid, especially if
they are poorly fixed. However, Sertoli cell tumors do not usually have a background lymphocytic infiltrate; they
express cytokeratin (strong, diffuse), calretinin, and inhibin.

Laboratory Markers
Dysgerminomas are associated with elevated serum levels of lactate dehydrogenase (LDH).
Although these tumors are thought to be hormonally inert, at least 1 case of precocious puberty occurring in
association with dysgerminoma has been reported.[5]The patient was a 6-year-old girl whose precocious
puberty was caused by elevations in the levels of betahuman chorionic gonadotropin (beta-hCG), alphafetoprotein (AFP), and estradiol.
Additionally, elevated serum levels of neuron-specific enolase, [6] calcium,[7] inhibin,[8]placental alkaline
phosphatase (PLAP), and prolactin [9] have been reported. These serologic elevations readily resolve following
surgical excision; after the elevations resolve, the serum levels may be used as tumor markers to monitor for
recurrence. Because these markers are more commonly associated with other germ cell tumors (ie, yolk sac,
embryonal carcinoma, choriocarcinoma), many scientists contend that secreting dysgerminomas are
misdiagnosed as pure lesions and that they actually represent mixed tumors containing other malignant germ
cell components.[2]
Go to Gynecologic Tumor Markers for complete information on this topic.

Gross and Microscopic Features

Dysgerminomas are characterized by their solid nature and rapid growth. Grossly, these tumors often measure
more than 10 cm in maximum dimension at the time of diagnosis. The classic histology of dysgerminomas
features a proliferation of epithelioid cells admixed with mature lymphocytes arranged in sheets or small
clusters separated by thin, fibrous septae resembling alveoli. The neoplastic cells are large and have moderate
to high nucleus-to-cytoplasm ratios. Other features are squared-off to round nuclei; vesicular chromatin;
prominent nucleoli; clear to eosinophilic cytoplasm rich in glycogen and lipid; and distinct cell borders.
Multinucleated forms may be present. Mitotic activity may be significant and may vary greatly, even within the
same tumor; atypical mitoses may be seen. Noncaseating granulomas, syncytiotrophoblastlike giant cells, and
germinal center formation are not uncommon. Additionally, foci of hemorrhage, necrosis, and small
microcalcifications may also be identified.
Examples of ovarian dysgerminoma histology are shown below.

Ovarian dysgerminoma histology (hematoxylineosin, 100)

Ovarian dysgerminoma histology. The arrows

indicate syncytiotrophoblastlike giant cells. A and B: Hematoxylin-eosin, 200. C: hematoxylin-eosin, 400. D: hematoxylineosin, 600.

Although numerous architectural variants exist, the cytologic features remain constant. These varying
architectural patterns include but are not limited to sparse lymphocytes, trabeculae, microcysts, and tubules, as
well as extensive hyalinization. As yet, no prognostic significance has been attributed to these architectural
patterns.
Dysgerminomas demonstrate a characteristic tigroid background and loosely cohesive, polygonal cells with
round to oval nuclei, vesicular chromatin, and multiple (1-4) distinct nucleoli on cytology preparations.

Immunohistochemistry
Immunohistochemistry (IHC) plays an important role in characterizing germ cell tumors. Although the wide
range of architectural patterns may make establishing the pathologic diagnosis difficult, the
immunohistochemical profile is often informative.[1, 2]
The neoplastic cells of dysgerminomas express placental alkaline phosphatase (PLAP), CD117 (c-kit), OCT
3/4, SALL4, and, variably, cytokeratin (see the images below). They do not express epithelial membrane
antigen (EMA), S100 protein, CD45 (LCA), or alpha-fetoprotein (AFP).

Dysgerminoma immunohistochemistry (x200).

CD117 = a proto-oncogen (c-kit) ; CKAE1/CAM5.2 = cytokeratins; D2-40 = a monoclonal antibody; H&E = hematoxylineosin; OCT 3/4 = a transcription factor; PLAP = placental alkaline phosphatase.

Syncytiotrophoblastlike giant cells are the source of beta-hCG production; this protein expression is confirmed
by immunohistochemistry. D2-40 membrane expression has been established in testicular seminoma[10] but has
not been extensively explored in dysgerminoma.

Molecular and Genetic Features

Isochromosome 12 (i(12p)) is seen in dysgerminomas, as it is seen in seminomas of the testis. A wide array of
genetic syndromes has been associated with ovarian dysgerminomas; however, many associations are loose,
and establishing molecular/genetic relationships is problematic. These syndromes include but are not limited to
Frasier syndrome,[11] pseudo-Meigs syndrome,[12] ataxia-telangiectasia,[13]and Apert syndrome.[14]
Swyer syndrome is an important disorder of intersex that has been shown to have a close relationship with
dysgerminoma, as well as its in-situ counterpart, gonadoblastoma. [15, 16] Swyer syndrome (pure gonadal
dysgenesis) is a disorder of sexual differentiation that is characterized by mutations of the SRY gene
responsible for male sex characteristics. This gene is located on the Y chromosome (p11.31); mutations at this
site result in phenotypic females with mllerian external genitalia, underdeveloped (streak) internal gonads,
amenorrhea, and rudimentary development of breasts, pubic hair, and axillary hair. These patients are at
increased risk (approximately 20-50% by adulthood) for dysgerminoma/gonadoblastoma in one or both ovaries.
[16]

Gonadoblastomas are neoplastic proliferations found almost exclusively in patients with gonadal dysgenesis
(pure or mixed), male pseudohermaphroditism, and Turner syndrome (45,XO and mosaics). More than 90% of
patients with gonadoblastomas have a Y chromosome.
Gonadoblastomas are histologically characterized by expanded nests containing Sertoli cells, germ cells, and
granulosa cells admixed with variable amounts of hyaline. These nests morphologically resemble the CallExner bodies associated with granulosa cell tumors. Leydig cells may also be found within the interstitium.
Characteristically, these neoplastic nests and/or fibrotic stroma between nests often contain large, irregular
calcifications. Mitotic activity, cytologic atypia, and necrosis are minimal or absent.
The following images depict examples of gonadoblastoma histology.

Dysgerminoma and gonadoblastoma histology.

A: Dysgerminoma with an adjacent zone of necrosis and large calcifications (40). B: Gonadoblastoma with an adjacent
dysgerminoma (40). C: Gonadoblastoma with an adjacent dysgerminoma (40). D: Gonadoblastoma (200).

Gonadoblastoma immunohistochemistry (200).

CD117 = a proto-oncogen (c-kit), ; CKAE1/CAM5.2 = cytokeratins; D2-40 = a monoclonal antibody; H&E = hematoxylineosin; OCT 3/4 = a transcription factor; PLAP = placental alkaline phosphatase.

It is not uncommon to see regions of neoplastic overgrowth by dysgerminoma; however, other malignant germ
cell elements may be seen, such as yolk sac and choriocarcinoma. [1, 2]

Prognosis of Ovarian Dysgerminomas

The prognosis and treatment of dysgerminomas are associated with their pathologic and clinical stage. The
overwhelming majority (approximately 75%) of these tumors are limited to one or both ovaries (International
Federation of Gynecologists and Obstetricians [FIGO] stage 1) at the time of diagnosis.
Patients with stage 1A disease (ie, disease that is limited to 1 ovary) may be treated by unilateral
oophorectomy alone, especially when fertility is to be maintained. The relapse rate ranges from 10% to 20%;
the overall survival rate is 90-100%.[17]Patients who suffer relapses may undergo chemotherapy; the survival
rate for such patients is greater than 90%.
Radiotherapy and 3-4 cycles of adjuvant chemotherapy with cisplatinum, etoposide/vinblastine, and bleomycin
are often reserved for patients with at least stage 1B disease (ie, disease that is limited to both ovaries) or for
those patients who suffer recurrences. For these patients, the results of therapy are similar to those of patients
with stage 1A disease.[18]