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Ovarian Dysgerminomas
Pathology Overview of Ovarian
Dysgerminomas

Author: Florette K Gray Hazard, MD; Chief Editor: Ramya Masand, MD more...

Updated: Oct 27, 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, mature teratomas; 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 the ovary (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]

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Common signs and symptoms of ovarian dysgerminomas include abdominal/pelvic pain (5585%), 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.
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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 SchillerDuvall 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.

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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 6year-old girl whose precocious puberty was caused by elevations in the levels of betahuman
chorionic gonadotropin (beta-hCG), alpha-fetoprotein (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.
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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-tocytoplasm 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 (hematoxylin-eosin, 100)

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Ovarian dysgerminoma histology.

The arrows indicate syncytiotrophoblastlike giant cells. A and B: Hematoxylin-eosin, 200.
C: hematoxylin-eosin, 400. D: hematoxylin-eosin, 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.
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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 alphafetoprotein (AFP).

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Dysgerminoma
immunohistochemistry (x200). CD117 = a proto-oncogen (c-kit) ; CKAE1/CAM5.2 =
cytokeratins; D2-40 = a monoclonal antibody; H&E = hematoxylin-eosin; 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.
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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] pseudoMeigs 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 Call-Exner bodies associated with granulosa cell tumors.
Leydig cells may also be found within the interstitium. Characteristically, these neoplastic

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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 = hematoxylin-eosin; 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]
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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

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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]