What is the diagnosis?
This is a malignant testicular germ cell neoplasm, which has both seminomatous and embryonal cell carcinoma components. The seminomatous component is present adjacent to the tunica albuginea and is composed of a relatively uniform population of undifferentiated, primordial-type germ cells with clear to frothy-appearing cytoplasm and nuclei containing prominent eosinophilic nucleoli. Bands of fibrous tissue and clusters of lymphocytes are interspersed among the tumor cells.
The predominant tumor component is embryonal cell carcinoma, composed of sheets and cords of anaplastic-appearing cells with vesicular nuclei that contain prominent eosinophilic nucleoli. Mitotic figures are easily found. As is characteristic of embryonal cell carcinoma, much of the tumor is necrotic and hemorrhagic.
Explain the laboratory test findings.
Neoplasms derived from germ cells may produce a variety of compounds related to germ cell lineage. In a male, the most commonly detected compounds are alpha-fetoprotein and human chorionic gonadotropin. The AFP is a marker that suggests a component of yolk sac tumor or embryonal carcinoma (which can have cellular elements similar to yolk sac tumor). The HCG suggests a component of cells that resemble syncytiotrophoblast of placenta. The higher the HCG, the more strongly a choriocarcinoma component to the neoplasm is suggested. Germ cell tumors in males are often composed of multiple elements. The most common "pure" tumor is seminoma, and even in these tumors one can sometimes detect small quantities of AFP or HCG. Other markers that have been employed in testicular tumors include placental alkaline phosphatase (PLAP) and lactate dehydrogenase (LDH).
What is the most probable reason for the gynecomastia and breast tenderness?
In addition to producing alpha fetoprotein, nonseminomatous germ cell tumors may, at times, produce human placental lactogen, chorionic gonadotropin, or estrogen. Gynecomastia may be associated with the secretion of these hormones.
