This paper reports a unique stage IV complex ovarian carcinosarcoma in a 69-year patient that had malignant mixed müllerian epithelial and mesenchymal components and also other malignant differentiation such as neuroectodermal (small cell, neuroendocrine, neuroglial, neuronal, and melanocytic) and endodermal (yolk sac tumor) tissues and trophoblastic cells. As its phenotype comprised elements derived embryologically from the 3 germ layers, it posed the problem of differentiating it from a teratoma originated from germ cells, with which it shared a trilaminar type differentiation. It was different from a teratoma as it coexisted with, and possibly originated from, a somatic tumor, namely a characteristic endometrioid adenocarcinoma. All neoplastic tissue patterns present in the neoplasm were malignant per se without an apparent gradient of maturation or presence of organoid structures.

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Embryonal-type differentiations in urothelial neoplasms are uncommon [1,2]. These frequently underdiagnosed phenomena may include either the presence of trophoblastic areas or, even more rarely, admixed yolk sac tumour patterns (YST) [2]. We present for the first time the association of both trophoblastic and malignant endodermal-type elements within an aggressive high-grade urothelial carcinoma (HGUC). Due to the presence of the endodermal component, which had cells with a prominent clear cytoplasm, a differential diagnosis with other papillary and clear cell renal neoplasms was necessary. Clinical historyA 47-year-old male presented with intense pain in the lumbar region. Seventeen years previously, he had been treated for a non-seminomatous testicular tumour with lung and liver metastases. He eventually underwent a right orchidectomy followed by platinum-based chemotherapy. Followup showed only residual mature teratomatous tissue in the biopsy material from the remaining testicle.On his recent admission, elevated levels of serum β-hCG of 9,897.06 mUI/ml (normal 0-2.6 mUI/ml) and a lactate dehydrogenase of 1,280 U/L (normal 0-480 U/l) were found. Serum α-foetoprotein (AFP) was negative. A CT scan showed a large, ill-defined retroperitoneal mass involving the left kidney and ureter. There was marked infiltration of the psoas, and lung and vertebral metastases were prominent. No lesions were detected in the left testicle after both clinical and ultrasonographical exploration. A left ureteronephrectomy with resection of the surrounding tissues was performed. Patient refused chemo-or radiotherapy and 18 months after diagnosis is alive but has a large residual mass and pulmonary metastases. Materials and methodsThe ureteronephrectomy specimen was bivalved and fixed overnight in 10% buffered formalin and routinely processed. Seven tissue blocks were taken, and H&E-stained sections were analysed. Immunohistochemistry was performed on representative sections with the antibodies shown in Table 1.