Central nervous system germ cell tumors: controversies in diagnosis and treatment

The variability and complexity of central nervous system germ cell tumors have led to controversy in both diagnosis and management. If a germ cell tumor is suspected, the measurement of cerebrospinal fluid and serum alpha-fetoprotein and beta-human chorionic gonadotropin is essential. A histologic specimen is not necessary if the patient has elevated levels; however, if the tumor markers are negative, a biopsy is needed to confirm the diagnosis of a germinoma. Germinomas are extremely radiosensitive, enabling 5-year survival rates that exceed 90%. Treatment has traditionally included focal and craniospinal axis irradiation; however, multiple ongoing studies are being conducted to examine the efficacy of reduction or elimination of radiation therapy with the addition of chemotherapy. Nongerminomatous germ cell tumors, on the other hand, are relatively radioresistant with a poorer outcome. The combination of chemotherapy and irradiation is associated with overall survival rates of up to 60%. This article provides a review of the controversies in diagnosis and treatment of central nervous system germ cell tumors.

[Therapy for recurrent testicular cancer]

In the case of an insufficient response to primary treatment or a tumor relapse, regardless of an initially complete remission, conventional as well as high dose chemotherapy regimens are available as salvage therapy for metastatic germ cell tumors. A multimodal approach should include the radiation of simultaneously occurring brain metastases as well as the surgical resection of residual tumour masses still detectable after completion of chemotherapy. Nowadays, an attempt is made to adjust the salvage modality selected to the individual situation according to a risk stratification of patients. However, a recurrence-free survival of 50% is worse when compared with that observed after primary chemotherapy. Salvage therapy should be reserved for specialized centres due to the increased complexity of a salvage approach and a significantly increased therapy-induced morbidity.

Intramedullary spinal cord germinoma expresses the protooncogene c-kit

A 33-year-old woman first noticed numbness in the both lower extremities and the numbness gradually extended up to the thorax. Magnetic resonance (MR) imaging demonstrated a mass with moderate and heterogeneous enhancement and peritumoural intramedullary cysts in the spinal cord at the T-1 to T-3 levels. The tumour was explored partially and intra-operative pathological examination demonstrated the so-called "two-cell pattern" typical of germinoma. The margin of the tumour was not clear. Histological examination showed germinoma with strong c-kit protein expression on the tumour cell surface. Chemotherapy and radiation therapy were given following surgery. Her neurological deficits were improved but not resolved.

Lectin-reactive alpha-fetoprotein as a marker for testicular tumor activity

BACKGROUND

Lens culinaris agglutin (LCA)-affinity electrophoresis resolves serum alpha-fetoprotein (AFP) into three isoforms, AFP-L1, -L2 and -L3. The ratio of AFP-L3 to total AFP (AFP-L3%) is frequently high in hepatocellular carcinoma (HCC) patients, and thus, it is widely used for early diagnosis of HCC. In the present study, we used the subfraction profile of LCA-binding AFP to diagnose and monitor testicular tumor activity.

METHODS

Serum samples were collected from 21 testicular tumor patients, and the LCA-reactive fractions were determined by LCA-affinity electrophoresis coupled with antibody-affinity blotting. The histological diagnosis was non-seminomatous germ cell tumor (NSGCT) in 15 patients and pure seminoma in six patients.

RESULTS

Serum AFP levels were abnormally elevated (>20 ng/mL) in 10 of 15 NSGCT patients. One NSGCT patient and two seminoma patients showed borderline AFP levels between 10 and 20 ng/mL. LCA-reactive AFP was detected in all 11 NSGCT patients with serum AFP levels above 10 ng/mL, but not in the two seminoma patients with serum AFP levels above 10 ng/mL. In testicular tumor patients, the broad band of AFP-L2 could not be completely separated from AFP-L3. The mean ratio of AFP-L3 plus AFP-L2 (AFP-L2 + 3%) was as high as 94% (range 80-99%) in these patients. Serial determinations of LCA-reactive fractions were performed in eight of the 11 LCA-reactive AFP-positive patients. They included five patients who received chemotherapy, and three patients who underwent orchiectomy for stage I NSGCT. In three of eight patients, LCA-reactive AFP was detected even after normalization of total AFP levels. All three patients relapsed, with elevation of serum AFP within several months.

CONCLUSION

Determination of LCA-reactive AFP might be a useful marker for testicular tumor activity in patients with lower AFP levels.

[Hypogonadism despite of normal testosterone levels]

We report on a 19 year old patient with clinical signs of hypogonadism (small testicles, missing pollutions and diminished beard growth) despite of normal testosterone levels. Further diagnostic procedures revealed panhypopituitarism with insufficiency of the gonadotrope, somatotrope and corticotrope axis due to a beta-HCG-producing suprasellar germinoma with intracerebral metastases. Paraneoplastic production of beta-HCG resulted in sufficient stimulation of Leydig cells with normal production of testosterone, which had partly masked clinical symptoms of gonatrope insufficiency. The patient was treated by combined radiochemotherapy and is in remission since 7 years.

Stage I nonseminomatous germ cell tumors: the case for management by risk stratification

For patients with clinical stage I nonseminomatous germ cell tumor (NSGCT), the therapeutic options after orchiectomy are retroperitoneal lymphadenectomy, surveillance, and chemotherapy. Ideally the option selected will be based on an individualized assessment of the estimated risk of progression based on prognostic factors, so called risk-adapted treatment, to reduce overall burden of therapy while maintaining survival. It is possible to identify patients at low risk of progression who can be followed by active surveillance initially. Prognostic factors for high risk, while well defined, do not identify all patients at risk and those that are destined to progress, can usually be salvaged with delayed therapy. Most centres recommend either surgery or primary chemotherapy for those defined as being at high risk for progression. Prognostic factors for high risk however, while well defined, do not identify all patients at risk and those that are destined to progress, can usually be salvaged with delayed therapy.

Pineal Germinoma With Granulomatous Reaction-Case Report-

A 20-year-old man presented with diplopia. Neurological examination revealed mild skew deviation and upbeat nystagmus. Computed tomography showed a clover-shaped isodense mass in the pineal region with homogeneous enhancement. The lesion was isointense on both T(1)- and T(2)-weighted magnetic resonance (MR) imaging with homogeneous enhancement by gadolinium-diethylenetriaminepenta-acetic acid. Cerebral angiography showed no tumor staining. Serum and cerebrospinal fluid were negative for beta-human chorionic gonadotropin, alpha-fetoprotein, and placental alkaline phosphatase. Open biopsy was performed using a right occipital transtentorial approach. Histological examination revealed a tumor consisting of clusters of germinoma cells, but with prominent infiltration of lymphocytes, plasma cells, and macrophages, and proliferation of small vessels. The histological diagnosis was germinoma with granulomatous reaction. MR imaging showed complete disappearance of the tumor after chemoradiotherapy. Neurosurgeons should be aware of this rare tumor to avoid misdiagnosis as granulomatous inflammation.

Germinoma of the basal ganglia. An 8-year asymptomatic history after detection of abnormality on CT

We describe a case of germinoma of the left basal ganglia. An 11-year-old boy, who demonstrated calcification of the left basal ganglia on CT scan following a head injury at the age of 3 years, presented with a weakness of the right upper extremity for 2 months. MRI demonstrated high intensity in the left basal ganglia on a T1-weighted image without enhancement as well as high intensity on a T2-weighted image. Ipsilateral hemiatrophy of the hemisphere and midbrain was also noted. In addition, high intensity in the left internal capsule and cerebral peduncle was demonstrated on T2-weighted image. Surgical specimens obtained by stereotactic biopsy showed germinoma with a two-cell pattern. The patient had remained asymptomatic for 8 years after abnormal calcification was initially detected on CT scan. Ipsilateral hemiatrophy of the hemisphere and midbrain was demonstrated before the onset of weakness.

Stem-cell transplantation for the treatment of advanced solid tumors

Over the past two decades, high-dose chemotherapy (HDC) with autologous stem-cell transplantation (ASCT) has been explored for a variety of solid tumors in adults, particularly breast cancer, ovarian cancer and non-seminomatous germ-cell tumors. The results of prospective phase II studies seemed superior in many cases to the outcome expected with standard-dose chemotherapy (SDC). The value of HDC for adult solid tumors remains, in most instances, a controversial issue, currently under the scrutiny of randomized phase III trial evaluation. ASCT pursuing an immune graft-versus-tumor effect has been evaluated in recent years for patients with advanced and refractory solid malignancies. This article reviews the results of the main phase II and III studies of HDC with ASCT, as well as the preliminary experience using allogeneic transplantation for solid tumors.

Testicular Seminoma 16 Years After Treatment for CNS Germinoma

Most patients with intracranial germinomas will be cured and become long-term survivors. Physicians caring for these patients should recognize that these patients may be at risk for disease-related and/or treatment-related late sequelae. We report the case of a 27-year-old man who developed testicular seminoma 16 years after treatment for intracranial germinoma. Like their testicular cancer counterparts, long-term survivors of intracranial germinomas may have a susceptibility to develop a subsequent germ cell tumor. These patients require lifelong medical follow-up and should be encouraged to perform testicular self-examination at the appropriate age.

Efficacy of routine follow-up after first-line treatment for testicular cancer

To define guidelines for the follow-up management of patients treated for testicular germ cell tumor this study assessed characteristics of patients with recurrent disease. The charts of 505 patients with testicular cancer treated and followed-up at the University Medical Centre Nijmegen between 1982-2000 were reviewed retrospectively. In 42 patients disease recurrence was found during routine follow-up. In a subset of patients no recurrences were seen after first-line treatment: (a) pathological stage IIa nonseminoma patients who were adjuvantly treated with chemotherapy and (b) histologically confirmed complete responders after primary chemotherapy. Furthermore, in low-stage disease no intra-abdominal recurrences were seen in (a) pathological stage I nonseminoma patients and (b) low-stage seminoma patients who received radiotherapy. The risk of recurrent testicular cancer depends on primary therapy and efficacy of it; these results indicate a limited role for follow-up in pathological stage II nonseminoma patients adjuvantly treated with chemotherapy and in histologically confirmed complete responders after chemotherapy. Abdominal computed tomography does not appear necessary in routine follow-up of patients treated for low-stage testicular cancer.

Sexual functions after high-dose chemotherapy in survivors of germ cell tumors

We investigated the changes in sexual function in male patients with germ cell tumor continuously disease free after one or two courses of high-dose chemotherapy with hematopoietic stem cell support. A questionnaire was mailed to 35 patients, and 30 patients sent it back. Sexuality was considered a problem by 10 patients (33%), but no patients considered sexuality a major problem. Erection was more difficult to achieve in seven patients (23%) and 10 patients (33%) experienced increased difficulty in maintaining an erection. Eight patients (27%) had the experience of less intensive and less frequent orgasm. In all, 13 patients (43%) thought that both the disease and treatment had worsened their sexual capacity, but 20 patients (67%) were satisfied with their sex life. Most of the patients (63%) considered that insufficient information and counselling had been given by their physicians about the sexual sequelae of therapy. However, the amount of information about the disease and treatment was considered good by 77 and 80% of the patients, respectively. This study shows that 27% of patients were not content with their ability to attain sexual satisfaction due to the illness or its treatment. Communication is an important issue and better information tools could lead to improved compliance in these patients.

Secondary leukemias in refractory germ cell tumor patients undergoing autologous stem-cell transplantation using high-dose etoposide

PURPOSE

To quantify the risk of secondary leukemias in relapsed testicular cancer patients undergoing autologous stem-cell transplantation with high-dose etoposide.

PATIENTS AND METHODS

Single institution, retrospective study of germ cell tumor patients who underwent autologous transplantation using high-dose etoposide from 1987 to 2001.

RESULTS

One hundred thirteen patients received high-dose etoposide and carboplatin followed by autologous stem-cell transplantations for germ cell tumors. Follow-up ranged from 12 to 166 months (median, 51 months). Three patients (2.6%; 95% CI, 0.55% to 7.50%) subsequently developed leukemia at an average of 16 months post-autologous transplantation (range, 11 to 21 months). All three had received tandem transplantations and had been heavily pretreated, including at least one prior cycle of etoposide. Following autologous transplantation, all three patients exhibited refractory cytopenias before developing overt leukemia. All leukemias were of myeloid lineage. One patient developed an M2 with a t(8,21) chromosomal translocation; another, an M5 with a t(11,19); and one patient exhibited an unclassified leukemia with cytogenetic abnormalities resulting in monosomy for 7p and partial monosomy of 7q. Treatment of the leukemias involved allogeneic bone marrow transplantation.

CONCLUSION

High-dose chemotherapy using high-dose etoposide as therapy for relapsed germ cell tumors was associated with a 2.6% risk of developing a secondary myeloid leukemia. This figure was not significantly different from the expected rate of secondary leukemias when patients receive additional cycles of standard-dose etoposide as salvage chemotherapy for germ cell tumors. Other factors, including the use of platinum agents, may also have a role in leukemogenesis in this patient population.

Thiotepa-Based High-Dose Chemotherapy With Autologous Stem-Cell Rescue in Patients With Recurrent or Progressive CNS Germ Cell Tumors

Purpose

To evaluate the efficacy and toxicity of high-dose chemotherapy (HDC) followed by autologous stem-cell rescue (ASCR) in patients with relapsed or progressive CNS germ cell tumors (GCTs).

Patients and Methods

Twenty-one patients with CNS GCTs who experienced relapse or progression despite having received initial chemotherapy and/or radiotherapy were treated with thiotepa-based HDC regimens followed by ASCR.

Results

Estimated overall survival (OS) and event-free survival (EFS) rates for the entire group 4 years after HDC were 57% ± 12% and 52% ± 14%, respectively. Seven of nine (78%) patients with germinoma survived disease-free after HDC with a median survival of 48 months. One patient died as a result of progressive disease (PD) 39 months after HDC, and another died as a result of pulmonary fibrosis unrelated to HDC 78 months after ASCR without assessable disease. However, only four of 12 patients (33%) with nongerminomatous germ cell tumors (NGGCTs) survived without evidence of disease, with a median survival of 35 months. Eight patients with NGGCTs died as a result of PD, with a median survival of 4 months after HDC (range, 2 to 17 months). Patients with germinoma fared better than those with NGGCTs (P = .016 and .014 for OS and EFS, respectively). Patients with complete response to HDC also had significantly better outcome (P < .001 for OS and EFS) compared with patients with only a partial response or stable disease. There were no toxic deaths because of HDC.

Conclusion

Dose escalation of chemotherapy followed by ASCR is effective therapy for patients with recurrent CNS germinomas and might be effective in patients with recurrent NGGCTs with a low tumor burden.

Impact of therapy and androgen receptor polymorphism on sperm concentration in men treated for testicular germ cell cancer: a longitudinal study

BACKGROUND

Testicular cancer (TC) patients have a high survival rate, and the question of post-therapy recovery of sperm production and its dependence on genetic predisposition is of major interest.

METHODS

Ejaculates were obtained from 112 TC patients at one or more of the following time points: post-orchidectomy, or 6, 12, 24, 36 and 60 months post-therapy. The lengths of the androgen receptor (AR) function modulating CAG and GGN repeats in leukocyte DNA were also analysed.

RESULTS

No significant decrease in sperm concentration was seen in men who received 1-2 cycles of adjuvant chemotherapy (ACT). Radiotherapy (RT) or more than two cycles of chemotherapy (HCT) caused an initial decline in sperm concentration, which returned to pre-treatment levels 2-5 years after therapy. In the HCT group, sperm concentration 12-24 months post-treatment (T(12-24)) was inversely correlated with CAG length (rho = -0.72, P = 0.03). The type of treatment, but not the concentration at T(0), was an independent predictor of sperm concentration at T(6) (P < 0.0005) and T(12-24) (P = 0.004).

CONCLUSION

ACT did not induce a significant decline in sperm concentration. After HCT and RT, a significant reduction of sperm concentration was observed, recovering to pre-treatment levels 2-5 years post-treatment. In HCT-treated patients, the AR CAG length influenced the recovery of spermatogenesis.

[Malignant pelvic neoplasms in children treated in two Polish oncology centres]

BACKGROUND

Extensive diagnostic and therapeutic dilemmas appear in children With primary malignant neoplasms located in the minor pelvis.

THE AIM OF THE STUDY

To evaluate the clinical symptoms, disease course and the results of treatment in patients with malignant pelvic neoplasms.

MATERIAL AND METHODS

The study included 31 children (13 boys and 18 girls; aged 2 months to 16 years; mean age -- 8 years) treated in the Departments of Paediatric Oncology and Haematology in Gdansk and Lublin during the period of 1992-2003. The group comprised 17 patients with soft tissue sarcomas (MTM) (55%), 12 with germinal tumours (TGM) (39%) and tow. with neuroblastoma (NBL) (6%). The great majority of children (90%) presented with highly advanced disease (stages III + IV -- in 28 out of 31 patients).

RESULTS

with data analysis we were able to distinguish two categories of patients with different prognosis: with MTM and TGM. Most of he MTM tumours (11/17 - 65%) were localized in the urinary tract, the remaining six developed within pelvic muscles. Ten out of twelve TGM tumours (83%) were located in the ovaries. Radical tumour resection, especially primary resection, was shown to play the key role in both groups. Among TGM patients it was performed in 75% while in MTM patients -- in only 12%. All of these patients entered clinical remission and remain disease free. After adjuvant chemo- and/or radiotherapy secondary tumour resection was done in 17% of TGM and 41% of MTM patients.

CONCLUSION

in patients, who were not able to undergo radical tumour resection (mainly MTM patients), the disease progressed and led to death.

Late relapse of testicular cancer

Due to its unique biological behavior, late relapse (LR) of testicular cancer has recently been described as an own tumor entity. It is currently defined as tumor recurrence more than 2 years after complete remission following primary treatment including chemotherapy. The incidence ranges from 2 to 6%, with a median relapse-free interval of 5.4-7.1 years from the initial treatment. Although histology shows a germ cell tumor (GCT) origin, the clinical biology is different. The dominant characteristics are slow tumor growth and chemoresistance. Molecular analysis currently focuses on the mechanisms of drug resistance. The initial response to chemotherapy is less than 30% and in most cases complete surgical resection remains the only treatment option with favorable long-term results. The most common site of LR is the retroperitoneum, with undifferentiated cancer (yolk sac) being the most frequent histology. In most cases, patients have already undergone previous retroperitoneal surgery. The overall cure rate is only about 50%, hence, adequate treatment of the primary tumor is essential to prevent the development of LR.

New insights into the pathology and molecular biology of human germ cell tumors

The group of human germ cell tumors (GCTs) is heterogeneous, and comprises neoplasms found at different anatomical locations. They are of interest not only for aspects of their tumor biology, but also from the point of view of developmental biology. GCTs show significant similarities to early germ cell development, most likely related to their cell of origin. Comparative analysis of the tumors and representative normal counterparts can therefore help to define events which are related to the pathogenesis of this cancer. Within the testis, three separate GCT entities have been identified, characterized by differing patho-biological, molecular/cytogenetic, and clinical observations, which will be described in more detail in this review. This article will highlight the most important contributions to the field in the last years. This includes the diagnostic value of OCT3/4, a transcription factor and marker for pluripotency. Furthermore, the invasive GCTs of young adults consistently show a gain of 12p-sequences, of which the exact role, including the gene(s) involved, remains to be elucidated, although interesting candidates have been identified. Finally, treatment sensitivity/resistance of GCTs most likely reflect the intrinsic characteristics of the cells of origin and their derivatives. The pluripotency of GCTs, in particular the possible loss of the embryonic characteristics and acquisition of somatic differentiation, could be a crucial phenomenon in this process.

Neonatal liver tumours

Primary liver tumours are very rare during the neonatal period, but increasing numbers of them are now diagnosed prenatally by routine ultrasound scan. A precise diagnosis is sometimes problematic because of non-specific clinical symptoms, misleading imaging and difficulties with histological interpretation. Benign infantile haemangioendothelioma usually undergoes spontaneous regression, but may be life-threatening due to congestive heart failure and/or consumptive coagulopathy when treatment with resection, embolization or arterial ligation is necessary. Malignant hepatoblastoma may occur in the newborn, and often has to be treated with chemotherapy to achieve resectability. Symptoms are less specific and the prognosis is worse than in older children. Mesenchymal hamartoma is a benign cystic lesion that should be resected whenever possible. Rarely, germ cell tumours occur in the neonatal liver. Benign teratomas have to be resected, while malignant choriocarcinomas may respond to chemotherapy and can be cured in some cases.

[Refractory germ cell cancer of testis treated by salvage high-dose chemotherapy: report of three cases]

We reported three cases (42, 20 and 18-year-old men) of advanced nonseminomatous testicular germ cell cancer treated by salvage high-dose chemotherapy (HDC) supported by peripheral blood stem cell autotransplantation. Two cases which had been refractory to (B) EP (bleomycin, etoposide, cisplatin) and VIP (etoposide, ifosfmide, cisplatin) chemotherapies received one course of high-dose CEI (carboplatin 1,250 mg/m2, etoposide 1,500 mg/m2 and ifosfamide 7.5 g/m2), and the other case had been refractory to PVB (cisplatin, vinblastine, bleomycin) and VIP chemotherapies received one course of high-dose CEI and high-dose CCT (carboplatin 800 mg/m2, cyclophosphamide 6 g/m2 and thiotepa 720 mg/m2). Only one case achieved an incomplete remission by HDC, which was verified as a pathological complete response at the following salvage surgery, and has been alive with no evidence of disease for 68 months. The others achieved no change of disease following HDC and died from cancer progression. Hepatotoxicity, neurotoxicity and severe depression occurred, but not fatal in 2 cases.

Long-term follow-up of patients with poor prognosis germ cell tumor treated with early high-dose chemotherapy with hematopoietic progenitor cell support: a single-center experience

The 5-year overall survival rate of patients with germ cell tumor (GCT) with poor prognosis, according to the International Germ Cell Cancer Collaborative Group (IGCCCG) classification, is 48% after standard-dose chemotherapy and surgery, if necessary. Two recent studies have showed that early high-dose chemotherapy (HDCT) with hematopoietic progenitor cell support (HPCS) may induce a 2-year overall survival rate of 78% in these patients. We report the long-term results of the experience at the Department of Oncology in Ravenna with early HDCT and HPCS in GCT patients with poor prognosis (IGCCCG criteria). Between 1987 and 2002, 18 poor prognosis GCT patients (17 M, one F), median age 24.5 years (range, 17-52), were treated with early HDCT with HPCS. In total, (67%) patients achieved a complete remission and they are continuously disease-free at a median follow-up of 9.2 years (range, 1.7-16.2). One treatment-related death occurred. No patient developed myelodysplasia or a secondary leukemia. This is notably the longest follow-up reported in patients having received HDCT in this setting. No patient achieving a complete remission relapsed. The role of HDCT in poor prognosis GCT will be defined from the ongoing phase III randomized trials.