Langerhans' cell histiocytosis: possible association with malignant germ cell tumour

A rare case of adult onset Langerhans' cell histiocytosis associated with dysgerminoma in a 35 year old Chinese woman is reported. The patient had a history of dysgerminoma of left ovary 15 years previously and had undergone surgery followed by radiotherapy and an uneventful recovery. She presented again in March 1994, this time with a left clavicular mass, which was shown histologically to be Langerhans' cell histiocytosis. The report illustrates the probable association between the two lesions, with some discussion on the underlying pathogenesis.

The clonal nature of mediastinal germ cell tumors and acute myelogenous leukemia. A case report and review of the literature

The clonal identity of a mediastinal germ cell malignant tumor and acute myelogenous leukemia is described in an 11-year-old boy in whom both tumors presented simultaneously. The relationship between these two histologically distinct malignancies is discussed in relation to this patient and 34 previously reported patients.

Appreciation of the significance of cytogenetic and FISH analysis of bone marrow in clinical oncology

Due to some empiric reasons, bone marrow (BM) has never been emphasized and appreciated as a valuable alternative source for metaphases of tumor nature. In the present study, we report the cytogenetic and fluorescence in situ hybridization (FISH) studies of BM in 172 patients with various tumors. Our results indicate that cytogenetic and FISH analyses of BM provide a valuable biologic approach concerning the diagnosis of tumors, evaluation of metastasis, and assessment of secondary hematologic malignancies. Thus, we suggest strongly that these studies become a standard part of clinical pathologic investigations in dealing with clinical oncology.

Refractory anemia with excess of blasts and isochromosome 12p in a patient with primary mediastinal germ-cell tumor

Isochromosome(12p), a cytogenetic abnormality characteristic of germ-cell tumors, is exceedingly rare in hematologic disorders. The cytogenetic analysis of a patient diagnosed as refractory anemia with excess of blasts with an associated i(12p), who previously had a teratocarcinoma of the mediastinum, is presented. The cytogenetic analysis was performed at diagnosis of the hematologic malignancy, with all 30 metaphases in the bone marrow culture showing a 47,X, -Y, +8, +i(12)(p10) karyotype. The cytogenetic findings in this patient are compared with those published concerning the association of mediastinal germ-cell tumors and malignant hematologic disorders.

Benign hematologic neoplasm associated with mediastinal mature teratoma in a patient with Klinefelter's syndrome: a case report

An 18-year-old male with Klinefelter's syndrome presented with a mature teratoma of the mediastinum. He was treated with debulking surgery and brief cisplatin-based chemotherapy. Ten years later, he presented with paraplegia and was found to have an isolated epidural mass. The mass was composed of mature histiocytoid cells reminiscent of those seen in malignant histiocytosis. There was no evidence of medullary dissemination and there was no evidence of recurrence of the germ cell tumor. He received local radiation therapy and a single course of leukemic induction. He remains well 4 years later. This case represents a localized variant of the diffuse histiocytic malignancies associated with malignant mediastinal germ cell tumors.

Hematopoietic precursor cells within the yolk sac tumor component are the source of secondary hematopoietic malignancies in patients with mediastinal germ cell tumors

BACKGROUND

Patients with mediastinal germ cell tumors (MGCT) have a high incidence of hematologic malignancies unrelated to cytotoxic chemotherapy. It has been suggested that these leukemic conditions originate from a MGCT progenitor cell capable of undergoing non-germ cell (hematopoietic) differentiation.

METHODS

To assess this hypothesis, histologic material from six patients with MGCTs associated with leukemia was examined using monoclonal and polyclonal antibodies capable of labeling cells of the different marrow cell lineages.

RESULTS

Morphologically identifiable hematologic cells were found within the yolk sac tumor component of the MGCT in four of these patients. In three of the four cases, the cells consisted of poorly differentiated blast cells, whereas in the fourth, clusters of erythroblasts were identified. The leukemic cells within the MGCT and in the bone marrow had similar morphology, constant expression of the early progenitor cell marker CD34, and variable expression of more mature myeloid, monocytic, erythroid, and megakaryocytic markers. Three cases expressed p53, a nuclear protein associated with neoplastic transformation in a wide range of malignancies, including testicular cancers, but which rarely is reported in leukemias. Karyotype of the leukemia was assessed in five cases: two showed an i(12p), a cytogenetic marker of GCT not identified in the usual cases of leukemia.

CONCLUSIONS

The results support the hypothesis that these leukemic conditions originate in the MGCT through a mechanism of differentiation from a yolk sac tumor-derived progenitor cell, with subsequent homing to the marrow.

Alternating combination chemotherapy in patients with extragonadal germ cell tumors. A Southwest Oncology Group study

BACKGROUND

Extragonadal germ cell tumors (EGGCT) are uncommon, occur primarily in the mediastinum and retroperitoneum, and have been noted to have variable response rates to cisplatin-based chemotherapy regimens.

METHODS

The Southwest Oncology Group (SWOG) has completed a prospective trial of combination chemotherapy followed by surgical removal of residual disease in patients with this type of germ cell neoplasm. Chemotherapy consisted of alternating cycles of vinblastine, bleomycin, and cisplatin with etoposide, bleomycin, doxorubicin, and cisplatin. Four cycles of therapy were given followed by surgical removal of residual disease where appropriate.

RESULTS

Fifty patients were entered into the trial, and 41 were eligible, with 4 patients excluded by pathology review. Of the 41 eligible patients, 24 had mediastinal tumors, 15 had retroperitoneal tumors, and 2 had unknown primary sites. Complete response rates (chemotherapy +/- surgery) for the various sites were as follows: mediastinum, 18 of 24 (75%); retroperitoneum, 10 of 15 (67%); and unknown primary, 2 of 2 (100%). At 2 years, the disease-free survival rate for all patients was 87%. At a median follow-up of 6.8 years, 26 of 41 patients (63%) are alive. The toxicity of the chemotherapy regimen was substantial, with neutropenic fever developing in 17 of 41 patients (41%) during treatment. Additional side effects included nausea and vomiting (76%), mucositis (27%), and pulmonary toxicity (5%).

CONCLUSIONS

This prospective trial of chemotherapy in patients with EGGCT demonstrates a significant response in patients with either mediastinal or retroperitoneal tumors and a 4-year survival rate of more than 60% and 70%, respectively.

Acute lymphoblastic leukemia and Klinefelter's syndrome

We report two children with acute lymphoblastic leukemia (ALL) who in initial cytogenetic investigation were coincidently found to have a 47, XXY karyotype. In one patient 100% of peripheral blood lymphocytes showed a 47,XXY complement, but in the other only 30% of cells had such a complement, the remainder having a normal male karyotype (46, XY). In neither case was the diagnosis of Klinefelter's syndrome clinically obvious. Antileukemic therapy may exacerbate both the hypogonadism and the learning difficulties seen in this condition. Routine cytogenetic investigations on peripheral blood and bone marrow should be performed in all new cases of leukemia. Cytogenetic analysis of cultured fibroblasts is essential in all cases in which the abnormal X line did not disappear after initial therapy. Evidence of an increased risk of leukemia in association with Klinefelter's is beginning to accumulate.

The unique association of malignant histiocytosis and a primary gonadal germ cell tumor

Previous reports of the association between hematologic malignancies and germ cell tumors have been limited to patients with nonseminomatous tumors, exclusively of mediastinal origin. Among the various hematologic disorders, a large proportion have involved histiocytic tumors, either acute monocytic leukemia or malignant histiocytosis. We now report the first case of simultaneously occurring malignant histiocytosis and testicular embryonal carcinoma. The patient, an 18-year-old male, presented with hepatosplenomegaly due to malignant histiocytosis and was found on further evaluation to have a stage I testicular cancer consisting of teratocarcinoma with endodermal sinus elements. Despite aggressive chemotherapy, the patient died of malignant histiocytosis 6 months after the original diagnosis. The autopsy revealed widespread organ involvement with malignant histiocytosis and no evidence of residual germ cell tumor. This case demonstrates that germ cell tumors associated with hematologic malignancy do not arise solely in extragonadal sites.

Mediastinal germ cell tumor with secondary nongerm cell malignancy, and extensive hematopoietic activity. Pathology, DNA-ploidy, and karyotyping

We report on a malignant germ cell tumor located in the anterior mediastinum. After chemotherapy the tumor was classified as residual teratoma with sarcomatous components. There was extensive hematopoiesis in the tumor tissue. The tumor cells had a modal chromosome number of 76; the only structural abnormality was a deletion of the long arm of chromosome 9. An i(12p) chromosome was lacking in this tumor. Karyotyping of peripheral blood and bone marrow occasionally showed metaphases with numerical and structural abnormalities, probably related to chemotherapy. The patient died within two years after the initial diagnosis, of a poorly differentiated hematopoietic malignancy, probably of myelomonocytic origin, based on morphology and the fact that non-specific esterase activity was demonstrated in the tumor cells. The karyotype of this malignancy was highly abnormal, but unrelated to that of the mediastinal malignant GCT. In this case there is no proof that the secondary malignancy was derived from the primary mediastinal malignant GCT. In view of the multiple aneuploid stem lines in the primary tumor, this possibility cannot be dismissed either.

Extragonadal and poor risk nonseminomatous germ cell tumors. Survival and prognostic features

One hundred forty-nine patients with poor risk nonseminomatous germ cell tumors (NSGCT) treated between 1975 and 1988 were studied. Patients were considered poor risk if they had an extragonadal primary site or testicular NSGCT with low predicted probability of achieving a complete response (CR). Primary sites were the testis (99 patients), retroperitoneum (18 patients), and mediastinum (32 patients). Patients with mediastinal NSGCT had lower human chorionic gonadotropin (HCG) (P less than 0.0001) and lactate dehydrogenase (LDH) levels (P less than 0.0001), and more frequent yolk sac elements (P = 0.002). CR rates were 38% for mediastinal, 61% for retroperitoneal, and 38% for testicular primary sites. Mediastinal NSGCT patients more frequently required resection of residual malignancy to attain a CR (6 of 12). Mediastinal NSGCT had the worst event-free survival (P = 0.02). Cox regression analysis identified brain or liver metastases as the most important predictor of event-free survival in poor risk patients. Retroperitoneal NSGCT often have a poor outcome due to advanced presentation, but the likelihood of a CR to therapy can be predicted using criteria applicable to testicular primary tumors. Therefore, not all retroperitoneal NSGCT are poor risk, and retroperitoneal tumors are probably of occult testicular origin. Mediastinal NSGCT have distinct clinical and pathologic features, do not respond as well to chemotherapy, relapse more frequently, and have the worst survival. The likelihood of a CR cannot be predicted using criteria developed for primary testicular tumors, suggesting that mediastinal primary NSGCT is a distinct clinical entity.

Hematologic neoplasia associated with primary mediastinal germ-cell tumors

Between September 1983 and December 1988, we observed 16 cases of hematologic neoplasia associated with mediastinal germ-cell tumors. Twenty-eight similar cases have been reported in the literature. A review of the clinical and cytogenetic details in these patients suggests that the hematologic neoplasia is not the result of cisplatin-based chemotherapy of the mediastinal germ-cell cancer. This syndrome was found only in patients with nonseminomatous mediastinal germ-cell tumors, particularly those with serologic or histologic evidence of yolk-sac elements. The two most common hematologic neoplasms seen in this syndrome were acute megakaryoblastic leukemia and malignant histiocytosis. Consistent cytogenetic abnormalities have not yet been identified, but the finding of the marker chromosome isochromosome (12p) in the mediastinal germ-cell tumor and associated leukemic blasts in one patient suggests that these tumors may arise from a common progenitor cell.

Leukemic differentiation of a mediastinal germ cell tumor

The biological basis for acute leukemia associated with mediastinal germ cell tumors has remained unexplained due to lack of critical data that would illuminate the genetic relationship between the two tumors in a given patient. Here we present results of serial cytogenetic investigations on the pretreatment and posttreatment mediastinal yolk sac tumor and immature teratoma biopsies and two separate leukemic bone marrow aspirates from a patient who developed acute nonlymphocytic leukemia 11 months after the initial diagnosis of the germ cell tumor. Presence of an i(12p) in all tumor clones and trisomy 21 in one clone in the posttreatment mediastinal tumor and all leukemic clones establishes the common origin of all tumor clones and shows that in this case the leukemia was derived from the malignant germ cell clone.

Cisplatinum-based chemotherapy in malignant mediastinal teratoma

Five patients with primary malignant mediastinal non-seminomatous germ cell tumours have been treated with a multimodality approach, including cisplatinum-containing chemotherapy, at this institution over the past 7 years. All patients had bulky disease (greater than 10 cm maximum diameter) at presentation and showed raised serum concentrations of human chorionic gonadotrophin or alpha-fetoprotein. Two patients are alive with no evidence of disease at 22 months and 6 years, respectively, from initial diagnosis; two patients have died from progressive disease and one from acute non-lymphocytic leukaemia without evidence of residual germ cell tumour. Long-term survival is achievable for these poor risk patients with a combined modality approach.

Results of the United Kingdom Children's Cancer Study Group's malignant germ cell tumor studies

The United Kingdom Children's Cancer Study Group's malignant germ cell tumor studies were undertaken to establish standard protocols for investigating, staging, and treating children, and to study the efficacy of new drug combinations and the value of serial measurement of serum alphafetoprotein (AFP) and human chorionic gonadotrophin (HCG). Boys with Stage I testicular tumors were treated by orchidectomy alone, whereas, after appropriate surgery, chemotherapy was recommended for children with more advanced testicular tumors or with tumors at other sites. From 1979 to 1987, 126 children aged 0 to younger than 16 years with malignant germ cell tumors were registered. They were similar to patients in other large pediatric series with respect to sites of origin, age at presentation in relationship to primary site, histology, female predominance for sacrococcygeal site, and presence of associated malformations (present in 17%). Serum AFP was measured in 123 patients and was elevated in 115, whereas HCG was raised in 19 of 77. Monitoring by serial AFP measurement proved valuable in assessing response to therapy and in early detection of tumor recurrence. When treatment results were assessed in February 1988, 101 of 122 patients were alive (four who received nonprotocol chemotherapy were excluded). Forty-four patients had been cured by surgery alone (41 with testicular tumors, two with ovarian tumors, and one with sacrococcygeal tumor). All of the remaining 78 children received chemotherapy. The initial low dose vincristine, actinomycin, and cyclophosphamide (LDVAC) regimen proved ineffective, actuarial survival at 5 years followup being 8% (12 patients), and a regimen of cisplatin, vinblastine, and bleomycin (PVB) caused unacceptable toxicity, with actuarial survival at 5 years follow-up being 67% (nine patients). Five-year actuarial survival was 87% for 17 children given high dose VAC with or without doxorubicin and 84% for 33 given bleomycin, etoposide, and cisplatin (BEP). All 7 children given various combinations of these regimens survived. Excluding the 12 LDVAC cases, patient survival by site was as follows: testis (59 patients, 100%); vagina, uterus, and prostate (four patients, 100%); ovary (25 patients, 88%); thorax (five patients, 40%), and other (four patients, 67%). Similarly, patient survival by stage was Stage I (62,97%), Stage II (14,86%); Stage III (18,83%); and Stage IV (16,72%). Survival by histology was analysed only in cases for which histologic review had been done the LDVAC cases were excluded.(ABSTRACT TRUNCATED AT 400 WORDS)

Age differences in the body temperature response to restraint-cold stress

Female Fischer 344 rats, 3, 11, and 24-months old were subjected to 3 hr of restraint-cold stress once each week for 4 weeks. Body (colon) temperature was recorded every 10 min during restraint and during postrestraint recovery until temperature returned to the prerestraint level. Thermoregulatory adaptation during consecutive restraint sessions was noted in 3- and 11-month-old rats but not in 24-month-old rats. Significant temperature recovery was accomplished after the second restraint session for 3- and 11-month-old rats, but this was not accomplished in the older 24-month rats until after four restraint sessions. The role of hypothermia in restraint-induced ulceration is questioned, especially as it pertains to elderly rats.

Primary mediastinal germ cell tumors. Histologic patterns of treatment failures at autopsy

Twenty-five patients presented with primary mediastinal germ cell tumors at Roswell Park Memorial Institute between 1959 and 1984. All patients were treated by surgery and chemotherapy with or without radiotherapy. Four patients are still alive, and 21 patients died of mediastinal germ cell tumor and its sequelae. Two patients were found to have testicular scars and were dropped from the study. Nongerm cell malignant transformation of a teratoma occurred in five of the remaining 17 patients (29%), resulting in three adenocarcinomas and two sarcomas. Another patient developed leukemia. Metastatic disease most commonly involved the lungs, mediastinal lymph nodes, liver, bone, retroperitoneum, and heart. Respiratory failure was the cause of death in 12 patients. Of the possible mechanisms of germ cell transformation into malignant nongerm cell tumors discussed, this study suggests that chemotherapy alone is unlikely to induce stem cell differentiation. The presence of mature, differentiated teratoma within the primary lesion may be indicative of a poorer prognosis.

Mediastinal germ cell tumors and histiocytosis

Two cases of mediastinal germ cell tumors associated with primary hemoproliferative disorders are reported. The first case was a 23-year-old man who presented simultaneously with a mediastinal immature teratoma with focal yolk sac differentiation and a cytologically benign histiocytic proliferation associated with refractory thrombocytopenia. In the second case, an unsuspected mediastinal immature teratoma with focal yolk sac and hepatic differentiation was found postmortem in a 33-year-old man who had died of fulminant malignant histiocytosis. Although the histiocytosis in the former case failed to fulfill all the usual diagnostic criteria of malignant histiocytosis, both cases probably represent different manifestations of the same pathologic process. Review of the 19 published cases of hematologic malignancies associated with mediastinal germ cell tumors and of related experimental studies suggests a role for yolk sac differentiation in the pathogenesis of this syndrome.

Primary choriocarcinoma of mediastinum with immunohistochemical study and review of the literature

Primary germinal tumors of the mediastinum are extremely rare. Most germ cell tumors in that location occur as metastasis from testis. A case report with immunocytochemical studies is described. Histologically, the tumor had features of choriocarcinoma and with immunoperoxidase technique stained positively for Beta human chorionic gonadotropin (BHCG). The patient is alive and asymptomatic 2 years post surgery and chemotherapy.

Precocious puberty associated with malignant thoracic teratoma and malignant histiocytosis in a child with Klinefelter's syndrome

A 10-year-old boy with precocious puberty of 2 1/2 years' duration presented with a malignant thoracic teratoma with elevated levels of beta human chorionic gonadotropin (beta-HCG) and alpha fetoprotein (alpha FP). The mediastinal tumor was completely excised and adjuvant chemotherapy commenced. Within 3 weeks of commencing chemotherapy he developed hematologic abnormalities that, with the subsequent clinical illness, led to a diagnosis of malignant histiocytosis. Death occurred a few days after start of therapy for malignant histiocytosis. Cytogenic studies showed the somatic karyotype to be that of Klinefelter's syndrome, while the malignant cells in marrow and lymph node carried an additional marker chromosome. This case, with others reported, suggest that the XXY karyotype may influence the development of mediastinal germ cell tumors, which in themselves appear to be associated with the early onset of a malignancy of the hemopoietic system.

Endodermal sinus tumor of the mediastinum. A report of seven cases and review of the literature

Primary mediastinal endodermal sinus tumor is rare, and to date only 49 cases have been described in the English-language literature. Seven new cases are reported. Light microscopic examination showed characteristic features including papillary, reticular, tubular and solid growth patterns, complete or incomplete Schiller-Duval bodies and intracellular or extracellular periodic acid-Schiff-positive material. Immunohistochemical studies showed alpha-1-antitrypsin in seven, alpha-fetoprotein in seven, keratin in six, and carcinoembryonic antigen in four cases. The beta subunit of human chorionic gonadotropin, albumin, fibronectin, and transferrin were not found in any case. Electron microscopic studies performed in four cases showed intracellular and extracellular basement membrane-like material, multiple large multivesicular bodies, desmosomes and microvilli. Mediastinal endodermal sinus tumor can and must be differentiated from poorly differentiated adenocarcinoma metastatic or extending to the mediastinum because of the distinctly different prognoses and therapies. In spite of modern chemotherapy, the prognosis of mediastinal endodermal sinus tumor remains poor. The single most important prognostic indicator is whether the tumor mass can be completely excised before or after chemotherapy.

Mediastinal germ cell tumour associated with malignant histiocytosis and high rubella titres

Two further cases of a haematological malignancy are reported in patients with mediastinal germ cell tumours. Two young men developed bone marrow infiltration with histiocytes showing erythrophagocytosis shortly after subtotal excision of a malignant teratoma of the anterior mediastinum. Serial viral titres showed a rise in rubella antibody titres by haemoagglutination inhibition in both cases, antirubella IgG (ELISA) in one case and rubella RH zone in the other, in the absence of detectable IgM rubella antibodies. In case 1 a diagnosis of virus associated haemophagocytic syndrome was made and he was treated with interferon and steroids. In case 2 the diagnosis was initially idiopathic thrombocytopenia purpura but he deteriorated on steroids, and was subsequently unsuccessfully treated with chemotherapy and gamma globulin infusions. The disease ran a rapid downhill course with progressive marrow failure and they both died 5 months after diagnosis. Review of the presenting histology, the progressive course of the disease and post mortem histology, suggests that they had malignant histiocytosis. The association between mediastinal teratoma and haematological malignancy is of biological importance. Serial viral titres should be measured in patients with malignant histiocytosis to see if there is a raised rubella titre. Such viral studies are also warranted where there is an association between a mediastinal germ cell tumour and haematological malignancy.