Yolk sac tumor (endodermal sinus tumor) and alpha-fetoprotein. A report of three cases

A Rare Case of Immature Sacrococcygeal Teratoma With Lymph Node Metastasis in a Neonate

This is the first report of an immature sacrococcygeal teratoma with inguinal lymph node metastasis, providing the histologic transformation of an immature teratoma in association with chemotherapy. Incomplete tumor resection with coccygectomy was performed, and the histopathologic diagnosis was a grade 3 immature teratoma. Following the initial surgery, the residual tumors enlarged and the tumors metastasized to the inguinal lymph node, demonstrating immature teratoma without yolk sac tumor components. Although the tumor markers normalized after chemotherapy, the residual tumors had enlarged significantly. Therefore, a complete resection of the residual tumors was performed, and they were found to be mature teratomas.

The diagnostic and prognostic value of tumor markers in giant mediastinal endodermal sinus tumor with prolonged survival: Twelve-year follow up after radical resection

We report a case of 16 -year male who presented with nonproductive cough, chest pain, and hemoptysis. His chest -x-ray and computerized tomographic scan (CT) of the thorax with contrast enhancement revealed a large mediastinal mass mostly occupying the left hemithorax. Percutaneous CT scan-guided biopsy of the mediastinal mass was reported as an endodermal sinus tumor (EDST). Serum alpha-fetoprotein levels were markedly raised (120,000 ng/ml). After completion of chemotherapy repeat, CT scan of the thorax revealed a large residual mass. Radical resection of the tumor was carried out. Twelve-year post-surgical resection follow-up with serial serum alpha-fetoprotein (AFP) tumor marker levels and CT scan of the thorax showed no recurrence.

Perspectives in Pediatric Pathology, Chapter 25. Testicular and Paratesticular Tumors in the Pediatric Age Group

Testicular tumors in the prepubertal age are relatively rare, representing only 9.4% of the total testicular and paratesticular specimens from a 20-year review performed at a large pediatric hospital [ 1 ]. They account for 1% to 2% of all solid tumors in the pediatric age group, with an annual incidence between 0.5/100 000 and 2/100 000 boys according to Coppes et al [ 2 ] and data from the Prepubertal Testicular Tumor Registry [ 3 ]. Similar to other neoplasms afflicting children, a bimodal age distribution is observed. The first peak is between birth and 3 years of age, and a second one occurs at the onset of puberty, extending to the fourth decade. Reports on their frequency vary because some investigators include the adolescent period, while others do not [ 4 ]. The vast majority of testicular tumors are germ cell neoplasms, accounting for 95% across all ages [ 5 ]. In children, germ cell tumors also predominate, representing 71% of all testicular neoplasms. These include yolk sac tumors (49%), teratomas (13%), seminomas and mixed germ cell tumors (9%), and sex-cord stromal tumors (29%). Malignant potential is significantly lower (less than 70%) in the pediatric age group compared to adults (90%) [ 6 ]. According to Pohl et al, 74% of prepubertal testicular tumors are benign [ 7 ].

Down-regulation of ATBF1 is a major inactivating mechanism in hepatocellular carcinoma

AIMS

alpha-Fetoprotein (AFP) is frequently detected in hepatocellular carcinomas (HCCs) and AT motif binding factor 1 (ATBF1) down-regulates AFP gene expression in hepatic cells. The ATBF1 gene also inhibits cell growth and differentiation, and altered gene expression is associated with malignant transformation. The aim was to investigate the potential role of the ATBF1 gene in HCCs.

METHODS AND RESULTS

Somatic mutations, allelic loss and hypermethylation of the ATBF1 gene were analysed in 76 sporadic HCCs. The level of ATBF-1 mRNA expression was analysed using quantitative real-time reverse transcriptase-polymerase chain reaction. Genetic studies of the ATBF1 gene revealed absence of somatic mutation in the hotspot region and 15 (25%) of 60 informative cases showed allelic loss at the ATBF1 locus. Hypermethylation in the intron 1 region of the ATBF1 gene was detected in only one case. Interestingly, ATBF1 mRNA expression in HCCs was significantly reduced in 55 (72.4%) samples compared with the corresponding surrounding liver tissues. Reduced expression was not statistically associated with clinicopathological parameters including stage, histological grade, infective virus type, and serum alpha-fetoprotein level.

CONCLUSIONS

The ATBF1 gene may contribute to the development of HCCs via transcriptional down-regulation of mRNA expression, but not by genetic or epigenetic alterations.

Genetic alterations of the ATBF1 gene in gastric cancer

PURPOSE

Alpha-fetoprotein (AFP)-producing gastric cancers are aggressive tumors with venous and lymphatic invasion and hepatic metastasis. The goal of the present study was to investigate whether somatic changes of the AFP-negative regulator AT motif binding factor-1 (ATBF1) gene are involved in the development or progression of gastric cancers and the production of AFP in gastric cancer cells.

EXPERIMENTAL DESIGN

We searched for genetic alterations of the ATBF1 gene by single-strand conformational polymorphism and sequencing methods as well as allelic loss analysis with the microsatellite markers D16S3066 and D16S3139. Immunochemistry for AFP expression in gastric cancer cells was also done.

RESULTS

In 81 sporadic gastric cancers, four mutations were detected in seven cases: one was a missense mutation and three were deletions; loss of heterozygosity at the ATBF1 locus was detected in 52.9% of informative samples. Five of the eight cancers with AFP expression showed ATBF1 genetic alterations.

CONCLUSIONS

These results suggest that genetic alteration of the ATBF1 gene may contribute to the aggressive nature of gastric cancers and the production of AFP in gastric cancer cells.

Intracardiac yolk sac tumor in an infant girl

We report about a two and a half year old girl with a primary yolk sac tumor (YST) of the heart, located in the interventricular septum. The girl was admitted to the hospital with a systolic cardiac murmur. Echocardiography revealed a smoothly surfaced tumor which based on the interventricular septum below the aortic valve and filled out more than half of the left ventricular cavity. Diagnosis of a yolk sac tumor was established on a frozen section of a biopsy taken at surgery and confirmed by the examination of the resected material. Excessively elevated serum alpha-fetoprotein (AFP) levels contributed to this diagnosis. Follow up examinations of the patient including computed tomography (CT) of head, thorax and abdomen, did not indicate an extracardiac tumor manifestation. We found no previous report of a primary intracardial yolk sac tumor in the literature.

Testicular yolk sac carcinoma in a calf

A testicular yolk sac carcinoma (YSCA) was diagnosed in a 28-day-old male Japanese black calf. Macroscopically, the abdominal cavity was filled with reddish gelatinous masses of various sizes. There were no testes in the scrotum or pelvic cavity. Histologically, the masses consisted of the tissues showing a variety of patterns; loose reticular network, pseudopapillary arrangement, festoon, solid nest, and labyrinthine pattern. Tumor cells were round to oval, with single central or polar nuclei with sharply defined nuclear borders and deeply basophilic chromatin. Tumor cells sometimes had glycogen granules, periodic acid-Schiff (PAS)-positive inclusions, or sudanophilic droplets in their cytoplasm. Hyaline matrices were found in extracellular areas and were intensely PAS positive. Immunohistochemically, most of the tumor cells and hyaline matrices had positive reactivity to anti-alpha-fetoprotein and anti-placental-alkaline-phosphatase antibodies. Positive reaction to anti-laminin antibody appeared only in hyaline matrices. This is the first case of a tumor in a domestic animal with histologic and immunohistochemical features analogous to those of human YSCA, endodermal sinus type.

Germ cell tumors in children: gonadal and extragonadal

Sixty-three pediatric patients with germ cell tumors are presented with details of symptoms, histological findings, staging, serological markers, treatment, and response to therapy. The primary sites were: ovarian 32, testicular 17, presacral 7, mediastinal 3, intraabdominal 2, vaginal 1, and right inguinal canal 1. These patients were treated with T2 (sequential use of dactinomycin, doxorubicin, vincristine, and cyclophosphamide, with or without radiation), T6 (combination chemotherapy with cyclophosphamide, bleomycin, dactinomycin, doxorubicin, methotrexate, vincristine), or VAB treatment protocols (velban, dactinomycin, bleomycin, cisplatin). The cure rate for stage I ovarian and testicular germ cell tumors was 100%; for stage III, all primary sites, 82% and for stage IV, all primary sites, 75%. Histology was prognostic in ovarian tumors of the immature malignant teratoma type; the neural type immature teratoma, grades II and III, had the worst prognosis. Initial debulking surgery in combination with chemotherapy and radiation plays an important role in germ cell tumors. Stages II, III, and IV germ cell tumors require aggressive treatment with surgery, radiation, and chemotherapy. For stage I patients, with primary ovarian malignant tumor, cure with surgery alone can be achieved in 50% of the cases and in testicular tumors in about 70% of the patients. For those with stage I and elevated serological markers, it is feasible to follow these markers and give no treatment until there is evidence of persistent elevation or a rise in titers after an initial fall. In those without elevated serological markers, one should take into consideration the size of the tumor and the histological type before taking the "wait and see" approach. These stage I tumors are highly curable when they first present but, if allowed to recur, chemotherapy may not offer the patient such a favorable response and cure rate.

Aggressive chemotherapy in endodermal sinus tumor

Twenty-eight patients with pure or predominantly endodermal sinus tumor were studied for their clinical behavior, relation with serum alpha-fetoprotein (AFP), and response to intensive postoperative combination chemotherapy. Eight percent of the patients were younger than 20 years of age. One patient was a pseudohermaphrodite. Serum AFP was estimated in 17 patients and was elevated in all. Seven patients were treated with adjuvant chemotherapy following surgery with a cisplatin-containing combination. Five patients (71%) are alive and continue to remain free of disease, with a median survival of 28 months after treatment and an overall median survival of 34 months. Two patients treated with adjuvant chemotherapy experienced early recurrence of the disease, which was detected with a rise in serum AFP before the clinical manifestation of recurrence.

Extraovarian pelvic yolk sac tumors

The clinical and pathologic features of four extraovarian pelvic yolk sac tumors (YST) are described. The women, 17 to 39 years of age, were found to have a pelvic mass on physical examination, or in one case, at cesarean section. The tumors were bulky and arose within, or in close proximity to, the uterus. One tumor involved the endometrial cavity and myometrium extensively, another was attached to the anterior uterine serosa, another was in the cul-de-sac, and one lay between the lower uterine segment and urinary bladder. The ovaries were grossly unremarkable in all cases. Peritoneal metastases were present at the time of operation in two patients and were documented on histologic examination in a third. The serum alpha fetoprotein (AFP) level was elevated postoperatively in the three patients in whom it was determined. Three of the YST were pure and had a typical histologic appearance, whereas the fourth had an endometrioid-like glandular pattern and was associated with a teratoma. Immunohistochemical stains performed in three cases all showed AFP and alpha-1-antitrypsin (AAT). All patients received postoperative combination chemotherapy. Two of them died of tumor 14 and 24 months, respectively, postoperatively and two were disease-free 6 and 8.5 years, respectively, postoperatively.

Production of alpha-fetoprotein by human germ cell tumors in vivo and in vitro

The production of alpha-fetoprotein (AFP) by human germ cell tumors was studied in surgical specimens, cultured cells and transplanted tumors in nude mice. AFP was detected most frequently in yolk sac (endodermal sinus) tumors, and it was also detected, though only occasionally, in embryonal carcinomas and in teratomas. AFP-positive cells in teratomas presented a glandular or hepatoid appearance. Our experimental data suggest that AFP production in embryonal carcinomas is due to the functional expression of yolk sac differentiation preceding its morphologic expression. Although the transplanted tumors maintained the productivity of AFP, the cultured cells were not successful in maintaining a continuous AFP production.

Plasma alpha fetoprotein reference ranges in infancy: effect of prematurity

The dearth of plasma alpha fetoprotein reference ranges for preterm infants often impairs the clinical interpretation of plasma alpha fetoprotein data collected from ill babies. This study tested our hypothesis that meaningful plasma reference ranges could be established for preterm infants by a simple correction of patient age at sampling date for gestational age deficit at birth. Using a modified radioimmunoassay kit method, determinations of alpha fetoprotein were performed on capillary and venous blood samples collected from 56 babies aged from birth to 5 months with gestational ages ranging from 26 weeks to 43 weeks. Unmodified plasma alpha fetoprotein values were grouped according to patient age and examined statistically using established normal theory methods, but these yielded excessively wide reference intervals and non-Gaussian distribution parameters. Acceptable reference ranges were derived using logarithmic transformation of plasma alpha fetoprotein values and rearrangement against patient age corrected for gestational age deficit. These provisional reference ranges for plasma alpha fetoprotein in preterm (and term) infants are applied to groups of previously meaningless alpha fetoprotein results and used to test the potential usefulness of plasma alpha fetoprotein determination as a diagnostic marker in biliary atresia, hepatitis, and yolk sac derived tumours.

Hepatoid adenocarcinomas of the stomach. An analysis of seven cases

Hepatoid adenocarcinomas of the stomach are gastric carcinomas with both adenocarcinomatous and hepatocellular differentiations. They usually produce large amounts of alpha-fetoprotein (AFP) with a Concanavalin A-binding property of hepatic type. In this study, these carcinomas occurred in older persons, with the antrum being a common site. Observed grossly, growth of the tumors was nodular and massive. Prognosis was poor because of frequent liver metastases. In the cytoplasms of tumor cells, various serum proteins were identified, including AFP, alpha-1 antitrypsin (AAT), alpha-1 antichymotrypsin (ACT), albumin, and prealbumin. Localizations of ferritin, prothrombin, and transferrin were demonstrated with less frequency. Adenocarcinomatous foci were composed of well-differentiated, intestinal-type epithelial cells and often contained carcinoembryonic antigen. These adenocarcinomatous and hepatoid areas were often intermingled with each other. There were extensive venous involvements by tumor cells. The poor prognosis of the tumors may be attributed to these involvements as well as to production of AFP and presence of AAT/ACT, which have immunosuppressive and protease-inhibitory properties, respectively.

Factors influencing the survival of patients with testicular teratoma

The histology of 51 cases of testicular teratoma, with or without seminoma, was reviewed and classified according to the World Health Organization criteria. Full pathological and clinical details were obtained, and patients were followed up for periods varying from one to 10 years from orchidectomy. Multiple factors were studied in order to discover which affected prognosis. The pathological stage of the tumour proved to be the most important indicator. The previously described poor prognosis associated with yolk sac tumour was not confirmed.

Yolk sac tumor of the testicle: is retroperitoneal lymph node dissection necessary?

We report our experience with 11 cases of yolk sac tumors, which were treated between 1960 and 1982 at the Hôpital Sainte-Justine and the Montreal Children's Hospital. The role of lymphadenectomy in yolk sac tumors is analyzed critically and put into perspective with the use of serum alpha-fetoprotein. A flow sheet is presented for the management of yolk sac tumors. It seems that the indication for lymphadenectomy in yolk sac tumor should be restricted to patients with persistently elevated serum alpha-fetoprotein after inguinal orchiectomy and chemotherapy.

Endodermal sinus tumor (yolk sac tumor) of the orbit

The endodermal sinus tumor is a malignant germ cell neoplasm that usually arises in gonads, but on rare occasion occurs in extragonadal locations. Five tumors of the orbit, which by light microscopy displayed features characteristic of gonadal endodermal sinus tumor, were tested for the presence of alpha fetoprotein using paraffin-embedded tissue and an immunoperoxidase technique. Each tumor contained intracytoplasmic alpha fetoprotein. Review of the clinical histories revealed that orbital endodermal sinus tumors differ from other extragonadal endodermal sinus tumors in that they occur at a younger age and when treated aggressively can result in long-term survival. In children with rapidly progressive proptosis the distinction between endodermal sinus tumor and rhabdomyosarcoma poses diagnostic difficulties for both the clinician and the pathologist. When considering the diagnosis of endodermal sinus tumor, the use of immunohistochemical testing for alpha fetoprotein can be helpful.

Hepatic teratomas in children

This report describes a hepatic teratoma in a newborn child. Microscopic examination showed a predominantly immature teratoma containing tissue representative of all three germ layers. No evidence of malignant tissue was found in the tumor, and no clinical evidence of metastasis was found in the child. A markedly elevated serum alpha fetoprotein was documented. A review of the literature on hepatic teratomas in children is also presented.

Ultrastructure and immunohistochemical staining of a transplanted endodermal sinus tumor

An endodermal sinus (yolk sac) tumor was successfully transplanted into athymic nude mice. Histologic and ultrastructural investigations revealed that the transplanted tumor had a characteristic appearance with numerous Shiller-Duval bodies, endodermal sinus structures and ultrastructural profiles as previously described in human material. The endodermal sinus tumor and normal human yolk sac have been found to synthesize not only alpha-fetoprotein (AFP), but also other serum proteins, namely, albumin, prealbumin, alpha 1-antitrypsin, and transferrin. Serological study by radioimmunoassay demonstrated AFP, carcinoembryonic antigen (CEA) and human chorionic gonadotropin (HCG) in the sera of the tumor-bearing nude mice and in cyst fluid from the transplanted tumor. Immunohistochemical investigation using the unlabeled antibody peroxidase-antiperoxidase method showed using the unlabeled antibody peroxidase-antiperoxidase method showed that the tumor cells produced CEA, alpha 1-antitrypsin, transferrin, HCG as well as AFP. These immunohistochemical staining properties were correlated with the findings on radioimmunoassay.

Cellular localization of AFP, hCG and its free subunits, and SP1 in embryonal carcinoma of the testis and ovary

An immunohistological study of AFP, hCG and its free subunits, and SP1 was investigated in 10 cases of non-seminomatous germ cell tumors of the testis and ovary. AFP was demonstrated in mononuclear embryonal tumor cells within embryonal carcinoma in a narrow sense, frequently in association with yolk sac tumor. AFP was more consistently demonstrated in vacuolated or elongated cells of yolk sac tumor, in which continuous transformation from tubular patterns of embryonal carcinoma was shown with positive reactions for AFP. The hCG was demonstrated in syncytiotrophoblastic giant cells scattered among the embryonal carcinoma, but rarely in mononuclear large cells. The occurrence of hCG and beta subunit was more frequently observed than a subunit or SP1, suggesting the unbalanced synthesis of hCG and free subunit in choriocarcinomatous element associated with embryonal carcinoma. These findings support the view that embryonal carcinoma has a developmental potential to the extra-embryonic components of both choriocarcinoma and yolk sac tumor.

Endodermal sinus tumour of the ovary: the place of alphafetoprotein detection, surgery and chemotherapy

New developments in the management of the rare endodermal sinus tumour of the ovary, together with the reporting of 2 additional patients, are presented. There is a need for accurate clinical and pathological evaluation of the disease. As shown in the present study, histochemical staining for alphafetoprotein (AFP) provides an additional factor in diagnosis, and monitoring of AFP levels in serum is a useful guide to treatment. The prognosis, previously uniformly poor, appears to be improved with the use of multidrug chemotherapy. In a collated series of 98 patients, the 24-month survival rate was 65% in Stage I disease and 67% in Stage II disease. However, the choice of effective drugs remains uncertain. The improved survival of young patients with aggressive chemotherapy has now raised the question of preservation of fertility at the time of surgery. In a small collated series of 26 patients with Stage I disease, survival to 36 months was not jeopardized by the conservative removal of one tube and ovary.

Biochemical markers in the plasma and tumors of patients with gynecologic malignancies

Tumor markers in gynecologic malignancies can be classified generally as oncofetal proteins, carcino-placental proteins, and more specific tumor-associated antigens. Carcinoembryonic antigen (CEA) is most effective as a tumor marker in mucinous adenocarcinomas of the endocervix and ovary and in keratinizing squamous cell carcinomas of the cervix. In contrast, the use of alphafetoprotein (AFP) in gynecologic cancer is limited to patients with germ cell tumors of the ovary and specifically endodermal sinus tumors. The beta subunit of human chorionic gonadotropin (beta-hCG) remains an exemplary tumor marker for trophoblastic malignancies and may be useful in selected patients with epithelial carcinomas of the ovary. Plasma levels of these antigens are generally related to total tumor burden (tumor antigen concentration x extent of disease)). Although the lack of specificity of these markers has limited their use in the diagnosis of gynecologic malignancies, they have been effective as a means of monitoring disease status in patients whose tumors contain high antigen concentrations. More specific tumor-associated antigens have been described in ovarian cervical cancers, but their clinical efficacy remains to be demonstrated in large numbers of patients. Immunohistochemical staining of tissue specimens identifies patients whose tumors contain high antigen concentrations and who therefore should benefit most from serial plasma determinations following therapy. Potential future uses of biochemical markers include radioimmunodetection procedures using radiolabelled antibodies to tumor-associated antigens and antigen-directed chemotherapy.

Intracranial germ cell tumor indicating a high level of alpha-fetoprotein (AFP)

An autopsy case of intracranial and extrapineal tumor is reported. The tumor, detected 2 years and 4 months before death, was an ectopic pinealoma (germ cell tumor) and showed elevated serum alpha-fetoprotein (AFP) of 48,000 ng/ml. Histologically, intra- and extracellular PAS-positive hyaline globules were observed in the tumor. The tumor tissues of the paraffin sections revealed a bright positive fluorescence for AFP with indirect immunofluorescence method. Besides, there were generalized metastases in this case.

Human chorionic gonadotrophin and alpha-fetoprotein in testicular germ cell tumours: a retrospective immunohistochemical study

A series of testicular germ cell tumours (46 seminomas and 27 non-seminomas) was studied immunohistochemically with regard to the presence of alpha FP and HCG. In three seminomas, HCG reactive syncitiotrophoblast-like giant cells (STLG) were found. Immunoreactive alpha FP did not occur in seminomas. In differentiated mature teratomas HCG or alpha FP could not be demonstrated. In embryonal carcinomas with or without teratoma (MTI/MTU/MTT) HCG immunoreactivity was found in 83%, usually localized in STLG. In 75% of these tumours alpha FP could be demonstrated. This protein was localized in foci of endodermal sinus or yolk sac differentiation, but also in single cells and cell clusters in areas of embryonal carcinoma. In some cases syncitial cells were present which contained both HCG and alpha FP. Immunostaining of tumour markers appeared not to provide important additional criteria for classification of these tumours in the currently available classifications. The significance of HCG containing STLG in seminomas deserves further investigation. Prospective studies of embryonal carcinoma with or without teratoma (MTI/MTU/MTT) will be necessary to evaluate the possible prognostic importance of the presence of alpha FP or HCG or both.

Endodermal sinus (yolk sac) tumor elements in testicular germ-cell tumors in adults: comparison of prospective and retrospective studies

The incidence of endodermal sinus tumor (EST) or yolk sac tumor (YST) elements has been studied in two series of testicular germ-cell neoplasms in adults. One series, consisting of 200 germ-cell neoplasms seen from 1053 through 1968, was studied retrospectively, and the other, consisting of 147 cases seen from May 1974 through February 1979, was studied prospectively. Excluding the cases of pure seminoma, EST(YST) elements were found in 21 (28.7%) of 73 cases in the retrospective series and in 27 (44.4%) of 61 cases in the prospective series. The EST(YST) elements were in all cases admixed with other neoplastic germ-cell elements and varied from microscopic foci to being the predominant element within a tumor. The EST(YST) elements were histologically similar to infantile EST(YST) and EST(YST) in other locations. Serum alphafetoprotein (AFP) was determined in the majority of patients in the prospective series, and there was good correlation between the presence of EST(YST) elements within the tumor and elevated levels of AFP. The results of the present study indicate that EST(YST) elements occur quite frequently in testicular germ-cell neoplasms in adults and provide an explanation for the raised levels of serum AFP found in many adults with testicular germ-cell tumors. The results emphasize the importance of a thorough and careful pathologic examination of testicular germ-cell tumors, and the value of AFP as a tumor marker in patients with EST(YST). The results also lend further support to the view that EST(YST) elements found in testicular germ-cell tumors in adults are homologous with infantile EST(YST) and that EST(YST) is a distinctive and specific type of germ-cell neoplasm and should be included as such in the classification of testicular tumors.

Serum alphafetoprotein (AFP) in patients with germ cell tumors of the gonads and extragonadal sites: correlation between endodermal sinus (yolk sac) tumor and raised serum AFP

During the last 6 1/2 years, serum AFP has been determined by radioimmunoassay in 387 patients with germ cell tumors of the gonads and extragonadal sites. The histological appearances of all these neoplasms were carefully reviewed. Highly elevated levels of serum AFP were noted in patients with tumors containing endodermal sinus (yolk sac) tumor elements irrespective of the location of the neoplasm or presence or absence of metastatic disease. There was good correlation between the presence and quantity of endodermal sinus (yolk sac) tumor elements within the primary tumor or its metastases and elevated levels of serum AFP. All patients with tumors composed of pure seminoma or dysgerminoma, and teratoma, had normal serum AFP levels. Slightly elevated levels of serum AFP up to 60 ng/mg (upper limit of normal 20 ng/ml) were noted in a few patients with testicular tumors composed of pure embryonal carcinoma, whereas patients with tumors composed of or containing endodermal sinus (yolk sac) tumor elements had serum AFP levels that could be measured in 100's or 1000's of ng/ml. Serum AFP was elevated only in patients with active disease. Serum AFP was determined in 81 patients with gonadal tumors of non germ cell origin and was normal in all these patients. Serum AFP is a very good tumor marker in patients with germ cell tumors composed of or containing endodermal sinus (yolk sac) tumor, irrespective of their location. Serial serum SFP determinations can be used for diagnostic purposes, for monitoring the results of treatment, and for early detection of metastases and recurrences. Serial serum AFP determination is a useful procedure in all patients with germ cell neoplasms and is highly recommended.

Endodermal sinus tumour of the ovary: serum alpha-fetoprotein levels before and after treatment and during pregnancy. Case report

We report the apparently successful treatment of an endodermal sinus tumour. The patient became pregnant after unilateral oophorectomy and adjuvant chemotherapy, and was delivered of a normal female infant. The levels of serum alpha-fetoprotein, having been raised before treatment of the tumour, were within the normal range during pregnancy and undectactable before and afterwards.

Therapy of endodermal sinus tumor of the ovary

Endodermal sinus tumor of the ovary can be differentiated histologically and immunohistochemically from ovarian embryonal cell carcinoma. A case report of a patient with endodermal sinus tumor is presented in which a long-term remission was achieved by unilateral adnexectomy and combination chemotherapy. Review of the current literature indicates that tumor removal followed by combination chemotherapy with vincristine, actinomycin D, and cyclophosphamide is the most effective method of therapy for this highly malignant ovarian neoplasm. The addition of hysterectomy with contralateral ovariectomy or radiation therapy does not appear to significantly improve the survival of patients with this tumor. Serial plasma determinations of alpha fetoprotein provide biochemical monitoring of response to therapy and may be useful in predicting occult tumor recurrence.

Endodermal sinus (yolk sac) tumors in infants and children

Endodermal sinus tumors, as a specific entity, were first proposed and described by Teilum on the basis of morphological and histogenetic features. Recent work utilizing tumor markers (alpha-fetoprotein), immunofluorescent and electron microscopic studies have supported Teilum's original concept as to the origin of these tumors. Five typical presentations of endodermal sinus tumors seen in the pediatric age group were reviewed with reference to the original presentation, the utilization of tumor markers (alpha-fetoprotein) and the prognostic implications of this neoplasm.

The endodermal sinus tumor: special features

Eight cases of endermal sinus tumor, two extragonadal and six gonadal, seen at the American University of Beirut are reviewed. Three of them present special clinical and pathologic features that further substantiate the extraembryonic origin of this teratoid tumor and its association with dysgenetic gonads. We consider the two histologic types, endodermal sinus pattern and polyvesicular vitelline architecture, to be part of the same tumor. The prognosis in this series was unfavorable.

Alpha-fetoprotein, alpha-1-antitrypsin, and transferrin in gonadal yolk-sac tumours

Since gonadal yolk-sac tumour in pure form or as a component of mixed germ cell tumour is in the majority of patients highly malignant, its histological recognition is of great prognostic importance. Yolk-sac tumour may assume various different histological guises, which have hitherto caused considerable terminological confusion; the present paper is aimed at correlating these morphological diversities with biochemical features which are consistent with yolk-sac differentiation. Using an enzyme-bridge immunoperoxidase technique, a series of 16 gonadal germ cell tumours with a yolk-sac component were screened for the presence of alpha-fetoprotein, alpha-1-antitrypsin, and transferrin. These proteins, normally produced by human yolk sac, were demonstrable in all the morphological patterns of yolk-sac tumour we have previously described. Six malignant non-germ cell tumours were submitted to the same investigations, and no evidence of the three protein markers was found in five; one tumour, however, an oat cell carcinoma of the bronchus, stained positively for transferrin.

Endodermal sinus tumor: the Stanford experience and the first reported case arising in the vulva

A review of the histology, clinical findings and results of therapy in 9 females with endodermal sinus tumor (EST) is presented. Five patients had histologically pure EST; 4 had EST mixed with other germ cell components. The site of primary tumor was the ovary in 8 of the 9 females; the remaining patient with an extraovarian primary represents the first reported case of EST arising in the vulva. The addition of combination chemotherapy has prolonged survival over historical controls treated with surgery or surgery plus irradiation. Adjuvant chemotherapy appears warranted as treatment for occult metastatic disease; postoperative radiation therapy appears useful in providing local control of primary disease. There is a suggestion of increased sensitivity of EST to combination chemotherapy as compared to other germ cell histologies with which it is commonly admixed.

Regional lymph nodes in infants with embryonal carcinoma of testis

Clinical and pathologic material from 16 infants with embryonal carcinoma of the testis was reviewed specifically as to the route of metastatic spread and the findings obtained from retroperitoneal lymphadenectomy. Hematogenous metastases were noted in 3 patients (19 per cent) and lymphatic metastases were observed in 2 patients (13 per cent). In 12 patients in whom disease was clinically limited to the testis retroperitoneal lymphadenectomy was negative, although a review of the literature suggests that unsuspected metastases might be expected in 6 per cent of such patients. The 2 patients who had lymph node metastases had large, clinically evident but unresectable retroperitoneal lymph node masses. The low yield of retroperitoneal metastases in early disease makes lymphadenectomy suspect as a primary staging or treatment procedure, but the occasional patient presenting with retroperitoneal disease requires that the procedure not be abandoned at this time.

Evaluation of alpha-fetoprotein in early infancy

Serum AFP concentrations of normal subjects were statistically analyzed in order to obtain the normal ranges in early infancy. The 95% prediction band would seem to offer a convenient means of evaluating serum AFP in the age range 0-300 days of life. Some illustrative cases, whose AFP values were formerly considered to be abnormally high but later proved to be within normal range, are presented.

Alpha-fetoprotein, prealbumin, albumin, alpha-1-antitrypsin and transferrin as diagnostic and therapeutic markers for endodermal sinus tumors

According to Gitlin, alpha-fetoprotein (AFP), albumin, prealbumin, alpha-1-antitrypsin and transferrin are normal products of the human yolk sac. They are expected to reappear in human endodermal sinus tumor (yolk sac tumor). The synthesis of alpha-fetoprotein and other serum proteins by human endodermal sinus tumor was studied in the culture cells and in the tumor tissue transplanted into nude mice. The results gave evidences of synthesis of some of these proteins including alpha-fetoprotein and alpha-1-antitrypsin. Serum concentrations of these proteins were studied in eight children having endodermal sinus tumors. Serum AFP levels were abnormally high in all cases, whereas concentrations of other serum proteins were almost within normal ranges. This might be simply reflected by the fact that pre-albumin, albumin, alpha-1-antitrypsin, and transferrin are already present in large quantities in sera of normal subjects while alpha-fetoprotein is present only in a negligible quantity. Alpha-fetoprotein, as a diagnostic and therapeutic marker of endodermal sinus tumor, showed good correlation to the tumor growth. Serum AFP concentrations declined almost to 0 ng/ml with a half-life of 4 days when surgical removal was complete, whereas serum AFP decreased only to 100-200 ng/ml with radiation and chemotherapy alone.

Serum alphafetoprotein (AFP) in diagnosis and management of endodermal sinus (yolk sac) tumor and mixed germ cell tumor of the ovary

Serum AFP was determined serially by radioimmunoassay in 13 patients with ovarian germ cell tumors and in one patient with bilateral pure gonadoblastoma. There were 4 patients with pure dysgerminoma, one with pure endodermal sinus tumor (EST) and 8 with mixed germ cell tumors, all containing EST. The patients with dysgerminoma and gonadoblastoma had normal serum AFP at all times. All patients with tumors containing EST had raised serum AFP, although in most cases it was first determined between 1 and 3 weeks after operation and there was no evidence of metastases. Serum AFP became normal 5 to 7 weeks after operation and began to rise when disease recurred. Serum AFP determinations detected presence of recurrent disease long before it became detectable by other methods. Serum CEA was determined serially by radioimmunoassay in 8 of these patients, including 2 who dies with metastases, and was normal on all occasions.