Germ cell neoplasms arising in gonadoblastomas

Malignant Gonadal Germ Cell Tumors (Other Than Pure Germinoma) in Patients With Disorders of Sex Development: A Report of 21 Cases Based Largely on the Collection of Dr Robert E. Scully, Illustrating a High Frequency of Yolk Sac Tumor With Prominent Hepatoid and Glandular Features

We describe 21 nonpure germinomatous gonadal germ cell tumors (9 with a germinoma component), all but 1 associated with gonadoblastoma, in patients with disorders of sex development who ranged from 7 to 36 years old (average, 20 y). Twenty patients were clinically described as phenotypic females with ambiguous genitalia/virilization and primary amenorrhea. The most common documented peripheral karyotype was 46,XY (10/12; 83%). Fifteen of 16 tumors with available clinicopathologic data were unilateral. They ranged from 7 to 30 cm (mean, 15.5 cm) and were solid and cystic with frequent necrosis and hemorrhage. Gonadoblastoma, in its classic (70%), dissecting (5%), or combined (25%) forms, was identified in all but 1. The malignant germ cell tumors were typically mixed except for 5 pure yolk sac tumors and 1 expansile gonadoblastoma with syncytiotrophoblast cells. When admixed, the most common component was yolk sac tumor (n=10), followed by germinoma (n=9), embryonal carcinoma (n=5), choriocarcinoma (n=4), immature teratoma (n=3), and teratoma (n=2). Typical morphologic patterns of yolk sac neoplasia, including reticular/microcystic, solid (including blastema-like), and endodermal sinus (Schiller-Duval bodies), were seen, as well as glandular (n=10) and hepatoid (n=6) differentiation, with cystically dilated glands and diffuse hepatoid morphology in 3 and 2 tumors, respectively. Two yolk sac tumors showed a sarcomatoid pattern. Somatic-type malignancies (alveolar rhabdomyosarcoma and low-grade spindle cell sarcoma, not otherwise specified) were identified in 1 case each. This is the first large series of germ cell tumors other than typical pure germinoma associated with gonadoblastoma. The high frequency of yolk sac tumor with glandular (especially cystic glandular) and hepatoid morphologies is noteworthy, and their presence should prompt further evaluation for an associated gonadoblastoma and possible disorder of sex development.

Gonadoblastoma with Coexistent Features of Mixed Germ Cell-Sex Cord Stroma Tumor: A Case Report

Gonadoblastoma and mixed germ cell-sex cord stroma tumor have been widely recognized as two separate entities on the basis of both clinical and pathological features. The typical morphological pattern of both tumor types was found by us to coexist in the same gonadal tumor in a 14-year-old 46,XY phenotypically female subject who also had a contralateral dysgerminoma. A subserous implant showing the mixed germ cell-sex cord pattern of the primary tumor was detected in the uterine body. Following therapy the patient is alive and well after a 7-year follow-up. The distinction between gonadoblastoma and mixed germ cell-sex cord stroma tumor requires discussion.

State of the art review in gonadal dysgenesis: challenges in diagnosis and management

Gonadal dysgenesis, a condition in which gonadal development is interrupted leading to gonadal dysfunction, is a unique subset of disorders of sexual development (DSD) that encompasses a wide spectrum of phenotypes ranging from normally virilized males to slightly undervirilized males, ambiguous phenotype, and normal phenotypic females. It presents specific challenges in diagnostic work-up and management. In XY gonadal dysgenesis, the presence of a Y chromosome or Y-chromosome material renders the patient at increased risk for developing gonadal malignancy. No universally accepted guidelines exist for identifying the risk of developing a malignancy or for determining either the timing or necessity of performing a gonadectomy in patients with XY gonadal dysgenesis. Our goal was to evaluate the literature and develop evidence-based medicine guidelines with respect to the diagnostic work-up and management of patients with XY gonadal dysgenesis. We reviewed the published literature and used the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) system when appropriate to grade the evidence and to provide recommendations for the diagnostic work-up, malignancy risk stratification, timing or necessity of gonadectomy, role of gonadal biopsy, and ethical considerations for performing a gonadectomy. Individualized health care is needed for patients with XY gonadal dysgenesis, and the decisions regarding gonadectomy should be tailored to each patient based on the underlying diagnosis and risk of malignancy. Our recommendations, based on the evidence available, add an important component to the diagnostic and management armament of physicians who treat patients with these conditions.

Testicular gonadoblastoma in two pet domestic rabbits (Oryctolagus cuniculus domesticus)

Testicular gonadoblastoma is an uncommon tumor in domestic animals. The current study describes a testicular gonadoblastoma in 2 pet domestic rabbits ( Oryctolagus cuniculus domesticus) based on the histomorphological, immunohistochemical, and ultrastructural characteristics of the tumor. The tumor tissue consisted of discrete tubular structures separated by a fibrous stroma. The tubular structures were composed of large round cells similar in appearance to germ cells in the seminiferous tubules, and small spindle cells with oval or elongated nuclei resembling Sertoli cells. The spindle cells showed peculiar structural patterns arranged in a coronal or follicular pattern, often forming Call–Exner bodies like those in an ovarian granulosa cell tumor. One case was concomitant with seminoma. Immunohistochemistry revealed large round cells that were positive for c-kit and placental alkaline phosphatase, while spindle cells were positive for vimentin and Wilms tumor protein. Ultrastructurally, the spherical eosinophilic material (Call–Exner body) consisted of duplicated basal lamina, and sex cord components surrounded a single degenerative cell similar to a germ cell.

Insights into selected genetic diseases affecting the female reproductive tract and their implication for pathologic evaluation of gynecologic specimens

CONTEXT

Recent advances in the understanding of genetic conditions involving the female genital tract and mechanisms of carcinogenesis in this setting affect patient management and thus necessitate appropriate pathologic evaluation of specimens. In the past, specimens from prophylactic surgery were a rarity; however, they are now more frequently encountered and often require a significant variation from routine processing methods. Pathologists also receive more specimens requiring prospective workup for possible underlying genetic conditions such as microsatellite instability.

OBJECTIVE

To summarize the current knowledge of important genetic and hereditary conditions affecting the female reproductive organs while highlighting the resulting practical significance for specimen handling, "grossing," and microscopic evaluation in gynecologic pathology.

DATA SOURCES

This update is based on a review of recent peer-reviewed literature and the experience with cases at the parent institutions.

CONCLUSIONS

Gynecologic specimens received from patients with certain genetic conditions require specific clinicopathologic knowledge for appropriate pathologic examination. The evaluation of prophylactic resection specimens focuses on the detection of cancer precursors and possible occult disease, which may require a more thorough and detailed examination than an obvious carcinoma. Standardized protocols for handling prophylactic gynecologic resection specimens are available for some, but not all, types of specimens. The prospective evaluation of a gynecologic pathology specimen for potential genetic conditions such as microsatellite instability is a very recent subject. Currently, well-established protocols are not available; however, as clinical and prognostic significance has become more clearly elucidated, familiarity with this evolving field is increasingly important to properly assess these pathologic specimens.

Clinical pathologic correlation: primary amenorrhoea and bilateral adnexal tumors

A case of bilateral gonadoblastoma in 46,XY gonadal dysgenesis is presented and discussed by both clinician and pathologist, in this traditional clinico-pathologic conference. The discussion includes the differential diagnoses of primary amenorrhoea.

Ovarian gonadoblastoma with mixed germ cell tumor in a woman with 46, XX karyotype and successful pregnancies

An extremely rare case of unilateral gonadoblastoma with mixed germ cell tumor arising in the ovary of a 27-year-old woman with 46,XX karyotype and two successful pregnancies is reported. The mixed germ cell tumor was composed of choriocarcinoma, embryonal carcinoma, yolk sac tumor, immature teratoma and dysgerminoma. The patient has been well, without evidence of disease for over 10 years since her first surgery and adjuvant chemotherapy.

Ki-A10, a germ cell nuclear antigen retained in a subset of germ cell-derived tumors

Monoclonal antibody Ki-A10 recognizes a nuclear antigen of 25 and 22 kd apparent molecular mass, which is abundantly expressed by immature gonocytes, spermatogonia, and spermatocytes, whereas it is absent in spermatids, spermatozoa, oocytes, and normal somatic tissues. In a broad spectrum of human cancers the antibody showed no reactivity except for a small subset of malignant lymphomas. Because of this restricted expression pattern, we examined 173 germ cell tumors and 18 sex cord stromal tumors immunohistochemically to assess the distribution of the Ki-A10 antigen. A strongly positive reaction was found in classic seminomas, dysgerminomas, spermatocytic seminomas, and the germ cell component of gonadoblastomas. Yolk sac tumors presented a heterogeneous reactivity pattern ranging from overall positivity to complete lack of antigen expression, and in three of eight choriocarcinomas, a few clusters of cytotrophoblast cells were strongly labeled. All other tumors, including Leydig and Sertoli cell tumors as well as placental tissue, were negative. Our findings suggest that specific germ cell antigens can be retained in germ cell tumors along particular differentiation pathways. Ki-A10 is the first marker that consistently labels spermatocytic seminoma, further confirming its germ cell origin and suggesting a close relationship to classic seminoma. The antibody may serve for diagnostic purposes and promises new insights into the process of germ cell differentiation and the development of germ cell-derived neoplasia.

DNA content of ovarian immature teratomas and malignant germ cell tumors

OBJECTIVE

Ovarian germ cell tumors (GCT) show greater histologic and biologic heterogeneity than their testicular counterparts and remain poorly understood. Ploidy analysis was performed on ovarian GCT registered on Pediatric Oncology Group germ cell tumor protocols 9048 and 9049 to distinguish biologically distinct subsets of immature teratomas and malignant ovarian germ cell tumors.

METHODS

Tumors from 22 patients (mean age 12 years) were analyzed and classified according to the submitting diagnosis; when pure samples of different histologic subtypes within a single tumor were possible, these were analyzed separately. Archival tissue was disaggregated and Feulgen stained; DNA index (DI) was determined by static image analysis utilizing internal normal cells as diploid controls.

RESULTS

26 histologic subtypes from 22 patients were analyzed. The tumors of 18 patients were composed of a single histologic subtype according to the submitting institution, including 6 dysgerminomas, 8 immature teratomas (IT), and 4 endodermal sinus tumors (EST). Two tumors contained both IT and EST components that were separately analyzed. Two tumors were classified as mixed germ cell tumors; 1 showed multiple intermingling subtypes unable to be separately analyzed and the second showed three histologic subtypes separately analyzed (IT, EST, embryonal carcinoma). From a total of 15 malignant histologic GCT subtypes in 14 patients, all but 2 demonstrated a DI of 1.4-2.4 (mean 1.85). Two diploid malignant GCT (1 EST, 1 dysgerminoma) were both associated with gonadoblastoma. Overall, 11 IT subtypes were analyzed and 9 were diploid (2 grade 1, 5 grade 2, and 2 grade 3). Two tumors originally submitted and classified as pure IT (grades 2 and 3) were aneuploid with a dominant diploid and a secondary aneuploid peak (both DI 1.7). On central review, both of these tumors demonstrated the presence of subtle patterns of EST that were unrecognized by the submitting institution and were much too small for separate analysis. Analysis of the 3 patients containing sufficient IT and EST to be separately analyzed all showed a diploid IT component and an aneuploid EST component.

CONCLUSIONS

Analysis of ploidy data suggests that polyploidization is a consistent finding in malignant ovarian GCT arising in normal patients, similar to the data for adult testicular GCT. Immature teratomas in this pediatric population, however, are most commonly diploid, regardless of grade. The development of EST within an IT is associated with the development of an aneuploid clone. Therefore, the finding of such a clone in an IT may be of diagnostic utility, as EST may be difficult to recognize. Last, the development of a malignant GCT in patients with gonadal dysgenesis may be pathogenetically different from those arising in normal patients, in that polyploidization is not required.

Germ cell tumours in a brother and sister

In familial germ cell tumour cases, a normal chromosomal karyotype pattern is rare. We report the findings of germ cell tumours in two siblings with a normal chromosomal karyotype. One of these patients had dysgerminoma in the right ovary and was treated successfully for this. At present, she is 23 years old and has two daughters. The other patient is a 15-year-old boy, who is the brother of the first patient and has mediastinal embryonal carcinoma. Although ultrasonography of the testes showed irregularity in the shape and non-homogeneity of the parenchyma, histopathological examination was found to be normal at the time of diagnosis. At present, he is doing well and his chemotherapy is continuing. Both of them have a normal chromosomal karyotype, 46, XX and 46, XY, respectively. We suggest that children who have a sibling with germ cell tumour should be carefully assessed for development of another germ cell tumour.

Occurrence of seminoma and dysgerminoma in father and daughter

We report the occurrence of seminoma and dysgerminoma in father and daughter. Both tumors exhibited similar histological appearances. This case supports the concept of a common genetic basis for these germ cell tumors.

Mixed gonadal dysgenesis: endogenous hormonal effects in the endometrium and histogenesis of germinoma

The clinicopathologic features of two patients with mixed gonadal dysgenesis are presented, with specific reference to the relationship between endogenous sex hormones and the endometrium and the development of neoplastic disease. One patient, whose immature gonad contained granulosa cells and theca cells, had elevated serum estrogen levels and an endometrium with frequent ciliated metaplasia and squamous metaplasia. Another patient had elevated serum testosterone levels and atrophic endometrium. Both had gonadal tumors, more specifically, germinomas, which contained many calcified nodules within the tumor. These findings suggest that these germinomas arose from a gonadoblastoma.

Malignant germ cell tumours in two siblings

Familial germ cell tumours are well recognised in kinship with gonadal dysgenesis, but their occurrence in siblings with normal chromosomes is rare. We report two sisters who presented within a 4 month period with malignant ovarian germ cell tumours; one a dysgerminoma and the other a mixed tumour with marked choriocarcinomatous elements. Both children had a normal female constitutional karyotype and normal phenotype.

Carcinoma in situ, gonadoblastoma, and early invasive neoplasia in a nine-year-old girl with 46,XY gonadal dysgenesis

Carcinoma in situ (CIS), gonadoblastoma, and early invasive neoplasia were detected in the dysgenetic gonad of a nine-year-old girl with 46,XY gonadal dysgenesis. A close relationship between the three neoplastic components was supported by morphological and immunohistochemical studies. Our findings support the hypothesis that all germ cell tumours, including gonadoblastomas, originate from CIS germ cells formed during early embryonic life.

The importance of determining karyotype in premenarchal females with gonadal dysgerminoma: two case reports

Gonadal dysgerminomas developed in two girls, aged 12 and 15 years. Both were initially treated with conservative unilateral gonadectomy. Forty-six, XY gonadal dysgenesis was not suspected in either patient due to the normal appearance of the contralateral gonads and internal female genital organs. One died of a second germ cell malignancy which developed in the contralateral ovary 9½ years later. The diagnosis of 46, XY gonadal dysgenesis was established by karyotype in both patients. Although conservative surgical management is desirable for nulliparous women with unilateral dysgerminomas, the presence of 46, XY gonadal dysgenesis should be suspected in all premenarchal girls with ovarian germ cell malignancies. If karyotyping reveals the presence of an Y chromosome, bilateral gonadectomy is indicated because of the risk that another neoplasm may develop in the contralateral ovary.

Gonadoblastoma in an anatomically normal man: a case report and literature review

Gonadoblastoma, a rare gonadal neoplasm, presents most frequently in phenotypic female or phenotypically male patients with dysgenetic gonads or undescended testes. To date, only 2 cases of gonadoblastoma have been reported in anatomically normal male patients with scrotal testes. Both of these patients presented with testicular masses and germ cell tumors. We report a case of a genotypically and phenotypically normal, fertile man with descended testes who on evaluation for chronic orchialgia had a gonadoblastoma unaccompanied by a germ cell neoplasm. The tumor was nonpalpable and was initially discovered on scrotal ultrasound.

Germ cell tumors of the ovary: the experience of the National Cancer Institute of Milan. I. Dysgerminoma

The experience of the Istituto Nazionale Tumori of Milan on dysgerminoma is presented. Between 1970 and December of 1982, 25 patients were treated with a unique protocol which considered surgery and radiotherapy with different schedules according to the extension of the disease. With this treatment protocol all 13 patients at Stage I were alive and free of disease with a median follow-up of 77 months. Of 12 patients at Stage III (10 retroperitoneal and 2 retroperitoneal and peritoneal) 4 relapsed. The 5-year relapse-free survival of Stage III patients was 61.4% and the overall survival 89.5%. Amenorrhea due to radiation dose absorbed by the contralateral shielded ovary was found in 7.7%. The excellent results in Stage I patients were balanced by the unsatisfactory results in Stage III patients. A more aggressive treatment and the knowledge of other prognostic factors seem necessary.

Chemotherapeutic complete remission in patients with metastatic ovarian dysgerminoma. Potential for cure and preservation of reproductive capacity

Two patients with metastatic dysgerminoma of the ovary were treated with a combination of etoposide, bleomycin, and cisplatin at The University of Texas M.D. Anderson Hospital and Tumor Institute at Houston. Both patients achieved a complete remission. Patient 1 developed a massive recurrence in the para-aortic lymph nodes 21 months after diagnosis and treatment with right salpingo-oophorectomy alone. She received four cycles of chemotherapy and is free of disease 21 months from the start of chemotherapy. Patient 2 had Stage III dysgerminoma and a lymphangiogram positive for tumor in the para-aortic lymph nodes. After surgery she received three cycles of chemotherapy and is free of disease 20 months from the start of chemotherapy. Both complete remissions were documented with second-look laparotomy. Chemotherapy may be an alternative to radiotherapy for the treatment of metastatic dysgerminoma and should also be considered for selected patients with Stage I disease. A literature review further supports the conclusion that additional clinical trials might expand the indications for chemotherapy in patients with this disease.

Invasive dysgerminoma in a girl with 45,X/46,X; mar mosaicism

We report a 16-year-old girl with features of Turner's syndrome from whom an invasive dysgerminoma was removed. Cytotoxic drugs were given for the next 12 months. Mosaicism of two karyotypes (45,X/46,X; mar) was found in various tissues. The literature is reviewed with special regard to cytogenetic findings and prognosis of malignant growth and differentiation of dysgenetic gonads.

Natural history of dysgerminoma

Data on 56 patients with pure dysgerminoma are discussed. Forty-nine patients were classified as having new disease or were to have reassessment of disease, and seven cases were to be restaged (one with and six without clinical evidence of disease). Of new and reassessment cases, 44 patients underwent lymphography, 16 underwent peritoneoscopy with diaphragmatic inspection and 30 had peritoneal cytologic testing performed. Positive lymphography resulted in restaging in 31.6% of patients. Diaphragmatic inspection was always negative. Peritoneal cytologic testing was positive for malignant cells in three patients and worsened the stage in one. Pathologic staging of disease was as follows: Stage IA, 24; Stage IB, one Stage IC, one; Stage III peritoneal disease, two. Stage III retroperitoneal disease, 12; Stage III peritoneal and retroperitoneal disease; four. The 5-year relapse-free survival rates were 91% in patients with pathologic Stages IA, IB, and IC; 74% in those with Stage III retroperitoneal disease, and 24% in patients with Stage III peritoneal disease or peritoneal plus retroperitoneal disease. The results indicate that the prognosis is excellent for patients with Stage I and Stage III retroperitoneal disease whereas peritoneal involvement is associated with a poor prognosis.

Ovarian neoplasms resembling sex cord tumors with annular tubules

A clinicopathologic analysis of 6 patients with ovarian neoplasms resembling sex cord tumors with annular tubules (SCTAT) was performed. The patients' ages ranged from 20 to 43 years. Most had signs and symptoms of estrogenic hormonal imbalance; none had evidence of the Peutz-Jeghers syndrome. The tumors were unilateral in all cases and, except for one lesion of microscopic size, were from 3 to 18 cm in greatest dimension. One tumor was combined with a germinoma. Surgery alone was the primary mode of therapy in all cases. Lymph nodal metastases developed in 2 patients 7.5 and 10.5 years postoperatively. They are the first documented examples of malignant behavior recorded. At the time of last known contact, all patients were alive without demonstrable tumor for intervals from 1.5 to 16.3 years (mean, 7.8 years) after initial treatment. While the annular patterns of growth have often been attributed to Sertoli cell differentiation, histologic and cytologic features of granulosa cell tumor were observed in areas of the primary tumors and in metastatic lesions. True lumen formation was never observed in the so-called tubules. We propose classification of SCTAT as a distinctive annular and membranous variant of granulosa cell tumor in view of the morphologic similarities and comparable clinical behavior of these two neoplasms.