Paradoxical response of a pineal immature teratoma to combination chemotherapy

Primary and Recurrent Growing Teratoma Syndrome in Central Nervous System Nongerminomatous Germ Cell Tumors: Case Series and Review of the Literature

BACKGROUND

The term "growing teratoma syndrome (GTS)" has been used as follows: patients with germ cell tumor (GCT) who present with enlarging original/metastatic masses during or after appropriate systemic chemotherapy despite normalized serum markers. In other words, the definition of the term GTS is not fully established. We analyzed and reviewed our case series regarding GTS that developed after the treatment of central nervous system (CNS) nongerminoatous germ cell tumors (NGGCTs).

METHODS

Our institutional review board approved this retrospective study. Between 2003 and 2018, we treated 16 patients (16 males; age ranging from 5.4 to 51.9 years, median 13.8) with CNS-NGGCT at our institution. We reviewed those patients and also reviewed the literature about GTS of CNS. We defined primary GTS (p-GTS) as the enlargement of cyst size and/or solid tumor occurred during treatment in the absence of marker elevation, and recurrent GTS (r-GTS) as the enlargement of teratoma after complete response of initial tumors.

RESULTS

Among 16 patients with CNS-NGGCT, we surgically confirmed mature/immature teratoma components in 15 patients. Two patients underwent surgical removal of tumor before neoadjuvant therapy, and among the rest 14 patients, 6 developed p-GTS, and 2 patients underwent salvage surgery during chemo-/chemoradiotherapy. Those with histologic diagnosis of immature teratoma during salvage surgery had a shorter interval from the initiation of chemoradiotherapy compared with mature teratoma (P < 0.05). One patient developed r-GTS. In the literature review, most of the p-GTS consisted of enlargement with the multicystic component. Histologic diagnosis of immature teratoma during salvage surgery was observed in earlier stages of chemoradiotherapy (P < 0.05, log-rank test). Previous history of p-GTS might be a risk factor of r-GTS.

CONCLUSIONS

The incidence of p-GTS, enlargement of the cystic component during treatment, is not rare. Physicians need to be aware of this important phenomenon.

The pathogenesis of intracranial growing teratoma syndrome: proliferation of tumor cells or formation of multiple expanding cysts? Two case reports and review of the literature

PURPOSE

Growing teratoma syndrome (GTS) is a rare clinical phenomenon defined as the paradoxical growth of mature teratoma components during or after chemotherapy. The mechanism of this phenomenon is not well understood. We present two cases of pineal mixed germ cell tumors that exhibited the similar course to GTS and speculate its pathogenesis.

CASE REPORT

The first case was accompanied by slightly elevated alpha-fetoprotein (8.8 ng/ml; normal <6.6 ng/ml). The tumor rapidly grew from 1.5 to 2.7 cm in diameter within 4 weeks. Despite this rapid preoperative growth, thorough pathological investigation found only mature teratoma components along with multiple micro- and macro-cysts. The other case was diagnosed as a pure germinoma based on biopsy and serological examinations. During three courses of chemotherapy, this tumor presented a honeycomb-like appearance on magnetic resonance (MR) images and an exceptionally rapid enlargement. Second-look surgery confirmed the histological diagnosis of a mature teratoma. In both cases, meticulous pathological examination of all whole tumor sections revealed no malignant histological features, and the MIB-1 labeling indices were too low to account for the extremely rapid tumor growth. Instead, both MR images and histological findings demonstrated a predominant formation of multiple cysts.

CONCLUSION

We speculate that this paradoxical growth might not be tumorous proliferation but instead the formation and expansion of multiple cysts inside mature teratoma components and that the presence or absence of growth might be a subsidiary phenomenon. Our hypothesis appears consistent with the characteristic radiological findings of GTS reported in the literature.

Paradoxical and bidirectional drug effects

A paradoxical drug reaction constitutes an outcome that is opposite from the outcome that would be expected from the drug's known actions. There are three types: 1. A paradoxical response in a condition for which the drug is being explicitly prescribed. 2. Paradoxical precipitation of a condition for which the drug is indicated, when the drug is being used for an alternative indication. 3. Effects that are paradoxical in relation to an aspect of the pharmacology of the drug but unrelated to the usual indication. In bidirectional drug reactions, a drug may produce opposite effects, either in the same or different individuals, the effects usually being different from the expected beneficial effect. Paradoxical and bidirectional drug effects can sometimes be harnessed for benefit; some may be adverse. Such reactions arise in a wide variety of drug classes. Some are common; others are reported in single case reports. Paradoxical effects are often adverse, since they are opposite the direction of the expected effect. They may complicate the assessment of adverse drug reactions, pharmacovigilance, and clinical management. Bidirectional effects may be clinically useful or adverse. From a clinical toxicological perspective, altered pharmacokinetics or pharmacodynamics in overdose may exacerbate paradoxical and bidirectional effects. Certain antidotes have paradoxical attributes, complicating management. Apparent clinical paradoxical or bidirectional effects and reactions ensue when conflicts arise at different levels in self-regulating biological systems, as complexity increases from subcellular components, such as receptors, to cells, tissues, organs, and the whole individual. These may be incompletely understood. Mechanisms of such effects include different actions at the same receptor, owing to changes with time and downstream effects; stereochemical effects; multiple receptor targets with or without associated temporal effects; antibody-mediated reactions; three-dimensional architectural constraints; pharmacokinetic competing compartment effects; disruption and non-linear effects in oscillating systems, systemic overcompensation, and other higher-level feedback mechanisms and feedback response loops at multiple levels. Here we review and provide a compendium of multiple class effects and individual reactions, relevant mechanisms, and specific clinical toxicological considerations of antibiotics, immune modulators, antineoplastic drugs, and cardiovascular, CNS, dermal, endocrine, musculoskeletal, gastrointestinal, haematological, respiratory, and psychotropic agents.

What's growing on? The growing teratoma syndrome

BACKGROUND

The growing teratoma syndrome (GTS) consists of a mature teratoma paradoxically enlarging during or after chemotherapy for malignant nongerminomatous germ cell tumors.

METHODS AND RESULTS

We report two cases of GTS occurring in association with NSGCT of the pineal gland. Although an unusual event, clinicians and radiologists should be aware of its natural history.

CONCLUSIONS

When normalized tumor markers after chemotherapy are associated with imaging features of a growing mass, the hypothesis of GTS must be taken in consideration. When early diagnosed, GTS can be managed surgically with good results.

Intracranial growing teratoma syndrome: clinical characteristics and treatment strategy

This study evaluated the clinical and radiological characteristics, as well as the treatment outcomes, for the rare phenomenon known as intracranial growing teratoma syndrome (iGTS). One hundred seventy patients diagnosed with intracranial germ cell tumours (GCT) between 1997 and 2008 were enrolled in this retrospective analysis. Thorough reviews of medical records, brain magnetic resonance images (MRI), pathological findings and tumour markers [alpha-fetoprotein (αFP) and beta-human chorionic gonadotropin (βHCG)] were performed to identify the incidence of iGTS cases and to clarify their clinical characteristics. Eleven out of the 170 intracranial GCT patients (6.5%) were identified as having iGTS. All instances of iGTS originated from non-germinomatous GCT (NGGCT), with incidence rate of 21% (11/52). Six iGTS cases developed from mixed GCTs, four from immature teratomas (ITs) and one from yolk sac tumour. All 11 iGTS patients showed honeycomb-shaped multi-cystic growth patterns on MRI, which is a typical characteristic of iGTS. Surgical excision was performed in all patients, and complete excision was possible in nine patients. Eight of them are alive with no evidence of recurrence; however, two patients who had residual masses died owing to progression of iGTS. Early recognition and suspicion of iGTS, during or after adjuvant therapy of NGGCT, is crucial to ensure that surgical intervention can be performed in a timely manner. Early radical excision may be the treatment of choice for better iGTS prognosis.

Intracranial growing teratoma syndrome following radiotherapy--an unusually fulminant course

INTRODUCTION

Residual radiologically progressive masses following multimodality treatment of malignant mixed intracranial germ cell tumors are described. Often these enlarge, and this is called the growing teratoma syndrome. A similar phenomenon during radiotherapy alone has not been described.

SUBJECTS AND METHODS

A 5-year old boy presented with features of raised intracranial pressure. Imaging revealed a posterior third ventricular mass, which was biopsied endoscopically.

RESULTS

A review of the scanty tissue was suggestive of a pineal parenchymal tumor, and hence radiation was planned. After just ten fractions, he developed rapid neurological deterioration. Repeat imaging raised a possibility of a teratomatous tumor. He underwent emergency excision. However, he had a stormy postoperative course and succumbed to deep venous infarction. Histology revealed a purely mature teratoma.

CONCLUSION

Though a growing teratoma syndrome has been described following chemotherapy, no such report while on radiation exists. Ours could be the first such reported case. We discuss the possible mechanisms with a review of the literature.

Treatment and outcomes of primary intracranial teratoma

PURPOSE

Until recently, postoperative adjuvant treatment for intracranial teratomas has remained controversial because of the rarity of the tumors and the heterogeneity of histologic types. To define optimal therapy modalities, we retrospectively analyzed the treatment of patients with intracranial teratomas.

METHODS

Between 1979 and 2007, 31 patients with intracranial teratomas were treated at our institution. The median age of the 31 patients was 14.8 years. The median follow-up time was 72.7 months (range 11 approximately 291 months). Perioperative radiochemotherapy was done in 19 patients. Proper chemotherapy regimens were followed, such as PE (cisplatin and VP-16), PVB (cisplatin, VP-16, and bleomycin), ICE (carboplatin, VP-16, and ifosfamide), and NGGCT (etoposide, carboplatin, bleomycin, and cyclophosphamide with mesna).

RESULTS

Eight patients experienced recurrence, and a second operation was carried out in six patients. Fifteen patients survived for more than 5 years without recurrence, irrespective of having received adjuvant therapies. The 5-year survival rate of the 31 patients was 74%.

CONCLUSION

Treatment of intracranial teratomas is very difficult because of the heterogeneity of the tumor cells from totipotent origins. Accurate histological diagnosis of teratoma subtypes is the most important factor for adequate treatment, and proper therapeutic protocols are needed to cure teratomas.

Intracranial teratomas in children: the role and timing of surgical removal

OBJECT

In this study, the authors report their experience with the surgical treatment of intracranial teratomas with an emphasis on the indications for delayed resection after oncological treatment.

METHODS

The authors retrospectively reviewed the cases of 14 children with intracranial teratomas. The mean age at diagnosis was 10.5 years (range 2 days-18 years), and 11 patients were male. The final histological analysis revealed pure mature teratoma in 5 cases, mixed teratoma with germinoma in 3 cases, and nongerminomatous malignant germ cell tumor in 6 cases. Thirteen patients underwent tumor resection, and these patients were divided into 2 subgroups according to the timing of surgery. In Group A, 10 patients underwent resection as the primary treatment because no tumor markers were detected in 4 patients, a teratomatous component was revealed on biopsy sampling in 3 patients, and a large tumor volume in 3 patients. In Group B, 3 patients underwent removal of residual pure mature teratoma after oncological treatment.

RESULTS

Seven of the 8 patients (87.5%) with pure mature teratomas or with mixed teratoma and germinoma are currently alive (mean follow-up of 9 years); the eighth patient died of postoperative meningitis. Two of the 6 patients (33%) with mixed nongerminomatous malignant germ cell tumors died of tumor progression regardless of the timing of surgery.

CONCLUSIONS

The results of this study support the belief that microsurgical removal is the only effective treatment for intracranial teratomas. Surgery may be performed as the primary therapy when there is evidence of a noninvasive teratoma, and as a secondary therapy if there is only a partial response to neoadjuvant therapy or if progression is observed in mixed malignant germ cell tumors.

Bifocal mixed germ-cell tumor with growing teratoma syndrome and metachronous mature metastases: case report

The authors report the case of a 16-year-old male who presented with a bifocal diencephalic tumor arising both in the neurohypophysis and the pineal region with hydrocephalus. The histological diagnosis obtained during endoscopic ventriculocisternostomy was germinoma. MRI revealed an increase of the neoplasm during chemotherapy with recurrent obstructive hydrocephalus. A new ventriculostomy was performed followed by total surgical resection. The final histopathological analysis demonstrated an immature teratoma. Subsequently, this patient developed metachronous cystic metastases in the cerebello-pontine angles, which were resected and identified as mature teratoma, then we observed a lesion of the brachium conjunctivum which stayed stable after 29 consecutive months. The patient is alive and feels well 6 years after the initial diagnosis and 5 years after the first metastasis. To our knowledge, this is the fifth case of the growing teratoma syndrome located in the brain but the first case with simultaneously bifocal location and infratentorial disseminated metastasis. Obviously surgical removal is the treatment of reference for teratomas. Metastases of teratoma can be mature and may be amenable to surgery with a favorable outcome. Primary intracranial germ-cell tumors (CGT) arise in the midline of the brain and are located in the diencephalon. The peak incidence occurs during the second decade of life. Germ cell tumor (CGT) includes germinomas and non-germinomatous tumors, mature and immature teratomas account for 19.6 % [1]. Curiously, teratomas are able to grow during the first weeks of chemotherapy while serum markers remain normal. This situation was originally described and designed as "the growing teratoma syndroma" (GTS) in primary testis tumors by Logothetis in 1982 [2]. Here we report the rare occurrence of a GTS in a teenager who presented metachronous cystic metastases located in posterior fossa which were histologically mature.

The Growing Teratoma Syndrome after Subtotal Resection of an Intracranial Nongerminomatous Germ Cell Tumor in an Adult: Case Report

OBJECTIVE AND IMPORTANCE:

We report a rare complication after resection of a recurrent intracranial nongerminomatous germ cell tumor in an adult. The growing teratoma syndrome, as originally described with pediatric germ cell neoplasms, represents tumor recurrence, often cystic, that sometimes is observed after partial response to multimodality therapy and despite decreasing tumor serum markers. The enlarging tumor consists of elements of a mature teratoma that presumably are refractory to chemotherapy or radiation. To our knowledge, this is only the third case of the growing teratoma syndrome in an adult patient with nongerminomatous germ cell tumor.

CLINICAL PRESENTATION:

A 26-year-old man had signs of recurrent obstructive hydrocephalus 6 months after multimodality treatment of a diencephalic yolk sac tumor and endoscopic third ventriculostomy. Imaging studies revealed large multilocular cystic masses originating from the tumor bed and partially obstructing the ventriculostomy.

INTERVENTION:

Near total tumor resection and fenestration was performed. Histopathological analysis demonstrated a mature teratoma.

CONCLUSION:

Surgical resection, if feasible, is the treatment of choice for the growing teratoma syndrome to establish the correct diagnosis and prevent complications.

Growing teratoma syndrome in a patient with a non-germinomatous germ cell tumor in the neurohypophysis--case report

A 16-year-old woman presented with a non-germinomatous germ cell tumor in the neurohypophysis manifesting as progressive visual disturbance, amenorrhea, hydrodipsia, and polyuria. Her serum alpha-fetoprotein and human chorionic gonadotropin levels were elevated. She experienced sudden, rapid visual deterioration and underwent emergency partial tumor removal to decompress the optic nerves. Her vision subsequently improved. Histological examination of the surgical specimens confirmed immature teratoma. She received chemotherapy (ifosphamide 900 mg/m2, cisplatin 20 mg/m2, etoposide 60 mg/m2) for 5 consecutive days. Although the tumor marker levels decreased remarkably, her vision again declined rapidly due to enlargement of the tumor after the first course of chemotherapy. A second radical operation resulted in vision improvement. The tumor specimen showed only mature teratoma elements. This phenomenon, called the growing teratoma syndrome, is very rare in intracranial non-germinomatous germ cell tumors.

Management of malignant pineal germ cell tumors with residual mature teratoma

OBJECTIVE

The treatment of intracranial mixed germ cell tumors presents a unique challenge, since eradication of malignant tumor by radiation and/or chemotherapy may spare the benign tumor component. We reviewed our surgical experience with residual malignant pineal germ cell tumors after neoadjuvant therapy.

METHODS

Between 1987 and 1997, 16 patients with malignant intracranial germ cell tumors were treated at the Mayo Clinic with a protocol of neoadjuvant chemotherapy and radiation therapy. After the diagnosis was confirmed by histopathological examination, all patients were treated with four cycles of etoposide and cisplatin as well as external beam radiation therapy (range, 3030-5940 cGy). Six patients had an incomplete response to therapy, as demonstrated by observation of residual tumor on magnetic resonance imaging scans. Initial pathology in these six patients was germinoma in four and combinations of yolk sac tumor, embryonal carcinoma, malignant teratoma, and germinoma in two. Two patients had synchronous pineal and suprasellar tumors, with leptomeningeal dissemination. Tumor markers were elevated in four of the six patients at presentation.

RESULTS

All patients with residual pineal tumors underwent surgical resection via an infratentorial, supracerebellar approach. Pathological examination revealed mature teratoma in five patients and amorphous debris in one patient. No patient had recurrent malignancy. Significant neurological morbidity occurred in one patient, with no mortality. At a mean follow-up of 23 months, no recurrence on magnetic resonance imaging has been documented.

CONCLUSION

Residual pineal tumor occurring after treatment of malignant intracranial germ cell tumor with neoadjuvant therapy is likely to be mature teratoma. Operative resection of these benign recurrences is safe and effective.

Teratomas of the central nervous system: treatment considerations based on 34 cases

OBJECT

The optimum clinical management of central nervous system (CNS) teratomas, particularly postsurgical adjuvant therapy, is still unclear, partly as a result of the tumors' low incidence. In this study the authors analyze 34 cases of CNS teratomas so that they may adequately indicate management of these lesions.

METHODS

The median age of the 34 patients was 13 years. Twenty-seven patients treated between 1970 and 1991 were retrospectively reviewed. Four of these 27 patients died as a result of radical surgery; each of them had a teratoma involving the hypothalamus. After initial treatment, which included radiation therapy, 20 patients (48%) had died. In all seven cases of mature teratomas there was no recurrence. In two cases of immature teratomas in which there was complete surgical resection there was recurrence; however, salvage therapies were effective. Seven of eight patients with highly malignant teratomas died; for these patients salvage therapies, including repeated radiation and chemotherapy, failed. Seven patients who presented with CNS teratomas between 1992 and 1996 received adjuvant chemotherapy and radiation therapy according to a prospective study protocol. All seven patients were free from recurrence with a 70 to 100% Karnofsky Performance Scale score at a median follow-up period of 41 months. Patients with CNS teratomas rarely responded completely to chemotherapy or radiation therapy; an effective adjuvant therapy produced a partial response at best.

CONCLUSIONS

Because teratomas show various responses to adjuvant therapy, a misdiagnosis of their histological subtype will lead to inadequate therapy. A diverse therapeutic protocol based on histological diagnosis is necessary to plan appropriate management. Treatment recommendations are discussed in detail in the article.

The growing teratoma syndrome in a nongerminomatous germ cell tumor of the pineal gland: a case report and review

BACKGROUND

The growing teratoma syndrome is a recognized complication of metastatic nonseminomatous germ cell tumors of the testis and is managed surgically. It may also occur in intracranial nongerminomatous germ cell tumors.

METHODS

The authors performed an English language computer search using the EMBASE data base (from January 1980 to December 1996) for pineal tumors, read all abstracts, and then selected all articles pertaining to germ cell tumors at this site.

RESULTS

The case history of a 19-year-old male who presented with a pineal nongerminomatous germ cell tumor, which was treated with chemotherapy, is reported. Despite normalization of raised tumor marker levels, the pineal mass enlarged during chemotherapy. This was excised and proved to be a mature teratoma. A review of the literature regarding this complication of intracranial germ cell tumors is also presented.

CONCLUSIONS

The authors believe this to be the first reported case of growing teratoma syndrome in the pineal gland of an adult patient, two previously reported cases occurred in children. The authors conclude that the pineal gland is an unusual but important site in which to recognize the growing teratoma syndrome.