Alpha-fetoprotein and endodermal sinus tumor of the ovary

Seven tumor markers in benign and malignant germ cell tumors of the ovary

Seven tumor markers were analyzed clinically in 135 patients with germ cell tumors of the ovary who were treated in Tokai Ovarian Tumor Study Group, an association comprising Nagoya University and its affiliated hospitals, between January 1979 and September 1990. Positive rate of AFP was 100% (36/36) in yolk sac tumor, 61.9% (13/21) in immature teratoma, and 11.8% (2/17) in dysgerminoma, but there were no positive cases of mature cystic teratoma with malignant transformation (0/7) and mature cystic teratoma (0/31). Positive rate of CA125 was over 50% in all tumor types except mature cystic teratoma, which showed a positive rate of 23.7%. CA125 was useful for the screening of malignant germ cell tumors. CA19-9 showed a high positive rate in teratomatous tumors, which were immature teratoma, mature cystic teratoma with malignant transformation, and mature cystic teratoma. Dysgerminoma and yolk sac tumor, especially dysgerminoma, had a high positive rate of LDH. TPA and CEA were not considered useful tumor markers for germ cell tumors of the ovary.

Alpha-fetoprotein in malignant germ cell tumors of the ovary

To investigate the clinical significance of alpha-Fetoprotein (AFP) in malignant germ cell tumors of the ovary, we studied 46 patients who were treated by the Tokai Ovarian Tumor Study Group. The 46 patients had the following tumors: immature teratoma (IT), 17 cases; endodermal sinus tumor (EST), 16 cases; mixed germ cell tumor containing EST, 11 cases; embryonal carcinoma, 1 case; polyembryoma, 1 case. In all 29 non-IT cases, AFP was positive, and in 27 cases (93%) the level was above 1000 ng/ml. In 11 of 17 cases of IT (64.7%), AFP levels were elevated and in 1 case the level was above 1000 ng/ml. Elevation of the AFP level above 1000 ng/ml suggested the presence of EST. AFP levels were monitored in 27 of 29 cases without IT during treatment and follow-up. It was found that AFP levels should be monitored closely for at least 1 year after induction of remission. No recurrence was observed when AFP continued to be negative longer than 1 year. The mean interval to clinical recurrence from the reelevation of AFP was 4 months (1.4-9 months). An increase in the AFP to a positive level, even without clinical signs of recurrence, should be regarded as a recurrence. AFP was found to be a useful tumor marker for the diagnosis and management of malignant germ cell tumors of the ovary.

An improved sensitive assay method for the heterogeneity of alpha-foetoprotein: possible application for early differential diagnosis

A combination of lectin-affinity electrophoresis and antibody-affinity blotting was used for the qualitative determination of molecular species of alpha-foetoprotein. Concanavalin A and erythrophytohaemagglutinin were used as lectins. This method was able to quickly discriminate between the molecular species of alpha-foetoprotein of recurrent ovarian yolk sac tumour and those of non-malignant liver diseases and cord sera at term, using only 3 microliters of sera containing 200 micrograms/l of alpha-foetoprotein. The results indicate that this assay method might be useful for the differential diagnosis of recurrent yolk sac tumour from drug- or blood transfusion-induced liver diseases and for the monitoring of the serum alpha-foetoprotein level of patients with yolk sac tumour producing less than 200 micrograms/l of alpha-foetoprotein.

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.

Basement membrane structures in tumors of the ovary

The location and amount of the basement membrane (BM) components collagen IV and laminin were studied in ovarian epithelial, sex cord-stromal and germ cell tumors. BM structures were found in the epithelial stromal interface of benign surface epithelial tumors and, though discontinuous, around well-differentiated tumor islets, being less well developed in invasive undifferentiated neoplasms. The stromal components in Müllerian mixed tumors had less distinct BM structures, a finding useful for the classification of these neoplasms. Thecomas and fibromas had scanty collagen IV and laminin; granulosa cell tumors contained large amounts of BM material. A fine diffuse BM-positive pattern occurred in dysgerminomas and endodermal sinus tumors; BM structures in cystic teratomas were distinct. Collagen IV and laminin were well-developed in benign and slow-growing tumors with epithelial components and in their metastases, but less distinct in stromal tumors and highly malignant undifferentiated tumors, showing the usefulness of this method for the clinical and biological classification of such tumors.

Vinblastine, bleomycin, and cisplatin in malignant germ cell tumors of the ovary

Fourteen patients with malignant ovarian germ cell tumors were treated with vinblastine, bleomycin, and cisplatin. A complete clinical response was achieved in all 14 patients; however, 1 patient had small macroscopic disease present at second-look laparotomy. One patient died of bleomycin pulmonary toxicity. The remaining 13 patients are alive and free of disease from 20 months to 8 years and 8 months after initial diagnosis. Serum alpha-fetoprotein and beta-human chorionic gonadotropin levels were monitored in all patients and were found to be reliable indicators of response to treatment and disease status. The uninvolved ovary was preserved in seven patients without compromising the response to treatment, and one patient subsequently became pregnant. Vinblastine, bleomycin, and cisplatin chemotherapy appears to be a safe, effective combination and is recommended as the primary treatment of choice in the management of patients with malignant ovarian germ cell tumors.

Modified VAB-3 combination chemotherapy of advanced and recurrent endodermal sinus tumors of the ovary

Three patients with advanced and recurrent endodermal sinus tumor (EST) of the ovary were treated with modified vinblastine, actinomycin-D, and bleomycin (VAB-3) regimen. Serum alpha-fetoprotein (AFP) levels were monitored for all patients during and after therapy. In all patients a clinical response was achieved. In one stage IV patient with huge multiple liver metastases complete response was attained and she is free of disease following secondlook larparotomy. In other two patients, one stage IV and another recurrent, with large liver metastases, partial responses were achieved with normalization of serum AFP. Serum AFP monitoring is valuable for the management of EST, but a negative AFP titer does not eliminate the possibility of persistent or recurrent disease. The VAB-3 combination, previously found effective in metastatic nonseminomatous testicular cancer, is also effective in advanced and recurrent EST of the ovary.

A VP16-213- and cisplatin-containing regimen for treatment of refractory ovarian germ cell malignancies

Chemotherapy with VP16-213 and cisplatin was administered to three patients with ovarian germ cell malignancies resistant to chemotherapy with methotrexate, actinomycin D, and chlorambucil and with vinblastine, bleomycin, and cisplatin. Remission was achieved in all patients and has been sustained for 9 to 50 months. Use of these agents in a salvage regimen for resistant germ cell malignancies is recommended.

Secretion of human chorionic gonadotropin and alpha-fetoprotein by an ovarian germ cell tumor of apparent yolk sac origin

alpha-Fetoprotein (alpha FP) and four placental proteins, human chorionic gonadotropin (hCG), human placental lactogen (hpL), pregnancy specific beta 1-glycoprotein (SP1), and placental protein 5 (PP5), were measured in a 17-year-old patient with endodermal sinus tumor of the ovary. The circulating levels of alpha FP were consistently high (more than 14 mg/ml), and alpha FP was localized in tissue sections using immunohistochemical techniques. None of the four placental proteins was detectable in serum samples, but hCG was detected in urinary concentrates in an episodic manner. This ectopic hCG resembled placental hCG in its physicochemical and immunological characteristics. Unlike alpha FP, hCG was not detected in the tumor by immunohistochemical methods. This study indicates that the neoplasm elaborated both hCG and alpha FP. Whether pure endodermal sinus tumor of the ovary is capable of secreting hCG cannot be answered by this study because of limited histologic sampling. The likelihood that this represents a mixed germ cell tumor in which only the endodermal sinus tumor element was sampled remains a possibility. This study also indicates that the 24-hr urinary concentrate is far more sensitive than serum samples for hCG detection.

Serial serum determination on alpha-fetoprotein as a marker of the effect of postoperative chemotherapy in ovarian endodermal sinus tumor

Serial serum determinations of alpha-fetoprotein (alpha FP) as a tumor marker were carried out in the management of six patients with endodermal sinus tumor (EST). Histological examinations in all six patients revealed a typical EST pattern, and in one of them another germ cell tumor, a malignant teratoma, was also found. All patients were treated postoperatively with combination chemotherapy. The serum alpha FP concentrations before treatment, using radioimmunoassay, were abnormally high and ranged from 2500 to 100,000 ng/ml. One patient having Stage Ia neoplasm is living at 50 months after diagnosis with a normal alpha FP concentration and without clinical evidence of recurrence. The other five patients with Stage III disease died from 4 to 9 months after surgery, respectively, although the serum alpha FP in all these cases during chemotherapy decreased markedly but temporarily to a normal level (less than 20 ng/ml) or to 3000 ng/ml and was paralleled by a certain improvement in the conditions of the disease. These results suggest that serial serum determination of alpha FP may be useful as a marker and prognostic indicator of endodermal sinus tumor.

Chemotherapy of Endodermal Sinus Tumour (Yolk Sac Tumour) of the Ovary: Preliminary Communication

Eight patients presenting with endodermal sinus tumour of the ovary have been treated with combination chemotherapy using cisplatin, bleomycin and vinblastine (PVB). Complete remission occurred in 7 out of 8 cases, all of whom are alive and well 3 to 33 months later. These preliminary results are compared with our own past experience and recent reports in the literature. It is concluded that the PVB regimen is probably as effective in female germ cell tumours as it is in testicular teratoma.

The detection and measurement of oncodevelopmental proteins in gynecological malignant disease

Data from the literature and our own measurements with alpha-fetoprotein (AFP), carcinoembryonal antigen (CEA), alpha 2-pregnancy-associated globulin (alpha 2-PAG), human chorionic gonadotropin (HCG), human placental lactogen (HPL) and pregnancy-specific beta 1-glycoprotein (SP-1) are related to clinical data. Only AFP in endodermal tumors and HCG in germ cell carcinomas can be used for clinical monitoring.

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.

AFP in yolk sac tumor and solid teratoma of the ovary: significance of postoperative serum AFP

Serial serum alpha-fetoprotein (AFP) was examined postoperatively in five patients with yolk sac tumor and in three with solid teratoma of the ovary. Serial estimation of AFP was also done in sera from postpartum patients to compare the decreasing ratio between the two groups. Serum AFP in these postpartum women decreased according to the exponential function curve as AFP = be-mx (x = days after delivery) with a mean m value of 0.1652 and a mean correlation coefficient of -0.9911. Half-time of serum AFP in postpartum subjects was 4.33 days. Exponential decrease of serum AFP was also found in postoperative patients with yolk sac tumor and solid teratoma of the ovary. However, in those in whom there was an incomplete removal of the tumors, the values of either m or coefficient of correlation were significantly lower as compared to those in patients with complete extirpation of lesions or those in postpartum subjects. Elevation of serum AFP was noted postoperatively in two patients with recurrences; however, significant decreases in AFP following chemotherapy were apparent in one patient with immature solid teratoma. These findings suggest that the decreasing ratio of postoperative serum AFP is an effective indicator to determine whether or not the lesions were completely extirpated, although a normal value may not always imply the absence of microscopic metastasis of tumor cells. Serial estimation of serum AFP was of value in assessing the presence of recurrences and evaluating the efficacy of chemotherapy.

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.

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 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.

Alpha-fetoprotein in ovarian teratoma with glial implants on the peritoneum

A case of ovarian teratoma with glial implants on the peritoneum associated with alpha-fetoprotein (AFP) in the blood is reported. After repeated surgical excision the AFP became negative. The AFP can also be considered as a tumor marker in case of ovarian teratoma. The literature concerning ovarian teratoma with glial implants on the peritoneum is reviewed. The pathogenesis of glial implantation on the peritoneum and the association with AFP is discussed.

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.

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.

Treatment of malignant ovarian germ cell tumors: response to vincristine, dactinomycin, and cyclophosphamide (preliminary report)

From November 1971 to November 1975, 27 patients with malignant germ cell tumors of the ovary (excluding pure dysgerminoma and tumors containing trophoblastic elements) were treated with vincristine, dactinomycin, and cyclophosphamide; 12 patients received other therapy. Fourteen tumors were pure endodermal sinus tumors, two were embryonal carcinomas, 11 were mixed germ cell tumors and 12 were immature teratomas. Of 23 patients with surgically resected disease (Stages I-IIA) only seven have failed. Median follow-up for 16 patients remaining free of disease is 24.5 months. Restaging (second-look) laparotomies were done in 15 patients. Eight were negative. Fifteen of the patients had tumors with endodermal sinus elements. Six of these have failed. Of 16 patients with advanced disease (Stage IIB, III and recurrent), eight have responded to chemotherapy, eight have failed. Median follow-up period for those remaining free of disease is 26.5 months. Six have had negative second-look surgery and one had mature teratoma. Four of eight cases which contained endodermal sinus elements responded to chemotherapy and remain disease-free. Grade 3 hematologic toxicity was seen in eight patients, dose-limiting gastrointestinal toxicity in five patients, dose-limiting neurotoxicity in five patients.

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.

Cellular localization of alpha-fetoprotein and human chorionic gonadotropin in germ cell tumors of the testis using and indirect immunoperoxidase technique

An immunohistologic study of 21 patients with germ cell tumors of the testis with measured serum levels of chorionic gonadotropin (HCG) and alpha-feto protein (AFP) was undertaken to correlate the various types of neoplasms with the presence of these tumor markers in the tissue and serum. AFP was demonstrated in mononuclear embryonal cells within embryonal carcinoma and endodermal sinus tumor. HCG was identified within syncytiotrophoblastic giant cells, frequently in association with embryonal carcinoma, and rarely with endodermal sinus tumor and seminoma, as well as in the syncytiotropho-blastic component of choriocarcinoma. Eighteen of the 21 patients (86%) had elevated tumor markers in their serum; serum HCG alone was elevated in five (24%), AFP alone in five (24%) and both were elevated in eight (38%). There was tissue localization of HCG in 12 of the 13 patients (92%) with elevated serum HCG while AFP was identified in the tumor in eight of the 13 patients (53%) with elevated serum AFP levels. Based on these findings, a tentative immunohistologic classification of germ cell tumors utilizing AFP and HCG is proposed. Thus, embryonal carcinoma, adult type, is frequently associated with both AFP and HCG, endodermal sinus tumor with AFP and choriocarcinoma with HCG, whereas pure seminoma and teratoma are unlikely to be associated with either marker.

Malignant germ cell tumors of the ovary

This article reviews 281 malignant germ cell tumors of the ovary from the Armed Forces Institute of Pathology and highlights their distinctive clinical and pathologic features. Emphasis is placed on the importance of a combined therapeutic approach utilizing surgery, chemotherapy, and radiation. The rationale for unilateral salpingo-oophorectomy in conjunction with chemotherapy for certain types of neoplasm confined to one ovary (stage 1a) is emphasized, and the role of human chorionic gonadotropin and alpha-fetoprotein as tumor markers in the management of patients with these tumors is discussed.

Alpha-1 antitrypsin (AAT) and alphafoetoprotein (AFP) in sera of patients with germ-cell neoplasms: value as tumour markers in patients with endodermal sinus tumour (yolk sac tumour)

Serum alphafoetoprotein (AFP) and serum alpha-1 antitrypsin (AAT) were determined in 24 patients with germ-cell neoplasms of the gonads and extragonadal sites and in two patients with hepatocellular carcinoma. In the majority of the patients serial determinations were performed. All seven patients with testicular seminoma and four patients without evidence of active disease had normal levels of serum AAT and AFP. The remaining 13 patients with germ-cell neoplasms had tumours containing endodermal sinus tumour (yolk-sac tumour) elemetns. All these 13 patients had elevated levels of serum AFP and the levels were high or very high in most cases. Nine of these 13 patients had raised serum AAT, although the elevation above normal levels was only slight in a number of cases. When serial determinations were performed serum AAT levels frequently followed the pattern of serum AFP levels, but the AAT levels were frequently within normal limits and therefore the interpretation of the results was difficult, and much less reliable as compared with those for serum AFP. The elevation of serum AAT levels following the recurrence of the tumour was found to occur much later and was much less marked than elevation of serum AFP, which occurred early, showed a large rise and was a reliable marker of tumour recurrence in patients with germ-cell neoplasms containing endodermal sinus tumour elements. It is therefore considered that, although there is good evidence that serum AAT is produced by endodermal sinus tumour elements, serum AAT is not a useful monitor of disease activity in these patients, especially when compared with serum AFP, the value of which is well recognized. Serum AAT may be a useful tumour marker in patients with hepatocellular carcinoma, and this aspect should be investigated further.

Ovarian extraembryonal teratoma. II. Endodermal sinus tumor mixed with other germ cell tumors

From the files of the Emil Novak Ovarian Tumor Registry, 18 cases of mixed ovarian germ-cell neoplasms containing endodermal sinus tumor as one element have been reviewed. The data regarding the patient age, presenting symptoms, gross appearance of the tumors, and response to therapy are similar to those reported in a previous series of pure endodermal sinus tumors. Response to all modes of therapy is disappointing but there is growing evidence that combination chemotherapy should be added to surgical excision as a routine part of therapy in such patients. The rarity of this lesion is such that meaningful data are likely to be available only if individual and institutional experiences are combined in central tumor registries.

Endodermal sinus tumor of the ovary and alpha fetoprotein: a case report

Yolk sac tumors of the ovary are associated with elevations in serum levels of alpha fetoprotein (AFP). Thus, an antigenic marker is provided for evaluating therapeutic results in selected patients. A patient with a pure endodermal sinus tumor of the ovary is presented who underwent serial determinations of AFP. The effectiveness and limitations of serial AFP levels as demonstrated by this case are discussed in addition to the surgical and chemotherapeutic management of patients with yolk sac tumor of the ovary.