Endodermal sinus (yolk sac) tumors in infants and children

Vaginal Yolk Sac Tumor: A Case Series and Review of the Literature

OBJECTIVE

To report diagnosis, treatment, and outcomes of vaginal yolk sac tumor (YST) cases at a single institution and review literature on vaginal YST to outline advancements in diagnosis, treatment, and survival.

DESIGN

Retrospective chart review of female patients less than 21 years of age with pathologic diagnosis of vaginal YST treated at a large children's hospital, and summary of a 100-year review of the literature on vaginal yolk sac tumor.

SETTING

Children's Healthcare of Atlanta, a tertiary center in Atlanta, GA.

PARTICIPANTS

Female patients less than 21 years of age diagnosed with vaginal YST.

RESULTS

Two cases of vaginal YST at our institution are outlined. Both patients presented within the first 2 years of life with vaginal bleeding and were treated successfully with chemotherapy alone. After review of the literature, 137 cases of vaginal YST were found. The mean age at diagnosis was 11 months, and all patients presented with vaginal bleeding. Before 2000, more radical treatments were pursued, and 40% resulted in death. Since the year 2000, treatment has shifted toward chemotherapy and more conservative surgical management, with 51% of vaginal YST cases treated with chemotherapy alone with 92% of patients alive at time of publication.

CONCLUSION

Our cases contribute to the limited literature demonstrating the efficacy of conservative management of rare cases of vaginal YST with chemotherapy alone. This case series and review of the literature provide mounting evidence that vaginal YST should be in the differential diagnosis in young girls with vaginal tumors, and conservative management of vaginal YST has excellent outcomes.

Yolk sac tumor of upper lip: A case report

Yolk sac tumors (YSTs) are a type of malignant germ cell tumor that usually grow in the gonads. They are difficult to recognize at other sites outside the gonads, and no case has been reported involving the upper lip. The present study reported the case of a 13-month-old girl exhibiting an isolated YST occurring in the upper lip. The histology and elevation of α-fetoprotein were typical for a YST. The patient was cured following effective chemotherapy and surgery resection. After 36 months of follow-up, there was no sign of recurrence or metastasis. A total of 20 cases of primary YSTs of the head and neck extracranial region since 1997 were reviewed. The present study aims to inform the scientific community of the clinical and pathologic features of this patient.

Endodermal sinus tumor in children

Malignant germ cell tumors account for about 3% of neoplasms in children, and endodermal sinus tumor (EST) is the most common histological subtype. The authors reviewed 22 years' experience (at their institution) in the management of 37 patients with this tumor. Fifteen of them (41%) had a sacrococcygeal primary, 10 had a testicular tumor (27%), 6 had an ovarian tumor (16%), 3 had a vaginal tumor (8%) and 3 had tumors at other sites (8%). Seven (19%) patients presented with metastatic disease, primarily pulmonary. The serum alpha-fetoprotein (AFP) level was elevated in all cases tested. The initial chemotherapy regimen included vincristine, actinomycin, cyclophosphamide (VAC), and Adriamycin (6 patients), but since 1985 the regimen has been changed to include cisplatin or Carboplatin, etoposide, and bleomycin (21 patients). Eight patients with testicular tumors initially were treated with surgical excision alone. Computed tomography results were a poor predictor of recurrence, but AFP surveillance was extremely sensitive. No second-look operation detected residual tumor in the absence of AFP elevation. Initial relapse for all patients tended to occur early (within 2 years), locally, and often with pulmonary metastases. Although historically the prognosis for patients with EST has been poor, the overall 2-year survival rate in this series was 70%. The best prognosis was among the children who had a testicular primary tumor (survival rate, 100%). The 2-year survival rate for patients with ovarian tumors was 67%; for those with sacrococcygeal primaries it was 60%. These results suggest that the prognosis for children with EST has improved significantly over the past decade. Contributing factors include therapy based on cisplatin, etoposide, and bleomycin, and relapse surveillance with serial AFP determinations. Second-look procedures should be reserved for patients who have an increasing level of serum AFP, suspicious computed tomography findings, and no obvious evidence of metastatic disease.

Clinical experience with conservative surgery for vaginal endodermal sinus tumor

Two cases of vaginal endodermal sinus tumor (EST), a rare pediatric malignancy, were managed with conservative surgery followed by adjuvant chemotherapy. The first case involved a 9-month-old girl with EST of the vagina, who was treated with a partial vaginectomy and VAC regimen (vincristine, actinomycin D, cyclophosphamide) during a 2-year period. The serum alpha-fetoprotein (AFP) level returned to normal after excision of the tumor, and it remained normal throughout the treatment period. There was no evidence of disease 30 months after diagnosis. The second case involved an 8-month-old girl with EST of the vagina, who was treated with local excision of the mass through a vaginotomy. The VAC regimen was administered, but the serum AFP level remained elevated. A follow-up abdominopelvic computed tomography scan, taken 4 months after the operation, showed local recurrence of the tumor. The VAC regimen was then changed to a BEP regimen (bleomycin, etoposide, cisplatin). The serum AFP level returned to normal after 2 courses of the new regimen, and no tumor was visible on the follow-up magnetic resonance imaging study. For vaginal EST, primary conservative surgery and adjuvant chemotherapy are attractive measures to preserve both reproductive and sexual function. The extent of conservative surgery requires at least a partial vaginectomy. Simple tumor excision may not be adequate to achieve cure or to prevent local recurrence, even with adjuvant chemotherapy. The serum AFP level is useful for diagnosing and monitoring vaginal EST in the infant.

Treatment of a stage I testicular yolk sac tumor with vascular invasion

There is controversy concerning the treatment of stage I yolk sac tumor of the testis, particularly of those with histological factors that indicate a high risk of relapse. Usually orchiectomy alone is sufficient and adjuvant chemotherapy is unnecessary. Retroperitoneal lymphadenectomy is indicated for patients with persistently high alpha-fetoprotein. Once recurred, treatment at that time is thought to be curative. However, postoperative chemotherapy may be necessary for patients with a tumor expressing histological factors that predict possible relapse. In this paper we report on a case of a 2 year old boy whose tumor invaded the testicular veins. The patient suffered from recurrent disease but was successfully treated by chemotherapeutic regimens including cisplatin and retroperitoneal lymphadenectomy. The importance of the histological factors in making a decision on the treatment strategy for stage I testicular yolk sac tumor is discussed.

Malignant head and neck germ cell tumours

Malignant germ cell tumours of the head and neck are extremely rare. Their behaviour, despite aggressive surgical and adjuvant therapy, is relentless with most cases resulting in a fatal outcome. In this paper we present a case of a cervical embryonal carcinoma and review the presentation, clinical course and treatment of malignant germ cell tumours.

A rare case of endodermal sinus tumour of the vagina in an infant

A rare case of endodermal sinus tumour (EST) of the vagina in a 1 year 5 months old Papua New Guinean female is described and the literature on vaginal ESTs in childhood is briefly reviewed.

Submandibular endodermal sinus (yolk sac) tumor in a female infant. A case report

A submandibular endodermal sinus (yolk sac) tumor (EST-YST) is reported. The patient was a 1.5-year-old girl exhibiting a rapidly growing tumor in the submandibular region. The lesion showed the typical microscopic features including Schiller-Duval bodies and colloid bodies. Alpha-fetoprotein immunoreactivity was expressed by most tumor cells. There was no clinical or radiological evidence of the presence of this tumor elsewhere in the body.

The diagnostic value of alpha-fetoprotein in an infant with sacrococcygeal teratoma

A newborn infant, surgically treated for a sacrococcygeal teratoma, had serially drawn alpha-fetoproteins before and after surgery. The elevated levels were plotted on the graph of normal range proposed by Tsuchida, and although very high, they still fell within the normal range, which suggested benignancy. Pathology showed mature elements, except for immature neuroectodermal tissue. Fetal liver was a prominent part of the teratoma and was stained for alpha-fetoprotein on immunoperoxidase preparation.

Congenital endodermal sinus tumor of the penis

Congenitally occurring endodermal sinus tumors are very rare and frequently occur in association with teratomatous growths. The most common location for these tumors in infancy is the gonads. Tumors of the penis are rare in any age group. As far as we know, this tumor has never been reported in the penis. A 17-month-old baby boy was noted to have a pimple-like lesion at the corona of the glans penis. This was stationary and ignored for a year. At this point, the lump began increasing in size. A further delay of 6 months elapsed before a definitive diagnosis was made. This case emphasizes that any nodule in this area in the neonate is ignored with jeopardy.

Malignant sacrococcygeal teratoma--endodermal sinus, yolk sac tumor--in infants and children: a 32-year review

Fifteen cases of malignant sacrococcygeal teratoma were treated at our hospital over the last 32 years. These included five cases of endodermal sinus (yolk sac) tumor that arose in otherwise benign or immature teratoma, and ten cases of pure endodermal sinus (yolk sac) tumor. Most were females, and only one was a neonate. The presence of symptoms almost always indicated local extension or distant metastases. According to Altman's classification, all but two of these malignant tumors were Types III and IV. The resectability was low, but with aggressive radiotherapy and chemotherapy, second look operations in five have been possible with increasing optimism for survival. Two of five patients with secondary resections are alive and tumor-free almost two years after therapy was discontinued. So far, only the newborn is a long-term (14 years) cure.

Endodermal sinus tumor of the vagina. The role of primary chemotherapy

Endodermal sinus tumor of the vagina, a rare pediatric malignancy, was managed with primary chemotherapy (vincristine, dactinomycin, cyclophosphamide [VAC]) followed by local excision without radical surgery or pelvic irradiation. Treatment-related complications were acceptable, and there is no evidence of disease 30 months after discontinuing all therapy (50 months after diagnosis). As a treatment option, primary chemotherapy is viewed as a highly attractive alternative modality, preserving potential reproductive and sexual function in long-term survivors, and appears to be the treatment of choice.

Endodermal sinus tumor of the vagina: a report of nine cases and review of the literature

Nine cases of endodermal sinus tumor of the vagina from children 6 months to 2 years of age are reported. The two patients treated before the advent of modern chemotherapy died 6 to 13 months postoperatively despite attempted complete surgical resection of the tumor in one of the cases. One patient who was treated initially by hysterectomy and vaginectomy had lung metastases 6 months postoperatively and died despite chemotherapy. Six patients who were treated by a surgical procedure and received vincristine, actinomycin D, and cyclophosphamide, with radiation therapy in two cases, were alive and free of disease from 2 to 9 years postoperatively.

The diagnostic value of alpha-fetoprotein in infants and children with teratomas: a questionnaire survey in Japan

Serum alpha-fetoprotein (AFP) values in 61 infants and children with mature, immature, or malignant teratoma were analyzed in comparison with the normal ranges of AFP. AFP was within the normal ranges in 23 of 24 mature teratomas, and higher than the upper border of the normal ranges in 31 of 32 malignant teratomas. The number of immature teratomas studied here was very small. These results suggest that the diagnostic value of AFP would seem very high even in infancy and childhood, if data are compared with the normal ranges. This conclusion appears particularly noticeable because the authors had once made a preliminary report on this subject in which they concluded that the differentiation between benign and malignant teratoma by AFP would be impossible under the age of 2 mo.

Extragonadal endodermal sinus tumors in children: a review of 24 cases

Endodermal sinus tumors (EST) are highly malignant lesions with a tendency to recur locally and with a high incidence of metastatic disease at the time of diagnosis. The clinical and radiographic spectra of 24 patients with extragonadal EST are reported. There were 17 females and seven males and the mean age of presentation was 21 months. The primary lesion occurred in the sacrococcygeal region in 16 patients; in the vagina in two patients; in the anterior mediastinum in two patients; and in the bladder, liver, nasopharynx and posterior cranial fossa in one patient each. Computed tomography (CT) is the most accurate study in delineating the extent of primary lesions particularly in the pelvis and head and neck and also for demonstrating metastatic disease in the lungs. Significant improvement in survival rates is obtained with a combination of surgery, chemotherapy and radiotherapy.

Endodermal sinus tumor: a clinical and pathological correlation

Endodermal sinus tumors occur in the gonads and in a variety of extragonadal locations, particularly as the malignant component of sacral teratomas. Light and electron microscopic studies as well as the presence of alpha fetoprotein support the concept that these lesions arise from germ cells that migrate from the extraembryonic yolk sac. These tumors in all locations are highly malignant and metastasize to lymph nodes, lung, liver and bone. Peritoneal implants are seen from tumors in the ovary, testis, and following ventriculoperitoneal shunts for yolk sac tumors of the pineal gland. There is no satisfactory therapy for the endodermal sinus tumor, regardless of location, when there are distant metastases at the time of diagnosis; however, we have documented complete regression of metastases in one child following therapy with vinblastine, bleomycin, and cis-platinum. Nine of 13 boys with endodermal sinus tumors of the testis survived in this series of patients. All survivors were treated with orchiectomy and lymph node excision. Surgical excision combined with chemotherapy and radiation led to survivors in children with large extragonadal pelvic and retroperitoneal tumors. We recommend vigorous multimodal therapy with surgery and chemotherapy. Radiation is given to the primary lesion when it is too extensive for initial resection or to eradicate residual disease following chemotherapy. Alpha fetoprotein is a valuable tumor marker.

Successful treatment of metastatic extragonadal endodermal sinus (yolk sac) tumor in childhood

Two children with metastatic extragonadal endodermal sinus tumor who had failed VAC chemotherapy were treated with combination chemotherapy consisting of cis-platinum, vinblastine, doxorubicin HCl (Adriamycin) and bleomycin (cis-VAB). There was a complete response in both patients with one child remaining tumor-free 3 1/2 years after metastasis and 2 1/2 years after stopping therapy. The main toxic reactions encountered were associated with the use of cis-platinum, but these were manageable and resolved upon completion of therapy. Cis-VAB appears to be a safe and effective regimen for the treatment of metastatic endodermal sinus tumor. A study of the efficacy of cis-VAB in a larger group of children with endodermal sinus tumor of poor prognosis seems indicated.