Prognostic Factors in Borderline and Invasive Ovarian Tumours of the Common Epithelial Type

The yolk sac tumor: reflections on a remarkable neoplasm and two of the many intrigued by it-Gunnar Teilum and Aleksander Talerman-and the bond it formed between them

One of the most remarkable of human neoplasms, the yolk sac tumor, is reviewed, emphasizing its histologic diversity and differential diagnosis, occurrence at many sites, and the shared passion for this unique neoplasm of Dr Gunnar Teilum (who deserves almost all credit for delineation of the nature of the tumor and its features) and Dr Aleksander Talerman (who made his own contribution to our knowledge of it) and the friendship it helped forge between these 2 distinguished pathologists. In a unique series of articles, beginning in the early 1940s, Teilum delineated the distinctive features of the neoplasm and recognized that it was 1 of 2 initially included as "mesonephroma ovarii" by Dr Walter Schiller in 1939 (the second we now know as clear cell carcinoma). Teilum named the tumor "endodermal sinus tumor" because it came to his attention that papillary formations common in the yolk sac tumor resembled the endodermal sinuses of the rat placenta. He focused on the histogenesis of the tumor and its morphologic features culminating in a classic paper in Cancer in 1959. Although Teilum and others recognized that yolk sac tumor could be a component of mixed germ cell tumors, Talerman was one of the first to emphasize that, particularly in the testis, it was common to see yolk sac tumor as a component of a mixed germ cell tumor. Teilum, working in Copenhagen, and Talerman, when the former was alive, working in Rotterdam, developed a warm friendship in part due to their great interest in the yolk sac tumor, although it also extended to other areas of gonadal neoplasia and indeed beyond the boundaries of medicine when they shared time together. The typical histologic features of the yolk sac tumor are the reticular-microcystic patterns Teilum described, but various other patterns, including solid and even rarer ones such as glandular and hepatoid, are now well known. There are some interesting variations in the age distribution of this tumor at various sites: for example, vaginal examples are almost restricted to children under 2 years of age; those of the testis that are pure also occur mostly in young boys (average age about 20 months) but are occasionally seen in later years; ovarian examples peak at about 19 years of age; mediastinal forms are mostly restricted to young adult males. Brief consideration is also given to the occurrence of this tumor at well-known extragonadal sites such as retroperitoneum, mediastinum, and pineal as well as more exotic locations. Note is made of the recently emphasized occurrence of the yolk sac tumor on the background of a somatic neoplasm, most often endometrioid carcinoma of the ovary. Given the wide ranging and fascinating clinical and pathologic aspects of the neoplasm, it is no surprise that it continues to be a source of great interest to any pathologist who sees one or more examples, and we are indebted to Dr Teilum for his monumental studies and to Dr Talerman for his own contributions.

Clear cell adenocarcinoma of the tunica vaginalis of the testis with an adjacent uterus-like tissue

Testicular and paratesticular neoplasms that resemble the common epithelial type of ovarian tumor are quite rare. Paratesticular clear cell carcinoma is very uncommon in the testis, with no reported cases of a tumor arising from the tunica vaginalis in the literature to our knowledge. The present case shows that it is highly malignant and metastatic. The differential diagnosis of the tumor was made after thorough clinical, pathological and immunohistochemical investigations, from the mesothelioma of the tunica vaginalis, paratesticular serous papillary carcinoma, carcinoma of the rete testis, epididymal adenocarcioma, yolk sac tumor of the testis and metastatic carcinoma. The tumor showed Bcl-2 and Her-2/neu immunoreactivity, but was non-reactive for p53. This tumor, with a uterus-like structure as a paratesticular tumor-like mass, was composed of endometrial-type glands and stroma surrounded by bundles of smooth muscle, and is the third example of this kind of structure in English written literature. The patient, having normal external genitalia and fertility, represents the first reported case of paratesticular malignant differentiation of müllerian-type epithelium in the normal gonadal state. Müllerian-type epithelium located in the vicinity of the testis and/or endometriotic metaplasia of the mesothelium of the tunica vaginalis might be the possible origins for this uterus-like structure, and as a result, for this tumor.

Influence of surgery and postoperative therapy and tumor characteristics on patient prognosis in advanced ovarian carcinomas

OBJECTIVES

The prognosis in advanced ovarian cancer depends on clinical, morphological, biological and therapeutic variables. However, little is known about their real influences and interrelationships.

STUDY DESIGN

One hundred and nineteen long-term, follow-up patients with advanced ovarian carcinoma were analyzed. Overall survival was related to the extent of debulking surgery, response to chemotherapy and several clinicomorphological, histopathological, and immunohistochemical variables.

RESULTS

Among all variables, both radical surgery and response to chemotherapy exerted the greatest influence on patient prognosis as shown in both univariate and multifactorial analyses. Most established prognostic factors were of minor importance. Success of chemotherapy correlated with lower residual tumor volume, CA125 expression, FIGO-stage, and serous tumor type.

CONCLUSION

Prognosis and chemotherapeutic success in advanced ovarian cancer seem to be interrelated and may be influenced by the intensity of surgical interventions. This demands for greatest cytoreduction during initial surgery and correction for residual tumor volume and success of therapy in studies of prognostic factors.

Immature teratomas in children: pathologic considerations: a report from the combined Pediatric Oncology Group/Children's Cancer Group

Pediatric germ cell tumors (n = 135) with a major component of immature teratoma (IT) registered on Pediatric Oncology Group/Children's Cancer Group treatment protocols from 1990 to 1995 were reviewed. Sixty cases were pure IT with no malignant component and 75 were mixed tumors with a major component of IT. Foci of yolk sac tumor (YST) were present in all 75 mixed tumors; additional malignant components were present in 15. The IT component was as follows: 47% grade 3, 29% grade 2, 24% grade 1. There were no significant correlations between tumor grade and patient age by specific subsets or overall (all p > 0.10). Significant correlations were detected between stage and the presence of foci of YST (p = 0.0145) and grade and the presence of foci of YST (p < 0.001). Serum alpha-fetoprotein concentrations were elevated at diagnosis in 96% of ovarian tumors with foci of YST and were mildly elevated (< 60 ng/dL) in only 16% of tumors without YST. Overall 2- to 6-year survival rate was 96% and was related to the presence of YST. Central pathologic review revealed aspects of morphologic diagnosis that were most frequently misinterpreted by contributing pathologists. These included the classification of differentiating tissues as immature and the failure to recognize two well-differentiated patterns of YST (the hepatoid pattern resembling fetal liver and the well-differentiated glandular pattern resembling fetal lung or intestine). Such foci were often overlooked. The authors conclude that the presence of microscopic foci of YST, rather than the grade of IT, per se, is the only valid predictor of recurrence in pediatric IT at any site.

Endometrioid-like variant of ovarian yolk sac tumor with foci of carcinoid: an ultrastructural study

The endometrioid-like variant of ovarian yolk sac tumor is a rare neoplasm composed partially or completely of glandular tissue resembling endometrioid carcinoma, but identifiable histologically and immunohistochemically as an extraembryonic endodermally differentiated germ cell tumor. Only nine examples of this neoplasm have been published previously, and none was studied by electron microscopy. One of these rare neoplasms, the first documented to have foci of carcinoid, has recently been observed and studied ultrastructurally. Electron microscopic observations showed that the main component of the neoplasm had glandular epithelial cells with nuclear and cytoplasmic features difficult to distinguish from the cells of Müllerian endometrioid and endometrial adenocarcinoma, but a minor component of mucinous adenocarcinoma was confirmed as intestinal by the epithelial cells having characteristic microvilli with filamentous cores and rootlets. In addition, neuroendocrine cells present in the glands and in nests were readily identified ultrastructurally by their dense-core granules. Electron microscopy may be useful in supplementing light microscopic and immunohistochemical examination of this variant of yolk sac tumor.

Correlation between nuclear DNA content and steroid receptor status in ovarian cancer

The nuclear DNA content of 47 malignant epithelial ovarian tumours and five ovarian tumours of borderline malignancy was correlated with estrogen (ER), progesterone (PR) and androgen receptor (AR) status. Aneuploidy was observed in 60% of the malignant tumours. The DNA index of poorly differentiated tumours was higher than that of well differentiated tumours (P less than 0.05). Ploidy did not correlate with histological type, stage of disease and ER content. Of the diploid tumours, 74% was PR-positive, in contrast to 36% of the aneuploid tumours (P less than 0.05). In addition, 89% of the diploid tumours had high AR levels (greater than or equal to 30 fmol/mg cytosol protein), in contrast to only 54% of the aneuploid tumours (P less than 0.05). These observations strengthen our previous findings on the prognostic importance of PR and also suggest that androgens may have a role in ovarian cancer.

Clinical applications of monoclonal antibodies against ovarian cancer-associated antigens

Monoclonal antibodies (McAbs), reactive with tumour-associated antigens (TAAs) present on tumour cells, appear to offer new possibilities in the diagnosis and treatment of cancer (Table I). In addition to these prospects for clinical application, monoclonal antibodies also serve as useful instruments in basic cancer research. The hybridoma technology initiated by Köhler and Milstein in 1975, underwent a very rapid development and has now shown its potential in the field of oncology. This technique made it possible to produce very large quantities of homogeneous antibodies of a stable quality. These McAbs often recognize only one antigenic determinant, or epitope, of cell surface and other molecules. This high specificity is essential for in vivo applications, especially in therapeutic immunotargeting. A central question is whether the antibodies can reach and identify those antigens on ovarian tumour cells that are not shared with normal tissues. Various antibodies have been described in the field of gynaecological oncology, which are assumed to be capable of recognizing such ovarian tumour-related antigens. These McAbs, single or in combination, are capable of showing, unambiguously, the presence of various tumour-associated antigens on ovarian carcinoma cells either in tissue or, when antigen shedding occurs, in blood. However, these McAbs may also react with tumour-associated antigens present on endometrial, cervical, colorectal, breast or other carcinoma cells. The original immunogens used to generate these McAbs differ as to their origin: ovarian cancer cells, breast cancer cells, human milk-fat preparations, trophoblastic cells, endometrial cancer cells have been used as well as osteogenic sarcoma cells, epidermoid carcinoma cells and small-cell lung cancer, colorectal, pancreatic and laryngeal carcinoma cells. The histological distribution patterns of the antigens recognized by these McAbs vary widely: cross-reactions with normal tissue and with carcinomas different from those used as immunogen are frequently seen.