Extragondal endodermal sinus tumours originating in the region of the pineal gland

Primary intracranial pure endodermal sinus tumor: A retrospective series of 6 cases in a single center and a systematic review of overall survival

BACKGROUND

Primary intracranial pure endodermal sinus tumor (EST) is a rare malignant nongerminomatous germ cell tumor. There is still lack of knowledge about the treatment and prognosis.

METHODS

We studied 6 cases of primary intracranial pure EST patients in Beijing Tiantan Hospital from June 2009 to June 2015. A comprehensive literature search was performed on Pubmed's electronic database using the search terms "primary intracranial endodermal sinus tumor", "primary intracranial yolk sac tumor" and "malignant germ cell tumor". Survival rates based on age, gender, tumor location, treatment, resection degree and metastatis were collected and analyzed.

RESULTS

Total resection was achieved in three patients and subtotal resection was achieved in three patients. Blood AFP level continuously decreased after tumor removal. In our case series, the longest survival time was 99 months; this patient received surgery+adjuvant therapy. Fifty-two cases were eligible and met the inclusion criteria for the review analysis. The majority of the population were in the young child to adolescent age and there is a male predominance in this study. In the Kaplan-Meier survival analysis, age, gender, tumor location and metastasis did not affect patients' OS. Better OS was found in patients who had subtotal and gross total resection of the tumor. Patients who had surgery combined with adjuvant therapy showed better OS compared to those who just had surgery.

CONCLUSION

Total resection of the tumor is necessary and EST is sensitive to adjuvant therapy.

Primary pure gastric yolk sac tumor

We describe here a case of pure gastric yolk sac tumor (YST). A 62-year-old patient underwent gastrectomy with D2 dissection. The histological report confirmed the diagnosis of YST and that two of the 14 regional lymph nodes removed were metastatic. Three courses of PEB regimen chemotherapy were delivered subsequently. Three months later the patient experienced dysphagia from stenosis of the anastomosis and a computerized tomography scan showed tumor recurrence with peritoneal nodules; the patient died one year after surgery. The origin of gastric YST is unclear but involvement of migrating germ cells during embryonic development or multipotential neoplastic protoepithelial cells of the gastric mucosa have been suggested. Generally the prognosis of gastric YST is poor and the standard therapeutic approach beyond surgery is still uncertain.

Ovarian endodermal sinus tumor in a postmenopausal woman

BACKGROUND

Ovarian endodermal sinus tumor is rare in postmenopausal women.

CASE

We report the case of a 75-year-old woman with a pure endodermal sinus tumor of the ovary.

CONCLUSION

We believe this to be the oldest patient reported with an ovarian endodermal sinus tumor. The histogenesis of this entity in older patients may be different than when it occurs in young women.

Pineal yolk sac tumor in a 65-year-old man

A 65-year-old man presented with a case of pure yolk sac tumor in the pineal region. The patient was admitted with a gait disturbance and elevated alpha-fetoprotein levels in serum and cerebrospinal fluid. He underwent total resection of the tumor. Cisplatin-vinblastine-bleomycin therapy was interrupted because of severe syndrome of inappropriate secretion of antidiuretic hormone, and there was recurrence of the tumor. Five months after the operation, he died in spite of carboplatin-etoposide therapy. A review of the literature revealed no previous report of pineal yolk sac tumor in an elderly patient. Problems in the diagnosis and treatment of such cases are discussed.

Primary cerebellar yolk sac tumor: case report

A rare case of cerebellar yolk sac tumor is described. A 4-year-old boy was admitted for the treatment of a cerebellar tumor and, following total removal of the tumor, he was treated with combination chemotherapy consisting of cisplatin, vinblastine, and bleomycin. He died 18 months after the primary diagnosis due to tumor recurrence. Serum alpha-fetoprotein level was well correlated with the clinical course and the amount of the tumor mass in neuroimaging.

MR findings of pineal yolk sac tumor in a patient with testicular embryonal carcinoma

Magnetic resonance imaging features of a rare pineal region yolk sac tumor found in a 31-year-old man with a history of previously treated embryonal cell carcinoma of the testicle are presented. No specific magnetic resonance imaging features that definitely differentiate yolk sac tumor from other pineal region tumors could be found. However, in individuals with a previously established testicular germ cell tumor, a metastatic or secondary primary germ cell tumor should be suspected when there is a newly diagnosed pineal region mass. Serum tumor markers are helpful in confirming the diagnosis of a germ cell tumor.

Primary yolk sac tumor of the cerebellar vermis: case report

A rare case of yolk sac tumor in the cerebellar vermis is reported. A 2-year-old boy developed headaches, vomiting, and an unsteady gait. Later a tumor was demonstrated in the medial part of the cerebellum by gadolinium-enhanced magnetic resonance imaging (MRI). The tumor was totally removed, and the surgery was followed by chemotherapy. Soon after surgery the elevated alphafetoprotein (AFP) levels in the serum and cerebrospinal fluid were observed to decrease to normal levels. Three months later enhanced MRI showed a lesion in the vermis without any elevation of AFP, and the lesion turned out to be a granuloma. Six months after the second surgery a tumor recurred that could not be totally removed. Cranial radiotherapy was given together with chemotherapy, which resulted in a decrease of AFP to the normal range. The patient is doing well without any elevation in AFP at 1 year 6 months after onset. Related problems in the diagnosis and treatment of yolk sac tumors are discussed.

Successful treatment of a pineal endodermal sinus tumor. Case report

A patient with a pineal endodermal sinus tumor is presented who was successfully treated by a combination of surgery, adjuvant chemotherapy, and craniospinal irradiation. Two years after diagnosis, he is free of any disease. A review of the literature shows that such an outcome is very unusual. A multidisciplinary treatment is recommended for this rare tumor, using chemotherapy as adjuvant treatment.

Mixed germ-cell tumor of the pineal region. Case report

The case is presented of a 15-year-old boy with a mixed nongerminomatous germ-cell tumor of the pineal region associated with elevated cerebrospinal fluid and serum levels of the beta subunit of human chorionic gonadotropin. Treatment consisted of initial subtotal resection followed by radiotherapy and systemic chemotherapy with cisplatin, vinblastine, and bleomycin. The patient is alive without evidence of tumor 37 months after his initial diagnosis. A literature review of intracranial embryonal carcinoma and choriocarcinoma provided the rationale for a combined-modality approach to this otherwise lethal neoplasm.

Successful treatment of yolk sac tumor of the lower abdominal wall with lymph node metastases

We report a case of a primary yolk sac tumor of the lower abdominal wall with inguinal lymph node metastases. To our knowledge, this is the first documented case originating in the lower abdominal wall. Radical surgery was performed, followed by combination chemotherapy consisting of bleomycin, vinblastine and cis-platinum. The patient has been free of disease for more than 2 years.

Intracranial germ-cell tumors: natural history and pathogenesis

The natural history of primary intracranial germ-cell tumors (GCT's) is defined from 389 previously published cases, of which 65% were germinomas, 18% teratomas, 5% embryonal carcinomas, 7% endodermal sinus tumors, and 5% choriocarcinomas. Intracranial GCT's display specificity in site of origin. Ninety-five percent arise along the midline from the suprasellar cistern (37%) to the pineal gland (48%), and an additional 6% involve both sites. The majority of germinomas (57%) arise in the suprasellar cistern, while most nongerminomatous GCT's (68%) preferentially involve the pineal gland (p less than 0.0001). The age distribution of afflicted patients is unimodal, centering with an abrupt surge in frequency in the early pubertal years; 68% of patients are diagnosed between 10 and 21 years of age. Nongerminomatous GCT's demonstrate an earlier age of onset than do germinomas (p less than 0.0001). Prolonged symptomatic intervals prior to diagnosis are common in germinomas (p = 0.0007), in suprasellar GCT's (p = 0.001), and among females (p = 0.02). Parasellar germinomas commonly present with diabetes insipidus, visual field defects, and hypothalamic-pituitary failure. Nongerminomatous GCT's present as posterior third ventricular masses with hydrocephalus and midbrain compression. Germ-cell tumors may infiltrate the hypothalamus (11%), or disseminate to involve the third ventricle (22%) and spinal cord (10%). Among a subpopulation of 263 conventionally treated patients, two factors were of prognostic significance: 1) histological diagnosis; germinomas were associated with significantly longer survival than nongerminomatous GCT's (p less than 0.0001); and 2) staging of the extent of disease; this emphasizes the ominous character of involvement of the hypothalamus (p = 0.0002), third ventricle (p = 0.02), or spinal cord (p = 0.01). Specific recommendations regarding the necessity of histological diagnosis and staging of the extent of disease are made in light of modern chemotherapeutic advances. The pathogenesis of GCT's may be revealed by their specificity of origin within the positive (suprasellar cistern-suprachiasmatic nucleus) and negative (pineal) regulatory centers for gonadotropin secretion within the diencephalon. The abrupt rise in age distribution at 10 to 12 years suggests that the neuroendocrine events of puberty are an "activating" influence in the malignant expression of these embryonal tumors.

Endodermal sinus tumor of the stomach

This is a case report of an endodermal sinus tumor arising in the stomach of a 72-year-old Japanese woman. The tumor showed Borrmann 2 type at the mucosal surface, and the main mass occupied the subserosal layer with outgoing extension. Microscopically, the tumor showed typical characteristics of the endodermal sinus tumor, associated with embryonal carcinoma, poorly differentiated adenocarcinoma and well differentiated tubular adenocarcinoma. Alpha-fetoprotein was detected in the serum of the patient by radioimmunoassay and within tumor tissue by immunohistochemical techniques. Ultrastructurally, a characteristic basement membrane-like material has been identified in intercellular spaces.

Malignant teratoma in the brain. An immunohistochemical study

A case of intracranial malignant teratoma found in a 27-year-old man was reported. This unique tumor was found in the right frontal lobe separated from the pineal region and revealed various tissue components such as stratified squamous epithelium, glandular tissues, neuron, glia, ependyma, fibromuscular tissue, cartilage, bone, hemangiomatous lesion, melanin-laden cells, and some germ cell components. An immunohistochemical study demonstrated the presence of S-100 protein, glial fibrillary acidic protein (GFAP), neuron-specific enolase (NSE), carcinoembryonic antigen (CEA), and Factor VIII in some tumourous components. In particular, the distribution of S-100 protein in some germ cells suggested the possibility of the neuroectodermal origin of the germ cells or, alternatively, differentiation to the neuroectoderm.

Endodermal sinus tumor of the pineal region. Metastases through a ventriculoperitoneal shunt

This case report concerns an endodermal sinus tumor (EST) arising in the pineal region of a 16-year-old boy who died 3 months after radiation. He developed extensive abdominal metastases through a ventriculoperitoneal shunt, whereas the primary tumor and a suprasellar metastasis could be controlled by radiotherapy, demonstrated by autopsy. The histologic diagnosis was supported by an elevated level of alpha-fetoprotein in serum and the demonstration of this marker in the tumor tissue by immunoperoxidase method. The poor diagnosis of all previously reported cases with pineal EST requires a combined modality of surgical approach, radiotherapy, and concomitant chemotherapy.

Endodermal sinus tumor (yolk sac tumor) of the orbit

The endodermal sinus tumor is a malignant germ cell neoplasm that usually arises in gonads, but on rare occasion occurs in extragonadal locations. Five tumors of the orbit, which by light microscopy displayed features characteristic of gonadal endodermal sinus tumor, were tested for the presence of alpha fetoprotein using paraffin-embedded tissue and an immunoperoxidase technique. Each tumor contained intracytoplasmic alpha fetoprotein. Review of the clinical histories revealed that orbital endodermal sinus tumors differ from other extragonadal endodermal sinus tumors in that they occur at a younger age and when treated aggressively can result in long-term survival. In children with rapidly progressive proptosis the distinction between endodermal sinus tumor and rhabdomyosarcoma poses diagnostic difficulties for both the clinician and the pathologist. When considering the diagnosis of endodermal sinus tumor, the use of immunohistochemical testing for alpha fetoprotein can be helpful.

A suprasellar embryonal carcinoma producing alpha-fetoprotein and human chorionic gonadotropin; treated with combined chemotherapy followed by radiotherapy

A case of primary suprasellar embryonal carcinoma that produced alpha-fetoprotein and human chorionic gonadotropin in a 12-year-old girl is reported. Partial removal of the tumor and cis-platinum-based combined chemotherapy followed by local radiotherapy resulted in a definite regression of the tumor and improvement from clinical signs and symptoms. After these treatments, the concentrations of alpha-fetoprotein and human chorionic gonadotropin in both serum and cerebrospinal fluid decreased to undetectable levels. Serum basic fetoprotein, another tumor marker, can be a tool for evaluating the clinical course following postoperative chemotherapy.

Endodermal sinus tumor of the mediastinum

Endodermal sinus tumor (EST) of the mediastinum is a rare germ-cell neoplasm affecting mainly young adult males. Ten patients with EST were treated with a multimodality approach that included surgery, chemotherapy, and radiotherapy. All patients had relapses after achieving a transient response except one who is still in complete remission more than five years following the diagnosis of the disease. Optimal therapy for this neoplasm has yet to be discovered. The disease is a subset of extragonadal germ cell tumors which appears to be lethal in most cases, particularly when the primary tumor is unresectable. The first case of five-year disease-free survival is described.

Yolk sac and allied tumours of the ovary

A review is presented of the histological appearances of 38 yolk sac tumours of the ovary and four so-called embryonal carcinomas together with the associated clinical features. It is suggested that these neoplasms belong to a single taxonomic group of embryonal ovarian tumours differing only in the concomitant types of differentiation. One yolk sac tumour occurred in an individual of 46 XY chromosome constitution and another in a patient with a gonadoblastoma in the contralateral ovary. The value of post-operative serial assays of serum AFP is stressed.

Intracranial germ cell tumor indicating a high level of alpha-fetoprotein (AFP)

An autopsy case of intracranial and extrapineal tumor is reported. The tumor, detected 2 years and 4 months before death, was an ectopic pinealoma (germ cell tumor) and showed elevated serum alpha-fetoprotein (AFP) of 48,000 ng/ml. Histologically, intra- and extracellular PAS-positive hyaline globules were observed in the tumor. The tumor tissues of the paraffin sections revealed a bright positive fluorescence for AFP with indirect immunofluorescence method. Besides, there were generalized metastases in this case.

Endodermal sinus tumor of the pineal region

Two cases of endodermal sinus tumor of the pineal region are reported and compared with 16 others in the literature. The preponderance of neoplasms occurs in boys, usually in their second decade. The diagnosis is usually established within three months of the onset of non-specific symptoms of an intracranial mass. Treatment with operation or radiotherapy alone is inadequate. Most patients have died within two years, some with widespread intradural metastases. The one individual who has survived five years was treated with both operation and radiotherapy.

Endodermal sinus tumor originating in the region of the pineal gland: ultrastructural and immunohistochemical study

This is a case report of an endodermal sinus tumor (EST) arising in the pineal region of a 19-year-old girl (first case studied by electron microscopy). The ultrastructure of the tumor was similar to that of the previously reported cases of EST of ovaries, mediastinum, and sacrococcygeal area. A characteristic basement membrane-like material has been identified within endoplasmic reticulum of tumor cells and in intercellular spaces. Alphafetoprotein has been detected in the spinal fluid of the patient by radioimmunoassays and within tumor tissue by immunohistochemical techniques. Combination therapy consisting of radiation, surgical decompression, chemotherapy (BCNU), and prednisone has been employed in the treatment of this patient without significant benefit. The patient expired three months after the surgery, no autopsy was obtained.

Endodermal sinus tumor of the pineal region: case report and review of literature

This is a case report of an endodermal sinus tumor occurring in the pineal region of a 14-year-old boy who died 4 weeks after surgery and irradiation. Germ cell tumors of this type demonstrate a selective overgrowth of yolk sac endoderm associated with extraembryonic mesoblast and arise preferentially in the gonads of young children. This tumor in the pineal region is rare and carries a grave prognosis as in other extragonadal sites. A summary of previously reported cases is also presented.

Extragonadal endodermal sinus (yolk sac) tumor. Angiographic findings and literature review

The angiographic and pathologic features of an endodermal sinus tumor (EST) arising from the retroperitoneum in a 19-month-old boy are presented. Although rare instances of extragonadal origin of EST have been reported, this is the first detailed description of the angiographic abnormalities. The angiographic appearance was that of a primarily retroperitoneal tumor with parasitized feeding arteries from the liver and right kidney, early filling venous radicles, sinusoidal pooling of contrast material, and inferior vena caval obstruction.

Archenteronoma (yolk sac tumors)

Ten cases of archenteronoma are reviewed with a follow-up between 2 mo and 7 yr. Their presentation was similar to that of rhabdomyosarcoma except for testicular tumors that may present as a hydrocele. A good prognosis was found with tumors amenable to primary resection and chemotherapy. Other tumors are best treated initially with chemotherapy before relatively conservative surgery, radiotherapy being used either pre- or postoperatively.

Endodermal sinus tumor of the pineal region: case report

This is a case report of an endodermal sinus tumor occurring in the pineal region of a 12-year-old Caucasian boy. Germ cell tumors of this type demonstrate a selective overgrowth of yolk sac endoderm associated with extraembryonic mesoblast and arise perferentially in the gonads of young children. This is the ninth known report of this tumor in the world literature. Its occurrence in the posterior third ventricle again confirms that pineal region germ cell tumors are histologically analogous to germ cell tumors originating in the gonads. A disturbance in the region of the primitive streak is thought to account for the exclusive midline location of this tumor in extragonadal sites. This patient was treated with a combination of vincristine, actinomycin D, and cyclophosphamide, and concomitant cobalt irradiation. For endodermal sinus tumors in the pineal region, this combination appears more effective than previously reported treatment by irradiation alone.

The human yolk sac and yolk sac carcinoma. An ultrastructural study

The ultrastructure of the yolk sac of a 39 day old human embryo was studied. The subcellular organization was suggestive of a highly specialized absorptive function proceeding in an exocelomic-viteline direction. These findings, compatible with intense metabolic activity, are at variance with the concept of rapid involution of the yolk sac following completion of its hemopoietic and angiogenetic functions. The speculation is advanced that a potential avenue exists in the yolk sac whereby maternally derived products encounter fetal endoderm. Ultrastructural features in the normal yolk sac were compared to those existing in a tumor showing the "endodermal sinus" pattern, and reviewed in the light of the pertinent literature. These findings support the concept that attributes an endomesoblastic derivation to such neoplasms.

Primary intracranial yolk sac tumor: immunofluorescent demonstration of alpha-fetoprotein synthesis

An autopsy case of 20-year-old male with primary intracranial yolk sac tumor (endodermal sinus tumor) is reported. Whereas the biopsy specimen obtained from the pineal region showed diffuse proliferation of atypical tumor cells, the metastatic subdural tumor removed from lumbar spinal region had the characteristic histologic appearance of yolk sac tumor. The histologic diagnosis was intracranial yolk sac tumor originating in the pineal gland. The elevated amount of alpha-fetoprotein in the cerebrospinal fluid and in the serum further supported the diagnosis. At autopsy, only metastatic tumor was present in the posterior fossa. The immunofluorescence study demonstrated the presence of intra- and extracellular alpha-fetoprotein globules in the tumor tissue. The intra- and extracellular distribution of alpha-fetoprotein, in general, appeared to coincide with that of the PAS-positive hyaline globules in the tumor.

Gonadal and extragonadal yolk sac carcinomas: a clinicopathologic study of 14 cases

Fourteen cases of yolk sac carcinoma, 10 occurring in gonadal, and four in extragonadal sites, seen at the Indiana University Hospitals from 1949 to 1974, were analyzed with respect to pathologic features, laboratory findings, and clinical course. Their histologic appearance was similar regardless of the site of origin. Two basic histologic types were observed--the more common endodermal sinus pattern and the rare polyvesicular vitelline form. The prognosis is unfavorable, but three of our cases exhibited objective responses to chemotherapy. In our small series, the better prognosis of testicular yolk sac carcinomas in children found by some authors was not evident. Four of the 6 patients with yolk sac carcinoma in which serum alpha-fetoprotein determinations were performed showed positive results. Three of these cases had residual or metastatic disease clinically. The demonstration of alpha-fetoprotein in the serum of patients with yolk sac carcinoma lends further support to the yolk sac origin of these tumors and could also prove to be of prognostic value by indicating the presence of residual or recurrent disease.

Mesonephroid tumours of the ovary

Thirty cases of mesonephroid tumour of the ovary were studied. The differential diagnosis is discussed and it is concluded that mesonephroid tumours form a distinct entity. An attempt is made to correlate the histological appearance of the tumours with the clinical course and criteria are suggested which might be a guide to prognosis. Views on histogenesis are discussed but at present there seems insufficient evidence to justify any particular hypothesis.