[Gastric metastases with a choriocarcinoma component from a postpuberal teratoma with mature histology]

Germ cell tumors are the most frequent neoplasia in young males. The aims of this study is to describe a case in which a postpuberal teratoma suffers a transformation to choriocarcinoma and metastasize to stomach. We have made a systematic review in PubMed and consensus documents to study this mismatch between the tumour, metastasis and the exception of gastric metastatic affectation. We describe three options to explain this discordance: a mixed germ cells tumour, a burned out tumour or a germ cells tumour derived from a malignant germ cell tumour precursor or different clonal strains. After made a thorough investigation we conclude that the most truly option is the last one as we extensive explain below. Once the gastric metastatic lesions are extremely rare and reach to <5%, but there are not conclusive assessments.

Growing teratoma syndrome after ovarian inmature teratoma: a case report and review of the literature

Growing teratoma syndrome is an uncommon complication of malignant germ cell cancer, characterised by the development of large tumours during or after chemotherapy, despite normalisation of tumour marker levels and metastasis, which contain only mature teratoma. Given its low incidence, little is data available. The authors present the case of a 15-year-old girl with a growing teratoma and the literature review outlines the current knowledge of its pathogenesis, common sites, diagnosis, natural course, treatment, and prognosis.

Cutaneous location of atypical teratoid/rhabdoid tumour

Atypical teratoid/rhabdoid tumour is a rare and highly malignant tumour of the posterior fossae nervous system that occurs in children especially in the first few years of life. Cutaneous location is not previously reported. A newborn boy was referred for both aqueductal stenosis detected antenatally and skin tags mimicking hamartoma. The cerebral tumour increased in size during a few months leading to both skin and cerebral biopsies. Integrase Interactor-1 (INI-1) immunostaining and tumoural and leukocytes INI-1 gene sequencing confirmed the atypical teratoid/rhabdoid tumour nature of the cerebral tumour. INI-1 immunostaining in skin biopsy confirmed the dermal location of rhabdoid tumour. Thus, unusual cutaneous lesions may be part of atypical teratoid/rhabdoid tumour. The loss of Integrase INI-1 on immunohistochemical staining is characteristic.

Mesenteric lymphadenopathy in testicular germ cell tumor

In approximately 25% of patients with testicular germ cell tumor (GCT), the cancer metastasizes to lymph nodes and distant organs. The initial lymphatic drainage site of GCTs is the retroperitoneum. GCTs rarely involve mesenteric lymph nodes. In this study, we report a case of a 32-year-old male patient with GCT and associated mesenteric lymphadenopathy.

[A case of mediastinum malignant teratoma which recurred as bone metastases seven years after a resection, and survived for a long-duration]

We performed median sternotomy, anterior mediastinum tumor resection+cardiac sac, and right pleural+superior vena cava partial excision in the anterior mediastinum, for which tumor markers were abnormal, after preoperative chemotherapy (PEB therapy)for a mediastinal malignant teratoma of 8×6 cm in a malignant germ cell tumor. The tumor markers became normal. We postoperatively performed a course of the same chemotherapy. In spite of the normal tumor markers, bone metastases recurred seven years later, and he underwent the ninth thoracic vertebra resection+spinal fusion. Five years have passed since surgery and he has survived without a recurrence. This seemed to be a rare case in which a part of the mediastinum malignant teratoma which did not produce a tumor marker had a recurrence.

A rare case of solitary metastatic non-seminomatous malignant germ cell tumor to the prostate

Testicular cancer is the most common solid malignancy of men aged 15-40 years and metastasizes in a predictable manner via lymphatic spread. Involvement of metastatic testicular cancer to the prostate is an exceedingly rare event which has only been previously described in patients with seminomatous germ cell tumors. In this report, we present a case of a 42-year-old man who presented with metastatic testicular cancer to the prostate 8 years after his original diagnosis of a mixed germ cell left testicular tumor.

Large teratoma at aortic bifurcation: an unusual metastasis of testicular cancer

A 29-year-old man presented with a right testicular mass. Serum tumor markers were within normal limits. When compared to a previous computed tomography (CT) scan, a new 4 cm presacral mass was present. He underwent radical right inguinal orchiectomy that demonstrated a mature teratoma and seminomatous components. The patient received four cycles of chemotherapy. Over the course of chemotherapy, the mass grew in size and therefore he underwent retroperitoneal lymph node dissection. Pathology confirmed it to be a teratoma with negative retroperitoneal lymph nodes. The unusual presentation of an isolated metastasis to the presacral region raises the question of altered lymphatic drainage.

Retroperitoneal cystic mature teratoma as the presenting clinical scenario of testicular carcinoma

OBJECTIVE

To describe a case of retroperitoneal mature teratoma presenting as metastasis of a testicular mixed germ cell tumor in a thirty year old man who had lumbar and abdominal pain and mass sensation in the left hemiabdomen.

METHODS

Abdominal ultrasound and thoracic-abdominal-pelvic CT multidetector scan were performed, and then after a Doppler ultrasound study of the testicles. Surgical treatment was performed: orchiectomy and retroperitoneal lesion resection.

RESULTS

Imaging studies showed a big cystic lesion in the left retroperitoneal space, 13 × 12 × 11 cm, well defined, with thin septa, displacing the kidney; and a solid-cystic 4 cm left testicular tumor, with multiple septa, solid poles and arterial flows with low resistances. Thoracic extension study did not show any finding. The histopathologic results of the orchiectomy and retroperitoneal resection pieces were, respectively, testicular mixed germ cell tumor (seminoma, with intratubular seminoma foci and teratoma) and mature cystic teratoma.

CONCLUSIONS

Germ cell tumors derive from multipotencial cells with a large capacity of differentiation, and the nodal paraaortic chains are a natural way of dissemination of these neoplasms. Because of that, in the presence of a retroperitoneal lesion in a young patient we have to rule out testicular tumor metastasis. The retroperitoneal mature cystic teratoma must be considered as a lesion with malignant potential.

Gliomatosis peritonei: recurrence, treatment and surveillance

BACKGROUND

Gliomatosis peritonei is the metastatic implantation of mature glial tissue within the peritoneal cavity of patients with ovarian teratomas. There is no clear guidance for how long these patients should be followed up.

CLINICAL CASE

We report the follow-up imaging findings of a 33-year-old female with abdominal distension and abdominal pain and who was postoperatively diagnosed with immature ovarian teratoma with gliomatosis peritonei.

CONCLUSIONS

Differentiation of peritoneal implants seems to be important for prognosis. Malignant transformations after several years cannot be excluded. Therefore, new studies will determine if it is necessary to create guidelines for the postsurgical monitoring of these patients.

[Long-term results of laparoscopic retroperitoneal lymph node dissection (RPLND) in low-stage nonseminomatous germ-cell testicular tumors (NSGCTT) performed by a senior surgeon: 1999-2003]

BACKGROUND

Laparoscopic RPLND for low-stages NSGCTT is controversial: it is performed and recommended by excellent laparoscopic surgeons, but it is not widely used. The aim of this paper is to evaluate the results achieved by a senior surgeon, expert in open RPLND, who was introduced to laparoscopic surgery by excellent laparoscopists (LN, CU, GJ).

PATIENTS AND METHODS

of the 48 operated patients, 36 had primary RPLND for clinical stage I disease (22 TIN0, 7 TxN0, 5 T2-3 N0 and 2 TIS1 N0) and 12 had post-chemotherapy surgery for IIA and IIB retroperitoneal nodes with normalized AFP and HCG. L-RPLND was performed with 4 ports and the en bloc removal of unilateral retroperitoneal nodes with the spermatic vessels. No post-operative adjuvant chemotherapy was planned for patients with documented nodal metastases as for open RPLND since 1985.

RESULTS

Average operative time was 3.30' for the 36 clinical stage I patients and 4 hours for post-chemotherapy surgery. Blood loss was minimal in all cases, because of early conversion to open surgery in all patients with no immediate hemostasis at L-RPLND. Metastases were found in 6 (17%) out of the 36 clinical stage I patients: none in the 22 pTI, 1 in the 7 Tx, 3 in the 5 pT2-3 and in 2 of the 2 pT1S1 patients. Residual teratoma was found in 6 of the 12 patients who received neo-adjuvant chemotherapy for clinical stage IIA or IIB disease. The other 6 had fibrosis-necrosis. Further metastases developed in 2 of the 30 patients with negative nodes: 1 in the lung in a pT1, and 1 in a pT2 patient with increasing markers. Surprisingly, the first two pT2-3 patients with positive nodes developed liver metastases in a few months after L-RPLND. Consequently, all following patients with active metastases at L-RPLND received 2 courses of adjuvant PEB. All 4 patients who relapsed were cured, are alive and disease-free.

CONCLUSIONS

L-RPLND is a very demanding operation, which appears to be more a staging procedure than a curative operation. It is ideal for pT1 clinical stage I and for post-chemotherapy stages IIA& B with residual teratoma and normalized markers, but wait & see in good risk and open RPLND in high risk patients are very competing. Only few reports compared laparoscopic versus open RPLND, but not in a randomized study.

Expression of benign and malignant thyroid tissue in ovarian teratomas and the importance of multimodal management as illustrated by a BRAF-positive follicular variant of papillary thyroid cancer

BACKGROUND

The most common type of ovarian germ cell tumor is the teratoma. Thyroid tissue, both benign and malignant, may be a component of an ovarian teratoma. Here we review this topic and illustrate major features by presenting multimodal management of a patient with BRAF-positive disseminated follicular thyroid cancer arising in an ovarian teratoma.

SUMMARY

Malignant thyroid tissue is often difficult to distinguish from benign thyroid tissue arising in ovarian teratomas. Preoperatively, an elevated thyroglobulin (Tg) level, laboratory or clinical evidence of hyperthyroidism, or ultrasonography appearance of "struma pearl" should prompt referral to oncologist for surgical management of a possibly malignant ovarian teratoma. Postoperatively, tumor tissue should be referred to pathologists experienced with differentiating benign from malignant struma ovarii. Once diagnosed, treatment of this rare condition should be handled by a team of specialists with combined treatment modalities. We cared for woman with disseminated thyroid cancer arising in an ovarian teratoma whose history illustrates the complexity of managing ovarian teratomas with malignant thyroid tissue. At age 33 she had an intraoperative rupture of an ovarian cyst, thought to be struma ovarii. During her next pregnancy, pelvic masses were noted; biopsies revealed well-differentiated papillary thyroid carcinoma, follicular variant. She was euthyroid, but had elevated serum Tg levels. Surgical staging demonstrated widely metastatic intraabdominal dissemination. A thyroidectomy revealed no malignancy. A post-(131)I treatment scan revealed diffuse uptake throughout the abdomen. She then developed abdominal pain and, on computed tomography, was found to have multiple intraabdominal foci of disease. Serum Tg was 264 ng/mL while on L-thyroxine for hypothyroidism and to obtain thyrotropin suppression. A 18 fluorodeoxyglucose positron emission tomography scan showed no pathological uptake. The tumor was found to be BRAF mutation positive (K601E). She underwent extensive secondary debulking and a second course of (131)I with lithium pretreatment. Posttreatment scan revealed diffuse abdominal uptake. Six months posttherapy, the patient is asymptomatic with a serum Tg of 18.1 ng/mL.

CONCLUSIONS

Aggressive multimodal management appears to be the most promising approach for malignant thyroid tissue arising in ovarian teratomas.

Case report: soft tissue metastasis from immature teratoma of the testis: second case report and review of the literature

BACKGROUND

Testicular cancer, like other histopathologic types, commonly metastasizes to the lungs, liver, and brain. Spread to soft tissue, however, is rare with only four cases with seminoma reported. However, one case with metastasis of testicular immature teratoma to soft tissue was documented previously.

CASE DESCRIPTION

We report the case of a 38-year-old man with recurrent immature teratoma of the testis who presented with a painless soft tissue mass in the left thigh previously treated with standard chemotherapy. After removal of the soft tissue mass, his serum alpha-fetoprotein level had returned to the normal range.

LITERATURE REVIEW

To our knowledge, this is the second case of immature teratoma of the testis metastasized to soft tissue.

PURPOSES AND CLINICAL RELEVANCE

We suggest that for a man with testicular cancer who has a soft tissue mass, metastasis of soft tissue from testicular cancer and other solid malignancies should be considered in the differential diagnosis of a soft tissue mass together with primary soft tissue sarcoma.

[A case of malignant germ-cell tumor with choriocarcinoma]

The authors describe a case of the malignant retroperitoneal germ-cell tumor in a 20-year-old male, which appears as several types of tissues that are derivatives of three germinal layers with the presence in its composition of choriocarcinoma, metastases of which to the vital organs were a cause of death.

Cranio-orbital teratoma

A new-born baby presented with a large, rapidly growing tumour. The tumour involved the right orbit, the anterior half of the right intracranial space and extended through the skull of the temporal region. The proptotic eye ruptured due to exposure. The tumour was extirpated when the patient was 12 days old. A large recurrence was extirpated two months later. The tumour was firmly bound to the medial aspect of the superior orbital fissure which probably was the location of origin of the tumour. Based on the size of the intracranial-and the orbital part of the tumour, it was classified as a secondary orbital teratoma. The tumour was macroscopically composed of cystic and solid areas. Microscopically it was seen to be a benign teratoma with tissue from all three germinal layers.

Late relapse of germ cell tumors

OBJECTIVE

To assess the main characteristics of late relapsing malignant germ cell tumors (MGCTs). These tumors are rare and occur by definition 2 years or later after successful treatment.

METHODS

We present relevant literature on relapsing MGCT in order to highlight the following issues: incidence, impact of initial treatment on the subsequent risk of late relapse, treatment, and survival.

RESULTS

A pooled analysis of 5,880 patients with MGCT revealed late relapses in 119 of 3,704 (3.2%) and in 31 of 2,176 (1.4%) patients with non-seminoma and seminoma, respectively. The retroperitoneal space is the predominant site of relapse in both histological types. The initial treatment is important for the risk and localization of late relapses. Patients with single site teratoma are usually cured by surgery alone, whereas viable MGCT or teratoma with malignant transformation may require multimodal treatment with chemo- and/or radiotherapy as well as surgery. Surgery is the most important part in the treatment of late relapses. Salvage chemotherapy should, if feasible, be based on a representative biopsy. Five-year cancer-specific survival is above 50% in the recent large series and reaches 100% in case of single site teratoma.

CONCLUSIONS

Treatment of late relapsing MGCT patients is challenging and should be performed in experienced centers only. Referral of late relapsing patients to high-volume institutions ensures the best chances of cure and enables multimodal treatment, and contributes to increased knowledge of tumor biology as well experience with the clinical course of these patients.

Sacrococcygeal teratoma with spinal canal invasion prenatally diagnosed

Fetal sacrococcygeal teratoma (SCT) is rarely associated with spinal invasion. The prognostic significance of spinal invasion is unknown. In the past, invasion has been discovered by postnatal imaging or in the operating room. As screening ultrasounds have become more prevalent in the United States, more SCTs have been discovered and characterized prenatally. This screening has allowed for better birth planning and neonatal therapy. We report a case of SCT invading the spinal canal seen on prenatal ultrasound. To our knowledge, this is the first documented case of prenatally diagnosed SCT intraspinal invasion.

Intraventricular dysembryoplastic neuroepithelial tumor-like neoplasm with disseminated spinal tumor

Dysembryoplastic neuroepithelial tumor (DNT)- like lesions arise in extracortical locations and behave in a benign fashion similar to that of cortical DNTs. They usually come to attention by symptoms and signs of increased intracranial pressure rather than focal neurological impairment. Here we report a case of 9-year-old boy with a complaint of headache and back pain. A third ventricular mass lesion with disseminated spinal tumor was detected on his magnetic resonance imaging. The presence of floating neurons in a mucinous matrix, oligodendrocyte-like cells (OLCs) aligning axonal columns and vessels, immunohistochemical profile of the neoplasm in addition to the clinical and radiological manifestations of the patient led to the diagnosis of "DNT-like neoplasm of the third ventricle".

Testicular mixed germ cell tumor metastasizing to heart

A 21 years old male presented with low grade fever, hemoptysis and progressively increasing dyspnoea of four month duration followed by acutely developing dizziness, hypotension, convulsion and altered sensorium. He had been operated (left inguinal orchidectomy) for left testicular swelling two years back with high alpha-fetoprotein and normal beta-human chorionic gonadotropin (beta-hCG). In view of this a possibility of metastasis secondary to a malignant testicular tumor was considered. Echocardiography demonstrated a large intracardiac mass, chest computed tomography (CT) revealed intracardiac mass, mediastinal masses and left sided pleural effusion. The histopathology revealed testicular mixed germ cell tumor (MGCT). This case is presented to demonstrate uncommon cardiac manifestations of secondary spread of testicular malignancy.

[The approach to tumors of the retrocrural mediastinum]

Retrocrural tumors of the lower posterior mediastinum are rare. Most tumors in this region involve lymphatic metastasis of germ cell tumors. Formerly these tumors were resected through a combined thoracoabdominal approach, with division of the diaphragm and effecting an at least partial phrenic paresis. The ventral approach via bilateral subcostal incision with cranial extension avoids this problem and allows a bilateral access to the retrocrural space. From November 1999 to December 2005, using this approach we operated on 12 patients with residual germ cell tumors after chemotherapy. In all cases radical resection was obtained. Intra- or postoperative complications did not occur. All patients are still alive and free of disease.

Incidence of metastatic nonseminomatous germ cell tumor outside the boundaries of a modified postchemotherapy retroperitoneal lymph node dissection

INTRODUCTION

Modified template retroperitoneal lymph node dissections (RPLND) have become increasing applied in the postchemotherapy (PC) setting. We evaluated our experience with PC-RPLND to determine the incidence of disease extending outside the boundaries of a modified PC-RPLND.

PATIENTS AND METHODS

From 1989 through 2003, a total of 532 men underwent PC-RPLND for metastatic nonseminomatous germ cell tumor (NSGCT). Of these, 269 (51%) had either viable germ cell tumor (GCT) or teratoma present in the RPLND specimen. After Institutional Review Board approval, clinical and pathologic data were obtained from our prospective surgical database. The incidence of retroperitoneal disease outside the boundaries of five modified templates was reported for the presence of viable GCT or teratoma.

RESULTS

Of the 269 patients with viable GCT or teratoma, 20 to 86 (7% to 32%) patients had evidence of extratemplate retroperitoneal disease, depending on the boundaries of the modified template. There was no difference in the histologic distribution for patients with disease confined to or outside of the modified templates. Despite the absence of preoperative radiographic evidence of disease outside the boundaries of the Testicular Tumor Study Group template, the incidence of extratemplate metastasis for men with residual retroperitoneal masses less than 1, 1 to 2, 2 to 5, and more than 5 cm was two of 24 (8%), seven of 38 (18%), 27 of 92 (29%), and 14 of 55 (25%), respectively.

CONCLUSION

Our data suggest a bilateral RPLND is a prudent approach for the management of men with metastatic NSGCT after chemotherapy, given that at least 7% to 32% of men will have teratoma or viable GCT outside the boundaries of a modified template.

Long-Term Clinical Outcome After Postchemotherapy Retroperitoneal Lymph Node Dissection in Men With Residual Teratoma

Purpose

The histologic finding of teratoma occurs in approximately 40% of all postchemotherapy retroperitoneal lymph node dissections (PC-RPLND). We evaluated patients at our institution undergoing initial PC-RPLND for teratoma to determine their clinical outcome.

Patients and Methods

We identified 210 patients from 1989 to 2003 with nonseminomatous germ cell tumors (NSGCT) who underwent initial PC-RPLND and were found to have only teratoma in the retroperitoneum. Clinical and pathologic information was obtained from our prospective surgical database, and clinical outcome was reported.

Results

Of the 210 patients in our series, 192 (92%) received only induction chemotherapy, and 18 (9%) required additional chemotherapy regimens. PC-RPLND pathology revealed mature teratoma in 178 patients (85%), immature teratoma in 15 patients (7%), and teratoma with malignant transformation in 17 patients (8%). With a median follow-up time for survivors of 37 months, disease recurred in 30 patients. The probability of remaining free of disease recurrence at 5 and 10 years was 83% and 80%, respectively. Of the 30 patients with disease recurrence, 10 (33%) had recurrence with teratoma, five (17%) had recurrence with teratoma with malignant transformation, and 15 (50%) had recurrence with viable germ cell tumor. On multivariable analysis, residual mass size and International Germ Cell Cancer Collaborative Group (IGCCCG) risk classification were predictors of disease recurrence (P < .0005 and = .001, respectively).

Conclusion

PC-RPLND remains critical in the management of patients with NSGCT. Patients found to have teratoma at PC-RPLND have a 10-year probability of freedom from recurrence of 80%. The size of the residual mass and IGCCCG risk classification were significant predictors of disease recurrence.

A giant testicular teratoma

We report a giant testicular in a 36-year-old farmer man, of 18-month duration admitted to the Surgical Department Erbil Teaching Hospital, Iraq. The tumor was invading the penis and lower part of abdominal wall including bilateral groin lymph nodes. Histological examination revealed mature and immature teratoma. Further investigations showed no evidence of any metastatic lesions apart from a solitary pulmonary nodule on the right side of the chest which proved by ultra sonic guide fine needle aspiration biopsy. Radical excisions of the tumor including the shaft of the penis, combined with bilateral block dissection of the inguinal nodes and resection of the lower anterior abdominal wall was performed. Six weeks later after a course of chemotherapy and radiotherapy, the patient underwent resection of metastatic lung lesion.

Congenital cervical immature teratoma arising in the left lobe of the thyroid gland

We report on a fetal autopsy case in which a congenital cervical immature teratoma was diagnosed. A 24-year-old Japanese woman had carried a male fetus that was aborted because of a cervical tumor at 20 weeks 5 days of gestation. The cervical tumor weighed 93 g and measured 7.5x5.5x5 cm. The soft tumor was encapsulated by a fibrous layer, was solid with small cysts on the cut surface, and showed a brain-like appearance. The tumor was composed of neoplastic cells derived from the three germ cell layers: ectoderm, mesoderm, and endoderm. The cells showed both immature and mature features. Small areas of thyroid tissue were detected in the cervical tumor. The left lobe of the thyroid gland was not observed, but the right lobe of the thyroid gland was present laterally between the trachea and the esophagus. Therefore, we concluded that the cervical tumor had arisen in the left lobe of the thyroid gland rather than from the soft tissue of the neck.

Pathologic findings and clinical outcome of patients undergoing retroperitoneal lymph node dissection after multiple chemotherapy regimens for metastatic testicular germ cell tumors

BACKGROUND

Postchemotherapy surgery is an essential component in the management of patients with metastatic germ cell tumors (GCT). The authors assessed their institutional experience of retroperitoneal lymph node dissection (RPLND) after multiple chemotherapy regimens for advanced GCT.

METHODS

By analyzing the institutional prospective surgical database from 1989 to 2004, 71 patients were identified who underwent RPLND after multiple chemotherapy regimens. Clinicopathologic and treatment trends were characterized, and predictors of disease-specific survival (DSS) were evaluated.

RESULTS

The histologic findings at RPLND were fibrosis in 36 men (51%), GCT in 20 men (28%), and teratoma in 15 men (21%). Patients who underwent RPLND from 1989 to 1998 (n = 47), compared with patients who underwent RPLND from 1999 to 2004 (n = 24) were more likely to have GCT (36% vs 13%; P = .04). Patients who received taxane-containing chemotherapy regimens as salvage therapy had lower rates of GCT at RPLND (14% vs 42%; P = .01), higher rates of fibrosis (63% vs 39%; P = .04), and similar rates of teratoma (31% vs 33%; P = .9). The 5- and 10-year DSS rates were 74% (95% confidence interval [95% CI], 62-86%) and 70% (95% CI, 56-84%), respectively. Five-year DSS based on worst histology of RPLND and extraretroperitoneal specimens was 87% (95% CI, 75-99%) for fibrosis, 87% for teratoma (95% CI, 63-100%), and 47% for GCT (95% CI, 23-71%; P = .004). On multivariable analysis, retroperitoneal mass > or = 5 cm and GCT were predictors of worse DSS (P = .03 and P = .005, respectively).

CONCLUSIONS

Taxane-based salvage chemotherapeutic regimens appear to have decreased the rate of GCT at RPLND. The current data support RPLND in select patients after salvage chemotherapy, because a considerable proportion has teratoma or GCT, and the 10-year DSS rate after resection is 70%.

Intestinal metastases in a squamous cell carcinoma arising in mature cystic teratoma of the ovary: a case report

Metastatic spread to the intestines by squamous cell carcinoma (SCC) arising in mature cystic teratoma (MCT) or dermoid cyst is a very rare event. A case of a 40-year-old cachectic woman is presented with an MCT of the left ovary found at autopsy. Focal mural thickening of the cyst wall harbored a moderately differentiated SCC with single cell keratinization. Intramural metastases were noted in the jejunum, ileum, colon transversum, and left colonic flexure. In addition, liver metastases were detected. The tumor was staged as FIGO IV. The peritoneum was covered diffusely by fibrinous and suppurative exudate. In this unusual case, metastasizing SCC of the ovary arising in an MCT led to suppurative peritonitis and consequently to death of the patient. Follow-up procedures regarding intestinal spread could be useful in patients with SCC in MCT.

Hepatectomy for metastatic noncolorectal gastrointestinal, breast and testicular tumours

BACKGROUND

The indications for hepatectomy for colorectal or neuroendocrine metastases are becoming clear with increasing experience reported. For other primary diseases, however, the overall number of cases is relatively small, and it is more difficult to derive clear guidelines. This paper reviews the reported experience of hepatectomy for metastases from non-colorectal gastrointestinal primary cancers, breast cancer and testicular teratoma. The aim is to determine for each whether and under what circumstances hepatectomy is indicated.

METHODS

A Medline search was used to identify papers reporting hepatectomy for metastases from non-colorectal gastrointestinal carcinomas, breast carcinomas and testicular teratomas. The data collected included the primary disease, the number of cases reported, the survival post-hepatectomy and any prognostic factors associated with outcome.

RESULTS

Of the gastrointestinal malignancies, hepatectomy for gastric metastases yields a 5-year survival, roughly half that reported for colorectal disease, and further elucidation of prognostic factors would be desirable. Results were poor for other gastrointestinal malignancies. Good results were reported for breast and testicular teratoma.

CONCLUSION

Of the non-colorectal gastrointestinal primaries, at present only hepatectomy for gastric metastases can be cautiously recommended. For nongastrointestinal primaries, hepatic metastases probably represent widespread dissemination even if occult, and therefore, hepatectomy may only be of use when effective adjuvant treatments are available.

Clonal Origin of Metastatic Testicular Teratomas

PURPOSE

Testicular teratomas in adult patients are histologically diverse tumors that frequently coexist with other germ cell tumor (GCT) components. These mixed GCTs often metastasize to retroperitoneal lymph nodes where multiple GCT elements are frequently present in the same metastatic lesion. Neither the genetic relationships among the different components in metastatic lesions nor the relationships between primary and metastatic GCT components have been elucidated.

EXPERIMENTAL DESIGN

We examined metastases from 31 patients who underwent primary retroperitoneal lymph node dissection for metastatic testicular GCT. All patients had metastatic mature teratoma with one or more other GCT components. This study included a total of 72 metastatic GCT components and 16 primary GCT components from 31 patients. Genomic DNA samples from each component were prepared from formalin-fixed, paraffin-embedded tissue sections using laser-assisted microdissection. Loss of heterozygosity (LOH) assays for seven microsatellite polymorphic markers on chromosomes 1p36 (D1S1646), 9p21 (D9S171 and IFNA), 9q21 (D9S303), 13q22-q31 (D13S317), 18q22 (D18S543), and 18q21 (D18S60) were done to assess clonality.

RESULTS

Twenty-nine of 31 (94%) cases showed allelic loss in one or more components of the metastatic GCTs. Twenty-nine of 31 mature teratomas showed allelic loss in at least one of seven microsatellite polymorphic markers analyzed. The frequency of allelic loss in informative cases of metastatic mature teratoma was 27% (8 of 30) with D1S1646, 34% (10 of 29) with D9S171, 37% (10 of 27) with IFNA, 27% (8 of 30) with D9S303, 46% (13 of 28) with D13S317, 26% (7 of 27) with D18S543, and 36% (10 of 28) with D18S60. Completely concordant allelic loss patterns between the mature teratoma and all of the other metastatic GCT components were seen in 26 of 29 cases in which the mature teratoma component showed LOH. Nearly identical allelic loss patterns were seen in the three remaining cases. In six cases analyzed, LOH patterns of each metastatic component were compared with each GCT component of the primary testicular tumor. In all six cases, each primary and metastatic component showed an identical pattern of allelic loss.

CONCLUSION

Our data support the common clonal origin of metastatic mature teratomas with other components of metastatic testicular GCTs and with each component of the primary tumor.

Growing Teratoma Syndrome After Ovarian Germ Cell Tumors

OBJECTIVE

To analyze a series of occurrences of growing teratoma syndrome after ovarian germ cell tumors.

METHODS

We analyzed a database containing 103 patients affected by pure or mixed ovarian immature teratoma.

RESULTS

We report 12 patients fulfilling growing teratoma syndrome criteria (incidence 12%). The median interval between the diagnosis of ovarian immature teratoma and growing teratoma syndrome was 9 months (range 4-55). Growing teratoma syndrome was revealed by radiological examinations in nine cases (75%). In all cases but one, growing teratoma syndrome occurred in the site involved by the primary tumor. The peritoneum was the first site involved (10 cases, 83%). A complete surgical resection of the growing teratoma syndrome was done in eight cases. The median follow-up was 144 months. Four patients presented a late growing teratoma syndrome recurrence after treatment (second event), more than 5 years after the initial diagnosis, and 14 years later for one patient. All patients but one (lost to follow-up) were still alive at the end of the study.

CONCLUSION

The treatment of growing teratoma syndrome consists of the surgical resection of the tumor, as completely as possible. Because of the possibility of very late recurrence of growing teratoma syndrome, a prolonged follow-up of patients treated for ovarian immature teratoma is mandatory.

[The treatment of metastasic testicular pure mature teratoma]

OBJECTIVE

Given the low frequency of testicular teratoma in relation to the rest of germ cell testicular tumors and the various treatment options for advanced stages, we report one case of advanced testicular mature teratoma with retroperitoneal adenopathy in which orchyectomy was performed after retroperitoneal lymphadenectomy, with the some pathology found in the primary tumor.

METHODS

We do an update on the treatment for these stages with the possibility of beginning with chemotherapy leaving lymphadenectomy for residual masses, or the contrary, being most cases treated in a mixed way.

CONCLUSIONS

Without clear evidence for guidelines in these tumors, it is recommended to individualize the treatment for each patient, accordingly to tumor characteristics, probability of relapse and follow-up.

Predicting Teratoma in the Retroperitoneum in Men Undergoing Post-Chemotherapy Retroperitoneal Lymph Node Dissection

PURPOSE

The biological potential of teratoma remains unpredictable, therefore identifying its presence in the retroperitoneum remains important. We evaluated patients undergoing post-chemotherapy retroperitoneal lymph node dissection for nonseminomatous germ cell tumors to determine predictors of teratomatous elements in the retroperitoneum.

MATERIALS AND METHODS

We identified 532 patients from 1989 to 2003 who underwent retroperitoneal lymph node dissection following chemotherapy for nonseminomatous germ cell tumors at our institution. Multiple clinical and pathological variables were reviewed from our prospective retroperitoneal lymph node dissection database. A logistic regression model was designed based on preoperative variables to predict the presence of teratomatous elements in the retroperitoneal lymph node dissection specimen.

RESULTS

Of the 532 patients in our series 450 (85%) received only induction chemotherapy and 82 (15%) required salvage chemotherapy. Teratomatous elements were identified in the orchiectomy specimen in 42% of patients. Retroperitoneal nodal pathology revealed teratomatous elements in 235 (44%) patients and only teratoma in 210 (40%) patients. By multivariate analysis testicular yolk sac tumor (p = 0.046), teratoma in the orchiectomy specimen (p <0.005), relative change in nodal size before and after chemotherapy (p <0.005), and no requirement for salvage chemotherapy (p = 0.03) were independent predictors for the presence of teratoma in the retroperitoneum.

CONCLUSIONS

Teratoma remains a common histological finding in the retroperitoneal lymph nodes following chemotherapy. We have identified several pre-retroperitoneal lymph node dissection variables that predict the finding of teratoma in the retroperitoneum for men treated with chemotherapy for metastatic nonseminomatous germ cell tumors.

Extraneural metastasis in intracranial tumors in children: the experience of a single center

Our aim is to evaluate the clinical features and outcomes of children with primary central nervous system (CNS) tumors who develop extraneural metastasis (ENM). We retrospectively evaluated children diagnosed with primary CNS tumors treated at our institution between 1972 and 2004. Of 1,011 patients these tumors, 10 (0.98%) developed ENM. The histopathologic diagnosis was medulloblastoma in six patients, germ cell tumors in two patients, and ependymoma and atypical teratoid rhabdoid tumor (ATRT) in one patient each. In six patients, the primary tumor was located in the posterior fossa; it had a supratentorial location in the patient with ATRT, was located in the sellar and suprasellar region in the two patients with germ cell tumors, and was found in the distal spinal cord in the patient with an ependymoma. In two patients ENM was detected at the time of diagnosis. In other patients ENM developed between 9 and 25 months after diagnosis. Metastatic sites included bone, bone marrow, lung, cervical lymph nodes, liver, and paranasal sinuses. Of the 10 patients who developed ENM, 8 died of their disease 0.27-16.2 months (median, 2.60 months) after it was detected. One patient with dysgerminoma is alive, without disease, 117.80 months after diagnosis of the ENM. One patient with germ cell tumor is alive with disease 11.3 months after diagnosis of the ENM. Systemic metastasis to other extraneural sites is extremely rare in children with intracranial tumors. In our series the rate of ENM is 0.98%. The liver and lung are the most common site for metastasis, followed by the bone and bone marrow. The outcome is poor in patients with CNS tumors with ENM.

Immature teratoma arising from a benign cortical abnormality

CASE REPORT

The authors report the case of an immature teratoma of the left parieto-occipital region in a 13-year-old girl. The patient had a computed tomographic (CT) scan of the brain aged 10 months old, following a minor head injury. This demonstrated an abnormality in the same region, which had been reported as 'a cortical malformation'.

DIAGNOSIS

We propose that the lesion on the original imaging is a mature teratoma or other silent dystopic germ cell element that subsequently transformed into the immature teratoma.

DISCUSSION

The potential triggers for such a transformation and the management of patients with similar incidental radiological findings are discussed.

Immature teratomas of the central nervous system: is adjuvant therapy mandatory?

OBJECT

Immature teratomas of the central nervous system (CNS) are rare neoplasms. Although adjuvant therapy is generally recommended after resection, the exact role of each therapeutic modality is not yet established. The purpose of this study was to analyze the clinicopathological correlation and the role of resection to define the optimal treatment modalities for immature teratomas of the CNS.

METHODS

Between 1987 and 2002, eight patients underwent radical surgery for a lesion diagnosed as a CNS immature teratoma at the authors' institution. The clinical courses of these patients and the pathological features of their tumors were retrospectively reviewed. Gross-total resection (GTR) was achieved in six patients at the initial operation. The mean follow-up period was 75 months. Two patients received postoperative adjuvant therapies and two patients did not, against medical advice. None of the four patients experienced recurrence after long-term follow up. Another four patients, all of whom underwent GTR of the tumor, did not receive adjuvant therapy as part of a prospective treatment scheme. One of them exhibited early recurrence and metastasis. The tumor had pathological features denoting a high-grade (Norris Grade III) lesion and neurocytomatous differentiation.

CONCLUSIONS

Aggressive resection seems to be of utmost importance in the treatment of immature teratomas of the CNS. Adjuvant chemotherapy and radiotherapy can be deferred if GTR is achieved in low-grade, immature teratomas, but adjuvant therapies may be warranted for high-grade ones.

[Aortic replacement during post chemotherapy retroperitoneal residual tumor resection for nonseminomatous germ cell tumor: a case report]

A 59-year-old man visited our hospital complaining of epigastralgia. A large hard mass was palpable in the abdominal cavity. Abdominal computed tomography revealed large retroperitoneal cystic tumors. His left testis was hard and swollen. Under the diagnosis of testicular tumor and retroperitoneal lymph node metastasis, left radical orchiectomy was performed and the histopathological examination showed mature teratoma. He was diagnosed with nonseminomatous germ cell tumor and retroperitoneal lymph node metastasis (TNM classification stage IIC). He received three cycles of chemotherapy with bleomycin, etoposide, and cisplatin and we performed retroperitoneal residual tumor resection. Because the tumor tightly adhered to the aortic wall, abdominal aorta was resected and replaced by an artificial vessel. The post-operative course was uneventful. Histopathological diagnosis was cystopapillary adenocarcinoma and mature teratoma. The patient is well 1 and a half years after the operation without recurrence.

Brain metastasis from non-seminomatous germ cell tumors of the testis: indications for aggressive treatment

Brain metastases from non-seminomatous germ cell tumors (NSGCTs) are rare and mainly occur in young men whose clinical condition is unimpaired. The records of 15 patients with brain metastasis from non-seminomatous germ cell tumors of the testis, who had been surgically treated between 1984 and 1998, were retrospectively reviewed. All of the patients had undergone surgery plus whole-brain radiotherapy (WBRT), and chemotherapy based on cisplatin. On admission they had a median age of 33 years and their mean Karnofsky performance scale (KPS) score was >70. Mean survival was 37.7 months. Eight patients had a survival period longer than 5 years. Five patients belonged to radiation therapy oncology group (RTOG) class I; all of them survived. There was a significant difference in survival time between patients in whom the brain metastasis was present at diagnosis (six survivors at 5 years; mean survival 53 months) and patients in whom the brain metastasis occurred during or after chemotherapy (two survivors at 5 years; mean survival 24 months) (P = 0.04). The presence of a trophoblastic component at histopathological analysis of the metastasis negatively influenced survival at univariate analysis. Multiple brain metastasis proved to be a significant risk factor at both univariate and multivariate analysis, while a metastatic residue with a diameter less than 2 cm after surgery did not negatively affect survival in our series. Prognosis is worst in patients with multiple brain metastases, in whom brain involvement occurred during or after cisplatin-based chemotherapy. Considering that these metastases are often both radiosensitive and chemosensitive, and mainly affect young men that are in very good clinical condition, we advocate aggressive treatment with surgery plus adjuvant radiotherapy and chemotherapy. This is mandatory in patients with large metastases (diameter >3 cm).

Role of postchemotherapy surgery in the management of patients with liver metastases from germ cell tumors

OBJECTIVE

To evaluate the role of postchemotherapy adjunctive surgery in patients with liver metastases from germ cell cancer (GCT).

PATIENTS AND METHODS

Forty-three male patients with nonseminoma were treated in different multicenter treatment protocols between 1990 and 1999, and they underwent hepatic surgery. The results of postchemotherapy surgical resection, histologic findings found during postchemotherapy surgery, and prognostic factors for survival were assessed.

RESULTS

Thirty-five of 43 patients (81%) were initially diagnosed with liver metastases and advanced GCT, and 8 patients (19%) presented with metachronous liver metastases after a median interval of 16 months (range, 6-103 months). Twelve patients (28%) had isolated liver metastases after completion of chemotherapy, while 31 patients (72%) had additional residual extrahepatic tumor masses. Liver surgery included tumor excision or segmentectomy in 32 patients (74%) and hepatectomy (right/left) or resection of multiple segments in 11 patients (26%). Histologic analysis of postchemotherapy resected residua yielded necrosis in 67%, teratoma in 12%, and viable cancer in 21%. Additional resections at other sites have been performed in 31 patients revealing necrosis in 61% (n = 19), teratoma in 29% (n = 9), and vital carcinoma in 10% (n = 3). In 39% of patients, histologic findings differed among liver and other resection sites. Refractoriness to chemotherapy was associated with a shorter survival after surgery, and a trend was seen in patients with elevation of AFP.

CONCLUSION

The high rate of viable cancer and teratoma found in liver specimens, differing histologic results at residual tumor locations, and the high survival rate achieved support a multidisciplinary approach including resection of liver masses since no accurate selection of patients can narrow the use of surgery.

Malignant teratoid medulloepithelioma with brain and kidney involvement in a dog

ANIMAL STUDIED

A tumor of the left eye with involvement of the brain and kidney was diagnosed in a 4-year-old Neapolitan mastiff.

PROCEDURE

The dog presented with acute glaucoma of the left eye. Peripheral corneal vascularization and severe corneal edema obscured examination of deeper structures. Because of concurrent progressive neurologic signs the dog was euthanized and a postmortem examination was performed. The eyes, brain and samples from the lung, heart, liver and kidneys were fixed in 4% neutral buffered formalin and embedded in paraffin wax. Sections were examined by light microscopy including histochemical and immunohistochemical staining.

RESULTS

The ocular tumor originated from the ciliary body and was composed of small islets and cords of poorly differentiated, oval to polyhedral cells surrounded by abundant ground substance. Areas with chondroid differentiation were observed. Rosettes were not found. Metastases with the same morphology were present in the brain and in one kidney.

CONCLUSION

An intraocular malignant teratoid medulloepithelioma with metastases to the brain and kidney is presented.