The value of serial measurement of both human chorionic gonadotropin and alpha-fetoprotein for monitoring germinal cell tumors

American Society of Clinical Oncology Clinical Practice Guideline on Uses of Serum Tumor Markers in Adult Males With Germ Cell Tumors

Purpose

To provide recommendations on appropriate uses for serum markers of germ cell tumors (GCTs).

Methods

Searches of MEDLINE and EMBASE identified relevant studies published in English. Primary outcomes included marker accuracy to predict the impact of decisions on outcomes. Secondary outcomes included proportions of patients with elevated markers and statistical tests of elevations as prognostic factors. An expert panel developed consensus guidelines based on data from 82 reports.

Results

No studies directly compared outcomes of decisions with versus without marker assays. The search identified few prospective studies and no randomized controlled trials; most were retrospective series. Lacking data on primary outcomes, most Panel recommendations are based on secondary outcomes (relapse rates and time to relapse).

Recommendations

The Panel recommended against using markers to screen for GCTs, to decide whether orchiectomy is indicated, or to select treatment for patients with cancer of unknown primary. To stage patients with testicular nonseminomas, the Panel recommended measuring three markers (α-fetoprotein [AFP], human chorionic gonadotropin [hCG], and lactate dehydrogenase [LDH]) before and after orchiectomy and before chemotherapy for those with extragonadal nonseminomas. They also recommended measuring AFP and hCG shortly before retroperitoneal lymph node dissection and at the start of each chemotherapy cycle for nonseminoma, and periodically to monitor for relapse. The Panel recommended measuring postorchiectomy hCG and LDH for patients with seminoma and preorchiectomy elevations. They recommended against using markers to guide or monitor treatment for seminoma or to detect relapse in those treated for stage I. However, they recommended measuring hCG and AFP to monitor for relapse in patients treated for advanced seminoma.

National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines for Use of Tumor Markers in Testicular, Prostate, Colorectal, Breast, and Ovarian Cancers

Background: Updated National Academy of Clinical Biochemistry (NACB) Laboratory Medicine Practice Guidelines for the use of tumor markers in the clinic have been developed.

Methods: Published reports relevant to use of tumor markers for 5 cancer sites—testicular, prostate, colorectal, breast, and ovarian—were critically reviewed.

Results: For testicular cancer, α-fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase are recommended for diagnosis/case finding, staging, prognosis determination, recurrence detection, and therapy monitoring. α-Fetoprotein is also recommended for differential diagnosis of nonseminomatous and seminomatous germ cell tumors. Prostate-specific antigen (PSA) is not recommended for prostate cancer screening, but may be used for detecting disease recurrence and monitoring therapy. Free PSA measurement data are useful for distinguishing malignant from benign prostatic disease when total PSA is <10 μg/L. In colorectal cancer, carcinoembryonic antigen is recommended (with some caveats) for prognosis determination, postoperative surveillance, and therapy monitoring in advanced disease. Fecal occult blood testing may be used for screening asymptomatic adults 50 years or older. For breast cancer, estrogen and progesterone receptors are mandatory for predicting response to hormone therapy, human epidermal growth factor receptor-2 measurement is mandatory for predicting response to trastuzumab, and urokinase plasminogen activator/plasminogen activator inhibitor 1 may be used for determining prognosis in lymph node–negative patients. CA15-3/BR27–29 or carcinoembryonic antigen may be used for therapy monitoring in advanced disease. CA125 is recommended (with transvaginal ultrasound) for early detection of ovarian cancer in women at high risk for this disease. CA125 is also recommended for differential diagnosis of suspicious pelvic masses in postmenopausal women, as well as for detection of recurrence, monitoring of therapy, and determination of prognosis in women with ovarian cancer.

Conclusions: Implementation of these recommendations should encourage optimal use of tumor markers.

Report of hereditary persistence of alpha-fetoprotein in a Spanish family: molecular basis and clinical concerns

The serum level of alpha-fetoprotein in normal adults is lower than 10 ng/ml. High levels of alpha-fetoprotein in adults are linked to cirrhosis, acute or chronic hepatitis, hepatocellular carcinomas and other pathologies, as well as to foetal malformation, and this protein is therefore used as a regular clinical marker for these diseases. We report a Spanish family in which very high levels of alpha-fetoprotein have been detected in nine members from the screening of a total of 17 relatives. These levels of alpha-fetoprotein are not accompanied by a causing pathology, are inherited as an autosomal dominant genetic trait, and are associated to a G-->A substitution at position -116 of the 5'-flanking region of the alpha-fetoprotein gene. This is an unusual benign trait of hereditary persistence of alpha-fetoprotein. This paper provides a detailed clinical report of the family including a study of the molecular basis of this trait. The desirability of a test to detect and/or rule out this benign trait in adults with abnormal levels of alpha-fetoprotein is considered.

Clinical use of tumor markers in childhood malignancies

Tumor markers are developmentally regulated proteins or carbohydrate molecules, which are expressed in specific tissues in the fetus during certain developmental periods. With malignant transformation, these molecules are reexpressed in neoplastic tissues. Some developmental or metabolic disorders can also lead to the expression of tumor marker genes, hereditary tyrosinaemia and ataxia teleangiectasia associating with elevated serum alpha-fetoprotein are examples of such conditions. In pediatric malignancies, the most common markers in clinical use are alpha-fetoprotein in liver and yolk sac tumors, chorionic gonadotropin in germ cell tumors, and catecholamines and neuron specific enolase in neuroblastoma. Several other molecules including carbohydrate antigens CA 19-9 and CA 125 may also have a role in the diagnosis and follow-up of distinct types of childhood malignancies. The non-specificity of several markers, such as tissue polypeptide antigen and sialic acid, greatly hampers their clinical use. In this review we will discuss the biology and current knowledge on the use of serum and urine tumor markers. We also highlight the putative future use of these molecules in cancer diagnosis and therapy, including the use of monoclonal antibodies directed against these antigens.

Hereditary persistence of alpha-fetoprotein. Case report and review of the literature

Persistently elevated alpha-fetoprotein (AFP) levels of 24 to 30 micrograms/ml (normal < 10 micrograms/ml) were found in a 38-year-old healthy man. Subsequently, AFP was found to be elevated in another five out of 13 family members within three generations. The pedigree is consistent with an autosomal dominant inheritance pattern. No discernible disease and no functional abnormality appears to be associated with this clinically benign disorder which has been recorded in the literature on four occasions to date. The reported AFP levels in these other cases ranged from 18 to 198 micrograms/ml. Physiologically, AFP is mainly produced in the liver and the yolk sac of human fetuses more than four weeks old, with peak values of up to 4 mg/ml at 12 to 16 weeks of gestation. After birth, AFP levels usually fall, within eight to 12 months, to a very low concentration of < 10 micrograms/ml and persist at low levels throughout life. However, AFP levels can rise above normal in both children and adults in distinct conditions and diseases which will be discussed. Hereditary persistence of alpha-fetoprotein (HPAFP) should be considered in both children and adults with unexplained and persistent elevation of AFP e.g., those screened for hepatocellular carcinoma or diagnosed for germ cell tumor. It should also be recognized in AFP screening for neural tube defects or Down's syndrome during pregnancy. Hereditary persistence of AFP can be easily confirmed by analyzing AFP levels in family members.

Alpha-fetoprotein half-life as a predictor of residual testicular tumor. Effect of the analytic strategy on test sensitivity and specificity

BACKGROUND

Alpha-fetoprotein (AFP) serum values after orchiectomy for testicular cancer can be used to predict the residual disease status. However, the optimal strategy for postorchiectomy marker analysis has not been studied. This article evaluated different analytic methods in an effort to identify the approach that provided the greatest sensitivity and specificity for occult residual disease.

METHODS

Statistical information on the AFP half-life (t1/2) derived from a clinical data set of 24 patients with AFP-secreting clinical Stage A testicular cancer and pathologically defined nodal status was incorporated into a mathematic model of postorchiectomy marker values as a function of residual tumor volume and time. The model was used to test the effect of various analytic strategies on detecting the residual tumor. The clinical data set then was analyzed to measure the effect of different analytic methods on the predictive value of the AFP t1/2.

RESULTS

In the model, the AFP t1/2 calculated from a single set of serum measurements obtained from the initial serum t1/2 was a poor predictor of disease status in patients with up to 40% residual tumor volume. Determined by the sequential addition of serum values obtained at normal t1/2 intervals, the AFP t1/2 improved in sensitivity but required up to seven serial values (35 days) to detect an abnormal t1/2 in patients with 10% residual tumor. By contrast, changes in the most recent interval t1/2 relative to the initial calculated t1/2 predicted the disease status in patients with 10% residual tumor after four t1/2 (20 days) and in patients with 1% residual volume after 35 days.

CONCLUSIONS

The use of this last strategy in the clinical data set improved both the sensitivity and specificity of the AFP t1/2 in predicting residual tumor relative to the other methods.

Testicular cancer

Although testicular cancer is a relatively rare tumor, it is the most common cancer among men aged 15 to 35 years. In the United States in 1989 approximately 5,500 men will be diagnosed with testicular cancer. Up until 2 decades ago, testicular cancer was the most common cause of a cancer death in this age group. The advances in diagnosis and treatment that will be described in this monograph represent one of the major achievements in the treatment of solid tumors. Testicular cancer is now one of the most curable of all cancers; the 5-year relative survival rate is in excess of 90%. In the U.S. fewer than 500 men will die from this disease in 1989. The primary goals in the treatment of testicular cancer as the 1990s approach will be to further decrease the mortality from this disease and to decrease the morbidity of treatment that has led to this dramatic improvement in survival.

An immunohistochemical study of intracranial germ cell tumours

Histologically verified intracranial tumours, mainly germ cell tumours of the pineal and suprasellar regions, were studied immunohistochemically using anti-serum of alpha fetoprotein (AFP), human chorionic gonadotropin (HCG), carcinoembryonic antigen (CEA), human placental lactogen (HPL), pregnancy specific beta-1 glycoprotein (SP-1), glial fibrillary acidic protein (GFAP), S-100 and neuron specific enolase (NSE). In germinomas, HCG positive cells were occasionally demonstrated in cells presenting as syncytiotrophoblastic giant cells (STGC), and GFAP and S-100 positive cells were found in the surrounding gliotic lesions. Teratomas were positive for CEA in their epithelial components. Endodermal sinus tumours were positive for AFP, choriocarcinomas for HCG and SP-1, and embryonal carcinomas for AFP, HCG and SP-1. HCG and SP-1 positive cells were demonstrated in STGC. As for the relationship between serum AFP level and tissue localization, many cases presenting a serum AFP level exceeding 220 ng/ml were positive for AFP in tumour tissue.

Trophoblastic proteins as tumor markers in nonseminomatous germ cell tumors

In order to examine the relative usefulness of measurements of oncoplacental proteins as tumor markers in patients with nonseminomatous germ cell tumors, the authors measured alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), pregnancy-specific beta 1-glycoprotein (SP1), human placental lactogen (hPL), and placental cystine aminopeptidase (oxytocinase, CAP) in serial blood samples obtained from 26 men with these neoplasms. HCG and AFP were each elevated in 62% of the patients and both were elevated in 38%. SP1 and hPL were increased in 31% and 12%, respectively. None of the patients had elevated CAP activity. Serum hCG and SP1 concentrations were strongly correlated (r = 0.78, P less than 0.001). No patient had an elevated SP1 without a concomitant elevation in serum hCG. Serial measurements of hCG and SP1 indicated that they were concordant in five of the eight patients in whom both were elevated, and AFP and hCG were concordant in only one half of the ten patients in whom both markers were elevated. The number of patients with hPL elevations were too few for meaningful comparison of this marker with the others. These results indicate that measurements of SP1, hPL, and CAP do not provide additional useful information over that obtained from measurements of hCG and AFP in patients with nonseminomatous germ cell tumors.

Indolent nonseminomatous germ cell tumor of testis. Prolonged survival of patient with persistent metastatic disease

The complete response rate of disseminated nonseminomatous germ cell tumors (NSGCT) of the testes with current aggressive chemotherapy and surgical resection of residual disease is between 70 and 80 per cent. Those patients who do not attain complete response tend to have short survivals. A case is presented of a forty-one-year-old white man who has had nearly continuous evidence of metastatic embryonal carcinoma for more than eleven years. Although NSGCTs are characterized by rapid proliferation, early metastasis, high response rate to chemotherapy, and rapid death if uncontrolled, this case demonstrates an indolent form of disease with poor response to chemotherapy and yet prolonged survival in spite of uncontrolled disease. This is the first reported case of indolent metastatic germ cell neoplasm with survival of more than ten years.

Pregnancy-associated plasma protein-A concentrations in men with testicular and prostatic tumors

Pregnancy-associated plasma protein-A (PAPP-A) is a macromolecular glycoprotein produced during pregnancy by the trophoblast and the decidua. It is not specific to pregnancy, since immunoreactive PAPP-A is in the circulation of normal women and men and in seminal fluid. Immunohistochemically, PAPP-A is localized in some Leydig cells, in the epididymis, in the rete testis, and in seminal vesicles. This study was conducted to learn whether circulating levels of PAPP-A can be used as a marker for the monitoring of human testicular cancer. PAPP-A was increased only in certain nonseminomatous germ cell tumor [malignant teratoma undifferentiated (MTU) + seminoma, malignant teratoma intermediate (MTI)], but the overlap with the normal values was too big for PAPP-A to have any clinical significance. After orchidectomy or prostatectomy, PAPP-A decreased but the levels were were similar to those of normal men. In men, PAPP-A can be produced by certain nonseminomatous germ cell tumors, but its origin in disease-free males is probably not the testis or the prostate.

Tumor markers: value and limitations in the management of cancer patients

Sixteen tumor markers are reviewed, and measured to the ideal: produced by the tumor cell alone absent in health and in benign disease present in all patients with a given malignancy level in the blood representative of tumor mass detectable in occult disease. The only marker that approaches the ideal is human chorionic gonadotropin (HCG) in gestational trophoblastic tumors. In this malignancy, the HCG level suggests the diagnosis and stage, confirms response to therapy, and predicts relapse. The three most widely used and intensely studied tumor markers are carcinoembryonic antigen (CEA), alphafetoprotein (AFP), and HCG. CEA cannot be used in screening for cancer, but in carcinoma of the colon its elevation preoperatively increases the likelihood of advanced disease and postoperative recurrence. Postoperatively, elevated titers are often but not invariably associated with recurrent disease. AFP and HCG are useful in the management of nonseminomatous germ cell testicular tumors. Like CEA, they cannot be used for screening. They are more likely to be increased with advancing stage, and after therapy rising levels almost always mean recurrent disease. Some markers are valuable in specific circumstances, such as calcitonin in screening for familial medullary carcinoma of the thyroid. In multiple myeloma, immunoglobulins are useful in determining the tumor mass and response to therapy. In neuroblastoma, catecholamine metabolites are useful primarily in making the diagnosis. In some malignancies, the absence of effective therapy lowers the value of the marker, as for AFP in hepatoma. The remaining markers are too unreliable or too little studied to be useful in the management of an individual patient with cancer. The purpose of this paper is to provide the clinician with an understanding of the limitations of the present tumor markers that will lead to wiser use of the tests, and to provide standards to which future tumor markers should be measured.

Serum tumour marker regression rate following chemotherapy for malignant teratoma

The rate of fall of the serum tumour markers alphafetoprotein (AFP) and the beta sub-unit of human chorionic gonadotrophin (HCG) was analysed following platinum-based chemotherapy for metastatic non-seminomatous germ cell tumours. Of 90 evaluable patients 81% were alive and disease-free 1.5-4 yr (median 28 months) from the start of chemotherapy and 69 (77%) had remained continuously disease free. All three patients with an initial AFP half-life greater than 9 days relapsed; however, a further eight relapsing patients had an initial regression rate of serum AFP within the same range as patients remaining in remission (half-life 6-9 days). The HCG regression rate did not discriminate between patients remaining well or those who relapsed after chemotherapy. In 11 examples of a pattern of late slowing of the rate of marker fall (i.e. increasing half-life), five relapses were seen (45%), though this pattern was also observed in the context of large residual differentiated teratoma masses.

Non-seminomatous germ cell tumors of the testis. Analysis of CEA production in primary tumors and in retroperitoneal lymph node metastases after PVB chemotherapy

In the present investigation we compared CEA immunoperoxidase staining in testicular tumors (before PVB chemotherapy) and retroperitoneal tumors (after PVB chemotherapy) with CEA levels in the cyst fluid of retroperitoneal mature teratoma and in the patients' serum. CEA had no value as a serum tumor marker since serum CEA elevations were not associated with tumor activity. Only one elevated CEA level after chemotherapy was associated with bleomycin pneumonitis. Despite normal serum levels, CEA was localized immunohistochemically in yolk sac tumor and mature teratoma in the primary tumors and in retroperitoneal mature teratoma following PVB chemotherapy. The presence of CEA in cells lining cystic mature teratoma was associated with high CEA levels in the cyst fluid.

Correlation of serum tumor markers in advanced germ cell tumors with responses to chemotherapy and surgery

Remission rates induced by chemotherapy alone or by combined chemotherapy and surgery were analyzed in relation to specific serum tumor marker abnormalities immediately before treatment in 103 patients with Stage III or bulky Stage II nonseminomatous germ cell tumors. Complete remission occurred in 92% (12 of 13) of patients with normal levels of alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG), in 26% (6/23) with elevated AFP only, in 46% (13/28) with elevated HCG only, and in 39% (13/36) with abnormalities of both AFP and HCG. Patients with elevated AFP less frequently had a complete remission (CR) to chemotherapy (CR, 34% versus 61% with normal AFP), but benefitted from adjunct surgery (CR, up to 59%). Patients with very high (greater than 1000 ng/ml) serum AFP or HCG responded poorly to chemotherapy (CR, 17%) but especially large tumor burdens may have contributed to these unfavorable responses. Patients with both minimal and advanced metastatic disease had higher CR rates if they had serum tumor marker levels below rather than above 1000 ng/ml. Adjunct surgery eliminated the correlation between the "poor prognostic factors" associated with specific marker abnormality and an incomplete response to chemotherapy by rendering a significant number of such patients free of disease through resection of residual metastatic deposits.

Immunosuppressive acidic protein in patients with ovarian cancer

Serum immunosuppressive acidic protein (IAP) was determined in 63 patients with ovarian tumors (33 benign and 30 malignant) and 79 healthy female controls, and was examined as a marker for ovarian cancer in comparison with carcinoembryonic antigen (CEA). The mean value of serum IAP in patients with ovarian cancer (1085 +/- 474 micrograms/ml) was statistically higher than those of both benign tumors (394 +/- 93 micrograms/ml) and controls (298 +/- 92 micrograms/ml). Elevated levels of IAP and CEA were found in 93.3% and 30.0% of patients with ovarian cancer, respectively. There were three false-positive cases with IAP and two with CEA. Elevation of IAP was recognized in all cancer patients in Stage I, whereas 33.3% of these patients showed elevated CEA. The occurrence of elevated serum IAP was not affected by tumor histologic features. Serial IAP determination appeared to provide a useful follow-up marker in patients in whom CEA was low in value. The measurement of serum IAP is highly recommended as an addition to the conventional diagnostic methods.

Testicular germ cell neoplasms

Rapid progress in the management and treatment of testicular germ cell neoplasms has been made during the last 20 years. The development of sensitive radioimmunoassays for the serum tumor markers alpha-fetoprotein and the beta subunit of human chorionic gonadotropin has greatly aided in the diagnosis, staging, and treatment of nonseminomatous neoplasms. The development of effective combination chemotherapy for nonseminomatous germ cell tumors represents the major advance, and has changed a disease that formerly had a 75 percent two-year mortality to one with a 75 percent cure rate. Cis-platinum, vinblastine, and bleomycin have formed the basis of the most effective regimens. All patients should be treated with curative intent, preferably at an academic center by experienced medical oncologists. Toxicity, particularly myelosuppression, with effective regimens has been significant, but is manageable in most cases. If feasible, surgical removal of residual disease should be considered in patients failing to achieve complete remission with induction chemotherapy. Prognosis is poor for patients with remaining disease after chemotherapy and surgery, but some have been saved with VP-16-containing regimens. Most seminomas are curable with radiotherapy alone, but patients presenting with advanced disease (stages III and IV) should be treated initially with chemotherapy.

Suprasellar germinoma. Unresolved problems in diagnosis, pathogenesis, and management

A suprasellar germinoma, initially thought to be granulomatous diencephalitis of uncertain cause, responded following chloramphenicol and methicillin treatment both by clinical and radiographic criteria and was not diagnosed until a third biopsy was performed. Analysis of this case and review of the literature lead to the conclusion that adequate diagnostic workup of such lesions requires that biopsy be extensive enough to include the central core as well as the granulomatous reaction that surrounds such tumors. Furthermore, since the degree of inflammation may fluctuate, regression does not mean that the lesion is not neoplastic in origin. In the present instance, the correct diagnosis could have been made earlier if the beta-chain of human chorionic gonadotropin had been measured in spinal fluid.

Acute-phase reactant proteins and carcinoembryonic antigen in cancer of the colon and rectum

One hundred and twenty-eight patients bearing primary malignancies of the large bowel were studied to ascertain the value of acute-phase reactant proteins (serum protein hexose, ceruloplasmin, transferrin, alpha-1-antitrypsin, seromucoid and haptoglobin) either alone or in conjunction with carcinoembryonic antigen to accurately reflect the disease status of patients both before and after resection of their large bowel malignancy. The results indicate that acute-phase reactant proteins have a higher diagnostic rate for the presence of malignancy than does CEA. Estimation of the serum protein hexose alone is of greater diagnostic value than a combination of acute-phase reactant proteins. Furthermore, serum protein hexose and CEA are complementary and when combined will reflect the presence of malignancy in a greater number of patients than either one alone. Following resection of primary large bowel cancer, acute-phase reactant proteins are as accurate as CEA in evaluating the disease-free status of patients and furthermore when combined with CEA increased the predictive value for the detection of patients with recurrent disease.

Serum tumor markers in patients with metastatic germ cell tumors of the testis. A 10-year experience

The serum values of alphafetoprotein, human chorionic gonadotropin, lactate dehydrogenase, and carcinoembryonic antigen in patients with metastatic testicular cancer were reviewed for the period 1972 to 1982. All values were obtained before chemotherapy was begun. Elevated values of alphafetoprotein were present in 47 percent of patients tested, of human chorionic gonadotropin in 60 percent, of lactate dehydrogenase in 64 percent, and of carcinoembryonic antigen in 11 percent. The frequency of elevated values of alphafetoprotein, human chorionic gonadotropin, and lactate dehydrogenase decreased during the study period. Inverse relations between elevated values of alphafetoprotein, human chorionic gonadotropin, and lactate dehydrogenase and both complete remission rate and survival rate were noted in some of the chemotherapy trials. Carcinoembryonic antigen was believed not to be useful as a marker in this disease. It is concluded that assays of alphafetoprotein, human chorionic gonadotropin, and lactate dehydrogenase are important both clinically and prognostically in patients with testicular cancer.

Haemoglobin-F levels in urogenital cancers

The haemoglobin-F levels and F-cell numbers were assessed in 19 patients with different urogenital cancers. Alpha-fetoprotein (AFP), beta human chorionic gonadotrophin (beta HCG), total and prostatic acid phosphatase levels were also measured. HbF levels were found to be elevated in patients with testicular and prostatic cancer. No significant correlation was observed between HbF, AFP and beta HCG levels. The findings suggest that HbF production could be enhanced in patients with testicular and prostatic carcinomas and might be a useful marker to the disease activity.

Diagnosis and management of pineal tumors

The management of pineal region tumors remains controversial. Advocates of a conservative approach emphasize the excellent results of radiotherapy, particularly with germinomas, while a number of recent reports have demonstrated the safety of direct surgery. In order to improve treatment planning, attempts have been made to distinguish the various tumor types by computerized tomography (CT) and by the use of markers for germ-cell tumors. This paper reports a study of 35 patients with pineal tumors including two ectopic germinomas. Pretreatment CT was performed in all 35 patients, and human chorionic gonadotropin and alpha-fetoprotein levels were assayed in 11. Histological verification was available for 33 tumors; the other two were characterized by clinical and CT features plus tumor markers. Of the 27 tumor operations, 21 were for a pineal mass and six for ectopic germinoma or metastasis. There was no operative mortality. Morbidity was minimal, and surgery did not increase the incidence of subarachnoid seeding. Each histological type of tumor has a typical appearance on CT scanning, although, in the individual case, a firm diagnosis is not always possible. However, consideration of CT scans together with the clinical features, cerebrospinal fluid cytology, tumor markers, and (if there is still doubt) response to a small dose of irradiation will generally allow a specific diagnosis with a high degree of probability. In this way, germinomas may be selected for radiotherapy and the tumors less likely to respond may be subjected to primary surgery.

The detection and evaluation of human tumor metastases

Many biochemical indices are purported to have clinical utility in the detection and management of neoplasia. Experience gained during the past decade tends to indicate their having a more important role in the detection and monitoring of metastases than of the primary lesion. From this present review of some of the commoner human tumours, it is concluded that such marker substances are important adjuncts in the management of germ cell and certain endocrine and endocrine-related tumours. The carcinoembryonic antigen (CEA) provides a marker for many gastrointestinal cancers, but there are no presently available substances with clinical usefulness for either breast or lung neoplasms. Alternative approaches to the detection of metastases are also presented. The particular use of antibody probes at an immunohistochemical level has been claimed to be able to detect micrometastastic disease in bone marrow or tumour-related monoclonal antibody probes may have application to other cancers in the future.

alpha-Fetoprotein (AFP), human chorionic gonadotropin (HCG), and carcinoembryonic antigen (CEA) demonstrated in the immature glands of mediastinal teratocarcinoma: a case report

A 21-year-old man with mediastinal teratocarcinoma showed high levels of serum tumor markers: alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and carcinoembryonic antigen (CEA). After modified VAC chemotherapy (vincristine, dactinomycin, and cyclophosphamide), AFP and HCG levels in the serum were reduced significantly, while serum CEA increased gradually to the level of 6.5 ng/ml. Histopathologic study of the tumor obtained by surgical resection and autopsy revealed teratocarcinoma (a combination of embryonal carcinoma and teratoma). By the indirect immunoperoxidase technique, the antigens AFP, HCG, and CEA were stained in the immature glandular tissues of teratoma. By serial section of the tumor, the antigens tested were found in the same gland of the tumor. In addition, the tumor contained high levels of AFP (17353.8 ng/g.wt.), beta-HCG (beta-HCG) (125.05 ng/g.wt.), and CEA (11.37 ng/g.wt.).

Serum ferritin as a third marker in germ cell tumours

Serial measurements of serum ferritin have been assessed as an additional marker in a study of 12 patients with germ cell tumours. The standard markers, serum AFP and beta HCG, were also assessed serially. During treatment elevated levels of serum ferritin were detected in 10 patients, elevated AFP in 10 patients and elevated beta HCG in 6 patients. A poor prognosis was associated with persistently raised serum ferritin and either, or both, elevated AFP and beta HCG levels. Decreasing levels of serum ferritin indicated favourable response to treatment; rising values were associated with recurrence or dissemination of tumour. Even if serum ferritin cannot be classed specifically as a tumour product, it may be useful in the early detection of residual or recurrent tumour.

Cellular localization of AFP, hCG and its free subunits, and SP1 in embryonal carcinoma of the testis and ovary

An immunohistological study of AFP, hCG and its free subunits, and SP1 was investigated in 10 cases of non-seminomatous germ cell tumors of the testis and ovary. AFP was demonstrated in mononuclear embryonal tumor cells within embryonal carcinoma in a narrow sense, frequently in association with yolk sac tumor. AFP was more consistently demonstrated in vacuolated or elongated cells of yolk sac tumor, in which continuous transformation from tubular patterns of embryonal carcinoma was shown with positive reactions for AFP. The hCG was demonstrated in syncytiotrophoblastic giant cells scattered among the embryonal carcinoma, but rarely in mononuclear large cells. The occurrence of hCG and beta subunit was more frequently observed than a subunit or SP1, suggesting the unbalanced synthesis of hCG and free subunit in choriocarcinomatous element associated with embryonal carcinoma. These findings support the view that embryonal carcinoma has a developmental potential to the extra-embryonic components of both choriocarcinoma and yolk sac tumor.

Evaluation of PS beta 1G and other tumor markers in germ cell tumors of the testis

Pregnancy Specific beta 1 Glycoprotein (PS beta 1G), human choriogonadotropin (hCG), alpha foeto protein (AFP) and Carcino Embryonic Antigen (CEA) were assayed in 58 patients with active germ cell tumors and 20 patients in complete clinical and radiological remission. The markers were negative in all the cases in remission as well as in one case of pure teratoma. The positivity rate of the four markers together is 75%, which is better than for any marker alone. All the markers except AFP seem ubiquitous with respect to the histological classification. The highest positivity rate is obtained for hCG in all the histological types. PS beta 1G is related to hCG but its positivity rate is quite lower. AFP is mainly related to embryonal carcinoma but can be associated with any type of tumor except seminoma. CEA is less frequently positive, always associated with other markers and seems therefore useless for the diagnosis of germ cell tumors.

Tumor markers in advanced nonseminomatous testicular cancer

The serum levels of human chorionic gonadotropin (HCG), alphafetoprotein (AFP), lactic dehydrogenase (LDH), and carcinoembryonic antigen (CEA) were measured in 62 men with advanced nonseminomatous germ-cell testicular tumors. The HCG level was elevated in 64%, the AFP level in 67%, and the LDH level in 62%, including three of the six men with normal levels of the other two markers. At least one of these three markers was elevated in 91% of patients. Sustained or rising levels of HCG or AFP always were accompanied by persistent or recurrent tumor. Carcinoembryonic antigen was found not to be a useful marker in testicular cancer. Patients whose tumors contained yolk-sac elements always had elevated AFP levels, and patients with choriocarcinoma always had elevated levels of HCG. However, absence of these histologic types did not preclude elevations of the respective markers. Tumor markers are indispensable in the management of patients with testicular cancer, and several markers must be measured repeatedly if the greatest percentage of patients is to benefit.

Human chorionic gonadotrophin and alpha-fetoprotein in testicular germ cell tumours: a retrospective immunohistochemical study

A series of testicular germ cell tumours (46 seminomas and 27 non-seminomas) was studied immunohistochemically with regard to the presence of alpha FP and HCG. In three seminomas, HCG reactive syncitiotrophoblast-like giant cells (STLG) were found. Immunoreactive alpha FP did not occur in seminomas. In differentiated mature teratomas HCG or alpha FP could not be demonstrated. In embryonal carcinomas with or without teratoma (MTI/MTU/MTT) HCG immunoreactivity was found in 83%, usually localized in STLG. In 75% of these tumours alpha FP could be demonstrated. This protein was localized in foci of endodermal sinus or yolk sac differentiation, but also in single cells and cell clusters in areas of embryonal carcinoma. In some cases syncitial cells were present which contained both HCG and alpha FP. Immunostaining of tumour markers appeared not to provide important additional criteria for classification of these tumours in the currently available classifications. The significance of HCG containing STLG in seminomas deserves further investigation. Prospective studies of embryonal carcinoma with or without teratoma (MTI/MTU/MTT) will be necessary to evaluate the possible prognostic importance of the presence of alpha FP or HCG or both.

Detection of human chorionic gonadotropin in fresh and formalin-fixed testicular tumor tissue. Comparison of sensitivity of immunoperoxidase to radioimmunoassay

Immunmocytochemical techniques for the detection of human chorionic gonadotropin (HCG), such as immunoperoxidase or immunofluorescence, allow detection but not quantification of this hormone. A modification of standard radioimmunoassay (RIA) techniques allows utilization of tissue slurries and yields quantitative data on tissue HCG levels. Tissue slurry RIAs and indirect immunoperoxidase were performed on fresh and formalin-fixed tissue specimens from 15 patients with nonseminomatous testicular tumors. HCG detectability by RIA or immunoperoxidase was markedly decreased by formalin fixation. Tissue specimens with high levels of HCG in the fresh state yielded positive immunoperoxidase and RIA results, while specimens with minimally elevated HCG levels tended to be negative. Results of tissue slurry RIAs correlated well with immunoperoxidase results. The detection of HCG in fixed tissue appears to underestimate the amount of HCG present in fresh specimens. Therefore, a negative RIA on formalin-fixed tissue slurry or negative immunoperoxidase of the formalin-fixed, paraffin-embedded tissue does not rule out the absence of HCG in fresh tissue.

Clinical radioimmunodetection of cancer with radioactive antibodies to human chorionic gonadotropin

Injection of iodine-131-labeled goat immunoglobulin G antibody to human chorionic gonadotropin (hCG) into patients with hCG-secreting trophoblastic and germinal tumors permitted tumor detection and location by external gamma-ray scintigraphy. Excision of one of the metastatic tumors located by this method indicated a tumor/nontumor ration of 39.29. The method appears to offer a new clinical tool for precisely locating hCG-producing tumors in the body, even when tumor identification by other clinical methods has failed.

Circulating choriogonadotropin beta subunit in a patient with primary amenorrhea and embryonal ovarian carcinoma

A 20-year-old patient, phenotypically female, genotypically male, who had previously sought medical attention for primary amenorrhea, developed an embryonal carcinoma in the right gonad. Selective formation of the beta subunit of choriogonadotropin was demonstrated by positive test results on native serum and after gel filtration with a classical "beta-HCG" assay and a specific assay for the beta subunit, but negative results with a specific assay for choriogonadotropin. The concentrations of placental lactogen, alpha-fetoprotein and choriogonadotropin alpha subunit were normal. This case illustrates the necessity for early diagnosis of primary ovarian insufficiency in cases of primary amenorrhea. The results indicate that, for the detection of certain neoplastic disorders, the lower specificity of the choriogonadotropin assay introduced in 1972 by Vaitukaitis and coworkers [25]--reacting equally well with choriogonadotropin and with free beta subunit--may have advantages over the more specific assays for choriogonadotropin and for the beta subunit described by Franchimont et al. [8,28,29]. The availability of the latter assays, however, facilitates the identification of the immunoreactive material found with the former assay. The ambiguity of the present nomenclature for "beta-HCG" assay is pointed out.

Hemoglobin F production in testicular malignancy

The peripheral blood of 3 patients with testicular malignancy and elevated hCG levels was examined for Hb F production. Increases of percent chemically determined Hb F and/or F cell number were observed in each case when or soon after the hCG level was elevated. In these cases, Hb F production correlated with the degree of clinically evident malignancy. These observations suggest that the reactivation of Hb F synthesis may be applied to the evaluation of disease activity in patients with testicular malignancy.

Acclerated growth of testicular cancer after cytoreductive surgery

Surgical removal of bulky metastases of non-seminomatous germ-cell testicular cancer has been advocated as an adjuvant to chemotherapy in patients whose disease probably is too extensive to be cured by chemotherapy or surgery alone. However, in 8 of our patients, cytoreductive surgery was followed by a sudden and dramatic exacerbation of the disease. In some cases, a marked rise in the serum levels of alpha-fetoprotein and human chorionic gonadotropin was the only evidence. The cause and prevalence of such exacerbations are unknown. Cytoreductive surgery in patients with advanced testicular tumor is accepted treatment and should be advocated, but it appears that in some cases such surgery may adversely alter the course of the malignancy. This must be considered in planning treatment for patients with advanced disease.

Testis cancer: the pendulum swings. Experience in 430 patients

A review of 430 patients with testis cancer followed for at least 3 years is presented. A protocol for actinomycin D therapy before and after node dissection had been instituted in 1966. In the 58 protocol cases studied there appeared to be an increase in the survival of patients with stage A disease and a significant increase in the survival of patients with stage B disease. There was an improvement in the survival of patients with stage C disease treated with actinomycin D alone. Since 1976 all patients with stages B and C disease have been treated with multiple drug regimens, showing dramatic results. The therapy of testis tumors is multimodal, using lymphadenectomy, radiation therapy and chemotherapy, but the pendulum has swung so that chemotherapy has assumed the vital role in management.

Alphafetoprotein and human chorionic gonadotropin determination in cerebrospinal fluid. An aid to the diagnosis and management of intracranial germ-cell tumors

The cerebrospinal fluid (CSF) and serum of six patients with histologically verified intracranial germ-cell tumors were assayed serially for the presence of alphafetoprotein (AFP) and the beta subunit of human chorionic gonadotropin (HCG). Two patients had embryonal carcinomas, two had choriocarcinomas, and two had dysgerminomas. The marker profile for a given tumor in either CSF or serum correlated with the histological diagnosis; that is, embryonal carcinoma produced AFP and HCG, choriocarcinoma produced HCG, and dysgerminoma produced no markers. The marker levels in serum and CSF declined with therapy and rose usually prior to the development of overt clinical symptoms if the patient's tumor recurred. A CSF-to-serum gradient of the marker levels was present in three of four patients, and the serum levels were often normal when the CSF values were elevated. Ventricular marker levels were lower than the lumbar levels in two of two patients. The assay of these biological markers is a sensitive indicator of the success of therapy, and the presence of a CSF-to-serum gradient suggests that the major portion of the neoplasm rests within the central nervous system. A histological diagnosis can be inferred without the necessity of surgery in appropriate clinical contexts.