The unrecognized extragonadal germ cell cancer syndrome

CUP Syndrome-Metastatic Malignancy with Unknown Primary Tumor

BACKGROUND

2-4% of newly diagnosed cases of malignant disease involve cancer of unknown primary (CUP). This mixed entity is one of the 6 most common types of malignant disease in Germany. Highly refined treatment strategies can now be offered to patients with CUP.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed with an emphasis on articles from the past decade. The current guidelines and recommendations of specialty societies were also considered in the evaluation.

RESULTS

CUP most commonly manifests itself as metastases to the lymph nodes, lungs, liver, or bones. With the aid of imaging studies, including functional hybrid imaging and further medical examination, a primary tumor can be discovered in up to 40% of patients initially diagnosed with CUP. Immunohistochemistry guided by histomorphology often enables precise characterization of the lesion and can be supplemented, in selected cases, by molecular-genetic diagnostic evaluation. The most commonly detected types of primary tumor are cancers of the lung, pancreas, liver, and biliary system. For patients with local metastases, surgical resection or radiotherapy with curative intent is usually indicated, sometimes in the framework of a multimodal treatment concept. The median 2-year survival of patients with disseminated CUP is only 20%. For such patients, specific types of systemic therapy are recommended on the basis of the diagnostic characterization of the disease. Immune-modulatory antibodies can be effective, particularly in the treatment of CUP that has been characterized with biomarkers, but should still be considered experimental at present.

CONCLUSION

A combination of conventional and innovative diagnostic methods enables the provision of highly refined therapeutic strategies to patients with CUP who are undergoing treatment in interdisciplinary cancer centers.

Management of cancer from an unknown primary

Treatment of cancer is reliant on identifying the organ of origin. However, in a significant minority of cases, the primary site is never identified. This paper reviews the diagnostic work-up and therapeutic management for patients presenting with unknown primary cancer, including the role of tumour markers, conventional pathology and positron emission tomography imaging. It is important to identify atypical presentations of known tumour types, such as extragonadal germ cell tumours, lymphomas and breast cancer. The results from chemotherapy trials performed in patients with unknown primary cancer are summarised. Few trials have included > 100 patients, and most are non-randomised. There is no clear standard of care from the available data, and no trials of chemotherapy versus best supportive care have been performed. Platinum is the mainstay of treatment regimens, and from the regimens tested, a taxane seems to be among the best of the cytotoxics to combine with platinum in terms of both tolerability and efficacy. There is no data to favour a three-drug combination over a two-drug combination. To improve on existing treatment, molecular techniques may provide a means to identify the organ of origin, and/or to select appropriate targeted therapies. Further research is needed to improve knowledge on the biology of cancer from an unknown primary and to develop more effective treatment.

Cancer of unknown primary site: review of consecutive cases at the National Cancer Center Hospital of Japan

BACKGROUND

Cancer of unknown primary (CUP) is not a rare clinical entity, accounting for 3%-5% of all solid malignancies.

METHODS

We retrospectively reviewed 86 (38 male/48 female) patients with a diagnosis of CUP (exclusive of female patients with adenocarcinoma involving the axillary lymph nodes alone and patients with squamous cell carcinoma of the cervical lymph nodes) who were referred to the National Cancer Center Hospital between April 1996 and October 2002.

RESULTS

The median interval between the first visit to a local community hospital and referral to our hospital was 1 month (range, 1 to 45 months). The histological diagnosis was adenocarcinoma in 61 patients (71%), poorly differentiated carcinoma in 18 patients (21%), and squamous cell carcinoma in 4 patients (5%). Twenty-three female patients had peritoneal carcinomatosis of adenocarcinoma. Seventy-eight patients (91%) received platinum-containing chemotherapy. Sixty-one of the 86 patients (71%) were categorized as a subgroup of CUP without a specific therapy, and 55 of these 61 patients (90%) received platinum-containing regimens. The median survivals of all 86 patients and the 61 patients in the subgroup without a specific therapy in this series were 13 months and 11 months, respectively.

CONCLUSION

In this series, the survival of the patients in the CUP subgroup without a specific therapy did not seem worse than that in previous reports. Empirical chemotherapy with platinum-containing regimens may benefit some CUP patients in a subgroup without a specific chemotherapy.

Les carcinomes de primitif inconnu

PURPOSE

Carcinoma of unknown primary site is a common clinical syndrome, accounting for 2% of cancer patients. Diagnosis is a recurrent challenge for internists. Treatment is difficult and prognosis is still poor. This review presents one synthesis of diagnosis strategies and therapeutic trials. It envisages the interest of new molecular biology methods as well as therapeutic perspectives.

CURRENT KNOWLEDGE AND KEY POINTS

Pathologic examination completed with immunohistochemical tests, and, depending on cases, with electron microscopy, cytogenetics, and molecular biology is a key-point for diagnosis. Diagnosis work-up, based on histological type and on individualization of some clinical presentation, proceeds in three steps. Positron emission tomography is recommended when a curative treatment is planed, particularly in cases of isolated metastasis. Functional status analysed using the performance status and simple biologic parameters (serum lactate dehydrogenase, serum alkaline phosphatase) permit us to assess prognosis. Chemotherapy is offered for patients with a good general health status.

FUTURE PROSPECTS AND PROJECTS

Further evaluation of positron emission tomography, as well as cost-benefit analyses, is warranted. Further randomised trials are necessary to determine the optimal chemotherapy regimen in good-risk patients and the interest of chemotherapy in patients with poor-risk disease. Gene expression profiling and proteomic evaluation, as well as pharmacogenomic offer new investigation fields.

Chemotherapy for patients with two favourable subsets of unknown primary carcinoma: active, but how effective?

Carcinoma of unknown primary (CUP) is characterized by dismal patient survival. The outcome of patients with two favourable risk CUP subsets was studied. Eighty patients diagnosed with either midline lymph node metastases (n=33) or peritoneal carcinomatosis (n=47) were analysed retrospectively. The majority had poorly differentiated adenocarcinoma or undifferentiated carcinoma, treated with platinum-taxane based chemotherapy from 1996 till 2002. Females with peritoneal carcinomatosis also underwent surgical debulking. Objective tumour regression was present in 44% of patients (nodal group 30% versus peritoneal group 53%, p=0.066). Complete responses were seen more often in peritoneal carcinomatosis patients (nodal group 9%, peritoneal group 36%, p=0.008). At a median follow up of 60 months, median progression-free and overall survival were 5 and 10 months respectively in the nodal group, 7 and 15 months in the peritoneal group. Five-year survival was 7% (nodal group 0% vs. peritoneal group 10%, p=0.05). Complete responders fared better than non-CR patients. Fewer than four metastatic sites, elevated CA 125, and normal CA 19-9 levels were favourable prognostic factors for survival. Modern combination chemotherapy has satisfactory activity, with a minority of CUP patients enjoying long-term responses. Research efforts towards complete remission consolidation and molecular profiling are imperative.

Diagnostic and therapeutic management of cancer of an unknown primary

Metastatic Cancer of Unknown Primary Site (CUP) accounts for approximately 3% of all malignant neoplasms and is therefore one of the 10 most frequent cancer diagnoses in man. Patients with CUP present with metastatic disease for which the site of origin cannot be identified at the time of diagnosis. It is now accepted that CUP represents a heterogeneous group of malignancies that share a unique clinical behaviour and, presumably, unique biology. The following clinicopathological entities have been recognised: (i) metastatic CUP primarily to the liver or to multiple sites, (ii) metastatic CUP to lymph nodes including the sub-sets involving primarily the mediastinal-retroperitoneal, the axillary, the cervical or the inguinal nodes, (iii) metastatic CUP of peritoneal cavity including the peritoneal papillary serous carcinomatosis in females and the peritoneal non-papillary carcinomatosis in males or females, (iv) metastatic CUP to the lungs with parenchymal metastases or isolated malignant pleural effusion, (v) metastatic CUP to the bones, (vi) metastatic CUP to the brain, (vii) metastatic neuroendocrine carcinomas and (viii) metastatic melanoma of an unknown primary. Extensive work-up with specific pathology investigations (immunohistochemistry, electron microscopy, molecular diagnosis) and modern imaging technology (computed tomography (CT), mammography, Positron Emission Tomography (PET) scan) have resulted in some improvements in diagnosis; however, the primary site remains unknown in most patients, even on autopsy. The most frequently detected primaries are carcinomas hidden in the lung or pancreas. Several favourable sub-sets of CUP have been identified, which are responsive to systemic chemotherapy and/or locoregional treatment. Identification and treatment of these patients is of paramount importance. The considered responsive sub-sets to platinum-based chemotherapy are the poorly differentiated carcinomas involving the mediastinal-retroperitoneal nodes, the peritoneal papillary serous adenocarcinomatosis in females and the poorly differentiated neuroendocrine carcinomas. Other tumours successfully managed by locoregional treatment with surgery and/or irradiation are the metastatic adenocarcinoma of isolated axillary nodes, metastatic squamous cell carcinoma of cervical nodes, or any other single metastatic site. Empirical chemotherapy benefits some of the patients who do not fit into any favourable sub-set, and should be considered in patients with a good performance status.

Cancer from an unknown primary site

Cancer from an unknown primary site (CUP) is frequently encountered in clinical practice. This review is designed to help physicians identify those patients with CUP that benefit from specific therapeutic approaches. The utility of pathologic and diagnostic tests in patients with CUP will also be discussed, as will the prognosis and appropriate treatment of these patients.

Primary prostatic endodermal sinus tumor (yolk sac tumor) combined with a small focal seminoma

We report on a primary endodermal sinus tumor (EST) (yolk sac tumor) combined with a focal seminoma of the prostate occurring in a 24-year-old man. The prostate was widely infiltrated with neoplasms that penetrated the capsule and invaded into the bladder wall and urethra. Most areas of the tumor were composed of papillary and glandular epithelium in the fibrous or myxoid stroma. Schiller-Duval bodies and periodic acid-Schiff-positive hyaline bodies were focally present. In addition to yolk sac tumor, solid nests of seminoma were found in some areas. Immunohistochemistry using specific antibodies for alpha-fetoprotein and cytokeratin showed positive reaction on the EST portion, and placental alkaline phosphatase revealed positive staining in the seminoma portion and a part of EST. Tumor cells exhibited negative staining for prostate-specific antigen, prostatic acid phosphatase, carcinoembryonic antigen, vimentin, chromogranin A, and human chorionic gonadotropin. Despite radical surgery and ordinary cisplatin-based chemotherapy, the patient died 8 months after operation. At autopsy, only EST elements had metastasized to the lungs, liver, and brain, and no tumors were found in either testis. To our knowledge, this is the first reported case of a primary EST combined with a focal seminoma in the prostate.

Prognostic stratification in UPC: a role for assessing the value of conventional-dose and high-dose chemotherapy for unknown primary carcinoma

High-dose chemotherapy has been advocated by some investigators as a means to circumvent drug resistance, thereby improving treatment results in patients with solid tumors. For patients with unknown primary tumors, this hypothesis has only recently undergone limited testing. Two groups (one from the USA and one from Europe) have published their experience with higher doses of chemotherapy in the treatment of UPC. The results are not superior to those reported by other investigators using more standard doses of chemotherapy. Most importantly, chemotherapy trials for UPC are usually conducted in small populations made up of heterogeneous patient subsets with varying sensitivity to chemotherapy. It seems likely that progress in the management of patients with unknown primary cancers will occur as a result of efforts to improve the understanding of the natural history of this disease coupled with the assessment of novel agents targeted against specific biochemical abnormalities that will be demonstrated to be important in the development and maintenance of these malignancies.

Treatable subsets in cancer of unknown primary origin

The purpose of this study was to investigate the treatable subsets in cancer of unknown primary origin (CUP). Fifty patients (27 males and 23 females; median age, 53 years) with CUP diagnosed between April 1992 and June 1999 were analyzed retrospectively. Of the 50 patients, 39 received chemotherapy: platinum-based in 31, non-platinum-based in 4, and clinical trials of new agents in 4. Of the 39 patients, 13 (33.3%; 95% confidence interval: 19.1 - 50.2%) showed objective responses, with 4 complete responders. Patients with poorly differentiated carcinomas in whom beta-subunit of human chorionic gonadotropin (beta-HCG) was elevated more than 10 mIU / ml and female patients with peritoneal adenocarcinomatosis achieved high response rates (83.3% and 80%, respectively) with platinum-based chemotherapy, as compared with only a 15.3% response rate in the remaining patients. Platinum-based chemotherapy provided promising results in patients with poorly differentiated carcinomas and in female patients with peritoneal adenocarcinomatosis. Significantly elevated serum levels of beta-HCG in patients with poorly differentiated carcinoma might predict a better response to platinum-based chemotherapy. However, the investigation of novel chemotherapeutic approaches is warranted for other groups of patients with CUP.

Carcinoma of an unknown primary site: a chemotherapy strategy based on histological differentiation--results of a prospective study

BACKGROUND

To evaluate the efficacy and toxicity of a chemotherapy strategy based on histological differentiation, for patients with carcinoma of unknown primary site.

PATIENTS AND METHODS

Forty-eight patients were prospectively included in the trial. Thirty patients with poorly-differentiated carcinoma or poorly-differentiated adenocarcinoma (group A) received a combination of cisplatin and etoposide. Patients with a responsive or stable disease after two cycles received the same regimen plus bleomycin, ifosfamide and G-CSF. Eighteen patients with well- or moderately-differentiated carcinoma (group B) received cisplatin, continuous infusion 5-fluorouracil (5-FU) and alpha-interferon. Treatment was maintained in case of response or stable disease for up to six cycles.

RESULTS

The overall response rate (RR) for the entire group is 43% (95% confidence interval (CI): 35.9%-50.1%): seven CR and five PR in group A (RR = 40%) and six CR and two PR in group B (RR = 44%). Grade 4 leucopenia was observed in 22 (46%) patients and sepsis in 3 (6%). Median survival is 9.4 months (range 5-13.7 months) and 16.1 months (range 11.8 20.3 months), respectively.

CONCLUSIONS

This chemotherapy strategy is one way to achieve high response rates, particularly for patients with well- or moderately-differentiated adenocarcinoma usually considered poorly chemosensitive.

A phase I/II study of leucovorin, carboplatin and 5-fluorouracil (LCF) in patients with carcinoma of unknown primary site or advanced oesophagogastric/pancreatic adenocarcinomas

Carcinoma of unknown primary site (CUPS) accounts for 5-10% of all malignancies. Forty patients with metastatic CUPS or advanced oesophagogastric/pancreatic adenocarcinomas were recruited. Eligibility included ECOG performance status 0-2, minimum life expectancy of 3 months and measurable disease. The regimen consisted of bolus intravenous 5 fluorouracil (5-FU) and leucovorin (20 mg m-2) days 1-5 and carboplatin (AUC5) on day 3. The leucovorin/carboplatin/5-FU (LCF) was repeated every 4 weeks. The starting dose of 5-FU was 350 mg m-2 day-1 with escalation to 370 and then 400 mg m-2 day -1 after the toxicity at the previous level had been assessed. The maximum tolerated dose (MTD) was defined as the dosage of 5-FU that achieved 60% grade 3/4 toxicity. In addition, objective and symptomatic responses, quality of life and survival were assessed. The MTD of 5-FU in the LCF regimen was 370 mg m-2. The predominant toxicity was asymptomatic marrow toxicity. The 350 mg m-2 level was then expanded. There were two toxic deaths due to neutropenic sepsis, one at 370 mg m-2 after one course and one at 350 mg m-2 after four courses. The objective response rate was 25% with one complete response (CR) and nine partial responses (PRs). The median duration of response was 3.4 months (range 1-10). The CR and eight of the nine PRs were in CUPS patients. Twelve patients developed progressive disease on LCF. Median survival for all 40 patients was 7.8 months (10 months median survival for those treated at 350 mg m-2). The majority of patients described a symptomatic improvement with LCF chemotherapy. The recommended dose of 5-FU for future studies is 350 mg m-2 combined with leucovorin 20 mg m-2 and carboplatin (AUC5).

Elevated germ cell markers in carcinoma of uncertain primary site do not predict response to platinum based chemotherapy

We carried out a retrospective review of the medical records of patients with metastatic carcinoma of unknown primary and either raised alpha fetoprotein (AFP) or beta human chorionic gonadotrophin (beta HCG) over a period of 6 years at three teaching hospital oncology units to assess response to platinum based chemotherapy. 15 patients were identified who fitted these criteria. Of these, 3 received no treatment because of poor functional status, 2 patients received only radiotherapy for symptomatic disease and died within 3 months of diagnosis and 1 patient died 2 weeks after diagnosis having received his first cycle of cisplatin-based chemotherapy. 9 patients received at least 2 cycles of chemotherapy. A complete tumour response was seen in only one patient who presented with midline lymphadenopathy and remains disease-free 46 months after treatment. This presentation was consistent with disease already known to herald platinum sensitivity. In the other 8 patients, there was only one partial response that lasted 2 months. The median survival for this group of 9 patients was 4.5 months (range 3 to > 46 months). Our data do not support the postulate that elevated germ cell markers in patients with carcinoma of unknown primary predict a response to cisplatin based chemotherapy.

Primary pulmonary germ cell tumor with blastomatous differentiation

We describe the clinical and pathologic findings of a patient with mixed blastoma-germ cell malignancy primary in the lung. Serum alpha-fetoprotein levels were elevated at presentation, and normalized with anti-germ cell chemotherapy. The resection specimen contained massively necrotic germ cell tumor with viable mature neural tissue, plus viable biphasic blastoma with stromal bone and skeletal muscle differentiation. It is not clear whether the germ cell component represents unusual differentiation of a somatic cell line or whether the blastoma component represents an unusual pattern of teratomatous differentiation.

Competitive in situ hybridization in a mediastinal germ cell tumor

We performed competitive in situ hybridization in a mediastinal germ cell tumor to identify chromosome 12 aberration(s). DNA from a mouse-human somatic hybrid cell line, containing an i(12p) as unique human material, was labeled and used as a probe. Our results confirm that the chromosome marker, observed in mediastinal germ cell tumor and cytogenetically identified as i(12p), is a true isochromosome of the short arm of chromosome 12.

Surgical and medical management of germ cell tumors of the chest

Germ cell tumors are highly curable when treated appropriately. The majority of germ cell tumors arise in the testes, with a proportion having pulmonary parenchymal or mediastinal metastases. For patients who have such tumors, prompt diagnosis and treatment with chemotherapy are essential. A subset of these patients will have persistent radiographic abnormalities after chemotherapy and will benefit from post-chemotherapy resection of residual masses. These patients need to be distinguished from those who should be observed and those who require further chemotherapy. A small proportion of patients with germ cell tumors will present with tumors arising in the mediastinum. Prompt diagnosis, with adequate tissue for histopathologic and immunohistochemical staining, is essential. Primary therapy for such patients should be chemotherapy, except for some patients with mediastinal seminomas in whom radiotherapy is preferable. Mediastinal nonseminomatous germ cell tumors have a poor prognosis due, in part, to their bulk and relative chemosensitivity, but also due in part to their association with non-germ cell elements and acute leukemia. Proper coordination of the different modalities is essential in optimizing the cure rate of patients with these tumors.

Subsets of tumors responsive to cisplatin or carboplatin combinations in patients with carcinoma of unknown primary site. A Hellenic Cooperative Oncology Group Study

In this retrospective analysis 48 patients with metastatic undifferentiated carcinoma, adenocarcinoma and epidermoid carcinoma of unknown origin were studied. The purpose of this analysis was to evaluate both the response rate and the toxicity of combination chemotherapy containing cisplatin or carboplatin, and to attempt to identify certain clinical subsets of patients sensitive to these drugs. Four patients were not evaluable and 13 (29.5%), eight of the 34 treated with regimens containing cisplatin and 5/14 with carboplatin-based chemotherapy, responded to treatment. Six of the 23 with undifferentiated tumours, 4/17 with adenocarcinomas and 3/8 with epidermoid cancers responded to chemotherapy. Four of 6 women with adenocarcinoma of the peritoneal cavity, 5/11 with undifferentiated carcinomas with midline distribution and 3/5 with epidermoid carcinomas of the cervical nodes responded. Seven patients achieved complete and six partial remissions. The mean duration of response was nine months; a number of patients enjoyed prolonged and/or durable remissions. Toxicity was tolerable. We conclude that: (a) both cisplatin and carboplatin are active agents in this syndrome with one-third of the evaluable patients responding, and (b) there may be chemosensitive subgroups, such as patients with peritoneal adenocarcinomatosis, undifferentiated carcinoma with midline distribution and metastatic epidermoid carcinoma of the neck nodes. The effectiveness of carboplatin in these patients and the responsiveness of metastatic epidermoid carcinoma of unknown origin have not been adequately dealt with in the literature.

Does extragonadal presentation impart a worse prognosis to abdominal germ-cell tumours?

The prognostic significance of extragonadal rather than gonadal presentation of germ-cell tumour in 51 patients presenting between 1979 and 1988 with abdominal tumours was compared with that of 51 control patients with testicular primary tumours matched for bulk fo disease, serum tumour marker concentration, age and year of treatment. Very large volume tumour was found at initial staging in 24 extra-gonadal cases (47%) and high tumour markers in 29 (57%). Actuarial survival at 2 and 5 years was 82% and 70% for cases and 78% and 63%, respectively, for controls. These outcomes were not significantly different and the relative hazard of death for cases compared with controls was 0.7 (95% confidence intervals 0.3-1.5). Thus the presentation of germ-cell tumours with a retroperitoneal mass does not itself adversely influence prognosis compared with testicular presentation with equivalent disease extent. However it is rare for extragonadal presentation to be associated with small volume disease.

Human chorionic gonadotropin and related glycoprotein hormones in lung cancer cell lines

Twenty-five non-small cell lung cancer (NSCLC), 42 small cell lung carcinoma (SCLC), one extrapulmonary small cell carcinoma, 4 carcinoid, and 13 non-lung cancer cell lines were analyzed for human chorionic gonadotropin (HCG) and related glycoprotein hormones. HCG or its subunits were present in 72% of NSCLC, 10% of SCLC, one extrapulmonary small cell carcinoma, 3/4 carcinoids and 2/13 non-lung cancer cell lines. Related glycoprotein hormones were undetectable. These data indicate a frequent production of HCG or its subunits by NSCLC cell lines and cell lines from tumors with carcinoid features. They confirm the clinical inclusion of carcinoids under the broad category of NSCLC rather than SCLC despite their neuroendocrine features. Clinicians should not assume that undifferentiated NSCLC with HCG production represent germ cell tumors.

The role of etoposide in the treatment of poorly differentiated carcinoma of unknown primary site

Patients with poorly differentiated carcinoma (PDC) or poorly differentiated adenocarcinoma (PDA) of unknown primary site comprise 25% to 35% of the patients with carcinoma of unknown primary site. Some of these patients have neoplasms that are highly responsive to combination chemotherapy, and a minority have potentially curable tumors. Between 1978 and 1982, 68 patients were treated with combination chemotherapy (most received cisplatin, vinblastine, and bleomycin [PVB] with or without doxorubicin). Thirty-eight patients (56%) responded to treatment, with 15 (22%) complete responder (CR) and 9 (13%) long-term, disease-free survivors. Since that time, we have incorporated etoposide into the treatment of these patients because of its synergism with cisplatin and its great activity against several other neoplasms, including germ cell tumors. Seventeen patients with PDC of unknown primary site received salvage therapy with etoposide and cisplatin after failing PVB. Ten of these patients had partial responses (PR), with a median response duration of 5 months (range, 2 to 12 months). Thirty-two previously untreated patients with PDC received etoposide and cisplatin combinations as initial treatment. Eighteen of 30 evaluable patients (60%) responded to therapy, and 11 patients (37%) had CR. Seven patients remain disease-free 39 to 63 months after the completion of therapy. Etoposide is an active drug in the treatment of PDC of unknown primary site. Preliminary results indicate that initial treatment with etoposide and cisplatin combinations produces results equivalent to or superior to those achieved with PVB.

Primary pulmonary alpha-fetoprotein-producing malignant germ cell tumor

We are reporting the clinical and pathologic features of a primary, pulmonary, malignant germ cell tumor associated with a marked elevation of serum alpha-fetoprotein (38,427 ng/mL) and lactate dehydrogenase activity (756 U/L), in a 26-year-old female. This controversial, rare neoplasm has not been extensively discussed in the pathology literature. We emphasize the clinical importance of establishing this diagnosis in view of the favorable response to chemotherapy shown by malignant germ cell tumors.

Empiric chemotherapy in patients with carcinoma of unknown primary site

Analysis of the results of chemotherapy in patients with carcinoma of unknown primary site is complicated by the small sizes of most treatment series and patient heterogeneity. Careful evaluation of clinical and pathologic information may identify patients with a relatively high likelihood of response to systemic therapy. This includes patients in whom immunohistochemical studies or electron microscopy, or both, suggest a likely tumor type responsive to systemic therapy, such as prostate cancer, lymphoma, or a neuroendocrine tumor. Clinical evaluation can also identify potentially responsive patients, particularly those with clinical features in common with the extragonadal germ cell tumor syndrome. For patients who do not fit into these more treatable categories, most combination chemotherapy programs have response rates of less than 30% and median survivals of less than one year. Randomized trials have not established any clearly superior chemotherapy program. Regimens containing both Adriamycin (doxorubicin) and mitomycin-C produce response rates of approximately 25% but are associated with the possibility of severe hematologic toxicity, and rarely a syndrome resembling the hemolytic-uremic syndrome. The choice between chemotherapy and supportive care only must be individualized, and the latter option is appropriate for many patients. More detailed clinical and pathologic analyses in conjunction with clinical trials, particularly employing newer diagnostic techniques, are vital to provide better prospective data from which to identify relevant clinical subsets that allow an estimate of an individual patient's likelihood of response and the suitability of systemic chemotherapy.

Isochromosome 12p in mediastinal germ cell tumor

The occurrence of an i(12p) in an extragonadal mediastinal germ cell tumor indicates that this chromosome change, which is characteristic for testicular germ cell tumors, can also occur in germ cell tumors present elsewhere in the body. In addition, the karyotype in this patient was near-diploid, in contrast with testicular germ cell tumors, which as a rule are near-triploid or near-tetraploid.

Primary malignant mediastinal germ cell tumors: a study of eleven cases and a review of the literature

From 1957 to 1988 eleven cases of primary mediastinal germ cell tumor were referred to the Peter MacCallum Cancer Institute (PMCI). Four were seminomas, three were mixed germ cell tumors, two were embryonal carcinomas and two were teratocarcinomas. Two of the eleven patients were female. For seminoma, surgical debulking and post-operative irradiation produced the best results. Mediastinal doses ranged from 30 to 37.5 Gy. Local control was achieved in all cases; two patients survive disease-free. The non-seminomatous germ cell tumors showed a significantly poorer survival with only one of seven patients remaining alive in remission at 15 months. One other case of non-seminomatous tumor remains alive but in relapse at 23 months. Attention is focused on the anterior position of primary germ cell tumors in the mediastinum. A review of the literature is presented.

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.

Experience with the management of primary endodermal sinus tumor of the mediastinum

Ten male patients with extensive primary endodermal sinus tumor of the mediastinum were treated with chemotherapy (with or without surgical excision and radiation therapy) between 1977 and 1985. Three patients, treated with cyclophosphamide-vincristine-based chemotherapy, died 1.5, 2.5, and 6.0 months, respectively, after initial diagnosis. Of the seven patients treated with cisplatin-based chemotherapy, one patient died of septicemia at 2.5 months after diagnosis and was disease-free at autopsy examination. Three other patients died of progressive disease at 7.0, 13.0, and 14.0 months, respectively. The three survivors remain alive at 17.0, 31.0, and 40.0 months from diagnosis; all are without evidence of disease. Of the three patients who underwent excision of the residual mediastinal tumor after cisplatin-based chemotherapy, persistent local disease was found in two patients. One of these two patients died of recurrent disease. All surviving patients had surgical resection of the tumor either before or after cisplatin-based chemotherapy, with or without radiotherapy and the timing of therapeutic interventions was guided by changes in the serum alpha-fetoprotein concentrations after initial therapy and during follow-up. Our experience suggests that the optimal management of patients with primary mediastinal endodermal sinus tumor requires an aggressive multidisciplinary approach guided by the extent of the tumor and the serum tumor marker levels.

[Primary mediastinal seminoma]

Primary mediastinal seminoma is an uncommon lesion and should be included in the differential diagnosis of mediastinal tumors. Symptoms and signs may not be clear and in most cases the diagnosis is made by sternotomy or thoracotomy. Our recommendation is that patients with primary mediastinal seminoma should undergo curative resection or reductive surgery. Curative resection should be followed by radiation therapy. Chemotherapy with cisplatin-containing combinations should be reserved for patients who have metastases at the time of diagnosis.

Bone disease in testicular and extragonadal germ cell tumours

Of 297 patients with metastatic testicular and extragonadal germ cell tumours (GCT), bone involvement was detected clinically in 3% (7/251) of those at first presentation and in 9% (4/46) of relapsed cases. This difference was not statistically significant (95% confidence limits -2%; +14%). Concurrent systemic metastases, commonly involving lung (7/11 cases) and para-aortic lymph nodes (6/11), were present in all patients with bone disease. All affected patients had localized bone pain and lumbar spine was the most frequent site involved (9/11). Spinal cord compression occurred in two patients while a third developed progressive vertebral collapse after chemotherapy and required extensive surgical reconstruction. At median follow-up of 4 years, survival among patients presenting with bone disease (6/7) was similar to overall survival in the whole group (84%) and appeared better than in those with liver (18/26, 69%) or central nervous system (6/9) metastases at presentation. Back pain in metastatic germ cell tumours is often due to retroperitoneal lymphadenopathy but lumbar spine osseus metastases must be recognized early if severe potential complications, such as spinal cord compression, are to be avoided. In this series, bone metastases were not seen in the absence of widespread systemic disease suggesting all solitary bony lesions in GCT patients should be biopsied.

Successful resection of alpha-fetoprotein-producing lung cancer

We present a case of successfully resected alpha-fetoprotein (AFP)-producing primary lung cancer. AFP in the serum decreased from 289 ng/ml to an undetectable level after a curative operation. The resected tumor was stained positively by the immunohistochemical study for AFP. The histologic appearance of the tumor was well-differentiated adenocarcinoma similar to that of fetal gut epithelium and apparently different from extragonadal germ cell tumor. This case provides evidence that lung cancer cells possess the potential to produce AFP.

Metastatic cancer with unknown primary

Close cooperation between an experienced pathologist and oncologist is essential in the management of patients with unknown primary carcinoma. A comprehensive pathological examination is crucial and, with undifferentiated tumors, this will include immunohistology and/or electron microscopy. Ample properly processed tissue therefore must be provided. Time-consuming and costly radiographic and imaging studies should be avoided. No matter how extensive the evaluation, in a majority of cases, the primary site will never be found, so a selective search for treatable tumors is most appropriate and cost-effective. With adenocarcinomas, this will include prostate, breast, and ovary; for undifferentiated tumors, small cell bronchogenic carcinoma, lymphomas, and germ cell tumors. Table 4 summarizes recommended studies for diagnosing unknown primary undifferentiated or adenocarcinomas. Women with adenocarcinoma in axillary nodes without a primary site should be treated as having breast cancer. Estrogen and progesterone receptor assays are to be obtained on the axillary biopsy. High and midcervical nodes with metastatic squamous cell carcinoma can be treated effectively and, not infrequently, cured with surgery and radiation therapy, even if the primary site never is detected. If doubt remains, treatment should be selected that offers the best chance of significant palliation or cure--for example, cisplatin-based chemotherapy in possible extragonadal germ cell tumors.

An Unusual Case of Primary Hormone-Secreting Germ Cell Tumor of the Retroperitoneum

An unusual case of primary retroperitoneal germ cell tumor is presented. Criteria for considering such a diagnosis in patients with apparent poorly differentiated carcinomas are discussed. An interesting hypothesis is presented to explain the hormonal abnormalities observed.

Late recurrence of a seminoma

We report a case of an extragonadal mediastinal seminoma that recurred almost 19 years after successful initial remission had been achieved with actinomycin D and chlorambucil. Treatment of the recurrence consisted of excision of a single involved supraclavicular lymph node followed by combination chemotherapy with cis-platinum, vinblastine and bleomycin. The patient has remained free of residual disease for 3 years. To our knowledge this case represents the longest reported interval to recurrence for a germ cell neoplasm.

Endodermal sinus tumor of the mediastinum. A report of seven cases and review of the literature

Primary mediastinal endodermal sinus tumor is rare, and to date only 49 cases have been described in the English-language literature. Seven new cases are reported. Light microscopic examination showed characteristic features including papillary, reticular, tubular and solid growth patterns, complete or incomplete Schiller-Duval bodies and intracellular or extracellular periodic acid-Schiff-positive material. Immunohistochemical studies showed alpha-1-antitrypsin in seven, alpha-fetoprotein in seven, keratin in six, and carcinoembryonic antigen in four cases. The beta subunit of human chorionic gonadotropin, albumin, fibronectin, and transferrin were not found in any case. Electron microscopic studies performed in four cases showed intracellular and extracellular basement membrane-like material, multiple large multivesicular bodies, desmosomes and microvilli. Mediastinal endodermal sinus tumor can and must be differentiated from poorly differentiated adenocarcinoma metastatic or extending to the mediastinum because of the distinctly different prognoses and therapies. In spite of modern chemotherapy, the prognosis of mediastinal endodermal sinus tumor remains poor. The single most important prognostic indicator is whether the tumor mass can be completely excised before or after chemotherapy.

Primary nonseminomatous germ cell tumor of the prostate

We describe a case of a primary nonseminomatous germ cell prostatic tumor and discuss the problem of extragonadal germ cell tumors. Prognosis, staging and management of these tumors are similar to that of metastatic primary testicular germ cell tumors.

Human chorionic gonadotropin production by colon carcinoma. Biochemical heterogeneity and identification of a chemotherapy-sensitive cell subpopulation

Human chorionic gonadotropin (hCG) is produced and secreted by a wide variety of human neoplasms and represents one example of biochemical heterogeneity in tumors. The authors report two patients with advanced hCG-producing colon carcinomas in whom immunohistochemical staining demonstrated a distinct hCG-producing cell subpopulation. Both patients had objective tumor responses when treated with chemotherapy effective against germinal neoplasms. Responses were characterized by prompt and substantial reduction in plasma hCG levels and by improvement in clinical status, radiographic tumor measurements, and other biochemical abnormalities. These epithelial carcinomas responded to chemotherapeutic agents that are usually ineffective, and striking chemosensitivity was observed in the hCG-producing cell subpopulation. These two cases provide initial evidence that hCG-producing cells are sensitive to certain chemotherapeutic agents even when they are a part of common epithelial somatic tumors, and that this sensitivity represents another type of heterogeneity in human tumors. The identification of hCG production in epithelial tumors may be important in determining therapeutic strategy.