Serum AFP, hCG and CEA in the management of patients with testicular, ovarian and extragonadal germ cell tumors.

Serum levels of AFP, hCG and CEA were initially and serially measured in 59 patients with testicular germ cell tumors, and serially in 37 with ovarian and 3 with extragonadal germ cell tumors. Patients with seminoma/dysgerminoma or mature teratoma had normal serum AFP and sporadically slightly elevated hCG. Some patients with embryonal carcinoma, pure or with admixture of seminoma, had serum AFP elevated to maximum 100 U/ml, yet its use for monitoring therapy was limited. Patients with yolk sac tumors had elevated AFP and sometimes CEA levels, those with choriocarcinoma had elevated hCG, and those with compound tumors had one or more of the markers highly elevated. High AFP and/or hCG levels indicated the presence of the relevant tumor cells both in the primary and in residual tumor and/or metastases, also those missed in histological material, and thus were useful in restaging. Unfortunately, their absence in serum did not exclude the presence of marker-negative subpopulations of tumor cells. Changes in marker values paralleled the effects of treatment: the level increasing from any nadir heralded recurrence in patients in remission; elevated or increasing levels during therapy implied resistance to the therapy; decreasing levels indicated regression even though a return to the normal range did not mean eradication of all tumor cells.     

Carcinoembryonic antigen levels in germ cell tumours

Elevated serum carcinoembryonic antigen (CEA) prior to specific treatment was noted in 3% (7/258) of assessable patients with testicular, extragonadal or ovarian germ cell tumours (GCT). In addition, persistently raised CEA was documented in 7% (26/385) of patients during or after cisplatin-based chemotherapy for metastatic GCT. Raised CEA did not appear associated with adverse prognosis. Among patients undergoing resection of residual tumour masses post-chemotherapy, 8 of 36 with mature differentiated teratoma excised had raised CEA compared with only one of 39 patients where no mature teratoma was found. However, CEA levels remained elevated in 6 of the 8 cases despite apparent complete resection of mature teratoma. Elevated CEA in treated GCT patients may be caused by hepatotoxicity from chemotherapy, intercurrent diseases, or other unknown factors. History of cisplatin-based chemotherapy may be a confounding factor in interpreting raised CEA levels. CEA measurements do not help in the management of patients with germ cell tumours.     

Radioimmunotherapy trials in germ testicular carcinoma: a phase I study

Two patients with germ cell testicular cancer were submitted to radioimmunotherapy (RIT) by using the monoclonal antibody 131I-radiolabelled (MoAb) H17E2, raised against placental alkaline phosphatase (PLAP). Both patients had been previously treated with repeated chemotherapy regimens assisted by autologous bone marrow transplant (ABMT), that, in the end were unsuccessful, thus necessitating further experimental treatment. RIT was well tolerated and the targeting of multiple neoplastic lesions was satisfactory. Nevertheless, the clinical results of treatment were minimal owing to the extension of the tumour. The data obtained suggest the possibility of applying this form of treatment in patients with minimal residual disease after previous traditional chemotherapy regimens.     

A case of central nervous system atypical teratoid / rhabdoid tumor

The atypical teratoid / rhabdoid tumour is a rare type of tumours of central nervous system appearing usually under 2 years of age, bearing a rather bad prognosis and it may cause serious differential diagnostic problem. The tumour is characterized histologically by the presence of the rhabdoid cells, immunohistochemically by vimentin, SMA, EMA positivity, the frequent presence of cytokeratin, GFAP positivity, but germ cell markers: AFP, hCG negativity, cytogenetically by aberrations of chromosome 22. The case of a one and half month old female infant is presented, who died 8 months after the appearance of the first symptoms. The diagnostic possibilities and the unsolved problem of the therapy are discussed.     

Serum and cerebrospinal fluid human chorionic gonadotropin (hCG) and alpha-fetoprotein (AFP) in intracranial germ cell tumors

We report a retrospective study on serum and cerebrospinal fluid (CSF) alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (betahCG) determination in a series of 30 patients bearing intracranial germ cell tumors. At diagnosis five patients had high serum and CSF AFP levels. No patient had positive serum AFP and negative CSF AFP or vice versa. Twelve of 30 patients had serum betahCG levels above 5 mlU/mL, eight had high betahCG only in CSF, and ten were completely negative. During treatment and follow-up both markers were accurate indicators of the response to therapy, decreasing rapidly and often becoming normal already after the first phase of treatment. We conclude that these two markers, and mostly betahCG, may be useful in the diagnosis and monitoring of the response to therapy of patients with intracranial germ cell tumors.     

Alpha-fetoprotein concentrations measured by radioimmunoassay in diagnosing and excluding hepatocellular carcinoma.

Serum alpha-fetoprotein (AFP) concentrations were estimated by sensitive radioimmunoassay in 30 patients with cirrhosis complicated by hepatocellular carcinoma and in 100 patients with cirrhosis in whom malignancy was excluded. Twenty-nine of the 30 patients with hepatocellular carcinoma had concentrations above 10 IU/ml (10.5 ng/ml) (median 3500 IU/ml (3675 ng/ml)), whereas only one of the 100 patients with cirrhosis and no tumour development had a raised concentration. Eleven out of 20 patients in whom hepatocellular carcinoma had developed in an apparently normal liver had raised AFP concentrations. In this group the differential diagnosis is usually secondary carcinoma, and three of 50 such patients had AFP concentrations above 10 IU/ml. Noting raised AFP concentrations is thus of considerable value both in detecting and in excluding hepatocellular carcinoma in cirrhosis, for in this case such concentrations gave only 1% false-positive and 3% false-negative results. They are less useful, however, in distinguishing between primary tumours arising in patients without cirrhosis and secondary hepatic deposits, giving 6% false-positive and 45% false-negative results.     

Fine needle aspiration cytology in ovarian lesions: an institutional experience of 584 cases

N. Gupta, A. Rajwanshi, L. K. Dhaliwal, N. Khandelwal, P. Dey, R. Srinivasan and R. Nijhawan
Fine needle aspiration cytology in ovarian lesions: an institutional experience of 584 cases Objective: To assess the diagnostic value of fine needle aspiration cytology (FNAC) in ovarian lesions. Methods: This was a retrospective study of ultrasound‐guided (US) FNAC of 584 ovarian lesions from January 1998 to July 2010. The lesions were categorized into non‐neoplastic lesions, neoplastic lesions and inadequate aspirates. The results were compared with the corresponding histopathology whenever available. Results: Of the 584 lesions, 180 (30.8%) were reported as non‐neoplastic (48 non‐specific inflammation, 11 tuberculosis, 63 functional cysts and 58 endometriotic cysts), 249 (42.6%) as neoplastic (81 benign lesions/tumours and 168 malignant) and 155 (26.5%) as inadequate. Based on the subsequent histopathology, which was available in 121 (20.7%), the cases were divided into those that were concordant and discordant. Concordant cases comprised 92/121 (76%), including 28 non‐neoplastic lesions (seven non‐specific inflammation, nine functional cysts and 12 endometriotic cysts), 42 surface epithelial tumours (13 benign and 29 malignant), 10 germ cell tumours (five mature cystic teratomas and five mixed germ cell tumours), seven sex‐cord stromal tumours (three granulosa cell tumours, one sclerosing stromal tumour, one strümal leutoma, one Sertoli Leydig cell tumour and one malignant Sertoli cell tumour) and five miscellaneous lesions (one plasma cell tumour, two leiomyosarcomas and two cases of necrosis). Discordant cases comprised 29/121 (24%) (21were inconclusive or inadequate on cytology), including four endometriotic cysts, 14 surface epithelial tumours (one cystadenofibroma, one borderline mucinous tumour and 12 carcinomas), five germ cell tumours (two immature teratomas and three mature cystic teratomas), two thecomas, one fibroma, one sclerosing stromal tumour, one fibrosarcoma and one myxoma. FNAC sensitivity for a diagnosis of malignancy was 85.7%, specificity 98.0%, positive predictive value 97.7%, negative predictive value 87.7% and accuracy 92.0%, if 21 inconclusive/inadequate FNACs were excluded; with the latter taken as false negatives, sensitivity was 73.7% and accuracy 76.0%. Conclusion: FNAC has a high specificity for diagnosis of ovarian/adnexal lesions but greater experience is required for the accurate subtyping of neoplasms and sensitivity is limited by inconclusive/inadequate results.     

Immunohistochemical diagnosis of preinvasive germ cell cancer of the testis

The aim of the study was to identify testicular carcinoma in situ (CIS), a precursor of germ cell tumours (GCT), in patients from the high risk groups, using classic and alternative immunohistochemical methods. 70 patients with 46,XY karyotype were examined. Whole gonads or biopsy specimens were fixed in Bouin's fluid. In cases with dysgenetic male pseudohermaphroditism (DMP), gross histopathology revealed sex cord tumour gonadoblastoma in 4 and malignant dysgerminoma in 1 out of 23 patients. In all patients, paraffin sections were treated with antibodies against placental-like alkaline phosphatase (PLAP), a classic immunohistochemical marker of GCT and CIS. CIS was detected immunohistochemically in 10 out of 23 cases with DMP (43.5%), in 1 out of 10 cases with androgen insensitivity syndrome (10%), in 3 out of 18 cases operated previously because of already developed GCT in contralateral testis (16.6%) and in 1 out of 3 patients with cryptorchidism in anamnesis (33.3%). CIS was not found in 16 examined adult infertile men with azoospermia. In addition to PLAP investigation, 12 cases with DMP and 6 cases with GCT were examined using M2A and TRA-1-60 antibodies, the alternative immunohistochemical markers of CIS. While in DMP positive reactions for M2A and TRA-1-60 accompanied PLAP reaction in 1/3 of cases, M2A accompanied PLAP in all cases with GCT. The positive reaction for TRA-1-60 accompanied PLAP and M2A in 1 case with GCT. The results indicate that among different risk groups the highest incidence of CIS occurs in DMP. Screening for CIS is of importance also in cryptorchidism, androgen insensitivity syndrome and in men who underwent gonadectomy because of unilateral GCT. The immunostaining for PLAP seems to be more discriminative procedure. The positive staining of CIS cells with M2A and TRA-1-60 antibodies may be indicative for more advanced neoplastic transformation.     

Puberty due to a mixed germ cell tumour of the hypothalamus secreting BhCG and alpha-fetoprotein

A 14 year-old boy presented with visual impairment due to a large suprasellar tumour secreting beta-human chorionic gonadotrophin (BhCG) and alpha-fetoprotein (alpha FP). He was sexually mature with an advanced bone age of 17 years, and suffering from partial hypopituitarism. Treatment with external radiotherapy resulted in a reduction of tumour size and fall of the serum testosterone BhCG and alpha FP levels. We conclude that pubertal development had been initiated and maintained by ectopic hCG production from his intracerebral mixed germ cell tumour. Patients with tumours in the pineal and suprasellar regions should be screened for elevated levels of BhCG and alpha FP. We suspect that many of these tumours cause precocious puberty by secreting BhCG.     

Clinicopathological study of pancreatic and ganglioneuroblastoma tumours secreting vasoactive intestinal polypeptide (vipomas).

During a six-year period (1973-9) 52 patients with pancreatic tumours and 10 with ganglioneuroblastomas were found to have raised plasma vasoactive intestinal polypeptide (VIP) concentrations. All the patients had severe secretory diarrhoea, weight loss, dehydration, hypokalaemic acidosis, and a raised plasma urea concentration. Reduced gastric acid secretion was seen in 72% of patients. Plasma VIP concentrations were not raised in patients with diarrhoea due to other types of tumour or disease or in hormone-secreting tumours not associated with diarrhoea. Plasma VIP measurement may therefore give clinical guidance in a patient with persistent watery diarrhoea and hypokalaemic acidosis. Surgical excision was clearly the treatment of choice, but metastatic pancreatic tumours usually responded to streptozotocin.     

Bromocriptine in management of large pituitary tumours.

Bromocriptine has an accepted place in the management of small pituitary tumours that secrete either prolactin or growth hormone. The treatment of large tumours with extrasellar extensions is more difficult, however: though surgery is the standard treatment, it is often unsuccessful in returning excessive hormone secretion to normal and may cause hypopituitarism. A prospective trial was undertaken to assess the frequency with which changes in pituitary function and size of large tumours occurs. Nineteen patients were studied before and during treatment with bromocriptine (7.5 to 60 ml/day) for three to 22 months, using contrast radiology and a detailed assessment of pituitary function. Eighteen patients had hyperprolactinaemia and two of these also had raised concentrations of growth hormones; one patient had an apparently non-functioning tumour. In 12 patients (63%) tumour size decreased with bromocriptine and no tumour enlarged. Nine patients had visual-field defects, which improved in seven, becoming normal in five. Pituitary function improved in nine patients (47%) becoming entirely normal in three. Bromocriptine should be the treatment of choice in patients with large pituitary tumours with extrasellar extensions, provided close supervision is maintained.     

Tumour Biological Aspects of CD24, A Mucin-Like Adhesion Molecule

CD24 is a molecule that recently has raised considerable attention in tumour biology. It is involved in cell adhesion and metastatic tumour spread. It has also been described as a new diagnostic marker of tumours, of neuroendocrine differentiation and, possibly most intriguing of all, of patient prognosis. High rates of CD24 expression detected by immunohistochemistry have been found in epithelial ovarian cancer (83%), breast cancer (85%), non-small cell lung cancer (45%), prostate cancer (48%) and pancreatic cancer (72%). With the exception of pancreatic cancer, high rates of CD24 are significantly associated with a more aggressive course of the disease, a finding that remains significant in a multivariate analysis. The aim of this review is to summarize relevant work covering these aspects of CD24.     

The Nature and Classification of Ovarian Neoplasms

The classification of ovarian neoplasms on a histogenetic basis according to presentday concepts of development and structure of the ovary is considered. There are four histogenetic categories of primary ovarian tumours: neoplasms of germ cell origin, neoplasms of celomic (germinal) epithelium and its derivatives, neoplasms of specialized gonadal stroma (sex cords and mesenchyme), and neoplasms of non-specialized gonadal stromal and heterotopic elements. In patients of all ages, 70% of ovarian neoplasms were of celomic epithelial origin, 16% of germ-cell origin, 5% of specialized gonadal stromal origin, and 9% arose from the non-specialized stroma and heterotopic elements. Before 20 years of age, 59% of ovarian neoplasms were of germ cell origin and before puberty they accounted for 90% of all ovarian tumours. The different structural types of neoplasms within the four categories are described. Accurate classification of ovarian neoplasms on a histogenetic basis is stressed if proper treatment is to be given and intelligent assessment of end results is to be made.     

Immunohistochemical demonstration of neuronal and astrocytic markers and oncofoetal antigens in retinoblastomas.

General opinion is that retinoblastomas, though not everyone agrees with that view. Some authors suggest that retinoblastomas are derived from a primitive retinal cell able to differentiate into both neuronal and glial cell lines. The aim of the present work was to study immunohistochemically the expression of neuronal and astrocytic markers in retinoblastomas and at the same time the presence of the oncofoetal antigens carcinoembryonic antigen (CEA) and alpha Foeto Protein (AFP), since patients with retinoblastomas often show high oncofoetal antigen in serum levels. For this purpose we employed the streptavidin-biotin immunoperoxidase technique in 13 cases of retinoblastoma to evaluate the presence and distribution of neuron-specific enolase (NSE), neurofilament protein (NF), glial fibrillary acidic protein (GFAP), S-100 protein, CEA and AFP. All 13 tumours studied stained for NSE. Seven of them showed GFAP- and S-100 positive perivascular glial cells as well as cells distributed randomly in the tumour that were interpreted as non tumour cells. All 13 retinoblastomas lacked detectable NF, CEA, and AFP. These results support the idea that retinoblastomas are neuronal tumours, although retinal glial cells may become incorporated in the tumour and proliferate in response to the tumour.     

Attachment of human placental-type alkaline phosphatase via phosphatidylinositol to syncytiotrophoblast and tumour cell plasma membranes

Phosphatidylinositol anchors human placental-type alkaline phosphatase (PLAP) to both syncytiotrophoblast and tumour cell plasma membranes. PLAP activity was released from isolated human placental syncytiotrophoblast plasma membranes and the surface of tumour cells with a phospholipase C from Bacillus cereus. This was a specific event, not the result of proteolysis or membrane perturbation, but the action of a phosphatidylinositol-specific phospholipase C in the preparation. Soluble PLAP, released with B. cereus phospholipase C and purified by immunoaffinity chromatography, ran on SDS-PAGE as a 66-kDa band. This corresponded to intact PLAP molecules. The protease bromelain cleaved lower-molecular-mass PLAP (64 kDa) from the membranes. Flow cytometry demonstrated that B. cereus phospholipase C released human tumour cell membrane PLAP in preference to other cell-surface molecules. This was in contrast to the non-specific proteolytic action of bromelain or Clostridium perfringens phospholipase C, which had no effect on membrane PLAP expression. Radiolabelling of tumour cells with fatty acids indicated PLAP to be labelled with both [3H]myristic and [3H]palmitic acid. This fatty-acid--PLAP bond was sensitive to pH 10 hydroxylamine treatment indicating an O-ester linkage.     

Human breast cancer cell lines and tissues express tartrate-resistant acid phosphatase (TRAP)

Tartrate-resistant acid phosphatase (TRAP) is expressed by osteoclasts, macrophages and dendritic cells. TRAP has been identified in a wide variety of tissues, however, its biological function is not fully understood. Serum TRAP is a marker of diseases involving excessive bone resorption including metastatic bone disease in breast cancer patients and can be used to monitor responses to treatment. Our aim in this study was to determine whether TRAP is expressed by human breast tumours. Four breast cancer cell lines were assayed for TRAP activity. MDA-MB-435, the most tumourigenic line, had an activity twofold higher than the other cell lines. Immunohistochemistry using a TRAP specific antibody confirmed that both cell lines and human breast tumours express TRAP. Expression was absent in benign tissues and abundant in more aggressive tumours. This work suggests that tumour derived TRAP contributes to the raised enzyme activity found in the serum of breast cancer patients.     

A case of Klinefelter's syndrome associated with hypothalamic-pituitary dysfunction caused by an intracranial germ cell tumor

A 17 year-old boy was admitted to the hospital because of thirst, polyuria (5-61/day), delayed sexual development and muscle weakness. He appeared obese, had an eunuchoidal body habitus and was excessively tall. Chromosomal analysis revealed a 47XXY karyotype. Serum cortisol was 1.3 microgram/dl, LH, 10.4 mIU/ml, FSH, 2.0 mIU/ml, and testosterone, 10 ng/dl. Endocrinological dynamic tests indicated diabetes insipidus and hypopituitarism of a hypothalamic type. Brain CT disclosed the existence of a tumor shadow around the calcified pineal body, extending towards the suprasellar region. Replacement therapy with glucocorticoid and DDAVP was started. The patient complained of a headache and plasma AFP and hCG concentrations were 868 ng/ml and 68.6 IU/ml respectively. A hCG- and AFP- producing germ cell tumor was suspected and radiation therapy with 60Co was performed. Plasma AFP and hCG were decreased with significant clinical improvement. Soon after irradiation, he started to complain of a headache and had elevated AFP and hCG levels. Right hemiparesis and unconsciousness suddenly appeared and he died of left thalamic bleeding. This is the first case of Klinefelter's syndrome associated with intracranial germ cell tumor. Plasma testosterone levels fluctuated in parallel with the change in plasma hCG levels. This shows that the Leydig cells in this patient could respond to some extent to tumor-producing hCG.     

Defective repair of cisplatin-induced DNA damage caused by reduced XPA protein in testicular germ cell tumours

Metastatic cancer in adults usually has a fatal outcome. In contrast, advanced testicular germ cell tumours are cured in over 80% of patients using cisplatin-based combination chemotherapy [1]. An understanding of why these cells are sensitive to chemotherapeutic drugs is likely to have implications for the treatment of other types of cancer. Earlier measurements indicate that testis tumour cells are hypersensitive to cisplatin and have a low capacity to remove cisplatin-induced DNA damage from the genome [2] [3]. We have investigated the nucleotide excision repair (NER) capacity of extracts from the well-defined 833K and GCT27 human testis tumour cell lines. Both had a reduced ability to carry out the incision steps of NER in comparison with extracts from known repair-proficient cells. Immunoblotting revealed that the testis tumour cells had normal amounts of most NER proteins, but low levels of the xeroderma pigmentosum group A protein (XPA) and the ERCC1-XPF endonuclease complex. Addition of XPA specifically conferred full NER capacity on the testis tumour extracts. These results show that a low XPA level in the testis tumour cell lines is sufficient to explain their poor ability to remove cisplatin adducts from DNA and might be a major reason for the high cisplatin sensitivity of testis tumours. Targeted inhibition of XPA could sensitise other types of cells and tumours to cisplatin and broaden the usefulness of this chemotherapeutic agent.     

恶性肿瘤中人绒毛膜促性腺激素β 亚单位的研究进展

人绒毛膜促性腺激素是一种糖蛋白激素.在妊娠期主要由胎盘合体滋养层细胞分泌产生,在非妊娠情况下,机体内含量极微.目前发现几乎所有组织,尤其是肿瘤包括乳腺癌、子宫颈癌、卵巢癌、膀胱癌等均可产生人绒毛膜促性腺激素β亚单位.人绒毛膜促性腺激素对胎盘和生殖细胞起源的滋养细胞肿瘤是一个非常敏感和特殊的肿瘤标志物.很多非滋养细胞肿瘤只产生3hCG,而这是侵袭性疾病的标志,血清中提高的3hCG水平是和肿瘤的不良预后相联系的.     

Recurrence of granulosa cell tumour after thirty years with small bowel obstruction

Granulosa cell tumours of the ovary are rare, comprising around 3% of ovarian tumours. These tumours have preponderance for local spread and extremely late recurrence. Although previous cases of recurrence have been described, it is extremely unusual for these tumours to recur after thirty years. We describe a case of recurrence of granulosa cell tumour after 30 years, presenting as small bowel obstruction. The patient had not been followed up after the original surgery, and on histological analysis, recurrence of the original tumour was confirmed. This case report emphasises the necessity for lifelong follow-up of patients who have had these tumours excised, and also the unusual way in which these tumours can recur.