General Information About Childhood Extracranial Germ Cell Tumors (GCTs)
Cancer in children and adolescents is rare, although the overall incidence of childhood cancer has slowly increased since 1975. Children and adolescents with cancer should be referred to medical centers that have a multidisciplinary team of cancer specialists with experience treating the cancers that occur during childhood and adolescence. This multidisciplinary team approach incorporates the skills of the following health care professionals and others to ensure that children receive treatment, supportive care, and rehabilitation that will achieve optimal survival and quality of life:
Primary care physicians.
Pediatric medical oncologists and hematologists.
Pediatric nurse specialists.
Child life professionals.
Guidelines for pediatric cancer centers and their role in the treatment of pediatric patients with cancer have been outlined by the American Academy of Pediatrics. At these pediatric cancer centers, clinical trials are available for most of the cancer types that occur in children and adolescents, and the opportunity to participate in these trials is offered to most patients and families. Clinical trials for children and adolescents with cancer are generally designed to compare potentially better therapy with therapy that is currently accepted as standard. Most of the progress made in identifying curative therapies for childhood cancers has been achieved through clinical trials. Information about ongoing clinical trials is available from the NCI website.
Dramatic improvements in survival have been achieved for children and adolescents with cancer. Between 1975 and 2010, childhood cancer mortality decreased by more than 50%. During the period from 2002 to 2010, cancer mortality continued to decrease by 2.4% per year for children and adolescents with acute lymphoblastic leukemia, acute myeloid leukemia, Hodgkin and non-Hodgkin lymphoma, neuroblastoma, central nervous system tumors, and gonadal tumors, as compared with the period from 1975 to 1998 (plateauing from 1998 to 2001). Childhood and adolescent cancer survivors require close monitoring because late effects of cancer therapy may persist or develop months or years after treatment. (Refer to the PDQ summary on Late Effects of Treatment for Childhood Cancer for specific information about the incidence, type, and monitoring of late effects in childhood and adolescent cancer survivors.)
GCTs arise from primordial germ cells, which migrate during embryogenesis from the yolk sac through the mesentery to the gonads.[4,5] Childhood extracranial GCTs can be divided into the following two types:
Most childhood extragonadal GCTs arise in midline sites (i.e., sacrococcygeal, mediastinal, and retroperitoneal); the midline location may represent aberrant embryonic migration of the primordial germ cells.
Childhood extracranial GCTs are broadly classified as the following:
GCTs comprise a variety of histologic diagnoses and can also be divided into the following histologic types:
Teratoma (mature and immature).
Yolk sac tumor (endodermal sinus tumor).
Mixed GCT (contains more than one of the histologies above).
Childhood GCTs are rare in children younger than 15 years, accounting for approximately 3% of cancers in this age group.[6-9] In the fetal/neonatal age group, most extracranial GCTs are benign teratomas occurring at midline locations, including sacrococcygeal, retroperitoneal, mediastinal, and cervical regions. Despite the small percentage of malignant teratomas that occur in this age group, perinatal tumors have a high morbidity rate caused by hydrops fetalis and premature delivery.[10,11]
Extracranial GCTs (particularly testicular GCTs) are much more common among adolescents aged 15 to 19 years, representing approximately 14% of cancers in this age group.
The incidence of extracranial GCTs by 5-year age group and gender is shown in Table 1.
Table 1. Incidence of Extracranial Germ Cell Tumors by Age Group and Gender (per 106 population)a
aRates are per 1 million children from 1986 to 1995 for the nine Surveillance, Epidemiology, and End Results regions plus Los Angeles.
Histologic Classification of Childhood Extracranial GCTs
Childhood extracranial GCTs comprise a variety of histologic diagnoses and can be broadly classified as the following:
The histologic properties of these tumors are heterogeneous and vary by primary tumor site and the gender and age of the patient.[12,13] Histologically identical GCTs that arise in younger children have different biological characteristics from those that arise in adolescents and young adults.
Mature teratomas usually occur in the ovary or at extragonadal locations. They are the most common histological subtype of childhood GCT.[15-17] Mature teratomas usually contain well-differentiated tissues from the ectodermal, mesodermal, and endodermal germ cell layers, and any tissue type may be found within the tumor.
Mature teratomas are benign, although some mature teratomas may secrete enzymes or hormones, including insulin, growth hormone, androgens, and prolactin.[18,19]
Immature teratomas contain tissues from the ectodermal, mesodermal, and endodermal germ cell layers, but immature tissues, primarily neuroepithelial, are also present. Immature teratomas are graded from 0 to 3 on the basis of the amount of immature neural tissue found in the tumor specimen. Tumors of higher grade are more likely to have foci of yolk sac tumor. Immature teratomas may be classified as malignant tumors.
Immature teratomas occur primarily in young children at extragonadal sites and in the ovaries of girls near the age of puberty, but there is no correlation between tumor grade and patient age.[21,22] Some immature teratomas may secrete enzymes or hormones, such as vasopressin.
GCTs contain frankly malignant tissues of germ cell origin and, rarely, tissues of somatic origin. Isolated malignant elements may constitute a small fraction of a predominantly mature or immature teratoma.[22,24]
Malignant germ cell elements of children, adolescents, and young adults can be grouped broadly by location (refer to Tables 2 and 3).
Table 2. Histology of Malignant Germ Cell Tumors in Young Childrena
It should be emphasized that very few pediatric GCT specimens have been analyzed to date. Biologic distinctions between GCTs in children and GCTs in adults may not be absolute, and biologic factors have not been shown to predict risk.[26-28]
Children: During early childhood, both testicular teratomas and malignant testicular GCTs are identified. The malignant tumors are commonly composed of pure yolk sac tumor (also known as endodermal sinus tumor), are generally diploid or tetraploid, and often lack the isochromosome of the short arm of chromosome 12 that characterizes testicular cancer in young adults.[26,29-33] Deletions of chromosomes 1p, 4q, and 6q and gains of chromosomes 1q, 3, and 20q are reported as recurring chromosomal abnormalities for this group of tumors.[31-34]
Adolescents and young adults: Testicular GCTs typically possess an isochromosome of the short arm of chromosome 12 [35-38] and are aneuploid.[29,38] Although adolescent testicular germ cell patients may be best treated at pediatric oncology centers, the treatment for adolescents older than 14 years follows the regimens used in adults. (Refer to the PDQ summary on Testicular Cancer Treatment for more information.)
Ovarian GCTs occur primarily in adolescent and young adult females. While most ovarian GCTs are benign mature teratomas, a heterogeneous group of malignant GCTs, including immature teratomas, dysgerminomas, yolk sac tumors, and mixed GCTs, do occur in females. The malignant ovarian GCT commonly shows increased copies of the short arm of chromosome 12.
Patients with pediatric ovarian GCTs have an excellent prognosis. One series of 66 patients monitored for more than 44 years reported recurrence rates of 4.5% and mortality rates of 3%.
Extragonadal extracranial GCTs occur outside of the brain and gonads.
Children: These tumors typically present at birth or during early childhood. Most of these tumors are benign teratomas occurring in the sacrococcygeal region, and thus are not included in Surveillance, Epidemiology, and End Results (SEER) data.[41,42] Malignant yolk sac tumor histology occurs in a minority of these tumors; however, they may have cytogenetic abnormalities similar to those observed for tumors occurring in the testes of young males.[30-32,34]
Older children, adolescents, and young adults: The mediastinum is the most common primary site for extragonadal GCTs in older children and adolescents. Mediastinal GCTs in children younger than 8 years share the same genetic gains and losses as sacrococcygeal and testicular tumors in young children.[43-45] The gain in chromosome 12p has been reported in mediastinal tumors in children aged 8 years and older.[45,46]
There are few data about the potential genetic or environmental factors associated with childhood extragonadal extracranial GCTs. Patients with the following syndromes are at an increased risk of extragonadal extracranial GCTs:
Klinefelter syndrome—increased risk of mediastinal GCTs.[47-49]
Swyer syndrome—increased risk of gonadoblastomas and germinomas.[50,51]
Turner syndrome—increased risk of gonadoblastomas and germinomas.[52,53]
Childhood extracranial GCTs develop at diffuse sites that include the testicles, ovaries, mediastinum, retroperitoneum, sacrum, and coccyx. The clinical features at presentation are specific for each site.
Diagnostic and Staging Evaluation
Diagnostic evaluation of GCTs includes imaging studies and measurement of tumor markers. In suspected cases, tumor markers can suggest the diagnosis before surgery and/or biopsy. This information can be used by the multidisciplinary team to make appropriate treatment choices.
Yolk sac tumors produce alpha-fetoprotein (AFP), while germinomas (seminomas and dysgerminomas), and especially choriocarcinomas, produce beta-human chorionic gonadotropin (beta-hCG), resulting in elevated serum levels of these substances. Most children with malignant GCTs will have a component of yolk sac tumor and have elevations of AFP levels,[54,55] which are serially monitored during treatment to help assess response to therapy.[22,24,54] Benign teratomas and immature teratomas may produce small elevations of AFP and beta-hCG.
During the first year of life, infants have a wide range of serum AFP levels, which are not associated with the presence of a GCT. Normal ranges have been described but are based on limited data.[56,57] The serum half-life of AFP is 5 to 7 days, and the serum half-life of beta-hCG is 1 to 2 days. Even though the data are limited, tumor markers are measured with each cycle of chemotherapy for all pediatric patients with malignant GCTs. It should be recognized that after initial chemotherapy, tumor markers may show a transient elevation.
Although few pediatric data exist, adult studies have shown that an unsatisfactory decline of elevated tumor markers is a poor prognostic finding.
Imaging tests may include the following:
Computed tomography (CT) scan of the primary site and chest.
Magnetic resonance imaging (MRI) of the primary site.
Radionuclide bone scan or positron emission tomography scan (for postpubertal males).
Prognosis and Prognostic Factors
Prognosis and prognostic factors for extracranial GCTs depend on many circumstances, including the following:
Histology (e.g., seminomatous vs. nonseminomatous).
Age (e.g., young children vs. adolescents).
Stage of disease.
Primary site of disease.
Tumor marker decline (AFP and beta-hCG) in response to therapy.
To better identify prognostic factors, data from five U.S. trials and two U.K. trials for malignant extracranial GCTs in children and adolescents were merged by the Malignant Germ Cell Tumor International Collaborative (MaGIC). The goal was to ascertain the important prognostic factors in 519 young patients, incorporating age at diagnosis, stage, and site of primary tumor, along with pretreatment AFP level and histology. Of these, patients aged 11 years and older with stage III or stage IV extragonadal disease or ovarian stage IV disease had a less than 70% likelihood of long-term disease-free survival, ranging from 40% (extragonadal stage IV) to 67% (ovarian stage IV). AFP levels and histologies other than pure yolk sac were also negative factors, but did not achieve statistical significance at the 0.05 level.[Level of evidence: 3iiiDii] This is the first age-focused investigation of these factors in young children and adolescents.
There is little evidence to provide guidance on the follow-up care of children with extracranial GCTs.
The following tests and procedures may be performed at the physician's discretion when tumor markers are elevated at diagnosis:
AFP and beta-hCG. Monitor AFP and beta-hCG levels monthly for 6 months (period of highest risk) and then every 3 months, for a total of 2 years (3 years for sacrococcygeal teratoma).
Imaging tests. MRI/CT may be performed at the completion of therapy. Further imaging intervals have not been defined.
The following tests and procedures may be performed at the physician's discretion when tumor markers are normal at diagnosis:
Imaging tests. Ultrasound or CT/MRI may be performed every 3 months for 2 years and then annually for 5 years for germinomas.
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