Germ Cell Tumors Health Article

Diagnosis

Most germ cell cancers are initially identified by the discovery of lump in the testicles or somewhere else along the midline of the body. When a lump is identified, often the person's physician will arrange for a biopsy of the lump. During a biopsy, a small piece of the lump is removed and cut into thin sections. A specialist examines these sections under a microscope, looking for abnormal kinds of cells. How much the biopsied tissue is different from healthy tissue is a good indication of how severe the disease will probably be, and the results of biopsies are used to give tumors a grade that indicates the patient's chances of survival.

Tests that give a doctor pictures of the tumor are also used, such as x rays, computed tomography (CT) scans, or ultrasound. X rays can show the doctors where calcium deposits have occurred in normally soft tissues (an indication of disease). Ultrasound and CT scanning give more details with regard to a specific tumor, such as its site of origin, whether it is solid or cystic, and how well defined its borders are. Well-defined borders have a better chance of complete surgical removal.

Another type of useful test which is specific to germ cell tumors is the measurement of several tumor markers. Tumor markers are proteins, often identified in blood samples, that are produced by tumor cells. Two main tumor markers are commonly seen to suggest a germ cell tumor, alpha-fetoprotein (AFP) and ß-Human Chorionic Gonadotropin (ß-HCG). Germ cell tumors which produce elevated levels of AFP include endodermal sinus tumors and teratoma, although high levels of AFP are also produced by normal infants. ß-HCG is usually associated with tumors which contain elements of the choriocarinoma or embryonic carcinoma types of germ cell tumors. These markers are also used as a measure of the success of surgery or other therapies, and to monitor patients for a recurrence of the disease.

Treatment team

As the understanding of cancer grows and new treatment approach are developed, the complexity of cancer treatment also increases. Today, a multi-disciplinary approach to cancer treatment is considered necessary for effective patient care. People involved in the treatment of a germ cell cancer will typically include the referring physician (often a gynecologist or pediatrician), a gynecological oncologist, a pathologist, and a nurse. If radiation therapy is pursued, a radiation oncologist, radiation therapist, radiation nurse, radiation physicist, and a dosimetrist will also be involved. Treatment may also include a psychologist, nutritionist, social worker and chaplain.

Clinical staging, treatments, and prognosis

Staging

Staging and grading tumors is a way of predicting the severity of the disease. Tumor grades are based on the types of tissues present in the tumor; stages indicate the cancer's spread. Separate staging systems exist for both adult and childhood ovarian cancers and adult and childhood testicular cancers. These are developed separately by groups of pediatric and adult oncologists.

OVARIAN CANCERS.

Pediatric ovarian cancers are usually graded according to the following scheme: Grade 0 contains only mature tissues (tissues which have already become specific kinds of tissues, rather than primitive developing cells. Grade 1 contains mostly mature tissues, with some immature cells present. Grade 2 contains a moderate amount of immature cells, and in Grade 3, numerous immature cells are present.

Adult ovarian cancer is usually staged, with Stage I being found only in the ovaries. Stage II in adult ovarian cancer means that the cancer has spread to the uterus or the fallopian tubes, or other structures in the pelvic area. Stage III tumors are those which have spread to the lymph nodes or outer parts of abdominal organs. Stage IV tumors have spread to the interior of abdominalorgans such as the liver or the intestines.

TESTICULAR CANCERS.

Pediatric testicular cancers are typically staged in a manner similar to adult ovarian cancers: Stage I tumors are limited to the testes, with normal postoperative tumor markers. Stage II tumors have spread to the abdominal lymph nodes and have elevated tumor markers; Stage III have greater involvement of the abdominal lymph nodes. Stage IV tumors have spread to other organs such as the lung.

Adult testicular cancers are commonly staged according to a simplified TNM system. Stage T (with several levels described) indicates a tumor that is localized, N means a tumor that has spread to local lymph nodes, and M means a tumor that has spread to distant lymph nodes and organs.

Treatment

The treatment choice in any specific germ cell tumor depends mainly on the type of tumor and the stage at diagnosis, although the age of the patient and whether or not future childbearing is an issue will also influence treatment choices. Treatment of most germ cell tumors involves surgical removal of the tumor. Advanced cancers normally will be followed by chemotherapy. For some tumors, it may not be possible to completely remove the cancerous tissues. In those cancers, "debulking" surgery will be performed in order to reduce the size of the tumor in order for chemotherapy (or radiation) to be most effective.

Chemotherapy can be given through pills taken by mouth, by injections or through IVs. Chemotherapy works by killing cancerous cells, and can kill cancer cells that have traveled away from the initial site. Therefore, in more advanced stages of disease, chemotherapy will sometimes be the primary treatment. Possibly another surgery will be performed after radiation therapy or chemotherapy is finished. This surgery (second-look surgery) allows the doctor to confirm that cancerous tissues have been eradicated.

Chemotherapy usually involves a platinum-based drug such as cisplatin in combination with one or two other anti-cancer medications. These drugs are used in combination because, since they each have different side effects, high doses can be given without increasing the risk of a serious drug reaction. Using combinations also decreases the chance that a cancer will develop resistance to any particular drug. Different combinations of drugs are used to treat different types of tumors.

The treatment of some types of germ cell cancers may follow a slightly different pattern. Germinomas are especially sensitive to radiation. This may be the primary treatment mode for those kinds of tumors. Radiation is used to shrink the size of tumors, and even in ovarian cancers usually involves only external irradiation. The only type of germ cell tumor in children in which radiation is regularly used is germinomas occurring in the brain.

When first-line treatments fail, stronger combinations of drugs may be given, or different, sometimes experimental therapies may be tried. These kinds of therapies includes immune system products like interferons that have been shown to destroy cancerous cells and new drugs being developed that decrease blood flow to tumors. Therapies like immunotoxins, which include anti-cancer drugs attached to antibodies specific to tumor cells, and other ways of making drugs more specific for tumor cells, are also being investigated. Many clinical trials for germ cell cancers are evaluating a therapy called "peripheral stem cell rescue, " in which the patient's red blood cells are removed before high-dose chemotherapy is given, then replaced after the chemotherapy is complete. This decreases the side effects of the medications and improves the patient's chances of successful treatment.

The prognosis for germ cell tumors depends greatly on the type of germ cell tumor involved and the location in which it is found. Generally, about 90% of patients diagnosed with only localized tumors survive, compared to 50-70% of those who are diagnosed with tumors which have already spread. There is wide variation in the cure rates, depending on the tumor types involved. Mature teratomas of the ovaries, which are by far the most common type of ovarian tumor, are almost always benign, unless mixed with other, more malignant germ cell tumor types. Choriocarcinomas and embryonal carcinomas, on the other hand, are especially malignant, with an average survival time without treatment of only a few months. Since ovarian cancers are the most difficult to catch early, ovarian cancers of types more malignant than the mature teratoma have the worst prognosis among the germ cell tumors. With modern treatment methods, most often including chemotherapy after surgical removal, survival rates have greatly improved. If caught early, most germ cell tumors have good cure rates.

Alternative and complementary therapies

Alternative and complementary therapies are therapies which fall outside the scope of traditional, first-line therapies like surgery, chemotherapy and radiation. Complementary therapies are meant to supplement those traditional therapies with the objective of relieving symptoms. Alternative therapies are nontraditional, unproven attempts to cure the disease.

Common complementary therapies in germ cell disease include aromatherapy, art therapy, massage, meditation, music therapy, prayer, t'ai chi, yoga, and other forms of exercise. These therapies have the objective of reducing anxiety and increasing a patient's feeling of well-being.

Numerous alternative therapies exist in cancer treatment. Laetril, a product of apricot seeds, is probably one of the most well known. Laetril contains a form of cyanide that may be released by tumor enzymes and may act to kill cancerous cells. However, the product is not approved for use in the United States, and the National Cancer Institute sponsored two clinical trials for the drug in the late 1970s and early 1980s, and decided that no further investigation into the drug was necessary. Vitamins and other nutritional elements like vitamins A, C, and E, and selenium are thought to act as antioxidants. Vitamin E, melatonin, aloe vera, and a compound called beta-1, 3-glucan are thought to stimulate the immune system. Natural substances like garlic, ginger, and shark cartilage are also commonly held to shrink tumors, with less defined modes of action. Antineoplastons are believed by some to be another alternative approach to a cancer cure. Antineoplastons are small proteins which may act as molecular messengers and which may be absent from the urine and blood of many cancer patients. Replacing these proteins may have beneficial effects. After some proposed clinical trials were not completed, the National Cancer Institute draws no definitive conclusions about the effectiveness of antineoplaston therapy. Patients should discuss any supplements with their treating physicians.