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| Germ cell tumors can be classified based on their histologic features into:
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| {{familytree/start}}
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| {{familytree| | | | | | | | | A01 | | | |A01=Germ cell tumors}}
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| {{familytree| | | | |,|-|-|-|-|^|-|-|-|-|-|.| | | }}
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| {{familytree| | | | B01 | | | | | | | | | B02 | | B01=Germinomatous/Undifferentiated/Immature|B02=Nongerminomatous/Differentiated/Embryonal}}
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| {{familytree| | |,|-|^|-|-|.| | | | | | | |!| | | |}}
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| {{familytree| | |!| | | | |!| | | | | | | |!| | | |}}
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| {{familytree| | C01 | | | C02 | | | | | | |!| | | | | C01=[[Dysgerminoma(Ovary)]]|C02=[[Seminoma(Testis)]]}}
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| {{familytree| | | | | | | | | | | | | | | |!| | | | | | |}}
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| {{familytree| | | | |!| | | | | | | |!| | | | | | |!| | |}}
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| {{familytree| | | | D01 | | | | | | D02 | | | | | D03 | | |D01=[[Embryonal carcinoma]]| D02=[[embryonic tissue]]| D03=[[Extraembryonic tissue]]}}
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| {{familytree| | | | | | | | | | | | |!| | | | | | |!| | | | }}
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| {{familytree| | | | | | | | | | | | E01 | | | | | |!| | |E01=[[Teratoma]]}}
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| {{familytree| | | | | | | | | | | | | | | | | |,|-|^|-|.| | }}
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| {{familytree| | | | | | | | | | | | | | | | | |!| | | |!| | }}
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| {{familytree| | | | | | | | | | | | | | | | | F01 | | F02 | |F01=[[Yolk sac tumor]]|F02=[[Choriocarcinoma]]}}
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| {{familytree/end}}
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| {{familytree/start}}
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| {{familytree| | | | | | | | | A01 | | | |A01=Germ cell tumors}}
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| {{familytree| | | | |,|-|-|-|-|^|-|-|-|-|-|.| | | }}
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| {{familytree| | | | B01 | | | | | | | | | B02 | | B01=Germinomatous/Undifferentiated/Immature|B02=Nongerminomatous/Differentiated/Embryonal}}
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| {{familytree| | |,|-|^|-|-|.| | | | | | | |!| | | |}}
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| {{familytree| | |!| | | | |!| | | | | | | |!| | | |}}
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| {{familytree| | C01 | | | C02 | | | | | | |!| | | | | C01=[[Dysgerminoma(Ovary)]]|C02=[[Seminoma(Testis)]]}}
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| {{familytree| | | | | | | | | | | | | | | |!| | | | | | |}}
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| {{familytree| | | | |,|-|-|-|-|-|-|-|v|-|-|^|-|-|-|.| | |}}
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| {{familytree| | | | |!| | | | | | | |!| | | | | | |!| | |}}
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| {{familytree| | | | D01 | | | | | | D02 | | | | | D03 | | |D01=[[Embryonal carcinoma]]| D02=[[embryonic tissue]]| D03=[[Extraembryonic tissue]]}}
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| {{familytree| | | | | | | | | | | | |!| | | | |,|-|^|-|.| | |}}
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| {{familytree| | | | | | | | | | | | E01 | | | E02 | | E03| | |E01=[[Teratoma]]|E02=[[Yolk sac tumor]]|E03=[[Choriocarcinoma]]}}
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| {{familytree/end}}
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| Germ cell tumors classification is based on the histologic features and whether they are differentiated or not into:
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| * Germinomatous tumors: (non-differentiated): Gonadal and Extra-gonadal
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| ** Germinoma ( Gonadal: dysgerminoma and seminoma), (Extra-gonadal: mediastinum, or pineal region)
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| ** Dysgerminoma (Ovary)
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| ** Seminoma (testes)
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| * Nongerminomatous tumors: all other germ-cell tumors, pure and mixed
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| ** Embryonal carcinoma
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| ** Endodermal sinus tumor, also known as yolk sac tumor (EST, YST)
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| ** Choriocarcinoma
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| ** Teratoma including mature teratoma, dermoid cyst, immature teratoma, teratoma with malignant transformation
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| ** Polyembryoma
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| ** Gonadoblastoma
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| * Mixed germ cell tumors:
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| Germ cell tumors can also be classified based on their location into:
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| * Gonadal (ovary and testes)
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| * Extra-gonadal (MC:mediastinum, retroperitoneal. Less common: Pineal gland, sacrococcigeal)
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| * Ovarian germ cell tumors (OGCTs ): The histologic types that arise from the ovary are similar to those arising from the testes of men
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| ** Embryo-like neoplasms
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| *** Teratomas and their subtypes
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| *** Dysgerminomas: The female version of the male seminoma (comprised of immature germ cells)
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| ** Extraembryonic fetal-derived (placenta-like) cell populations
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| *** Yolk sac/primitive placenta forms (epithelial neoplasms differentiate into yolk sac tumors)
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| ** Rare OGCTs
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| *** Pure embryonal carcinomas
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| *** Nongestational choriocarcinomas
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| *** Pure polyembryoma.
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| ** Mixed germ cell tumors (teratoma with yolk sac, dysgerminoma, and/or embryonal carcinoma)
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| * Extragonadal germ cell tumors (GCTs): no evidence of a primary tumor in the testes or ovaries
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| ** Typically arise in midline locations,
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| ** Specific sites vary with age
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| ** The most common sites in order of frequency
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| ** In adults:
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| *** Anterior mediastinum
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| **** Mature teratomas
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| **** Immature teratoma
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| **** Mediastinal seminoma
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| **** Mediastinal non-seminomatous GCT:
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| ***** Yolk sac tumor (most common, pure or mixed)
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| ***** Choriocarcinoma (less common)
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| ***** Embryonal carcinoma (infrequent)
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| ***** Mixed GCTs (a mixture of teratoma, seminoma, and other cell types)
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| *** Retroperitoneum
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| **** Retroperitoneal seminoma
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| **** Retroperitoneal non-seminomatous GCTs (Embryonal carcinoma is common)
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| **** Retroperitoneal teratomas (rare)
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| *** Pineal and suprasellar regions
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| ** In infants and young children:
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| *** Sacrococcygeal
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| *** Intracranial GCTs
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| {| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
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| ! rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF| Types}}
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| ! rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Subtypes}}
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| ! colspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Signs and Symptoms}}
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| ! rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF|Histopathology}}
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| ! rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF| Lab finding }}
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| ! rowspan="1" style="background: #4479BA; padding: 5px 5px;" |{{fontcolor|#FFFFFF| Prognosis}}
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| | rowspan="2;" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |Germinomatous
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| /Undifferentiated
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| <br />
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| Seminoma (Testis)
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| * Painless [[testicular mass]] with discomfort
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| *[[Back pain]]
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| *[[Abdominal discomfort]]
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| *[[Abdominal mass]].
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| | style="padding: 5px 5px; background: #F5F5F5;" |Gross: pale gray to yellow nodules that are uniform or slightly lobulated and often bulge from the cut surface
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| * Complete blood count and blood chemistry tests.
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| * Abnormal serum tumor marker levels ([[LDH]], [[HCG]]).<ref name="Diagnosisoftesticularcancer1" />
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| * CT: Metastases to the para-aortic, inguinal, or iliac lymph nodes. Visceral metastasis may also be seen.
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| * Pelvic MRI: may be diagnostic. multinodular tumors of uniform signal intensity
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| * Hypo- to isointense on T2-weighted images and inhomogenous enhancement on contrast enhanced T1-weighted images.
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| * Other diagnostic studies for seminoma include [[biopsy]], [[PET|FDG-PET scan]], and [[bone scan]].
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| *[[Prognosis]] of [[seminoma]] is good for all stages with greater than 90% cure rate.
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| * The International Germ Cell Cancer Consensus Group divides [[seminoma]] into two prognosis groups: good and intermediate.
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| * Common complications of [[seminoma]] include recurrence, [[lymph node]] [[metastasis]], distant [[metastasis]], and secondary [[malignancies]].
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| |-
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| Dysgerminoma
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| (Ovary)
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| * Depend on the type of the [[tumor]] and its potential to produce [[hormonal]]<nowiki/>materials
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| *[[Abdominal pain]] or distention
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| *[[Menstrual irregularities]]
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| * Symptoms of [[virilization]]
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| * Rapidly growing [[abdominal]]/[[pelvic]] [[mass]]
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| *[[Acute abdominal pain]] from [[complications]] such as:
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| *[[Necrosis]]
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| *[[Capsule|Capsular]] distention
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| * [[Rupture]] or [[torsion]] and or simply they can be [[asymptomatic]].
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| *The majority of [[ovarian]] [[germ cell]][[tumors]] have a [[solid]] and [[cystic]] appearance with areas of [[hemorrhage]]<nowiki/>and [[necrosis]]
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| * A uniform “fried egg” appearance ([[dysgerminoma]])
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| *[[Beta-hCG]] to rule out [[pregnancy]] in women with abdominopelvic [[symptoms]]
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| *Cultures for [[gonorrhea]] and [[chlamydia]] and a wet mount in [[reproductive]] and [[sexually active]] women to role out and treat before [[surgery]] if [[positive]].
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| *[[Lactate dehydrogenase]] ([[LDH]]), [[alpha-fetoprotein]] ([[AFP]]), [[beta-human chorionic gonadotropin]] ([[beta-hCG]]) levels. If any levels are elevated, they may assist in [[diagnosis]] and/ or follow-up of women [[Diagnosis|diagnosed]] with [[malignant]] [[Ovarian germ cell tumor|ovarian GCTs]].
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| *[[Inhibin A]] and B
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| *[[CA-125|Cancer antigen 125]] ([[CA-125]]) - For epithelial tumors
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| *[[Ultrasound]]: [[Dysgerminoma]] often appears as a [[Echogenicity|hypoechoic]] [[mass]]
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| *
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| *
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| *
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| * Chemotherapy: except those with stage 1a, stage 1a, 1b [[dysgerminoma]]
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| * Radiotherapy:
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| <nowiki>**</nowiki> [[Dysgerminoma]] is radiosensitive.
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| [[Radiotherapy|** Radiotherapy]] is not anymore the first option of treatment for [[dysgerminoma]] considering its association with [[ovarian failure]]<nowiki/>development.
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| * Surgery: for diagnostic grading and therapy depending on if the patient prefers to preserve the ovary or not.
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| <br />
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| |-
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| | rowspan="6;" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | Germinomatous/
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| Differentiated
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| | rowspan="1;" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" | Embryonic
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| *
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| Teratoma
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| *[[Chest pain]]
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| *[[Cough]]
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| *[[Shortness of breath]]
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| *[[Abdominal pain]]
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| *[[Lump]], Abdominal(ovarian teratoma)
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| * Abnormal [[bleeding]] from the vagina
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| *[[Fatigue]], [[weight loss]]
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| * Limited ability to tolerate exercise
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| * Teratomas belong to a class of tumors known as [[Nonseminoma|nonseminomatous]] [[germ cell tumor]] (NSGCT).
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| * All tumors of this class are the result of abnormal development of [[pluripotent]] cells: [[Germ cell|germ cells]] and [[Embryo|embryonal cells]].
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| * Teratomas of embryonal origin are [[Congenital disorder|congenital]]; teratomas of germ cell origin may or may not be congenital (this is not known).
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| * Embryonal teratomas most commonly occur in the sacrococcygeal region: [[sacrococcygeal teratoma]] is the single most common tumor found in [[Infant|newborn babies]].
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| * AFP
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| * MSAFP
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| * CT scans are often used to diagnose teratoma.
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| <br />
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| * For malignant teratomas, usually, surgery is followed by chemotherapy.
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| * Teratomas that are in surgically inaccessible locations, or are very complex, or are likely to be malignant (due to late discovery and/or treatment) sometimes are treated first with chemotherapy.
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| | rowspan="1;" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;" |
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| Extraembryonic
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| [[Choriocarcinoma]]([[Gestational Trophoblastic Neoplasia]])
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| | style="padding: 5px 5px; background: #F5F5F5;" |Early Symptoms:
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| *[[Vaginal bleeding]] <ref name="xxx">Signs and symptoms of gestational trophoblastic disease. Canadian Cancer Society. http://www.cancer.ca/en/cancer-information/cancer-type/gestational-trophoblastic-disease/signs-and-symptoms/?region=ns Accessed on October 10, 2015</ref>
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| *[[Nausea]] and [[vomiting]]
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| *Passing of [[Tissue (biology)|tissue]] resembling a “bunch of grapes” from the [[vagina]]
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| *Absent [[fetal]] movement during [[pregnancy]]
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| *[[Abdomen|Abdominal]] distension
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| Rare Symptoms:
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| *[[Headache]]
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| *[[Edema ]]of the [[Hand|hands]] and feet
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| *[[Abdomen|Abdominal]] or [[Pelvis|pelvic]] pain
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| *[[Vaginal discharge]]
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| *Overactive [[thyroid gland]] ([[hyperthyroidism]]) that causes:
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| *[[Tachycardia]]
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| *[[Sweating]]
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| *Shaking
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| *Heat intolerance
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| *[[Fever]]
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| Late Symptoms
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| *[[Hemoptysis]]
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| *Dry [[cough]]
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| *[[Chest pain]]
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| *Trouble [[breathing]]
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| *[[Headache]]
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| *[[Dizziness]]
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| *[[Jaundice]]
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| *[[Paralysis]]
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| *[[Seizure]]
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| *[[Dysarthria]] and [[dysphasia]]
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| *[[Visual system|Vision]] problems
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| *[[Lump]] in the [[vagina]]
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|
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| | style="padding: 5px 5px; background: #F5F5F5;" |[[Gross pathology|Gross pathological]]:
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|
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| * Bulky, destructive mass with [[Bleeding|hemorrhage]] and [[necrosis]]<ref name="OberEdgcomb1971">{{cite journal|last1=Ober|first1=William B.|last2=Edgcomb|first2=John H.|last3=Price|first3=Edward B.|title=THE PATHOLOGY OF CHORIOCARCINOMA|journal=Annals of the New York Academy of Sciences|volume=172|issue=10 Physiology a|year=1971|pages=299–426|issn=0077-8923|doi=10.1111/j.1749-6632.1971.tb34943.x}}</ref><ref name="SmithKohorn2005">{{cite journal|last1=Smith|first1=Harriet O.|last2=Kohorn|first2=Ernest|last3=Cole|first3=Laurence A.|title=Choriocarcinoma and Gestational Trophoblastic Disease|journal=Obstetrics and Gynecology Clinics of North America|volume=32|issue=4|year=2005|pages=661–684|issn=08898545|doi=10.1016/j.ogc.2005.08.001}}</ref>
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| * Can be associated with deep [[Myometrium|myometrial]] invasion
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| [[Microscopic]] [[Histopathology|histopathological:]]
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| *Columns and sheets of [[Trophoblast|trophoblastic]] [[Tissue (biology)|tissue]] invading [[Uterus|uterine]] [[muscle]] and [[Blood vessel|blood vessels]]
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| *[[Syncytiotrophoblast|Syncytiotrophoblasts]] (large [[eosinophilic]] smudgy [[Multinucleate|multinucleated]] [[Cell (biology)|cells]] with large [[Hyperchromicity|hyperchromatic]] [[Cell nucleus|nuclei]]) are intermixed with [[Cytotrophoblast|cytotrophoblasts]] (polygonal [[Cell (biology)|cells]] with distinct borders, and single irregular [[Cell nucleus|nuclei]])
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| <br />
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| | style="padding: 5px 5px; background: #F5F5F5;" |[[Human chorionic gonadotropin]] (HCG or b-HCG) is the most common [[tumor]] marker test used to diagnose GTD<ref name="abc">Diagnosing gestational trophoblastic disease. Canadian Cancer Society. http://www.cancer.ca/en/cancer-information/cancer-type/gestational-trophoblastic-disease/diagnosis/?region=ns Accessed on October 13, 2015</ref>
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|
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| *Human placental lactogen (hPL) is a tumor marker that may be used to follow women with placental site [[trophoblastic]] tumors
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| * Elevated hPL levels are found in women with some types of GTD
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| *[[Complete blood count]] can check for [[anemia]] from long-term (chronic) [[vaginal bleeding]]
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| <br />
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| Poor [[prognosis]] of gestational trophoblastic neoplasia (GTN) can be determined by the following factors:
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| * Age over 35 years ([[P-value|P]] = 0.025)
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| * Interval since the last [[pregnancy]] of over 2 years ([[P-value|P]] = 0.014)
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| * Deep [[Myometrium|myometrial]] invasion ([[P-value|P]] = 0.006)
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| * Stage III or IV ([[P-value|P]] < 0.0005)
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| * Maximum [[Human chorionic gonadotropin|βhCG]] level > 1000 mIU/ml ([[P-value|P]] = 0.034)
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| * Extensive [[coagulative necrosis]] ([[P-value|P]] = 0.024)
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| * High [[Mitosis|mitotic]] rate ([[P-value|P]] = 0.005)
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| * Presence of [[Cell (biology)|cells]] with clear [[cytoplasm]] ([[P-value|P]] < 0.0005)
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| [[Yolk sac tumor]]
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| (Endodermal sinus tumor)
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| | style="padding: 5px 5px; background: #F5F5F5;" |Symptoms:<ref name="www">{{cite book | last = Hoffman | first = Barbara | title = Williams gynecology | publisher = McGraw-Hill Medical | location = New York | year = 2012 | isbn = 9780071716727 }}</ref><ref name="pmid6185892">{{cite journal| author=Gershenson DM, Del Junco G, Herson J, Rutledge FN| title=Endodermal sinus tumor of the ovary: the M. D. Anderson experience. | journal=Obstet Gynecol | year= 1983 | volume= 61 | issue= 2 | pages= 194-202 | pmid=6185892 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6185892 }}</ref>
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| *[[Abdominal distention]]
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| * Acute/sub acute [[abdominal pain]]
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| *Signs:<ref name="abc2">{{cite book | last = Hoffman | first = Barbara | title = Williams gynecology | publisher = McGraw-Hill Medical | location = New York | year = 2012 | isbn = 9780071716727 }}</ref>
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| * Abdomen:
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| **[[Abdominal distention]]
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| ** Abdominal [[tenderness]]
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| ** Pelvis:
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| ** Adnexal mass <br />
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| <br />
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| ** On gross [[pathology]]:
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| ** Encaptulated, firm, smooth, round, globular, solid gray-white with a gelatinous, myxoid, or mucoid appearance, [[necrosis]], [[cystic]] changes, and [[hemorrhage]] are characteristic findings of endodermal sinus tumor.
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| ** On microscopic [[histopathological]] analysis:
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| ** Schiller-Duval bodies (invaginated papillary structures with central vessel) is a characteristic finding of endodermal sinus tumor. The [[tumors]] are composed of irregular space lined by flattened to cuboidal cells and recticular stroma
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| | style="padding: 5px 5px; background: #F5F5F5;" |
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| *
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| |}
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| ==References==
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| {{reflist}}
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