Germ cell tumours

Germ Cell Tumours

Germ cells are cells in the body that produce sperm in the male and eggs in the female. Tumours or cancers that develop from these cells are known as germ cell tumours.

Types of Germ cell tumours

Germ cell tumours can be of many types and are listed below.

Tumours in the testes(male)

  • – Seminoma
  • – Teratoma

Tumours in the Ovary(female)

  • – Teratoma
  • – Dysgerminoma
  • – Mixed tumour

Others

  • – Mediastinal germ cell tumours(chest)
  • – Germ cell tumours in the brain

For germ cell tumours of the testes, please see section on testicular tumours. See below for other types. In the woman, germ cell tumours tend to occur in the younger age group between the ages of 15-30 years. Mature teratoma which is a benign tumour is the most common of all.

Germ cell tumours of the ovary can be divided into benign and malignant tumours. Benign tumours include a mature teratoma of the ovary.

Malignant tumours include immature teratoma, dysgerminoma, yolk sac tumour, choriocarcinoma and embryonal carcinomas.

Common symptoms associated with germ cell tumours include swelling and pain in the abdomen, irregular periods and a feeling of bloating in the abdomen.

When a testicular to ovarian cancer is suspected, the following investigations are considered.

Ultrasound scan of the abdomen

An ultrasound scan of the abdomen will be able to give information about the swelling in the abdomen and whether the ovaries are normal or increased in size due to the tumour.

Blood Tests

Tumour markers are blood tests that are done to check for the presence of cancer. Tumour markers can be raised in certain germ cell tumours and therefore these tests are done in all patients who are suspected of having such a cancer. The commonly measured tumour markers are Alfa feto protein (AFP), B Human Chorionic gonadotrophin (b HCG) and LDH. Apart from tumour markers, routine blood tests to assess liver, kidney function are done.

Staging refers to a process that helps to find out whether the cancer has spread from its site of origin to other parts of the body.

Chest X-ray

An x-ray of the chest is done to look for spread of the cancer into the chest.

CT Scan

A CT scan of the chest abdomen and pelvis with contrast is done to stage a patient who is suspected of having an ovarian germ cell tumour. The scan will give information about whether the cancer or tumour has spread to other areas in the body or not and this determines what treatment is given.

PET CT Scan

A PET CT scan is generally not recommended for initial staging of germ cell cancer but is useful in situations when there is concern of spread of the cancer into other parts of the body.

These tumours are staged from stage 1 to stage 4 depending on the location of the tumour or cancer in the body.

Stage 1

The tumour is present in the ovary only and can be in one or both ovaries.

Stage 2

In stage 2, the tumour spreads from the ovary to nearby organs such as the fallopian tube, uterus(womb) or to areas within the pelvis(lower part of the tummy).

Stage 3

In stage 3, the tumour or cancer has spread to other areas in the abdomen such as lymph nodes or peritoneum which is a lining on all the organs of the abdomen.

Stage 4

In stage 4, there is spread of the cancer to other parts of the body such as the lungs or liver.

Treatment options for ovarian germ cell tumours depend on whether the tumour is benign or malignant and if malignant, on the stage of the cancer at the time of diagnosis.

Surgical management of these tumours involve removal of one or both ovaries depending on whether they are both affected or not. In younger women who wish to have children in the future, removal of one ovary is done if possible. In women who do not have plans for more children in the future, the uterus, fallopian tubes are also removed along with the ovaries. In patients with higher stage disease, other areas affected by the cancer are also removed such as lymph nodes, peritoneum etc. The aim of the surgery will be to remove all the tumour even in patients where the it is stage 2 or 3.

Chemotherapy is commonly used in management of most patients with malignant ovarian germ cell tumours. Only those with early stage 1 tumours do not benefit from this treatment. Chemotherapy is aimed to control and cure the disease. The need for chemotherapy and the choice of drugs used depends on the type of cancer and the stage of the cancer at diagnosis.

Dysgerminoma

Chemotherapy is used in treatment of dysgerminomas. The drugs commonly used include Carboplatin, EP or BEP chemotherapy regimens. BEP regimen consists of drugs Bleomycin, Etoposide and Cisplatin. The dugs selected depends on the stage of cancer and the patient’s general condition and preferences. In early stage tumours, chemotherapy is considered after surgery and in advanced stages, chemotherapy can be used as a first treatment. EP or BEP chemotherapy is given as cycles which are every 3 weeks. In the 3 week period, the treatment is given over 3 or 5 days depending on the regimen that is selected.

Non-dysgerminoma Cancers

Cancers other than dysgerminomas are immature teratoma, yolk sac tumour, embryonal carcinomas and mixed germ cell tumours. The treatment options of these tumours depend on the stage of cancer at diagnosis. In early cancers, the use of chemotherapy is not required and only surgery is enough, whereas in more advanced cancers chemotherapy is beneficial. The commonly used chemotherapy option here is BEP as described above. Up to 4 cycles are usually given.

Germ cell tumours of the ovary can be divided into benign and malignant tumours. Benign tumours include a mature teratoma of the ovary.

Malignant tumours include immature teratoma, dysgerminoma, yolk sac tumour, choriocarcinoma and embryonal carcinomas.
The mediastinum is the part of the body in the chest in between the lungs. The mediastinum contains the main blood vessels in the chest, oesophagus(gullet) and lymph nodes. Germ cell tumours that develop in this area are known as mediastinal germ cell tumours.

Germ cell tumours in the mediastinum are similar in type as seen in the testes or ovaries. When a mediastinal germ cell tumour is suspected or seen, scans and tests are done to make sure it has started in the mediastinum only and not in the ovary or testes and spread there.

Symptoms produced by mediastinal tumours include cough, chest pain, heaviness in the chest, weight loss, breathlessness or difficulty in swallowing.

Once a mediastinal germ cell tumour is suspected, the following tests are done to make a diagnosis and stage the disease.

Blood tests including complete blood picture, kidney and liver function tests, LDH, Alfa feto protein (AFP) and Beta HCG. Other tests including a chest x-ray, CT scan of the chest abdomen and pelvis or a whole body PET-CT scan are done in this setting.

Treatment for mediastinal germ cell tumours is dependent on whether the tumour is a seminoma type (seminoma in male or dysgerminoma in female) or other type.

Mediastinal seminomas or dysgerminomas, which are common in patients aged 20-40 years of age are treated usually with combination chemotherapy with BEP regimen. BEP is a combination of drugs called Bleomycin, Etoposide and Cisplatin. It is given as a drip every 3 weeks for up to 4 such cycles. In each cycle, the treatment is usually for 5 days. In some patients, Bleomycin is omitted, and EP chemotherapy is given.

Radiotherapy is an option of treatment in patients who cannot have chemotherapy but is used less commonly. If given, it is done over 5 weeks.

Surgery as a treatment option is rarely used in this setting

Mature teratomas which are considered as benign tumours are treated with surgical removal.

Immature teratomas, which are considered as malignant tumours or cancers are treated with chemotherapy and surgery with chemotherapy given either before or after surgery.

Other mediastinal germ cell tumours such as mixed germ cell tumours, yolk sac or embryonal carcinomas are treated with chemotherapy.

Commonly used regimens are BEP as described above or VIP which is a mixture of Cisplatin, Etoposide and Ifosfamide.