Mediastinal teratomas: review of 15 pediatric cases

One hundred fifty-three children with a teratoma presented to one hospital between 1970 and March 1992. The clinical and pathological features of 15 patients with mediastinal teratomas are reviewed; six were newborn and nine aged from infancy to 13 years. Thirteen patients including the six newborns presented with respiratory distress and all 15 patients had a mass on chest radiograph. A definite diagnosis of teratoma was not made preoperatively in any of these patients. At operation, a median sternotomy was used to approach seven anterior tumors and a lateral thoracotomy performed in the other eight patients. Histologically two were mature, 10 had immature elements, and three were malignant teratomas. The patients with malignant tumors were all over 12 years of age and died within 6 months of treatment. All six neonates had immature teratomas. Raised serum alpha-fetoprotein levels provided useful markers in two patients with recurrent tumors. Three conclusions can be drawn: (1) mediastinal teratomas are rare in children and frequently are not diagnosed before operation; (2) in newborns these tumors may be immature and present with respiratory distress; and (3) a median sternotomy gives excellent exposure for anterior mediastinal tumors.     

Tumor markers CA 125 and CA 19-9 in cord blood and during infancy: developmental changes and use in pediatric germ cell tumors

Tumor markers CA 125 and CA 19-9 are elevated in a variety of malignancies in adult patients, but only little is known of their biology during gestation or infancy. We have addressed the developmental pattern of these carbohydrate antigens in pediatric patients by measuring their serum levels in 133 cord blood samples from the second through third trimester of gestation and in 39 infants aged less than 1.5 y. The serum concentrations of both markers revealed developmental changes, the levels being higher at earlier gestation (wk 24 through 37) than at term or during infancy. The clinical value of the markers was evaluated by monitoring 26 children with germ cell tumors; 14 benign and 2 immature teratomas, and 11 malignant germ cell tumors. Patients with immature sacrococcygeal teratomas showed constant and prolonged elevations of serum CA 125 and CA 19-9. In contrast, all but two children with mature teratomas had normal marker levels; these two patients with abnormally high serum CA 125 and CA 19-9 values for the first 4 postoperative weeks had a benign ovarian and ventricular teratoma, respectively. Of the 11 children with malignant germ cell tumors, serum CA 125 or CA 19-9 concentration was elevated in four patients at diagnosis and declined to normal within 2 wk after institution of therapy. Malignant recurrence in two patients was not associated with a reelevation of the CA 125 level. Taken together, our results demonstrate a developmentally regulated pattern of serum CA 125 and CA 19-9. The carbohydrate markers were usually inferior to alpha-fetoprotein in monitoring of germ cell tumors, but may be a useful adjunct in the follow-up of immature teratomas.     

Decreased serum apolipoprotein AII/AI ratio in systemic amyloidosis

BACKGROUND: Intrapericardial teratomas are rare and usually present early in infancy or childhood. PROCEDURE: We describe herein a rare case of an adult patient with an intrapericardial teratoma who presented with fever, cardiac arrhythmias, and oppressive substernal chest pain. Preoperative diagnosis was suggested by echocardiography and computerized tomography of the chest. The tumor weighed 530 g and its histologic features were those of a mature cystic teratoma. It was excised totally and 10 years' follow-up revealed no evidence of residual disease. DISCUSSION: Our patient is one of the very few adult patients with intrapericardial teratomas who was treated successfully with surgery. Both echocardiography and tomography of the chest suggested the diagnosis and delineated the relationship of the tumor to the great vessels. CONCLUSION: The diagnosis of Intrapericardial teratomas is suspected by echocardiography and/or tomography of the chest and confirmed by specific histologic features. These tumors should be excised whenever detected.     

Utility of lentil lectin affinity of alpha-fetoprotein in the diagnosis of hepatocellular carcinoma

AIMS/METHODS: Frozen sera obtained from 70 patients (35 with hepatocellular carcinoma and 35 with benign chronic liver disease) with serum alpha-fetoprotein > 20 ng/ml were studied to evaluate the diagnostic indices of lentil lectin affinity of alpha-fetoprotein in detecting hepatocellular carcinoma. RESULTS: The proportion of alpha-fetoprotein-L3 was significantly higher in patients with hepatocellular carcinoma than in those with benign chronic liver disease (41.0 +/- 33.6% vs. 16.4 +/- 15.3%, p < 0.001). This difference led to a sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 57, 89, 83, 67 and 73%, respectively, in detecting hepatocellular carcinoma using the proportion of alpha-fetoprotein-L3 > 35% as a parameter. Within a 1-year period, 1500 high-risk persons were collaborating, leading to 22 cases with serum total alpha-fetoprotein > 20 ng/ml. These 22 cases included six pregnant women. The parameter, alpha-fetoprotein-L3 > 35% was used along with sonography to detect hepatocellular carcinoma for the remaining 16 cases. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 75, 83, 60, 91 and 81%, respectively, by the proportion of alpha-fetoprotein-L3 > 35%; and 100, 92, 80, 100 and 94%, respectively, by sonography. CONCLUSIONS: Lentil lectin affinity of alpha-fetoprotein provides a moderately high sensitivity and a high specificity in the detection of hepatocellular carcinoma for persons with high alpha-fetoprotein levels. It may be a useful adjuvant tool of sonography and total alpha-fetoprotein level in a mass survey of hepatocellular carcinoma for a high-risk population.     

Kinetics of piperacillin and tazobactam in ventricular cerebrospinal fluid of hydrocephalic patients

OBJECTIVE: The purpose of this study was to determine, among six second-trimester maternal serum analytes, the best three-analyte combination for fetal Down syndrome detection. STUDY DESIGN: With use of commercially available assay kits, medians for free beta-human chorionic gonadotropin, CA 125, and dimeric inhibin A were established in stored sera from 45 to 50 euploid pregnancies at each week of gestation from 14 to 22 weeks and from 33 Down syndrome pregnancies. Maternal serum alpha-fetoprotein, unconjugated estriol, and intact human chorionic gonadotropin levels measured in each sample before storage were retrieved. All 20 possible three-analyte combinations were evaluated in the multiple-marker screening test for Down syndrome. RESULTS: The mean maternal age of the study population was 35.6 +/- 5.3 years. The best three-analyte combination was maternal serum alpha-fetoprotein, free beta-human chorionic gonadotropin, and dimeric inhibin A: 97% of Down syndrome cases were detected at a false-positive rate of 16%. At a slightly higher false-positive rate (18%) maternal serum alpha-fetoprotein, estriol, and intact human chorionic gonadotropin detected only 79% of cases. CONCLUSIONS: Of six second-trimester maternal serum analytes, the best three-analyte combination for fetal Down syndrome detection was maternal serum alpha-fetoprotein, free beta-human chorionic gonadotropin, and dimeric inhibin A. This retrospective analysis should now be confirmed prospectively.     

Ovarian stimulation and in vitro fertilization in women with mature cystic teratomas

OBJECTIVE: To report the results of ovulation induction and in vitro fertilization-embryo transfer (IVF-ET) in patients with ovarian cystic teratomas. METHODS: Six women with ultrasonographically diagnosed ovarian cystic teratomas (mean diameter 2.4 cm) who presented with infertility underwent IVF-ET (n = 4) or ovulation induction (n = 2). Serial ultrasound examinations were used to determine the size of the cystic teratomas during therapy and throughout pregnancy. RESULTS: Ovarian stimulation was successful, as evidenced by the serum estradiol concentration on the day of hCG administration (mean in IVF-ET patients, 3558+/-1319 pg/mL) and the number of oocytes retrieved (10+/-4.24). Three patients having IVF-ET and both patients having ovulation induction conceived, and six healthy infants were born. Cyst sizes remained unchanged throughout treatment and pregnancy. There were no cyst-related complications during ovulation induction or IVF-ET, or during the entire course of pregnancy, labor, and delivery. CONCLUSION: The presence of ovarian cystic teratoma should not be considered a contraindication for therapy in women undergoing ovulation induction and IVF-ET.     

Primary germ cell tumors of the mediastinum: I. Analysis of 322 cases with special emphasis on teratomatous lesions and a proposal for histopathologic classification and clinical staging

BACKGROUND: Primary germ cell tumors of the mediastinum are unusual neoplasms with histopathologic features that are similar to those of germ cell tumors in the gonads. However, their clinical features, behavior, and spectrum of pathologic features in the mediastinum have not yet been fully defined. METHODS: The clinical and pathologic features of 322 cases of primary mediastinal germ cell tumors were reviewed, with special emphasis on teratomatous lesions. The tumors were divided into groups according to their histologic features and correlated with their order of frequency, patient gender and age distribution, and morphologic features. A clinical staging scheme based on the extent and location of the lesions was devised. RESULTS: The overwhelming majority of patients were men (320); only 2 were women (both had teratomatous lesions with additional malignant components). The patients' ages ranged from 1 to 79 years (mean, 40 years). Histologically, all types of germ cell tumors were represented, including 138 teratomas (87 mature teratomas, 6 immature teratomas, and 45 teratomas with additional malignant components); 120 seminomas; 52 nonseminomatous, nonteratomatous germ cell tumors (38 yolk sac tumors, 6 embryonal carcinomas, and 8 choriocarcinomas); and 12 combined germ cell tumors without teratomatous components. The teratomatous lesions with additional malignant components were further separated into subtypes based on the histologic types of their malignant components, i.e., epithelial, mesenchymal, etc. Clinical staging was possible in 242 cases, with 191 cases (79%) in Stage I, 4 cases (1.6%) in Stage II, and 47 cases (19.4%) in Stage III. In each group, the clinical staging correlated well with the clinical outcome for the majority of patients. CONCLUSIONS: The results of this study showed that mediastinal germ cell tumors have demographic and histopathologic distributions similar to those of tumors occurring in the male gonads, with teratomatous and seminomatous lesions being the most common. Among the nonseminomatous germ cell tumors in this study, the yolk sac tumors appeared to occur the most frequently (the ratio of yolk sac tumor occurrence to embryonal carcinoma occurrence was 6.1:1). In addition, the subclassification of teratomas with additional malignant components based on the histologic types of malignancies may lead to more therapy choices for patients. At the same time, the use of a clinical staging scheme may be of value in predicting clinical outcome and planning therapy.     

Prognostic features of teratomas with malignant transformation: a clinicopathological study of 21 cases

PURPOSE: Teratomas with malignant transformation comprise up to 6% of metastatic teratomas. The prognosis of patients with these tumors can vary considerably. We delineate factors that may be related to prognosis in a cohort of men with teratoma with malignant transformation. MATERIALS AND METHODS: We analyzed pathological features, treatment, response, recurrence, time to recurrence, subsequent followup and survival for 21 patients (median age 28 years) diagnosed with teratoma with malignant transformation during a 7-year period at our institution. RESULTS: Malignant nongerm cell elements were present in the primary tumor in 11 cases (52%). Of 18 patients with testicular primaries 17 (94%) presented with metastatic disease. Despite aggressive treatment with surgery and chemotherapy 17 of 21 cases (81%) recurred (median time 6 months). Overall, 5 patients (24%) died of disease (median survival 23 months), 5 (24%) are alive with metastases (median followup 41 months) and 11 (52%) have no evidence of disease (median followup 50 months). Progression/recurrence was substantially greater for 2 of 2 cases with a mediastinal origin, 3 of 4 with rhabdomyosarcomatous differentiation and 5 of 6 with neural differentiation compared with the remainder of the cohort (p < 0.05). CONCLUSIONS: Teratomas with malignant transformation are usually metastatic at presentation, have a high recurrence rate and are more aggressive than teratomas without malignant transformation. Prognosis is especially poor for mediastinal teratomas with malignant transformation and for those with neural or rhabdomyosarcomatous differentiation. Complete surgical resection of residual or recurrent disease appears to offer the best chance for prolonged survival.     

Mediastinal teratoma: CT differentiation of ruptured and unruptured tumors

OBJECTIVE: The purpose of this study was to differentiate ruptured from unruptured mediastinal teratomas using CT. MATERIALS AND METHODS; CT findings in 17 cases of surgically resected mediastinal teratomas were reviewed retrospectively. Preoperative rupture was found in seven patients during surgery. We compared the clinical symptoms and CT findings of ruptured tumors with those of unruptured tumors. On CT, we evaluated size, wall thickness, location of the mass, presence or absence of internal septation, homogeneity of the internal components of each compartment, calcification or fat within the mass, and ancillary findings in adjacent structures. RESULTS: Severe symptoms (chest pain or hemoptysis) were more commonly found in ruptured (71%) than in unruptured tumors. All ruptured mediastinal teratomas had a tendency to display inhomogeneity of the internal components, whereas 90% of unruptured masses showed homogeneous densities of internal components in each compartment of the mass. Ancillary CT findings in ruptured tumors included fat-containing masses in adjacent lung parenchyma in two patients, consolidation or atelectasis in the adjacent lung in three patients, pericardial effusion in one patient, and pleural effusion in four patients. CONCLUSION: In cases of mediastinal teratoma, CT findings of inhomogeneity of the internal components and changes in the adjacent lung parenchyma, pleura, or pericardium can be used as signs of tumor rupture.     

Serum alpha-L-fucosidase activity and early detection of hepatocellular carcinoma: a prospective study of patients with cirrhosis

BACKGROUND: Serum alpha-L-fucosidase activity is considered a marker of hepatocellular carcinoma. To the authors' knowledge, its clinical usefulness in the early detection of hepatocellular carcinoma in the follow-up of cirrhotic patients has not been reported previously. METHODS: The authors prospectively studied serum alpha-L-fucosidase activity, in addition to alpha-fetoprotein and ultrasonography, in a regular screening of 132 cirrhotic patients during an 8-year follow-up. RESULTS: At enrollment, 120 patients had low alpha-L-fucosidase activity (below the cutoff value) and 12 had high activity. All patients had serum alpha-fetoprotein levels below the cutoff value. During the follow-up, hepatocellular carcinoma was detected in 19 patients, 16 with alpha-L-fucosidase activity below the cutoff value at enrollment and 3 with activity above it. In 7 of those 16 patients with carcinoma and low enzyme activity, the enzyme activity showed a significant increase 6-9 months before there was ultrasonographic evidence of a focal lesion, and by the time of diagnosis it had risen above the cutoff value in all of them; in only 3 of the 7 patients was the increase in alpha-L-fucosidase activity associated with an increase in alpha-fetoprotein. In another 4 of the 19 patients with carcinoma, only alpha-fetoprotein increased. CONCLUSIONS: Serum alpha-L-fucosidase activity is useful in the early detection of hepatocellular carcinoma. The data from this study suggest that cirrhotic patients who have a marked increase in serum alpha-L-fucosidase levels during follow-up should be closely monitored for signs of hepatocellular carcinoma development.     

2nd-trimester maternal serum marker results are not altered by delayed analysis

OBJECTIVE: The goal of the study was to evaluate the significance of delayed laboratory analysis of maternal serum alpha-fetoprotein, beta-subunit of human chorionic gonadotropin, and unconjugated estriol for prenatal screening. METHODS: Biochemical analysis of 30 consecutive biochemical screening specimens of maternal serum alpha-fetoprotein, beta-subunit of human chorionic gonadotropin, and unconjugated estriol was performed immediately upon arrival to the laboratory, 7 days later, and again 14 days after maternal blood was drawn. Differences among the results of the three sets of biochemical studies were evaluated by one-way analysis of variance for repeated measures. RESULTS: No significant differences were found among the results of immediate assays as compared with those at a 7- or a 14-day delay for all three biochemical markers. CONCLUSIONS: Our data suggest that up to a 14-day delay in the performance of the 2nd-trimester maternal serum biochemical screening assays will not alter the results significantly. The results of maternal serum screening are, thus, clinically valid even if the laboratory assays were performed several days after maternal blood was drawn.     

Predictive factors of survival and intrahepatic recurrence of hepatocellular carcinoma in cirrhosis after percutaneous ethanol injection: analysis of 71 patients

BACKGROUND/AIMS: This study was undertaken to determine the factors predicting survival and intrahepatic recurrence in hepatocellular carcinoma patients treated with percutaneous ethanol injection. METHODS: Seventy-one patients with cirrhosis and hepatocellular carcinoma underwent percutaneous ethanol injection (54 males/17 females; median age 66 years; Child A 54/B 17). Fifty-two patients had a single nodule < or = 5 cm and 19 had multiple nodules, up to three, each one < or = 4 cm. Follow-up ranged from 2-63 months (median 26). RESULTS: Overall survival rates were 89%, 54% and 24% and new lesions recurrence rates 32%, 73% and 81% at 1, 3 and 5 years, respectively. At univariate analysis, monofocal tumor (p<0.05), absence of ascites (p<0.05), complete tumor necrosis at CT-scan or MRI (p<0.01), post-treatment alpha-fetoprotein < or = 10 ng/ml (p<0.05) and Child A class in patients with a single nodule (p<0.05) were associated with higher survival. Presence of tumor capsule at imaging (p<0.05), complete tumor necrosis at CT-scan or MRI (p<0.01) and post-treatment alpha-fetoprotein < or = 10 ng/ml (p<0.01) were associated with lower recurrence rates. At multivariate analysis, basal alpha-fetoprotein (p=0.040) and tumor number (p=0.032) significantly affected survival; stepwise analysis revealed basal alpha-fetoprotein, tumor number and serum albumin (p=0.0012) as the best combination predicting survival. No variable reliably predicted recurrence by multivariate analysis. CONCLUSIONS: In patients with cirrhosis and hepatocellular carcinoma, treated with percutaneous ethanol injection, survival depends on: the severity of the underlying liver disease, uni/multifocality of the tumor and basal alpha-fetoprotein. Presence of a tumor capsule is associated with lower recurrence rates. At post-treatment evaluation, both survival and recurrence rates are positively affected by complete tumor necrosis and alpha-fetoprotein < or = 10 ng/ml.     

Serial changes in serum alpha-fetoprotein prior to detection of hepatocellular carcinoma in liver cirrhosis

In 49 liver cirrhosis patients with hepatocellular carcinoma in which the hepatocellular carcinoma nodule was smaller than 30 mm in size, serial changes in serum alpha-fetoprotein levels prior to the detection of the hepatocellular carcinoma were studied retrospectively, and compared with those of 70 cirrhotic patients with no hepatocellular carcinoma. The changes in alpha-fetoprotein levels were classified into the 4 types normal, low plateau, high plateau and spiky type. The spiky type (spiky elevation during a short period) was more frequently noted in the patients with hepatocellular carcinoma than in those with liver cirrhosis. In a prospective analysis of 39 patients with liver cirrhosis, hepatocellular carcinoma was detected in 6, and was also more frequently noted in the spiky type than the other types. Moreover, in the hepatocellular carcinoma patients with the spiky type of alpha-fetoprotein, hepatocellular carcinoma was suspected, on the basis of the tumor doubling time, to exist at the time of the first elevation of alpha-fetoprotein. These results suggest that the liver cirrhotics with the spiky type of alpha-fetoprotein may be considered to be a high-risk group of hepatocellular carcinoma.     

Genetic analysis of ovarian germ cell tumors by comparative genomic hybridization

Ovarian germ cell tumors (OGCTs) show a heterogeneity that is not seen in their testicular counterparts and include benign mature cystic teratomas, intermediate immature teratomas, malignant germ cell tumors [GCTs (dysgerminomas, endodermal sinus tumors, and mixed GCTs)], and GCTs arising in dysgenetic gonads of 46,XY individuals. Comparative genomic hybridization was used to analyze 27 OGCTs for regions of relative gain or loss. The analysis of 21 malignant OGCTs (12 dysgerminomas, 6 endodermal sinus tumors, and 3 mixed GCTs) demonstrated genetic alterations similar to those reported in adult testicular GCTs. The most common regions gained include chromosomes 12p (16 of 21 tumors), 21 (10 of 21 tumors), 8 (8 of 21 tumors), and 1q (6 of 21 tumors). The most common region lost was chromosome 13. Regions of high-level gain were identified at 12p11-12 and 4q11. The profile of gains and losses was similar in the different histological subtypes within this category. One tumor presented in a 46,XY patient; this tumor was diploid and showed a gain of 12p. Immature teratomas (six cases) showed only one case with an abnormality, which was a gain of chromosome 14. We conclude that malignant OGCTs are genetically similar to those found in the adult testis; however, immature teratomas show no consistent gains or losses and are therefore different from those presenting in the adult testis. A review of the literature suggests that genetic abnormalities in this group may herald a worse prognosis. Lastly, OGCTs in dysgenetic gonads arise in a diploid rather than a tetraploid cell line, yet they also show a gain of 12p.     

Patients'' requests and satisfaction with services in an outpatient psychiatric setting

Teratomas are embryonal neoplasms consisting of tissues from at least two of the three germ layers. Teratomas can occur in almost any region of the body and in any organ, but they are most commonly observed in the paraxial and midline locations. Excluding teratomas of the testes, 75% to 80% of teratomas occur in females. Approximately 80% are benign and 20% are malignant. The presenting location of teratomas correlates with patient age. Teratomas occurring in infancy and early childhood are usually extragonadal, whereas older children predominantly present with gonadal teratomas. The most common site of occurrence in neonates is in the sacrococcygeal and presacral region. Prognosis depends on patient's age, the resectability of the tumor, and the presence of metastases or metastatic potential.     

Maternal serum alpha-fetoprotein and dimeric inhibin A detect aneuploidies other than Down syndrome

OBJECTIVE: Our purpose was to determine whether the combination of maternal serum alpha-fetoprotein, free human chorionic gonadotropin-beta, dimeric inhibin A, and maternal age detects aneuploidies other than Down syndrome. STUDY DESIGN: We retrieved stored serum from pregnancies complicated by aneuploidies other than Down syndrome from 1988 to 1997 (n = 55, mean maternal age 35.2 +/- 5.6 years). Alpha-fetoprotein levels were obtained from our database, and free human chorionic gonadotropin-beta and dimeric inhibin A levels were measured in the thawed serum with use of commercial assays. Analyte values were used in both 3-analyte and 2-analyte multiple-marker screening tests; detection rates were determined at several different Down syndrome risk-positive cutoff values. RESULTS: In the 3-analyte test 58% (32/55) of all aneuploidies were detected with use of both the Down syndrome protocol at a screen-positive risk cutoff value of 1:300 (false-positive rate 17%) and a novel trisomy 18 screening algorithm. However, 67% (37/55) detection was obtained with use of the 2-analyte combination of alpha-fetoprotein and dimeric inhibin A, with both the Down syndrome protocol (screen positive cutoff value 1:300) and the trisomy 18 algorithm: 12 of 13 trisomy 18 (92%), 9 of 17 Turner's syndrome (53%), 10 of 17 other sex chromosome aneuploidies (59%), 1 of 1 trisomy 22 (100%), and 5 of 7 trisomy 13 (71%). CONCLUSIONS: The combination of maternal serum alpha-fetoprotein, dimeric inhibin A, and maternal age detects autosomal trisomies other than Down syndrome at a rate superior to that of the traditional analyte combination.     

Differential expression of protooncogenes in human germ cell tumors of the testis

BACKGROUND: It has been suggested that tumorigenesis of the germ cell tumor of the testis includes abnormal and developmentlike differentiation of primordial germ cells to several mature type tumors. METHODS: To clarify roles of protooncogenes in the unique tumorigenic mechanism in the human germ cell tumor, the authors examined the expression of 15 protooncogenes in human primary germ cell tumors of the testis with Northern blot analyses. RESULTS: Fifteen (94%) of 16 seminomas and 5 (83%) of 6 embryonal carcinomas had a significant levels of N-myc expression, whereas they did not express two receptor type protooncogenes, c-erbB-1 and c-erbB-2. In contrast, some immature teratomas had a high level of c-erbB-1 expression, and an advanced case showed a significant level of c-erbB-2 expression. Immature teratomas did not show N-myc expression. Higher levels of c-mos expression were observed in several cases of seminomas and embryonal carcinomas. Expression of c-Ki-ras or N-ras was observed in all histologic subgroups and normal testes. CONCLUSION: A significant level of N-myc expression may be essential for undifferentiated tumors including seminoma and embryonal carcinoma, whereas c-erbB-1 and possibly c-erbB-2 may have important roles in the differentiated tumors such as immature teratoma. These results suggest that some of the protooncogene expression may be switched critically during the differentiation from seminomas or embryonal carcinomas to the more differentiated-type tumor.     

Surgically excised primary mediastinal tumors and cysts: a report of 43 cases

Forty-three primary mediastinal tumors or cysts were surgically treated in 41 patients during a 10-year period. These tumors consisted of 20 thymic tumors, 10 neurogenic tumors, 5 teratomas, 3 lymphoid tumors, 2 congenital cysts, 2 mediastinal thyroid tumors, and 1 chondroma. There were 16 male and 25 female patients. The mean age was 44 years with a range of 6 to 79 years. Sixteen patients (39%) were symptomatic. There were 20 thymic tumors including 13 thymomas, 5 thymic cysts, and 2 hyperplasia with myastenia. Additional radiation therapy was recommended for all but stage I thymomas. Only 1 of the 10 neurogenic tumors was malignant. Eight teratomas were all cystic and matured. Early operative intervention is mandatory in these cases.     

Prospective, randomized, double-blind study of high-dose aprotinin in pediatric cardiac operations

OBJECTIVE: To describe the characteristic cytologic features of fine needle aspirates (FNAs) of primary extragonadal germ cell tumors (PEGCTs). STUDY DESIGN: Thirteen patients with PEGCTs, including 2 seminomas, 2 mixed germ cell tumors, 3 immature teratomas, 1 choriocarcinoma and 5 yolk sac tumors (YSTs) were studied. The final diagnosis of PEGCT in all cases was established by histologic examination of the tumor tissues. Fine needle aspiration was done on either the primary tumor or metastatic foci. The aspirates were stained with one of the Romanovsky stains and Papanicolaou stain. RESULTS: Each type of PEGCT has its own morphologic characteristics. In seminoma, the tumor cells are large and noncohesive, with one to several distinct nucleoli; some lymphocytes are also present. YSTs show many pleomorphic cells with vacuoles in the cytoplasm and nuclei; tumor cells frequently aggregate in a microglandular or papillary pattern. Choriocarcinoma consists of syncytiotrophoblasts and cytotrophoblasts. The former are very large cells with eosinophilic cytoplasm, one to several nuclei and distinct nucleoli; the latter are medium-sized cells with vacuolated, basophilic cytoplasm and eccentric nuclei. Immature teratomas are composed of a mixture of cell types, including elongated epithelioid cells, mesenchymal cells and many large, naked, amorphous nuclei with a homogeneous chromatin pattern. Diagnosis of mixed germ cell tumor is difficult but can be made if two or more subtypes of tumor cells are observed in the FNA. CONCLUSION: Cytologic examination of FNAs of primary or metastatic lesions of PEGCTs, stained either with Romanovsky or Papanicolaou stain, is of diagnostic value for such diseases. The use of immunochemistry can help to confirm the cytologic impression.     

Results of radiotherapy of malignant testicular neoplasms

It is very difficult to compare the therapeutic results of malignant testicular tumours because of the different histological classification systems, the uncertainty in the definition of the different stages, the error rate of the lymphography which amounts up to 35%, and the multitude of surgical, radiation, and chemotherapeutic methods. A histological classification and an exact determination of the stage is required as a condition of beginning a radiotherapy. The desirable focal dose for seminomas is between 4000 and 5000 rad, the maximum dose for teratomas is 6000 rad. For the stages T1-3N0 the iliac and the paraaortic lymph nodes are irradiated, for the stages T1-4N1-2 the interpleural space andthe supraclavicular region are included. For a group of 91 patients there was reached a five-year survival rate of 85,5% in case of seminomas and of 64% in case of teratomas.