The pathology of late recurrence of testicular germ cell tumors

A total of 91 men had histologically documented late recurrences of testicu lar germ cell tumors characterized by a complete response to treatment with a subsequent disease-free interval of at least 2 years and no evidence of a second primary lesion. Ninety percent of the patients for whom informatio n was available received chemotherapy shortly after their initial diagnosis of testicular germ cell tumors; most of the other patients were known to h ave stage I disease initially. Overall, 60% of patients had teratoma in the ir late recurrences, including 20 patients (22%) in whom teratoma was the o nly element. Thus, teratoma was the most common type of neoplasm in late re currences. Excluding teratoma coexisting with other types of neoplasms, yol k sac tumor was the most frequent type of tumor in patients with late recur rence. It occurred in 47% of patients, either alone or with teratoma, anoth er nonteratomatous germ cell tumor type, or a "nongerm cell malignant tumor ." Unusual types of yolk sac tumor, including glandular, parietal, clear ce ll, and pleomorphic patterns, were seen frequently in late recurrences and often raised differential diagnostic problems with "nongerm cell" carcinoma s. A smaller number of late recurrences consisted of other types of neoplas ms. Twenty percent of patients with late recurrence had a nonteratomatous g erm cell tumor other than yolk sac tumor, either alone, with yolk sac tumor , or with a "nongerm cell malignant tumor." Most of these nonteraromatous g erm cell tumors other than yolk sac tumor were embryonal carcinoma, althoug h rarely seminoma and choriocarcinoma were encountered. "Nongerm cell malig nant tumors," including both sarcomas and carcinomas of various types, occu rred in 23% of late-recurrence patients, either alone or with a nonteratoma tous germ cell tumor. Late recurrences were seen in many different sites in these patients, including the retroperitoneum, abdomen, pelvis, liver, med iastinum, lung, bone (femur, vertebra, and rib), lymph nodes outside the re troperitoneum and mediastinum (supraclavicular, neck, and axillary regions) , scrotum and inguinal regions, adrenal gland, chest wall, and buttocks. Fo llow-up data were available for 79 of the 91 patients studied. Duration of follow-up ranged from 2 months to 13 years after the patient's first late r ecurrences; the mean length of follow-up was 4.8 years. Patients whose late recurrences consisted of teratoma only had the most favorable outcomes, wi th 79% having no evidence of disease at last follow-up. Patients whose late recurrences consisted of pure "nongerm cell malignant tumor" or pure germ cell tumor (yolk sac tumor or other types) had a much worse prognosis: Only 36% to 37% were alive with no evidence of disease. Patients with two diffe rent types of nonteratomatous malignancies in their late recurrences had a dismal clinical course: Only 17% with both yolk sac tumor and other nontera tomatous germ cell tumor had no evidence of disease, whereas no patient wit h both nonteratomatous germ cell tumor and "nongerm cell malignant tumor" w as disease free. Late recurrences consisting of teratoma alone often have a favorable out come, but the prognosis in all other patients is poor. Furth ermore, late recurrence is not likely to respond to chemotherapy and is bes t treated by surgical excision when possible.