1. Dr Jane Skeen- for the NZ NCCN Pacific working group
Germ cell Tumours
Fiji 1 December 2016
Dr Jane Skeen- for the NZ NCCN Pacific working group

2. Germ cell tumours Rare and highly varied group of tumours
Occurs at several anatomical sites
Histological spectrum from mature to immature teratoma to 4 different malignant subtypes
Prior to platinum based chemotherapy -survival poor
BEP :bleomycin etoposide and cisplatin – nephro and ototoxic
JEB : bleomycin etoposide and carboplatin

3. Risk groups LOW INTERMEDIATE HIGH Gonadal Stage 1 (regardless of AFP)
Testis <5yrs, any AFP, Stages 2-4
All Stage 4 tumours except testis <5yrs and germinoma and seminoma
Testis ≥5yrs, AFP <10000, Stage 2+3
AFP ≥10000 except all Stage 1 tumours and testis <5yrs Stages 2-4
All other sites AFP <10000, Stage 2+3, except thoracic tumours
All thoracic tumours Stages 2-4
Pure germinoma, seminoma, any site, Stages 2-4
Pure HCG secreting tumours, any HCG, Stage 2+3

4. Histological classification Germ cell tumours
Germinoma
Teratoma
-Mature
-Immature
-Malignant teratoma
Embryonal carcinoma
Yolk sac tumour
Choriocarcinoma
Gonadoblastoma
Mixed malignant germ cell tumour

5. PI GC 1 Protocol
6* cycles of identical treatment for all stages and histologies
Carboplatin (JM8), Etoposide, Bleomycin (JEB)
Each cycle 21 days
(* Number of cycles (x+2) where x is the number required to achieve CR)
CR assessment will be assisted by ability to measure and follow appropriate tumour markers
 Total therapy duration usually no more than 6 months

6. Initial Evaluation Complete history including family history.
Complete physical examination
Chest X-ray and abdominal ultrasound.
CT scan of affected area plus chest and abdomen .
Full blood and platelet count.
Urea, creatinine, electrolytes, calcium, liver function tests
Tumour Markers- alpha fetoprotein / βHCG / Ca 125

7. Eligibility/Treatment
All patients with biopsy proven Germ cell Tumours (with the exception of Stage 1 Testicular tumours)
Stage 1 testicular tumours that post-orchidectomy show decreasing AFP at expected rate, will receive no further treatment unless there is arise in the AFP or clinical recurrence.
The initial cycle of therapy should be given as soon as practically possible after appropriate supportive care has been given This will include correction of anaemia (if applicable), treatment of infection and any co-morbidities.

8. Treatment The half-life of alpha fetoprotein is 4-7 days
AFP levels should reduce by at least 50% each week.
If AFP fails to normalise or having fallen starts to rise again, reimaging indicated, with a view to second look surgery.

9. 9 yr old - female
January 2007 presented with a painful distended abdomen
History of becoming unwell whilst on extended holiday
Transferred to Starship
Imaging : an extensive non-calcified abdomino-pelvic mass, ascites, peritoneal and subdiaphragmatic deposits
AFP (alpha-fetoprotein) > 60,000 units
Presumptive diagnosis : Germ cell tumour

10. 12.1.07 Laparotomy and biopsy of mass
large intra-operative bleed
tumour appeared necrotic
omentum was studded with nodules
presumed prior tumour rupture
urinary output compromised due to the raised intra- abdominal pressure related to the ascites

11. Chemotherapy commenced carboplatin/etoposide (JE)
Evening of collapsed
Resuscitated then admitted to PICU for ventilation
Abdomen decompressed after insertion of pigtail catheter under ultrasound guidance
3 litres of ascitic fluid was drained and the catheter remained in situ

12. Histology :
tumour was haemorrhagic and necrotic with a typical endodermal sinus pattern
Features of yolk sac tumour with positive markers for alpha-fetoprotein, other tumour markers negative
No ovarian tissue seen in the biopsies
Presumed extra gonadal advanced stage III yolk sac tumour
Presumed that tumour ruptured pre-biopsy with subsequent peritoneal seeding (family later stated abdominal massage)
With chemotherapy- good chance of cure

13. α-FP decline

14. Received 6 cycles chemotherapy ( JE/JEB x5) (carboplatin/Etoposide/bleomycin)
Post cycle 6 : AFP (N< 10)
Second look surgery 21 May: right ovary normal left in situ- some residual tissue resected
28 May AFP 11.4
Histology- no viable tumour
5 June AFP normal 4
Remains well AFP normal
Last reviewed September 2016
Wants to join the Navy