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Recent Advances in Understanding the Etiology

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 MEDICAL PROGRESS
Recent Advances in Understanding the Etiology and
Pathogenesis of Pediatric Germ Cell Tumors
Christiane H. Mosbech, BSc,* Catherine Rechnitzer, MD, DMSc,w Jesper S. Brok, MD, PhD,w
Ewa Rajpert-De Meyts, MD, DMSc,* and Christina E. Hoei-Hansen, MD, DMSc*z
Summary: Pediatric germ cell tumors (GCTs) are rare neoplasms
arising predominantly in the gonads and sacrococcygeal, media-
stinal, and intracranial localizations. In this article, we review
current knowledge of pathogenesis of pediatric GCTs, which differs
from adult/adolescent GCTs. One distinctive feature is the absence
of a progenitor stage, such as carcinoma in situ or gonado-
blastoma, which are seen in adult/adolescent GCTs, except
spermatocytic seminoma. The primordial germ cell (PGC) is the
suggested origin of all GCTs, with variations in histology reflecting
differentiation stage. Expression of pluripotency transcription fac-
tors OCT-3/4, NANOG, and AP-2g in germinomas/seminomas/
dysgerminomas is consistent with retaining a germ cell phenotype.
Teratomas, in contrast, develop through a pathway of aberrant
somatic differentiation of immature germ cells, and the yolk sac
tumors and choriocarcinomas result from abnormal extra-
embryonic differentiation. In pediatric GCTs, origin is suggested at
an earlier developmental stage because of predisposing genetic
factors, although responsible genes remain largely unknown. Some
extragonadal GCTs have been linked to overexpression of the KIT/
KITLG system, allowing for survival of aberrantly migrated
ectopic PGCs. Infant gonadal/sacrococcygeal GCTs may be caused
by apoptosis-related pathways, consistent with an association with
polymorphisms in BAK1. Although recent advances have identified
candidate pathways, further effort is needed to answer central
questions of pathogenesis of these fascinating tumors.
Key Words: germ cell tumor, children, primordial germ cell,
pathogenesis
(J Pediatr Hematol Oncol 2014;36:263–270)
G erm cell tumors (GCT) are a heterogenous group of
neoplasms that develop in both sexes at any age. They
vary in histology and occur at different anatomic sites.
GCTs can be found in the gonads and at extragonadal sites
along the midline of the body (Fig. 1). Extragonadal tumors
predominate in children younger than 3 years of age,
whereas the gonads are the main localization during and
after puberty.2 The tumors have been characterized on the
basis of histology and site of occurrence, and—more
recently—on the pattern of cytogenetic aberrations, gene
expression, gene variants, and miRNA expression.
Received for publication November 16, 2013; accepted January 15,
2014.
From the *Department of Growth and Reproduction; wDepartment of
Pediatrics, University Hospital of Rigshospitalet, Copenhagen; and
zDepartment of Pediatrics, University Hospital of Hilleroed,
Hilleroed, Denmark.
Supported by The Danish Cancer Society, The Danish Child Cancer
Foundation.
The authors declare no conflict of interest.
Reprints: Christina E. Hoei-Hansen, MD, DMSc, Department of
Pediatrics, University Hospital of Hilleroed, Dyrehavevej 29, DK—
3400 Hilleroed, Denmark (e-mail: chh@dadlnet.dk).
Copyright r 2014 by Lippincott Williams & Wilkins
J Pediatr Hematol Oncol  Volume 36, Number 4, May 2014
Each year, 1 of 500 children is diagnosed with cancer
worldwide3 with 2.5% being GCTs. Extragonadal tumors
are slightly more frequent among girls, but the sex ratio is
approximately equal.4 Testicular teratomas make up the
majority of GCTs in neonates. The incidence of GCTs
peaks first within the first 3 years of age, reflecting the
incidence of sacrococcygeal tumors and yolk sac tumors
(YST).1 At the onset of puberty, the gonadal tumors of
adolescent and adult type account for the second peak in
incidence.5 Reports on pediatric GCTs in general differ-
entiate the pediatric population as opposed to the adult
population based on age, that is, 15 years, whereas the
differences in pathogenesis in the 2 populations most likely
are based on the impact of the endocrinological changes
occurring in and after puberty.
Survival rates of childhood GCTs have markedly
improved in the last decades to >70% to 80% after
introduction of platinum-based chemotherapy.3 Current
chemotherapy protocols take into account age, site, his-
tology, stage, completeness of surgical resection, and
treatment response monitored by the tumor markers a-
fetoprotein (AFP), human choriogonadotropin (b-HCG),
and appropriate scans.6 In general, gonadal encapsulated
tumors can be completely resected, whereas larger gonadal
or extragonadal tumors may require neoadjuvant or pre-
operative chemotherapy. Specific protocols are used for
management of intracranial GCTs. Complete resection may
be associated with significant morbidity; hence, radio-
therapy is part of treatment for some intracranial tumors,
but long-term neuropsychological and endocrine sequelae
are observed.5,7 With regard to the clinical response to
chemotherapeutic regimens, a number of studies have
attempted to identify molecular predictive factors, for
example, hypermethylation of tumor suppressor genes in
some aggressive YSTs,8 or variants in genes coding for
transport proteins and receptors associated with ototoxicity
of cisplatinum treatment.9
The knowledge about etiology and pathogenesis of
GCTs in children is still limited, partly because the malig-
nancy is rare but also because research has focused on
GCTs of adults. It has been hypothesized that GCTs
originate from primitive germ cells that failed to differ-
entiate further in fetal life and that GCTs in adults originate
from a different progenitor and harbor different cytogenetic
traits as compared with GCTs in children.10 The devel-
opmental stage of origin of the pediatric neoplasms may
arise earlier than in adults because of predisposing genetic
factors. A question of interest has been whether the histo-
logic phenotype is explained by the differentiation stage of
the early germ cells that have undergone neoplastic trans-
formation. In this article, we review the current knowledge
concerning the pathogenesis of pediatric GCTs in relation
to early development and maturation stages of germ cells.
www.jpho-online.com | 263
Mosbech et al
FIGURE 1. Relative incidence of GCTs in children below 15 years
of age according to site of origin is marked by the size of the
circular diagrams: sacrococcygeal region (35%), ovary (25%),
testis (20%), central nervous system (CNS; 5%), mediastinum
(5%), retroperitoneum (5%), head/neck (3%), and vagina (2%).
Relative incidence of histologic subtype is marked for each site of
origin: Seminoma/germinoma is marked in red (SE/GER), mature
teratoma in turquoise (MT), immature teratoma in yellow (IT),
embryonal carcinoma in orange (EC), yolk sac tumor in purple
(YST), and mixed GCTs in green (MIX). Modified from Pinkerton
et al1 with permission from Elsevier Adaptations are themselves
works protected by copyright. So in order to publish this adap-
tation, authorization must be obtained both from the owner of
the copyright in the original work and from the owner of copy-
right in the translation or adaptation.
METHODS OF THE REVIEW
The search for relevant articles was conducted through
the PubMed Database using the MeSH function to specify
the search criteria. The search was performed in May 2013
by C.H.M. with the following search profile: “Neoplasms,
Germ Cell, and Embryonal/Etiology” (Majr) AND
“Infant” (MeSH Terms) OR “Child” (MeSH Terms) OR
“Adolescent” (MeSH Terms) (9539 results).
Subsequent search criteria were added with increasing
specificity: “Germ Cell Tumors” OR “Germ Cell Tumours”
(374 results); “Germ Cell Tumors” OR “Germ Cell
264 | www.jpho-online.com
J Pediatr Hematol Oncol  Volume 36, Number 4, May 2014
Tumours” AND “Origin” OR “Etiology” OR “Patho-
genesis” OR “Biology” (129 results); “Germ Cell Tumors”
OR “Germ Cell Tumours” AND “Cytogenetic” OR
“Marker” (74 results).
Articles were included based on their relevance to the
origin of GCTs in children and the most recent published
articles were of highest priority.
DEVELOPMENT AND DIFFERENTIATION OF
GERM CELLS DURING EMBRYOGENESIS
Understanding of human embryogenesis and stages of
germ cell development is important to recognize the cell of
origin of GCTs. A brief summary of germ cell differ-
entiation and maturation is therefore presented here.
During the third gestational week formation of the 3
germ layers occurs and the primordial germ cells (PGC)
arise from the extraembryonic tissue in the epiblast, where
they initially were pluripotent. PGCs can be identified by
staining for enzyme alkaline phosphatase or OCT-3/4, a
transcription factor characteristic for PGCs and embryonic
stem cells.11,12 PGCs do not undergo differentiation in the
epiblast, although it has been shown that PGCs undergo
methylation, leading to loss of pluripotency. During
migration into the gonadal ridge methylation is removed
and the cells reenter their pluripotent state.13 At the sixth
gestational week PGCs migrate from the yolk sac wall in
the midline into the gonadal ridge, aided by folding of the
embryo, chemotactic factors, and ameboid movements.12
This migration pattern is controlled by several proteins
including KIT/KIT ligand (stem cell factor) signaling
pathway and E-cadherin, wherein blocking of E-cadherin
may affect PGCs interaction, and possibly their migration,
leading to ectopic PGCs.11 A role for microRNAs in reg-
ulation of PGC formation and survival has also been sug-
gested.14 Before the sixth gestational week fetal gonads are
found in a sexually indifferent stage. Once PGCs colonize
the primitive gonads, sex-specific development begins. The
coelomic epithelium develops into granulosa cells in females
and Sertoli cells in males, mesenchyme into theca and
Leydig cells, and PGCs into gonocytes and oogonia/
oocytes, respectively. During normal development the
oocytes in the ovaries enter first meiotic division, which
specifically is inhibited in the testes until puberty.11 Gon-
ocytes in the testis continue to express pluripotency genes,
which are downregulated within the fetal period and early
infancy, and thereafter the gonocytes mature to pre-
spermatogonia (also called prospermatogonia). If this
process is delayed, for example, in cases of gonadal dys-
genesis, the immature gonocytes expressing pluripotency
genes may persist after the infantile period.
The morphologic subtype of GCTs reflects the differ-
entiation stage of the progenitor cells (summarized
in Fig. 2, modified from1,15–17), which in turn, is influenced
by interaction of molecular, genetic, and environmental
factors.1,18
CLASSIFICATION AND CHARACTERISTICS OF
TUMOR SUBTYPES
The WHO classification of GCTs distinguishes mature
teratomas from immature teratomas, as well as teratomas
with malignant transformation. Several other classification
systems are based on the original description of endodermal
sinus tumors by Gunnar Teilum. He was the first to
describe embryonal carcinomas as tumors of totipotential
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J Pediatr Hematol Oncol  Volume 36, Number 4, May 2014 Etiology and Pathogenesis of Pediatric Germ Cell Tumors

FIGURE 2. Marker profile of main histologic subtypes of pediatric GCTs. Staining intensity: + + = expression in the majority of tumor
cells; ± = expression in few cells;  = no expression. *Carcinoma in situ is the precursor stage in adult testicular GCTs; #gonadoblastoma
is associated with dysgenic gonads, no precursor has been found in the pediatric GCTs. AFP indicates a-fetoprotein; b-HCG, b-human
choriogonadotropin; CC, choriocarcinoma; CIS, carcinoma in situ; DG, dysgerminoma; Ger, germinoma; IT, immature teratoma; MT,
mature teratoma; NA, not analyzed; Sem, seminoma; YST, yolk sac tumor.1,15–17

cells that may give rise to either embryonal neoplasms, with
the potential to differentiate into derivatives of all 3 germ
layers (teratoma), or extraembryonal neoplasms (YST
and choriocarcinoma).15 A classification proposed by
Oosterhuis and Looijenga11 separates the GCTs into 5
groups according to the phenotype of the tumor as well as
the anatomic localization, originating cell, age group, and
epidemiology. Tumors found in neonates and children,
which are typically YSTs or benign teratomas, are classified
as type I GCTs. Type II GCT’s include germinomas/semi-
nomas/dysgerminomas, embryonal carcinomas, teratomas,
choriocarcinomas, and YST in adolescents and young
adults, whereas spermatocytic seminomas of older men are
distinguished as type III GCTs.
Characteristics of the various types are summarized
below and schematically depicted in Figure 1. Mature ter-
atomas most frequently occur in the ovary or at extra-
gonadal sites, like the sacrococcygeal region. This is the
most common subtype of childhood GCT.2 The teratomas
are well differentiated and may contain tissue derived from
the 3 germ layers (endodermal, mesodermal, and ecto-
dermal layer).19 Immature teratomas also contain tissue
from all 3 germ layers but are poorly differentiated. These
teratomas are graded I to III based on the amount of
immature neural tissue found in the tumor. High-graded
tumors are more likely to have foci of YST. The immature
teratomas occur primarily at extragonadal sites and in the
ovaries of adolescent girls.10,19 Testicular seminomas and
ovarian dysgerminomas most frequently occur in young
adults. If they are found in younger children they are
typically in association with gonadal dysgenesis.2 They
arise from cells that remain in the pluripotent state with
morphologic features of undifferentiated germ cells.
In extragonadal sites these tumors are named germinomas
and are the most frequent GCT subtype in the central
nervous system, where they are often located in the pineal
and suprasellar regions.20 Embryonal carcinomas consist of
immature totipotent cells resulting presumably from
embryonic reprogramming of germ cells. Tumor cells may
exceptionally replicate the structure of an early embryo,
forming embryoid bodies, which include germ cell discs and
miniature amniotic cavities.15 Embryonal carcinomas often
differentiate into or are accompanied by YST and chorio-
carcinoma, the latter composed of cytotrophoblasts
and syncytiotrophoblasts.2,5 YSTs differentiate into struc-
tures analogous with the yolk sac. Both choriocarcinomas
and YSTs result from an abnormal extraembryonic
differentiation.2
Pediatric gonadal tumors, which are not derived from
germ cells, are even more rare than GCTs. Granulosa cell
tumors, Sertoli cell tumors, and Sertoli-Leydig cell tumors
have a sex cord-stromal origin, whereas Leydig cell tumors
are derived from androgen-producing interstitial cells.21
These somatic gonadal tumors are not a focus of this review
and will not be further discussed.
GCT PROTEIN MARKERS AND GENE
EXPRESSION PROFILES
Certain proteins secreted by tumors are measurable in
serum and can be used in diagnosis and monitoring of
treatment of some GCT types. AFP is an a-globulin that
has a high serum level at birth. At 8 to 12 months of age the
concentration falls to adult levels. YSTs are the main tumor
type producing AFP, but AFP can also be secreted at lower
levels by some embryonal carcinomas and immature ter-
atomas.5 HCG is a glycoprotein produced by the
placenta. To avoid cross-reactivity with other hormones,

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Mosbech et al
the b-subunit is typically measured. b-HCG is secreted by
choriocarcinomas and at lower levels by germinomas and
embryonal carcinoma, indicating the presence of syncytio-
trophoblastic giant cells.5 The carbohydrate antigen CA-
125 is a commonly used marker of ovarian cancer in adults.
During gestation, serum levels are high in the fetus, but
in children only a few cases of immature teratomas with
elevated serum levels of CA-125 have been reported.22
As far as the cellular markers are concerned, only few
studies of pediatric GCT gene expression profiles have been
published.18,23–26 High expression of several stem cell–
related factors is a hallmark of most GCTs that occur
in adolescents and adults, which—except spermatocytic
seminomas—originate from the precursor stage carcinoma
in situ (CIS).27 These proteins have been used as immu-
nohistochemical markers (see examples in Fig. 3). We list
here a few markers, which we have previously studied and
which are most commonly used in the clinical practice
for differential diagnosis of the tumors: KIT, OCT-3/4,
NANOG, SOX2, AP-2 g, and GATA4.
KIT (c-kit) is a tyrosine kinase receptor for stem cell
factor (also called KIT ligand [KITLG]) and one of the
factors traditionally described as proto-oncogenes. KIT is
expressed in the preinvasive stage of testicular tumors, CIS,
and in adult and pediatric germinomas, dysgerminomas,
and seminomas.28,29 A prolonged or increased expression of
KIT may be linked to the neoplastic transformation of
FIGURE 3. Examples of AFP, GATA4, SOX2, and AP-2g expression in pediatric GCTs. A, AFP staining of yolk sac tumor in the ovary of a
15-year-old girl. B, GATA4 staining of granulosa cell tumor in the testis of 1-month-old baby boy. C, SOX2 staining of an immature
teratoma in the testis of a 3-month-old baby boy. D, AP-2g staining in a dysgerminoma located in the pelvis of a 13-year-old girl,
scalebar 50 mm.
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J Pediatr Hematol Oncol  Volume 36, Number 4, May 2014
germ cells by increasing their survival. KIT/KITLG is
important for PGCs migration and homing during
embryogenesis, and an abnormally high expression of KIT
was suggested as a possible mechanism of survival of
ectopic PGCs in the central nervous system.17
OCT-3/4, NANOG, and SOX2 are 3 prototypic
embryonic pluripotency-maintaining factors. OCT-3/4
(POU5F1) is a member of the POU family of transcription
factors expressed in human embryonic stem cells and germ
cells. The protein has a function in regulating and main-
taining pluripotency during normal development of the
embryo and germ cells. It is detected in CIS and gonado-
blastoma, as well as most of GCTs (germinoma/dysgermi-
noma/seminoma and embryonal carcinoma) except ter-
atomas and extraembryonic-type tumors. In the fetal
ovaries OCT-3/4 is silenced at the first meiotic prophase,
whereas in the testis downregulation of OCT-3/4 is a
gradual process following the differentiation of gon-
ocytes.30,31 NANOG is also a key regulator of self-renewal
and pluripotency, and its expression prevents differ-
entiation of embryonic stem cells. Downregulation of
NANOG in fetal testes has been seen to occur somewhat
earlier than OCT-3/4, suggesting that NANOG acts
upstream to OCT-3/4.32 In adult type GCTs, NANOG is
expressed in CIS, seminomas, dysgerminomas, and
embryonal carcinomas. SOX2 is suggested to act in col-
laboration with NANOG and OCT-3/4 in promoter
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J Pediatr Hematol Oncol  Volume 36, Number 4, May 2014
regions of genes that encode 2 types of transcription fac-
tors: one that activates expression of those that maintain
pluripotency and the one that inhibits expression of those
that stimulate differentiation of the germ cells. CIS cells
express SOX2 only at the transcriptional level; in addition,
GCTs with a germ cell phenotype (seminomas and dys-
germinomas) do not express the SOX2 protein. In contrast,
embryonal carcinomas and immature teratomas highly
express SOX2.33,34
AP-2g (TFAP2C) is a transcription factor regulated by
BLIMP1 (PRDM gene family), and both factors are
expressed in CIS and seminomas in adult testis, and sug-
gested to have a function in repressing somatic differ-
entiation in germ cells.35,36 In addition to the above-listed
pluripotency-related tumor markers, SALL4, a tran-
scription factor involved in the stemness maintenance in
various embryonic tissue types and self-renewal in several
types of cancers, has been reported as an excellent marker
of YST and other GCT components, including even some
expression seen in pediatric teratomas.37 Another tran-
scription factor related to embryonic germ cell differ-
entiation is GATA4, which is variably expressed in a subset
of CIS, seminomas, dysgerminomas, and YST. Fur-
thermore, it is an excellent marker of granulosa and Sertoli
cell tumors. In tumor cells the varying expression of
GATA4 in differentiated and nondifferentiated (pluri-
potent) tumor cells may be explained by cell-specific func-
tion in germ cells and somatic cells.38
After many years of studying expression of genes one-
by-one at the protein level, the advent of high throughput
array methods allowed genome-wide evaluation of entire
transcriptome. Several such studies have been performed in
adolescent and adult GCTs (reviewed in Alagaratnam et al
201139). To our knowledge, only 1 study evaluated the
genome-wide transcriptome of pediatric GCTs, and the
data identified some differences in transcript profiles of
childhood YST compared with adult counterparts.40 Other
studies have focused on selected pathways, especially those
involved in early embryonic development and which have
also been implicated in cancer. The WNT/b-catenin sig-
naling pathway displays differences in distinct subtypes of
GCT, with particularly strong expression of b-catenin in
YST and immature teratomas.41 Similarly, multiple com-
ponents of the TGFb/BMP (bone morphogenetic protein)
signaling pathway, including inhibitory SMAD6 and
SMAD7 were differentially expressed in childhood germi-
nomas versus YST.42 Profiling of microRNA (miRNA)
expression in this pathway revealed miR-155 was most
highly expressed in germinomas, suggesting that miR-155
may inhibit BMP signaling in the tumor subtype.42 In
contrast, numerous miRNA were significantly higher
expressed in YST, including some miRNAs previously
identified in this tumor type by global miRNA profiling.43
When the pediatric GCT data were compared with
data from adult GCTs from previous work, the RNA and
miRNA profiles differed with age (pediatric vs. adult).
Germinomas showed an undifferentiated and pluripotent
phenotype, overexpressing the embryonal stem cell markers
NANOG, OCT-3/4, and UTF1, whereas YSTs displayed
extraembryonic differentiation maintaining a proliferative
phenotype. This significant difference between miRNA
profiles in germinomas and nongerminomas has also been
shown in pediatric tumors localized in the central nervous
system.44 It opens up for use in future clinical diagnosis and
treatment, as the differential miRNA expression (especially
r 2014 Lippincott Williams & Wilkins
Etiology and Pathogenesis of Pediatric Germ Cell Tumors
miR-302) is likely to contribute to the relatively aggressive
behavior of YST.43 The miR-371-373 is involved in main-
taining the pluripotent state, whereas miR-302 is induced
during the first stages of in vitro differentiation. The miR-
302 levels are high in extraembryonic differentiated tumors
like YSTs, whereas virtually undetectable in somatically
differentiated teratomas. The let-7 family of microRNA
tumor suppressor genes is significantly downregulated in
pediatric GCTs irrespective of patient’s age, tumor local-
ization, and histology. LIN28 has been shown to down-
regulate let-7, resulting in expression of a number of
oncogenes.45
GENETIC ABERRATIONS, GENE
POLYMORPHISMS, AND EPIGENETIC FEATURES
The cytogenetic features in GCTs differ depending on
age and histology. Virtually, all pediatric teratomas have a
normal karyotype.19,46 In contrast, GCTs of adults and
adolescents, including teratomas, very consistently have
structural abnormalities involving the chromosome 12p
sequence; many tumors have an isochromosome 12p, others
have large regional gains or amplifications of 12p.11,47
Palmer et al’s48 data showed gain of 12p in more than half
of the cases aged 5 to 16 years and in only 4 of 14 cases of
YST in children younger than 5 years of age. GCTs without
12p gain more often had a loss on 16p. One of the most
frequent aberrations in childhood GCTs is the deletion of
1p, although there is a significant variance among different
studies. Zahn et al49 found deletions of 1p in 8/9 pediatric
malignant GCTs but not in adult GCTs. Bussey et al47
showed that deletion of chromosome 1p and gain of 1q and
3 were the most frequent abnormalities among the pediatric
GCTs from both sexes. Palmer et al48 have shown that loss
of 1p, 4q, 6q and gain of 3p is more frequent in YSTs of
children as compared with germinomas.
Loss of heterozygosity (LOH) of a number of candi-
date loci has been investigated in pediatric GCTs but very
few were identified. An LOH in 5q22 encompassing the
ACP gene, which is often mutated in colon neoplasms, was
reported in a small series of YSTs and teratomas but
mutations have not been identified.50
In recent genome-wide association studies of adult
GCTs, susceptibility loci near KITLG, SPRY4, DMRT1,
and BAK1 have been identified.51–53 The loci play a role in
the survival of PGCs during migration (KIT-KITLG),
inhibiting MAP kinase pathway downstream to KIT
(SPRY4), promotion of apoptosis (BAK1), and regulation
of sexually dimorphic meiotic entry (DMRT1). In their
replication study of childhood GCTs (including adoles-
cents), Poynter et al54 suggested that variants in KITLG and
SRPY4 are susceptibility alleles only for GCTs of adoles-
cents and young adults, whereas BAK1 may be a suscepti-
bility allele for childhood GCTs, including neonates, young
children, and adolescents.
Analyses of the imprinting status of GCTs have sup-
ported that gonadal and extragonadal GCTs share a com-
mon cell of origin, the PGC, but the imprinting varies
according to the stage of development of the germ cell.55–57
Schneider et al55 studied DNA methylation of CpG
nucleotides in H19, IGF-2, and SNRPN, and the results
differed from what was found in adult testicular GCTs. The
pediatric GCTs originated from PGCs that showed con-
sistent loss of imprinting of SNRPN and partly loss of
imprinting of H19 and IGF-2, suggesting that pediatric
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Mosbech et al
TABLE 1. Molecular Characteristics of Pediatric GCTs
Cytogenetic Aberrations IHC Markers
DG i12p (adolescents) HCG
SEM OCT-3/4
GER NANOG
KIT
GATA4
SALL4
YST Loss of 1p AFP
4q GATA4
6q SALL4
Gain of 3p
3
1q
2p
13
20q
MT No characteristic alterations AFP
IT SOX2
For study marked with *there is no distinction of the childhood tumors into histologic subtypes, and DG/SEM/GER and YST are rated
collectively.5,23–29,33,37,38,40,42–49,51,54
DG indicates dysgerminoma; GER, germinoma; IHC, immunohistochemistry; IT, immature teratoma; MT, mature teratoma; SEM, seminoma; SNP,
single nucleotide polymorphism; YST, yolk sac tumor.
GCTs arise from a different germ cell developmental stage.
Molecular characteristics are summarized in Table 1.
Extragonadal GCTs develop from a germ cell that has
migrated aberrantly during embryogenesis, but it seems
that both gonadal and extragonadal GCTs arise from
PGCs that have erased their imprinting. The patterns of
erasure are different in adults and children; therefore, the
development of testicular GCTs in adults occurs at a later
stage. Hoffner et al58 have suggested that extragonadal and
testicular GCTs in children originate from a mitotic divi-
sion of a premeiotic germ cell or a pluripotent somatic cell
based on centromeric and DNA polymorphism analysis. In
contrast, they suggested that ovarian and extragonadal
teratomas may arise from germ cells more advanced in their
development, because of errors in first meiotic division,
second meiotic division, or endoreduplication.
CONCLUDING REMARKS
Pediatric GCT origin differs from adult GCTs with
regard to patterns of histology, cytogenetics, and absence
of a preinvasive stage.18 It is generally accepted that adoles-
cent and adult testicular GCTs, both seminomas and non-
seminomas, but not the spermatocytic seminomas, originate
from the precursor stage CIS.27 Visfeldt et al59 and Jorgensen
et al18 were the first to investigate a possible association
between CIS and pediatric testicular GCTs and found no CIS
in infantile YSTs and teratomas. In contrast, 5 of 6 cases of
adolescent GCTs showed presence of CIS cells, suggesting a
common origin with adult GCTs.18 It is important to stress
that the presence of CIS markers in the infantile testes does
not equal the presence of CIS, because at this age some germ
cells may still be at the stage of fetal gonocytes that are
morphologically very similar to CIS cells.60,61
The current consensus concerning the pathogenesis of
different GCTs stipulates the origin from the same cell type
(germ cell) but at different developmental stages. As out-
lined above, this has been investigated by use of tumor
markers, cytogenetic analyses, imprinting status,
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J Pediatr Hematol Oncol  Volume 36, Number 4, May 2014
Gene Variants (SNPs) miRNA
BAK1* (children) Under-expression of miR-200
KITLG miR-205
SPRY4 (adolescents) let-7
Over-expression of miR-371-373
miR-142-3/5p
miR-146a
BAK1* (children) Under-expression of let-7
KITLG Over-expression of miR-371-373
SPRY4 (adolescents) miR-302
miR-122
None studied No characteristic alterations
microRNA, and mRNA expression. The pluripotency of
the progenitor cell may result in extraembryonically dif-
ferentiated GCTs with choriocarcinoma and yolk sac ele-
ments maintaining a proliferative phenotype. The differ-
entiation of GCTs may be a recapitulation of embryonal
somatic differentiation, resulting in mature and immature
tissue from all 3 germ cell layers (teratomas). Lastly, the
pluripotency state may be maintained in a subset of
immature germ cells, with prolonged expression of self-
renewal and pluripotency regulators (eg, OCT-3/4,
NANOG, and AP-2g) but without any somatic differ-
entiation, resulting in development of seminomas, dysger-
minomas, and germinomas. Exact causative factors
involved in initiation of GCTs are not known, but the eti-
ology of these tumors most likely involves complex inter-
play of genetic mutations, predisposing polymorphisms,
and, possibly, also environmental damaging influences.
Research has been hampered by the low incidence of GCTs,
and multicenter studies to obtain more valid data should be
supported.
REFERENCES
1. Pinkerton CR. Malignant germ cell tumours in childhood. Eur
J Cancer. 1997;33:895–901.
2. Horton Z, Schlatter M, Schultz S. Pediatric germ cell tumors.
Surg Oncol. 2007;16:205–213.
3. Imbach P, Kühne T, Arceci RJ. Pediatric Oncology: A
Comprehensive Guide. 2nd ed. Berlin: Springer; 2011.
4. Schneider DT, Calaminus G, Koch S, et al. Epidemiologic
analysis of 1442 children and adolescents registered in the
German germ cell tumor protocols. Pediatr Blood Cancer.
2004;42:169–175.
5. Gobel U, Calaminus G, Schneider DT, et al. Management of
germ cell tumors in children: approaches to cure. Onkologie.
2002;25:14–22.
6. Mann JR, Raafat F, Robinson K, et al. The United Kingdom
Children’s Cancer Study Group’s second germ cell tumor
study: carboplatin, etoposide, and bleomycin are effective
treatment for children with malignant extracranial germ
r 2014 Lippincott Williams & Wilkins
J Pediatr Hematol Oncol  Volume 36, Number 4, May 2014
cell tumors, with acceptable toxicity. J Clin Oncol.
2000;18:3809–3818.
7. Kiltie AE, Gattamaneni HR. Survival and quality of life of
paediatric intracranial germ cell tumour patients treated at
the Christie Hospital, 1972-1993. Med Pediatr Oncol. 1995;
25:450–456.
8. Jeyapalan JN, Noor DA, Lee SH, et al. Methylator phenotype
of malignant germ cell tumours in children identifies strong
candidates for chemotherapy resistance. Br J Cancer. 2011;105:
575–585.
9. Pussegoda K, Ross CJ, Visscher H, et al. Replication of TPMT
and ABCC3 genetic variants highly associated with cisplatin-
induced hearing loss in children. Clin Pharmacol Ther. 2013;
94:243–251.
10. Veltman IM, Schepens MT, Looijenga LH, et al. Germ cell
tumours in neonates and infants: a distinct subgroup? APMIS.
2003;111:152–160; discussion 160.
11. Oosterhuis JW, Looijenga LH. Testicular germ-cell tumours in
a broader perspective. Nat Rev Cancer. 2005;5:210–222.
12. Wylie CC. The biology of primordial germ cells. Eur Urol.
1993;23:62–66.
13. Hajkova P, Erhardt S, Lane N, et al. Epigenetic reprogramming
in mouse primordial germ cells. Mech Dev. 2002;117:15–23.
14. Eini R, Dorssers LC, Looijenga LH. Role of stem cell proteins
and microRNAs in embryogenesis and germ cell cancer. Int J
Dev Biol. 2013;57:319–332.
15. Teilum G. Classification of endodermal sinus tumour (meso-
blatoma vitellinum) and so-called “embryonal carcinoma” of
the ovary. Acta Pathol Microbiol Scand. 1965;64:407–429.
16. Rescorla FJ. Pediatric germ cell tumors. Semin Pediatr Surg.
2012;21:51–60.
17. Hoei-Hansen CE, Sehested A, Juhler M, et al. New evidence
for the origin of intracranial germ cell tumours from
primordial germ cells: expression of pluripotency and cell
differentiation markers. J Pathol. 2006;209:25–33.
18. Jorgensen N, Muller J, Giwercman A, et al. DNA content and
expression of tumour markers in germ cells adjacent to germ
cell tumours in childhood: probably a different origin for
infantile and adolescent germ cell tumours. J Pathol.
1995;176:269–278.
19. Harms D, Zahn S, Gobel U, et al. Pathology and molecular
biology of teratomas in childhood and adolescence. Klin
Padiatr. 2006;218:296–302.
20. Echevarria ME, Fangusaro J, Goldman S. Pediatric central
nervous system germ cell tumors: a review. Oncologist.
2008;13:690–699.
21. Borer JG, Tan PE, Diamond DA. The spectrum of Sertoli cell
tumors in children. Urol Clin North Am. 2000;27:529–541.
22. Lahdenne P, Pitkanen S, Rajantie J, et al. Tumor markers CA
125 and CA 19-9 in cord blood and during infancy:
developmental changes and use in pediatric germ cell tumors.
Pediatr Res. 1995;38:797–801.
23. Talebagha S, Rizk C, Elawabdeh N, et al. Usefulness of OCT4/
3 immunostain in pediatric malignant germ cell tumors. Fetal
Pediatr Pathol. 2013;32:82–87.
24. Ho DM, Liu HC. Primary intracranial germ cell tumor.
Pathologic study of 51 patients. Cancer. 1992;70:1577–1584.
25. Siltanen S, Anttonen M, Heikkila P, et al. Transcription factor
GATA-4 is expressed in pediatric yolk sac tumors. Am J
Pathol. 1999;155:1823–1829.
26. Perlman EJ, Hawkins EP. Pediatric germ cell tumors:
protocol update for pathologists. Pediatr Dev Pathol. 1998;1:
328–335.
27. Skakkebaek NE. Possible carcinoma-in-situ of the testis.
Lancet. 1972;2:516–517.
28. Hoei-Hansen CE, Kraggerud SM, Abeler VM, et al. Ovarian
dysgerminomas are characterised by frequent KIT mutations
and abundant expression of pluripotency markers. Mol
Cancer. 2007;6:12.
29. Chou PM, Barquin N, Guinan P, et al. Differential expression
of p53, c-kit, and CD34 in prepubertal and postpubertal
testicular germ cell tumors. Cancer. 1997;79:2430–2434.
r 2014 Lippincott Williams & Wilkins
Etiology and Pathogenesis of Pediatric Germ Cell Tumors
30. Looijenga LH, Stoop H, de Leeuw HP, et al. POU5F1 (OCT3/
4) identifies cells with pluripotent potential in human germ cell
tumors. Cancer Res. 2003;63:2244–2250.
31. Rajpert-De Meyts E, Hanstein R, Jorgensen N, et al. Devel-
opmental expression of POU5F1 (OCT-3/4) in normal and
dysgenetic human gonads. Hum Reprod. 2004;19:1338–1344.
32. Hoei-Hansen CE, Almstrup K, Nielsen JE, et al. Stem cell
pluripotency factor NANOG is expressed in human fetal
gonocytes, testicular carcinoma in situ and germ cell tumours.
Histopathology. 2005;47:48–56.
33. Sonne SB, Perrett RM, Nielsen JE, et al. Analysis of SOX2
expression in developing human testis and germ cell neoplasia.
Int J Dev Biol. 2010;54:755–760.
34. Perrett RM, Turnpenny L, Eckert JJ, et al. The early human
germ cell lineage does not express SOX2 during in vivo
development or upon in vitro culture. Biol Reprod.
2008;78:852–858.
35. Schafer S, Anschlag J, Nettersheim D, et al. The role of
BLIMP1 and its putative downstream target TFAP2C in germ
cell development and germ cell tumours. Int J Androl.
2011;34:e152–e158.
36. Hoei-Hansen CE, Nielsen JE, Almstrup K, et al. Transcription
factor AP-2gamma is a developmentally regulated marker of
testicular carcinoma in situ and germ cell tumors. Clin Cancer
Res. 2004;10:8521–8530.
37. Cao D, Li J, Guo CC, et al. SALL4 is a novel diagnostic
marker for testicular germ cell tumors. Am J Surg Pathol.
2009;33:1065–1077.
38. Salonen J, Rajpert-De Meyts E, Mannisto S, et al. Differential
developmental expression of transcription factors GATA-4
and GATA-6, their cofactor FOG-2 and downstream target
genes in testicular carcinoma in situ and germ cell tumors. Eur
J Endocrinol. 2010;162:625–631.
39. Alagaratnam S, Lind GE, Kraggerud SM, et al. The testicular
germ cell tumour transcriptome. Int J Androl. 2011;34:e133–e150.
40. Palmer RD, Barbosa-Morais NL, Gooding EL, et al. Pediatric
malignant germ cell tumors show characteristic transcriptome
profiles. Cancer Res. 2008;68:4239–4247.
41. Fritsch MK, Schneider DT, Schuster AE, et al. Activation of
Wnt/beta-catenin signaling in distinct histologic subtypes of
human germ cell tumors. Pediatr Dev Pathol. 2006;9:115–131.
42. Fustino N, Rakheja D, Ateek CS, et al. Bone morphogenetic
protein signalling activity distinguishes histological subsets of
paediatric germ cell tumours. Int J Androl. 2011;34:e218–e233.
43. Murray MJ, Saini HK, van Dongen S, et al. The two most
common histological subtypes of malignant germ cell tumour
are distinguished by global microRNA profiles, associated with
differential transcription factor expression. Mol Cancer.
2010;9:290.
44. Wang HW, Wu YH, Hsieh JY, et al. Pediatric primary central
nervous system germ cell tumors of different prognosis groups
show characteristic miRNome traits and chromosome copy
number variations. BMC Genomics. 2010;11:132.
45. Murray MJ, Saini HK, Siegler CA, et al. LIN28 expression in
malignant germ cell tumors downregulates let-7 and increases
oncogene levels. Cancer Res. 2013;73:4872–4884.
46. Schneider DT, Schuster AE, Fritsch MK, et al. Genetic
analysis of childhood germ cell tumors with comparative
genomic hybridization. Klin Padiatr. 2001;213:204–211.
47. Bussey KJ, Lawce HJ, Olson SB, et al. Chromosome
abnormalities of eighty-one pediatric germ cell tumors: sex-,
age-, site-, and histopathology-related differences—a Child-
ren’s Cancer Group study. Genes Chromosomes Cancer.
1999;25:134–146.
48. Palmer RD, Foster NA, Vowler SL, et al. Malignant germ cell
tumours of childhood: new associations of genomic imbalance.
Br J Cancer. 2007;96:667–676.
49. Zahn S, Sievers S, Alemazkour K, et al. Imbalances of
chromosome arm 1p in pediatric and adult germ cell tumors
are caused by true allelic loss: a combined comparative
genomic hybridization and microsatellite analysis. Genes
Chromosomes Cancer. 2006;45:995–1006.
www.jpho-online.com | 269
Mosbech et al
50. Okpanyi V, Schneider DT, Zahn S, et al. Analysis of the
adenomatous polyposis coli (APC) gene in childhood and
adolescent germ cell tumors. Pediatr Blood Cancer. 2011;56:
384–391.
51. Rapley EA, Turnbull C, Al Olama AA, et al. A genome-wide
association study of testicular germ cell tumor. Nat Genet.
2009;41:807–810.
52. Kanetsky PA, Mitra N, Vardhanabhuti S, et al. Common
variation in KITLG and at 5q31.3 predisposes to testicular
germ cell cancer. Nat Genet. 2009;41:811–815.
53. Turnbull C, Rapley EA, Seal S, et al. Variants near DMRT1,
TERT and ATF7IP are associated with testicular germ cell
cancer. Nat Genet. 2010;42:604–607.
54. Poynter JN, Hooten AJ, Frazier AL, et al. Associations
between variants in KITLG, SPRY4, BAK1, and DMRT1 and
pediatric germ cell tumors. Genes Chromosomes Cancer.
2012;51:266–271.
55. Schneider DT, Schuster AE, Fritsch MK, et al. Multipoint
imprinting analysis indicates a common precursor cell for
gonadal and nongonadal pediatric germ cell tumors. Cancer
Res. 2001;61:7268–7276.
56. Sievers S, Alemazkour K, Zahn S, et al. IGF2/H19 imprinting
analysis of human germ cell tumors (GCTs) using the
270 | www.jpho-online.com
View publication stats
J Pediatr Hematol Oncol  Volume 36, Number 4, May 2014
methylation-sensitive single-nucleotide primer extension
method reflects the origin of GCTs in different stages of
primordial germ cell development. Genes Chromosomes Can-
cer. 2005;44:256–264.
57. Bussey KJ, Lawce HJ, Himoe E, et al. SNRPN methylation
patterns in germ cell tumors as a reflection of primordial
germ cell development. Genes Chromosomes Cancer. 2001;32:
342–352.
58. Hoffner L, Deka R, Chakravarti A, et al. Cytogenetics and
origins of pediatric germ cell tumors. Cancer Genet Cytogenet.
1994;74:54–58.
59. Visfeldt J, Jorgensen N, Muller J, et al. Testicular germ cell
tumours of childhood in Denmark, 1943-1989: incidence and
evaluation of histology using immunohistochemical techni-
ques. J Pathol. 1994;174:39–47.
60. Jorgensen N, Giwercman A, Muller J, et al. Immunohisto-
chemical markers of carcinoma in situ of the testis also
expressed in normal infantile germ cells. Histopathology.
1993;22:373–378.
61. Honecker F, Stoop H, de Krijger RR, et al. Pathobiological
implications of the expression of markers of testicular
carcinoma in situ by fetal germ cells. J Pathol. 2004;203:
849–857.
r 2014 Lippincott Williams & Wilkins