Yolk sac cancer is more common with age. germ cell tumors. lesions in children. The exact causes of development and who is at risk

Yolk sac tumor (syn. endodermal sinus tumor) usually occurs in women in their 20s and 30s, although it can also affect children in the first decade of life. Macroscopically, the tumor is a large neoplasm with an average node diameter of 15 cm and a smooth outer surface. On the section, the tissue has a solid-cystic structure, its loose consistency, grayish-yellow color, numerous zones of necrosis and hemorrhages are determined. Sometimes the cut surface may look like a honeycomb. The tumor is almost always unilateral, although in a small number of cases, foci of mature teratoma are determined in the opposite ovary. The yolk sac tumor metastasizes extensively.

under the microscope the tumor is characterized by an extremely variegated structure, reflecting different stages of development of extraembryonic structures and the beginning of the formation of the mesoderm (elements of the gastrointestinal tract and liver). Its parenchyma consists of many epithelial complexes, most of which have a reticular structure with reticulate cavities, between which lie solid layers. The majority of tumor cells have a light cytoplasm, hyperchromic nuclei and large nucleoli. They test positive for alpha-fetoprotein and alpha-1 antitrypsin. In the cytoplasm and outside the cells, eosinophilic drops are determined, as well as CHIC (PA5) - positive hyaline-like balls. Single papillae protrude into the lumen of the cysts, in the stromal rods of which large vessels are visible. The papillae are covered with cells of various shapes and sizes: cylindrical, cuboidal, flattened, and cells in the form of "upholstery nails". The tumor stroma may be myxomatous, resembling embryonic mesenchyme.

Another type of microscopic structure in a yolk sac tumor is the so-called polyvesicular-yolk structure. They are represented by many vesicular structures lying in loose mesenchyme. Each bubble can be intercepted by an asymmetric constriction dividing it into two parts. Its large part is usually lined with flattened cells, the smaller part is lined with high epithelium.

Embryonic cancer

In the ovary, this form of germ cell tumors is very rare. Persons aged 4-38 years are affected. Macroscopically is a node with a smooth surface, up to 20 cm in diameter, soft to the touch. The incision reveals a tissue of solid consistency with cysts filled with mucus, as well as foci of necrosis and hemorrhage. The tumor is usually unilateral . under the microscope in the glandular, tubular, papillary and solid structures of the tumor parenchyma, large cells with amphophilic cytoplasm and well-defined cell boundaries are determined, forming solid nests or lining the glands and papillae. Cell nuclei are vesicular, rounded, with a thick membrane and large nucleoli. Hyaline balls and single cells of syncytiotrophoblast come across. A positive reaction to cytokeratins, placental alkaline phosphatase, and sometimes alpha-fetoprotein is characteristic.

Description:

Germ cell tumors develop from a population of pluripotent germ cells. The first germ cells can be found in the endoderm of the yolk sac as early as a 4-week-old embryo. During embryonic development, the original germ cells migrate from the endoderm of the yolk sac to the genital ridge in the retroperitoneum. Here, the sex glands develop from the germ cells, which then descend into the scrotum, forming the testicles, or into the small pelvis, forming the ovaries. If during the period of this migration, for some unknown reason, a violation of the normal migration process occurs, the germ cells can linger at any place along their route, where a tumor can subsequently form. Germ cells can most often be found in areas such as the retroperitoneum, mediastinum, pineal region (pineal gland), and sacrococcygeal region. Less often germ cells linger in the area of ​​the vagina, bladder, liver, nasopharynx.

Germ cell tumors are an uncommon type of neoplastic lesion in children. They make up 3-8% of all children and adolescents. Since these tumors can also be benign, their frequency is probably much higher. These tumors are two to three times more common among girls than boys. Mortality among girls is three times higher than among boys. After 14 years, mortality among males becomes higher, due to an increase in the incidence of testicular tumors in adolescent boys.

Symptoms:

The clinical picture of germ cell tumors is extremely diverse and, first of all, is determined by the localization of the lesion. The most common locations are the brain (15%), ovaries (26%), coccyx (27%), testicles (18%). Much less often, these tumors are diagnosed in the retroperitoneal space, mediastinum, vagina, bladder, stomach, liver, neck (nasopharynx).

Testicle.
Primary testicular tumors are rare in childhood. Most often they occur before the age of two years and 25% of them are diagnosed already at birth. According to the histological structure, these are most often either benign teratomas or tumors of the yolk sac. The second peak in the diagnosis of testicular tumors is the pubertal period, when the frequency of malignant teratomas increases. Seminomas in children are extremely rare. Painless, rapidly increasing testicular swelling is most often noticed by the child's parents. 10% of testicular tumors are associated with hydrocele and other congenital anomalies, especially of the urinary tract. On examination, a dense, tuberous tumor is found, there are no signs of inflammation. An increase in the level of alpha-fetoprotein before surgery confirms the diagnosis of a tumor containing elements of the yolk sac. Pain in the lumbar region may be symptoms of metastatic lesions of the para-aortic lymph nodes.

Ovaries.
Ovarian tumors often present with abdominal pain. On examination, one can detect tumor masses located in the small pelvis, and often in the abdominal cavity, an increase in the volume of the abdomen due to. These girls often have a fever.

Dysgerminoma is the most common ovarian germ cell tumor, which is mainly diagnosed in the second decade of life, and rarely in young girls. The disease quickly spreads to the second ovary and peritoneum. Yolk sac tumors are also more common in puberty girls. Tumors are usually unilateral, large in size, therefore, rupture of the tumor capsule is a frequent occurrence. Clinical manifestations of malignant teratomas (teratocarcinomas, embryonic carcinomas) usually have a non-specific picture with the presence of tumor masses in the small pelvis, and menstrual irregularities may be observed. Patients in the prepubertal period may develop a state of pseudopuberty (early puberty). Benign teratomas - usually cystic, can be detected at any age, often give a clinic of ovarian torsion, followed by rupture of the ovarian cyst and the development of diffuse granulomatous.

Vagina.
These are almost always tumors of the yolk sac, all described cases occurred before the age of two years. These tumors usually present with vaginal bleeding or spotting. The tumor originates from the lateral or posterior walls of the vagina and looks like polypoid masses, often pedunculated.

Sacrococcygeal region.
This is the third most common localization of germ cell tumors. The frequency of these tumors is 1:40,000 newborns. In 75% of cases, the tumor is diagnosed before two months and almost always it is a mature benign teratoma. Clinically, in such patients, tumor formations are detected in the perineum or buttocks. Most often these are very large tumors. In some cases, neoplasms have intra-abdominal distribution and are diagnosed at an older age. In these cases, the histological picture most often has a more malignant character, often with elements of a yolk sac tumor. Progressive malignant tumors of the sacrococcygeal region often lead to dysuric phenomena, there are problems with the act of defecation and urination, neurological symptoms.

Mediastinum.
Germinogenic in most cases represent a tumor of large size, however, the syndrome of compression of the superior vena cava occurs rarely. The histological picture of the tumor is predominantly of mixed origin and has a teratoid component and tumor cells characteristic of a yolk sac tumor. Brain.
Germinogenic brain tumors account for approximately 2-4% of intracranial neoplasms. In 75% of cases, they are observed in boys, with the exception of the area of ​​the Turkish saddle, where tumors are favorably localized in girls. Germinomas form large infiltrating tumors, which are often the source of ventricular and subarachnoid cerebrospinal metastases. may precede other symptoms of the tumor.

Causes of occurrence:

Malignant germ cell tumors are very often associated with various genetic abnormalities, such as -telangiectasia, Klinefelter's syndrome, etc. These tumors are often combined with other malignant tumors, such as hemoblastoses. Undescended testicles pose a risk for the development of testicular tumors.

Patients with germ cell tumors most often have a normal karyotype, but a breakdown in chromosome I is often detected. The genome of the short arm of the first chromosome may be duplicated or lost. Multiple examples of germ cell tumors have been noted in siblings, twins, mothers and daughters.

Differentiation along the embryonic line gives the development of teratomas of varying degrees of maturity. Malignant extraembryonic differentiation leads to the development of choriocarcinomas and yolk sac tumors.

Often, germ cell tumors may contain cells of different lineages of germ cell differentiation. Thus, teratomas may have a population of yolk sac cells or trophoblasts.

The frequency of each histological type of tumor varies with age. Benign or immature teratomas are more common at birth, yolk sac tumors between one and five years of age, dysgerminomas and malignant teratomas are most common in adolescence, and seminomas are more common after 16 years of age.

Factors causing malignant changes are unknown. Chronic diseases, long-term drug treatment during pregnancy of the mother may be associated with an increase in the incidence of germ cell tumors in children.

The morphological picture of germ cell tumors is very diverse. Germinomas consist of groups of large neoplastic cells of the same type with a swollen nucleus and light cytoplasm. Tumors of the yolk sac have a very characteristic picture: a mesh stroma, often called a lacy one, in which rosettes of cells containing a-fetoprotein in the cytoplasm are located. produce chorionic gonadotropin. Benign, well-differentiated teratomas often have a cystic structure and contain various tissue components, such as bone, cartilage, hair, and glandular structures.

The pathological report for germ cell tumors should include:
-localization of the tumor (organ affiliation);
- histological structure;
- state of the tumor capsule (its integrity);
-characteristics of lymphatic and vascular invasion;
-spread of the tumor to surrounding tissues;
-immunohistochemical study for AFP and HCG.

There is a correlation between the histological structure and localization of the primary tumor: tumors of the yolk sac mainly affect the sacrococcygeal region and gonads, and in children under two years of age, tumors of the coccyx and testicles are more often recorded, while in older children (6-14 years old) tumors of the ovaries and pineal region.

Choriocarcinomas are rare but extremely malignant tumors that most commonly occur in the mediastinum and gonads. They may also be congenital.

For dysgerminomas, the typical localization is the pineal region and the ovaries. Dysgerminomas account for approximately 20% of all ovarian tumors in girls and 60% of all intracranial germ cell tumors.

Embryonic carcinoma in its "pure form" is rare in childhood, most often a combination of elements of embryonic with other types of germ cell tumors, such as teratoma and tumor of the yolk sac, is recorded.

Treatment:

For treatment appoint:

If a germ cell tumor is suspected in the abdominal cavity or in the small pelvis, surgery can be performed to remove the tumor or (in the case of a large tumor) to obtain morphological confirmation of the diagnosis. However, surgical intervention is often used for urgent indications, for example, in case of torsion of the cyst stem or rupture of the tumor capsule.

If you suspect an ovarian tumor, you should not be limited to the classic transverse gynecological incision. Medium is recommended. When opening the abdominal cavity, the lymph nodes of the small pelvis and retroperitoneal region are examined, the surface of the liver, subdiaphragmatic space, greater omentum and stomach are examined.

In the presence of ascites, a cytological examination of ascitic fluid is necessary. In the absence of ascites, the abdominal cavity and pelvic area should be washed and the resulting lavage should be subjected to cytological examination.

If an ovarian tumor is detected, the tumor should be subjected to urgent histological examination, removal of the ovary only after confirmation of the malignant nature of the tumor. This practice avoids the removal of unaffected organs. If there is a massive tumor lesion, non-radical operations should be avoided. In such cases, a preoperative course of chemotherapy is recommended, followed by a "second look" operation. If the tumor is localized in one ovary, removal of one ovary may be sufficient. If the second ovary is affected, if possible, part of the ovary should be preserved.

Recommendations when using the surgical method for ovarian lesions:
1. Do not use a transverse gynecological incision.
2. Median laparotomy.
3. In the presence of ascites, a cytological examination is mandatory.
4. In the absence of ascites - rinse the abdominal cavity and pelvic area; cytological examination of washing waters.
5. Examination and, if necessary, biopsy:
- lymph nodes of the small pelvis and retroperitoneal region;
- surface of the liver, subphrenic space, greater omentum, stomach.

Sacrococcygeal teratomas, most often diagnosed immediately after the birth of a child, should be removed immediately to avoid malignancy of the tumor. The operation must include the complete removal of the coccyx. This reduces the likelihood of recurrence of the disease. Malignant sacrococcygeal tumors should be treated first with chemotherapy, followed by surgery to remove the residual tumor.

Surgical intervention for the purpose of biopsy in case of a local tumor in the mediastinum and persistence of AFP is not always justified, as it is associated with risk. Therefore, it is recommended to perform preoperative chemotherapy and, after reducing the size of the tumor, surgical removal of it.

If the testicle is affected, orchiectomy and high ligation of the spermatic cord are indicated. Retroperitoneal lymphadenectomy is performed only when indicated.
.
Medical therapy has very limited use in the treatment of germ cell tumors. It may be effective in the treatment of ovarian dysgerminomas.

Chemotherapy.
The leading role in the treatment of germ cell tumors belongs to chemotherapy. Many chemotherapy drugs are effective in this pathology. For a long time it was widely used by three cytostatics: vincristine, actinomycin "D" and cyclophosphamide. However, in recent years, preference has been given to other drugs, on the one hand, new and more effective, on the other hand, having the least number of long-term effects, and, first of all, reducing the risk of sterilization. Platinum preparations (in particular, carboplatin), vepezid and bleomycin are currently used most often for germ cell tumors.

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Embryonic carcinoma. Embryonal carcinoma. 9070/3

Usually in embryonic cancer structures of a tumor of a yolk sac come to light.

The tumor is extremely rare in prepubertal patients. the peak of detection occurs at 30 years.

Clinically characterized by an increase in the level placental alkaline phosphatase (PLAP), lactate dehydrogenase (ldh), CA-19-9 in serum. At the time of diagnosis, 40% of patients already have distant metastases.

Grossly, fetal cancer usually presents as an ill-defined grayish-white nodule with areas of necrosis and hemorrhage. Microscopically revealed areas of three types, represented by primitive anaplastic epithelial cells.

In solid areas, cells are located in the form of diffuse fields (Fig. 4.15), in other areas, glandular structures lined with cubic or elongated cells are determined (Fig. 4.16).

Rice. 4.15. Embryonic cancer. Solid structure; fields of primitive anaplastic epithelial cells. Stained with hematoxylin and eosin. x400

Rice. 4.16. Embryonic cancer. Glandular structures, tubular structures of primitive epithelial cells that form glands. Stained with hematoxylin and eosin. x200

There are also papillary structures, the papillary stroma may be pronounced or poorly developed (Fig. 4.17).

Rice. 4.17. Embryonic cancer. Papillary structures formed by primitive epithelium. Stained with hematoxylin and eosin. x200

All forms of embryonic carcinoma are characterized by fields of eosinophilic coagulation necrosis. Tumor cells have a wide cytoplasm, polymorphic hyperchromic nuclei with large nucleoli. Mitotic activity is high. Embryonic carcinoma often coexists with structures of intratubular carcinoma, which are characterized by central necrosis of the comedocarcinoma type.

Part of the necrosis undergoes dystrophic calcification with the formation of so-called hematoxylin-stained bodies. Occasionally, degenerative changes occur and the cells may resemble syncytiotrophoblast, leading to a misdiagnosis of choriocarcinoma.

In nonseminoma germ cell tumors, including embryonic carcinoma, it is often difficult to assess the presence of vascular invasion, and intratubular structures may mimic intravascular structures. If there is ingrowth into vessels in mixed germ cell tumors, then it is embryonic cancer that serves as an angioinvasive element.

Embryonic carcinoma should be differentiated from yolk sac tumor, typical seminoma, especially with its tubular and pseudoglandular structures, and anaplastic spermatocytic seminoma.

Tumor of the yolk sac. Yolk sac tumour. 9071/3

Macroscopically, the tumor of the yolk sac in children is represented by a solid single homogeneous gray-white nodule with a myxoid or gelatinoid incision surface, there may be small cysts. In adults, the tumor is usually heterogeneous, with hemorrhages, necrosis, and multiple cysts of various sizes.

The microscopic structure is complex and very diverse: the tumor may contain a microcystic part, structures of the endodermal sinus, papillary, solid and alveolar structures, macrocysts (Fig. 4.18). There may be areas of myxomatosis, foci of sarcomatoid and hepatoid structure.

Rice. 4.18. Tumor of the yolk sac. Microcysts in the tumor. Stained with hematoxylin and eosin. x 400

The microcystic part of the tumor contains vacuolated cells. Quite large vacuoles located in the cytoplasm make the cells look like lipoblasts, although the vacuoles do not contain lipids. In some cases, cells form peculiar chains surrounding extracellular spaces and form reticular areas.

The microcystic part often includes a myxoid stroma. Sections of the endodermal sinus contain a central vessel, including a section of the fibrous stroma, in which the anaplastic epithelium is located. These structures, resembling the endodermal sinus, are sometimes called glomeruloid or Schiller-Duval bodies (Figures 4.19 and 4.20).

Rice. 4.19. Tumor of the yolk sac. Schiller-Duval bodies (structures of the endodermal sinus) in the tumor. Stained with hematoxylin and eosin. x200

Rice. 4.20. Tumor of the yolk sac. PLAP expression. Immunohistochemical study with antibodies to PLAP. x200

The papillary portion of the tumor contains papillary structures with or without fibrovascular stroma. The papilla-covering cells are cuboidal, columnar, or hobnail-like. The papillary part is often mixed with the structures of the endodermal sinus.

The solid part is similar in structure to seminoma and consists of fields of cells with light cytoplasm and clear cell boundaries, however, fibrous septa characteristic of seminoma with dense lymphoid infiltration are absent, cells are less monomorphic than in seminoma.

Some of the solid areas contain noticeable thin-walled vessels and single microcysts. Well-formed glands are present in about 1/3 of yolk sac tumors. The myxomatous part is characterized by the presence of elitelioid and fusiform tumor cells scattered in the mucopolysaccharide-rich stroma.

There are also numerous vessels. G. Telium described this part as "angioblastic mesenchyme". The sarcomatoid portion of a yolk sac tumor is composed of proliferating spindle cells, sometimes resembling fetal rhabdomyosarcoma but expressing cytokeratins.

Hepatoid areas are observed in about 20% of yolk sac tumors. They consist of small polygonal eosinophilic cells that form fields, nests, and trabeculae. The cells contain round, vesicle-shaped nuclei with prominent nucleoli. As a rule, separate parts of a yolk sac tumor are difficult to differentiate, as they mix and pass one into another.

A yolk sac tumor must be differentiated from seminoma, embryonic cancer, and a juvenile variant of granulosa cell tumor. The prognosis of the tumor is often determined by age, in children it is favorable and the 5-year survival rate exceeds 90%; AFP level is also associated with prognosis.

Choriocarcinoma and other trophoblastic tumors. Choriocarcinoma and other throfoblastic tumors

Hematogenous metastasis is typical, affecting the lungs, brain, gastrointestinal tract (GIT), although metastases can also be detected in the retroperitoneal lymph nodes. Isolated cases of metastases in the skin and pancreas have been described. Patients have a sharp increase in serum hCG levels.

On macroscopic examination, testicular tissue may appear normal. but areas of hemorrhage and necrosis on the cut surface attract attention. Classical choriocarcinoma consists of randomly arranged single-nuclear trophoblastic cells with light cytoplasm and multinucleated syncytiotrophoblast cells with blotched nuclei and dense eosinophilic cytoplasm.

In syncytiotrophoblast cells, there may be gaps filled with erythrocytes. In the center of the tumor and in the surrounding tissue, areas of hemorrhage are often detected. Diagnostic cells are found mainly on the periphery of the tumor.

In well-differentiated choriocarcinomas, syncytiotrophoblast cells surround or cover the trophoblast cells, giving them a similarity to the chorionic villus. In some cases, syncytiotrophoblast cells have scanty cytoplasm and dystrophic changes. Sometimes the biphasic component of mixed syncytiotrophoblast is absent in the tumor, instead only atypical trophoblast cells are found, such tumors are called monophasic choriocarcinoma.

There may be other trophoblastic tumors in the testis besides choriocarcinoma. One of them is a trophoblastic placental tumor, resembling a uterine tumor of the same name. The neoplasm consists of transitional trophoblast cells that stain with human placental lactogen. Some trophoblastic tumors contain cytotrophoblast-like cells lining hemorrhagic cysts.

Anti-hCG antibodies can be used to detect trophoblast proliferation. Expression of hCG is more pronounced in syncytiotrophoblast cells and in mononuclear trophoblast cells, which serve as a transitional variant to syncytium. Cytotrophoblast cells usually do not contain hCG or express it weakly.

In syncytiotrophoblast and trophoblast cells, the expression of pregnancy-specific proteins of human placental lactogen and β1-glycoprotein can be detected. These proteins are not synthesized by cytotrophoblast cells. Syncytiotrophoblast contains inhibin-a. In 50% of choriocarcinomas, PLAP is detected; in 25%, syncytiotrophoblast and cytotrophoblast cells express cancer embryonic antigen (CEA).

Cytotrophoblast and syncytiotrophoblast express cytokeratins, incl. cytokeratins (CK7, CK8, CK18 and CR19). Expression epithelial membrane antigen (EMA) observed in approximately half of choriocarcinomas. often in syncytiotrophoblast cells. while most other testicular tumors (with the exception of teratoid ones) do not express EMA.

Trophoblast fragments may be found in other testicular germ cell tumors; they are defined as nests or individual cells, the two-component structure of choriocarcinoma is lost. For example, syncytiotrophoblast cells, often found in seminomas, are diffusely distributed in the tumor, mononuclear trophoblast cells are absent.

These tumors differ from choriocarcinoma in the absence of necrosis, a negative reaction with hCG and a positive reaction with OST 3/4. In rare cases, embryonic cancer transforms into choriocarcinoma. In the presence of hemorrhages and the absence of hCG and OCT-3/4 expression by multinucleated cells, it is reasonable to make a diagnosis of choriocarcinoma. Monophasic choriocarcinomas must be differentiated from seminoma and solid growth of yolk sac tumors.

Andreeva Yu.Yu., Frank G.A.

Germ cell tumors are typical neoplasms of childhood. Their source is the primary sex cell, i.e. these tumors are malformations of the primary germ cell. During the development of the embryo, germ cells migrate to the genital ridge, and if this process is disturbed, germ cells can linger at any stage of their journey, and in the future there is a chance of tumor formation.

Tumors of this type account for up to 7% of all tumors in children and adolescents. 2-4% - in children under 15 years old and about 14% in adolescents from 15 to 19 years old. The probability of falling ill in adolescent boys under 20 is slightly higher than in girls - 12 cases versus 11.1 per million. According to some reports, the pathological course of pregnancy and smoking in the mother increase the risk of germ cell tumors in the child.

Germinogenic tumors are divided into gonadal, which develop inside the gonads, and extragonadal. There are two peaks in the incidence of germ cell tumors: the first - up to 2 years of tumors of the sacrococcygeal region (74% are girls) and the second - 8-12 years for girls and 11-14 years for boys with lesions of the gonads.

The most common symptoms of the disease are an increase in the size of the affected organ and pain. There may be complaints of difficulty urinating, intestinal obstruction, the appearance of clinical signs of compression of the mediastinal organs or CNS damage.

The most common localizations of germ cell tumors:

• cross-coccygeal region;
• ovary;
• testicle;
• epiphysis;
• retroperitoneal space;
• mediastinum.

Tumors are extremely diverse in their morphological structure, clinical course and prognosis, they can be both benign and malignant.

Morphological classification of germ cell tumors:

• Dysgerminoma (seminoma);
• Teratoma mature and immature;
• Tumor of the yolk sac;
• Choriocarcinoma;
• Embryonic cancer;
• germinoma;
• Mixed germ cell tumor.

Diagnostics

If a child develops symptoms, we recommend a comprehensive diagnosis at the Oncology Research Institute. Depending on the indications, the doctor may prescribe the following tests and studies:

• laboratory tests: complete blood count, general urinalysis, biochemical blood test, AFP, coagulogram;
• instrumental studies: chest x-ray, abdominal ultrasound, ultrasound of the affected area, CT of the chest and abdomen, MRI of the affected area, osteoscintigraphy, myeloscintigraphy;
• invasive examinations: puncture, bone marrow trepanbiopsy, lumbar puncture (according to indications); tumor biopsy.

Treatment

Treatment of children with germ cell tumors is to remove the tumor and conduct chemotherapy. The sequence of surgery and chemotherapy depends on the location of the tumor. As a rule, the defeat of the gonads dictates the removal of the tumor at the first stage with chemotherapy in the postoperative period. If a CT - or MRI - scan reveals clear infiltration into the surrounding tissue or metastases, the first therapeutic step is chemotherapy.

Most extragonadal germ cell tumors are of considerable size, and their removal is accompanied by an increased risk of opening the tumor capsule. In these cases, patients are given chemotherapy to reduce the risk of tumor recurrence. Radiation therapy is rarely used and has limited indications.

Ideally, the goals of treatment are to achieve recovery and maintain menstrual and reproductive function in patients.

Forecast

Overall survival for germ cell tumors is:

• at stage I 95%
• at stage II - 80%
• at stage III - 70%
• at IV - 55%.

The prognosis for patients with germ cell tumors is affected by the histological structure, the level of tumor markers, and the prevalence of the process. Unfavorable factors are late diagnosis, large tumor size, tumor rupture, chemoresistance, and relapse of the disease.