Diagnostic challenge of fetal ontogeny and its application on the ovarian teratomas

Although neuroepithelial tubules (NET) often are a component of immature teratoma (IT), they are not always required for diagnosis. Other somatic elements are sufficient and often verified with immunohistochemical stain. This study was designed to determine the definition of immaturity versus fetal ontogeny, using several molecular markers in IT. It is our contention that IT is equivalent to an embryonic stage less than a fertilization age (FA) of 8 weeks, and a mature teratoma (MT) to a fetal stage later than a FA of 8 weeks, whereas an embryonal carcinoma (Eca) matches a pre-embryonic stage earlier than a FA of 2 weeks. The teratomatous components used as a roadmap to evaluate maturity included: a lobular structure of primitive endodermal tubules (FA 4 to 6 weeks), a ventricle-lined cortical plate (FA 9 weeks), a complex papillary choroid plexus (FA 10 weeks), melanin deposition in hair follicles (FA 15 weeks), and the bell stage of odontogenesis (FA 19 weeks). The teratomatous components of 25 resected ovarian solid teratoma samples were compared with fetal ontogeny. For an immunohistochemical analysis, the CD30, CD34, CD99, bcl-2, alpha-fetoprotein (AFP), and placenta-like alkaline phosphatase (PLAP) were assessed. The AFP and Ki-1 were positive in the embryoid body, which was identified at a FA less than 4 weeks in Eca. The AFP was positive in the primitive endodermal components and some of the squamous epithelium in IT. The CD99 and bcl-2 were selectively stained in the primitive NET, which was detected no later than a FA of 6 weeks. The CD34 and bcl-2 were positive in the immature-looking precartilage blastomatous components, which proved useful for detecting immature cartilage, corresponding to a FA of 5 to 6 weeks. The ontogeny of IT was found to correspond to the embryonic stage at a FA of 2 to 8 weeks, and CD99, CD34, bcl-2, AFP, CD30, and PLAP could be used as supportive tools to define IT. This new grading system could be more scientific and more reproducible in any spectra of teratoma.