Intracranial germ cell tumors (iGCTs) are a rare heterogeneous group of neoplasms mostly located in the pineal and/or sellar regions and mainly occur in children and adolescents2,24. Teilum established the called “germ cell theory” believed that germ cell tumors emerged from primordial germ cells (PGCs) mis-migrated to the midline of the body, which led to CNS lesion occur25. Confessedly, α-fetoprotein (AFP) and human chorionic gonadotropin (HCG) are credible tumor markers as confirmation of yolk sac tumors and choriocarcinomas26,27 diagnosis and monitoring the response to treatments and follow-up, even lacking histological data.27. Nevertheless, Although these two tumor indicators are fundamental in diagnosis and prediction of survival, it is challenging for patients with normal marker levels either in peripheral blood or in cerebrospinal fluid(CSF) to make clinical decisions and arduous to foresee the outcomes, if surgical resection cannot be performed. Increasing evidence supports that immune-related factors in the circulation have a major impact on treatment responses and clinical outcomes28–30. Under the circumstances, this study was designed to study lymphocyte subsets among iGCTs patients and its related significance to prognosis.
The incidence of iGCTs is regarded as limited with discrepancy across North America, Europe and East Asia. The gender distribution(males = 120 cases, females = 25 cases, ratio:4.8) in our centre was consistent with the ratio of males largely exceeded females. Compared with it of 0.17 per million per year (gender distribution, males = 0.3, females = 0.07), the incidence rate has dropped to 0.1 per million per year(gender distribution, males = 0.13, females = 0.08), population composition ratio is analogous with data in the USA and Europe31. What's more, the cases of younger patients preceded the older in females(< 16 years old: 17 patients; >16 years old: 8 patients), while the younger and the older counted for half in males (< 16 years old: 60 patients; >16 patients: 60 patients).
Internationally, iGCT arises in the pineal (40–60%) and suprasellar (30–40%) regions or both locations as so-called bifocal (5–15%)32. The male to female ratio is 2–3:1 and in the pineal region up to 15:133, which being an extremely rare location in females. In our centre, the incidence of common sites is about 50%, and the ratio of males to females is 4:1. Similarly, the incidence of bifocal and rare other areas was also consistent with the international.
Cell-mediated immunity is regarded as a crucial soldier in anti-tumor response. Patients who suffered from brain tumors had 3-8-fold lower percentages of circulating lymphocytes compared to those of melanoma or breast cancer. That was observed in the study analyzed all of the brain cancer patients and is homogeneous with a recent study claiming that newly-diagnosed glioma has very low numbers of T cells in peripheral blood34,35.
Brain tumor cells rupture the blood-brain barrier and they escape from tumor-associated antigens immune surveillance and finally lead to the entry of peripheral immune system components into the brain meanwhile communication between tumor microenvironment and peripheral circulation 36,37. Our study confirmed that T cells, and Tc cells were significantly decreased, while activated T lymphocytes collected from serum were significantly increased. It was partially contradictory with the study of D.Kempuraj, etc. They found out CD4+T cells and CD+19 B cells increased after the treatment in both benign and malignant brain tumor patients, on the contrary, CD8+T cells decreased38. The decreasing process of CD8+ T cells was commonly considered called “exhaustion.” CD8+ T cell exhaustion was first reported in a study using a mouse model of chronic lymphocytic choriomeningitis virus (LCMV) infection39, which pointed under continuously stimulation from antigens, LCMV-specific CD8+ T cells exhibited restricted cell proliferation and impaired immune function, compared to conventional memory CD8+ T cells40. These findings have also been confirmed in human patients with cancer4142,43. Th lymphocytes bias promoted by serum exosomes and cytokines(eg. concentrations of colony-stimulating factors 2 and 3, as well as interleukin2, 4, and 13) was observed in peripheral blood in glioblastoma patients44. It is consistent with the kinetics of lymphocytes in blood in our centre: patients with increased Tc(CD3+CD8+ ) cells were inclined to present significantly encouraging survival outcomes. Furthermore, the fact that increased CD8+ T cells in circulation play a crucial role in anti-tumor response is confirmed in other extracranial tumors. Interestingly, NK cells did not present any significancy change or relation in either course of chemotherapy or prognosis in our results. Commonly, they are responsible to cancer immune surveillance and killing by natural cytotoxicity triggered rapidly upon stimulation through germline-encoded cell surface receptors. We assumed it is similar to the fact that glioblastoma tumor cells and tumor microenvironment suppressed natural killer(NK) cells via expression of factors such as transforming growth factor (TGF)-β,and impairs NK cells by downregulating the mTOR pathway. B cells(CD19+) induced humoral immunity in patients with brain tumors was less markedly affected. Similarly, either increasing or non-increasing B(CD19+) cells monitored in this study cannot indicate any outcomes. Survival analysis confirmed that increased CD3+T cells are related to improved lifetime. Contradictorily, increased CD3+T cells indicated increased death risk in multivariate cox regression analysis. Thus we take the evidence that chemotherapy leads to reduction of leukocytes significantly(confirmed both in our center and common sense, p = 0.000) and CD3+ T cells count for the largest into consideration, which might lead to the confusing result that patients with increased CD3+T cells might not have the potential to enjoy life more.
Nonetheless, there are limitations of our study that should be claimed, and results should be interpreted with prudence. Firstly, considering the lack of a larger sample, some of the results could not be identified as significant. We would like to expand the scale of patients participants in future research. Besides, we did not compare the long-term dynamics of lymphocyte subsets, which are currently in progress under surveillance in another prospective program.
In conclusion, lymphocyte subsets distinct after chemotherapy on diagnosed intracranial germ cell tumors patients. Except for elevation of activated cytotoxic T cells, T lymphocytes, Tc cells, and B cells decreased after first chemotherapy, and dynamics of Tc cells, activated T cells were closely associated with exceptional prognosis in iGCTs patients and might be a potential auxiliary prognostic index.