PURPOSE: Germ cell tumors (GCTs) are highly sensitive to cisplatin-based
chemotherapy. This feature is unexplained, as is the intrinsic
chemotherapy resistance of mature teratomas and the resistant phenotype of
a minority of refractory GCTs. Various cellular pathways may influence the
efficacy of chemotherapy. Their impact has not been investigated in a
comprehensive study of tumor samples from clinically defined subgroups of
GCT patients. EXPERIMENTAL DESIGN: We investigated proteins involved in
regulation of apoptosis (p53, BAX, BCL-2, and BCL-X(L)), cell cycle
control [p21 and retinoblastoma protein (RB)], and drug export and
inactivation [P-glycoprotein, multidrug resistance-associated protein
(MRP) 1, MRP2, breast cancer resistance protein, lung resistance protein,
metallothionein, and glutathione S-transferase pi] immunohistochemically
in samples of unselected GCT patients (n = 20), patients with advanced
metastatic disease in continuous remission after first-line chemotherapy
(n = 12), and chemotherapy-refractory patients (n = 24). Mature teratoma
components (n = 10) within tumor samples from all groups were analyzed
separately. The apoptotic index was studied by terminal deoxynucleotidyl
transferase-mediated nick end labeling assay. RESULTS: Invasive GCTs of
all groups showed a correlation between wild-type p53 and apoptotic index
(r(s) = 0.66; P < 0.001). The levels of the antiapoptotic proteins BCL-2
and BCL-X(L) were generally low. p21 was hardly detectable and did not
correlate with p53 (r(s) = 0.29; P = 0.07). No significant differences
among the three patient groups were identified regarding any of the
investigated parameters (all Ps were >0.08), even though only individual
samples from chemotherapy-resistant cases showed a strong staining for
MRP2 and GSTpi. In contrast to other components, mature teratomas showed
an intense p21 and RB staining and were mostly positive for MRP2, lung
resistance protein, and GSTpi. CONCLUSIONS: Our results indicate a
multifactorial basis for the chemosensitivity of GCTs with lack of
transporters for cisplatin, of antiapoptotic BCL-2 family members, of p21
induction by p53, and of RB and an intact apoptotic cascade downstream of
p53. These findings suggest a preference for apoptosis over cell cycle
arrest after up-regulation of p53. None of the examined parameters offers
a general explanation for the chemotherapy-resistant phenotype of
refractory tumors. The up-regulation of various factors interfering with
chemotherapy efficacy and ability for a p21-induced cell cycle arrest may
explain the intrinsic chemotherapy resistance of mature teratomas