The role of chemotherapy in intracranial germinoma: a case report

Simultaneous intracranial and testicular germ cell tumors: illustrative case

BACKGROUND

Simultaneous intracranial and testicular germ cell tumors (GCTs) are extremely rare, leading to a lack of adequate experience in their treatment. Therefore, the authors report a case of this kind of GCT.

OBSERVATIONS

A 5-year-old boy was admitted to the hospital with headache and vomiting. Computed tomography and magnetic resonance imaging suggested the possibility of a GCT in the pineal region. The value of the serum tumor marker alpha-fetoprotein (AFP) was 5,396.1 μg/L, and β-human chorionic gonadotropin levels were within the normal range. Subsequently, the tumor was removed, and the final pathological result was a mixed GCT. Therefore, chemotherapy and radiation were added. However, the authors found a testicular tumor on ultrasound at the same time, and pathology after surgery suggested a mature cystic teratoma. Following treatment, the patient recovered well, and AFP levels dropped to normal values.

LESSONS

To the authors’ knowledge, this report is the fourth case of simultaneous intracranial and testicular GCTs and the first case of a simultaneous mixed GCT in the pineal region and mature teratoma of the testis. A combination of surgery, chemotherapy, and radiation therapy for mixed GCTs in the pineal region and surgical excision for testicular reproductive cell tumors are effective in these patients, but long-term monitoring is required.

Primary spinal germ cell tumors: a case analysis and review of treatment paradigms

Objective. Primary intramedullary spinal germ cell tumors are exceedingly rare. As such, there are no established treatment paradigms. We describe our management for spinal germ cell tumors and a review of the literature. Clinical Presentation. We describe the case of a 45-year-old man with progressive lower extremity weakness and sensory deficits. He was found to have enhancing intramedullary mass lesions in the thoracic spinal cord, and pathology was consistent with an intramedullary germ cell tumor. A video presentation of the case and surgical approach is provided. Conclusion. As spinal cord germinomas are highly sensitive to radiation and chemotherapy, a patient can be spared radical surgery. Diverse treatment approaches exist across institutions. We advocate biopsy followed by local radiation, with or without adjuvant chemotherapy, as the optimal treatment for these tumors. Histological findings have prognostic value if syncytiotrophoblastic giant cells (STGCs) are found, which are associated with a higher rate of recurrence. The recurrence rate in STGC-positive spinal germinomas is 33% (2/6), whereas it is only 8% in STGC-negative tumors (2/24). We advocate limited volume radiotherapy combined with systemic chemotherapy in patients with high risk of recurrence. To reduce endocrine and neurocognitive side effects, cranio-spinal radiation should be used as a last resort in patients with recurrence.

Pineal germinoma

Germinomas are gonadal neoplasms that rarely occur extragonadally in the midline structures of the human body. Newly diagnosed adult cases of pineal gland germinomas are very rare since most of the cases are diagnosed in the mid teens. The estimated incidence of this tumor in western countries is between 0.4-3.4%. Typically, this tumor is diagnosed by its characteristic radiological appearance alone, supported by tumor marker(s) or by stereotactic biopsy of the tumor. We are reporting a very unique case of pineal germinoma diagnosed in an adult at our institute by cerebrospinal fluid cytology with literature review. We analyzed case reports, literature reviews, and therapy and diagnostic articles about pineal germinoma in the English literature from 1983 to 2009 through the national library of medicine, Pubmed, and OVID search engines. We used key words "pineal germinoma," "pineal gland tumor," "CNS germinoma," and "extragonodal germinomas" to search for our articles.

Risk of second tumor in intracranial germinoma patients treated with radiation therapy: the Johns Hopkins experience

BACKGROUND

We reviewed the risk of second tumor (ST), both malignant and benign, in germinoma survivors followed at the Johns Hopkins Hospital (JHH).

METHODS

Between 1977 and 2002, 27 patients with intracranial germinoma were treated with radiation therapy (RT). In the presence of competing events, a cumulative incidence function of ST was estimated using the minimal time interval from the date of diagnosis to the date of ST, date of death, or date of last follow-up.

RESULTS

Five patients (18%) developed a ST of which 4 (15%) were malignant. One developed a benign falcine meningioma. The cumulative incidence of ST was 9% at 11 years (95% CI, 0-22%).

CONCLUSIONS

The relative contributions of RT and patient susceptibility to a ST cannot be determined but suggests the need for long-term surveillance, including testicular self-exams in male germinoma survivors. Current trials of chemotherapy and reduced RT dose and volume offer the prospect of a lower risk of treatment-induced ST.

Successful treatment of extracranially metastasized pineal gland germinoma with high-dose methotrexate

Germinoma of the pineal gland is a rare disease usually confined to the brain which responds well to radiotherapy. Spinal seeding occurs in approximately 4% of cases and distant metastases are extremely rare. We report on a 27-year-old female with an intracranially metastasized pineal gland germinoma, meningeal carcinomatosis and distant bone metastases. Treatment was initiated with intrathecal methotrexate (MTX) and continued with high-dose intravenous MTX. The therapy was very well tolerated apart from reversible hepatic toxicity requiring a dose reduction. The patient was in complete remission after three courses followed by two consolidation cycles; the patient has now been in continuous complete remission for more than 22 months. This is the first report to show that MTX is a potent drug in treating pineal gland germinoma. Long-term side effects of radiotherapy such as reduced mental function or hypopituitarism can probably be avoided. Single-agent high-dose MTX may provide high efficacy with limited adverse effects, especially at a more advanced tumor stage with spinal seeding and extracranial disease.

Metachronous gonadal and extragonadal primaries, or late relapse of germ cell tumor?

We report five distinct cases of apparently metachronous extragonadal and gonadal germ cell tumors (GCT) occurring in the same patient. Two patients had metachronous GCT of the central nervous system and the testis. One of these patients had been successfully treated for a germinoma of the pineal gland and developed a nonseminomatous GCT of the testis 10 years later. The second patient had a primary seminoma of the testis treated by orchiectomy followed by radiotherapy and developed a germinoma of the sphenoidal sinus 17 months later. Three other patients had an apparently metachronous retroperitoneal and testicular GCT with 22, 44, and 66 months elapsing, respectively, between the first and second neoplasms. These cases suggest that the remaining testis is not only at risk for a second primary GCT, but that a second GCT may emerge at an extragonadal site. A genetic predisposition may account for some of these cases and the occurrence of bilateral testicular GCT. In none of these cases, however, could we ascertain whether testicular GCT was truly a second primary or a relapse of a "primary" retroperitoneal GCT in our cases.