Germinoma of the basal ganglia. An 8-year asymptomatic history after detection of abnormality on CT

The clinical and imaging features of infratentorial germinomas compared with supratentorial ectopic germinomas

BACKGROUND

Intracranial germinoma is very sensitive to chemoradiotherapy, while the risk of infratentorial operation is high. The accurate diagnosis can provide the more reasonable treatment, avoiding the unnecessary therapeutic risks.

PURPOSE

To evaluate the clinical and imaging features of infratentorial germinomas.

MATERIAL AND METHODS

The clinical and imaging data of 13 infratentorial germinomas were collected and compared with 17 supratentorial germinomas in the same period. The clinical and imaging findings were retrospectively analyzed.

RESULTS

Infratentorial germinomas were more common in female patients than supratentorial ones (53.85% vs. 11.76%, P = 0.020). The mean age of the infratentorial group (23.0 ± 10.2 years) was significantly older than that of supratentorial group (12.4 ± 3.3 years, P = 0.003). Most infratentorial germinomas (12/13, 92.31%) underwent surgical resection, while stereotactic biopsy was more common in the supratentorial group (11/17, 64.71%, P = 0.002). Infratentorial germinomas were significantly smaller than supratentorial ones (25.85 ± 8.13 mm vs. 37.18 ± 18.11 mm, P = 0.031). Cystic lesions were more common in supratentorial germinomas (12/17, 70.59%), while most infratentorial germinomas were solid lesions (10/13, 76.92%, P = 0.025). On post-contrast T1-weighted imaging, obvious enhancement was more common in infratentorial germinomas than in supratentorial ones (100% vs. 64.71%, P = 0.024).

CONCLUSION

In addition to the common findings with supratentorial germinomas, infratentorial lesions have some specific clinical and imaging features.

A single-center study of treatment outcomes of pediatric basal ganglia germinoma in Taiwan

PURPOSE

A basal ganglia (BG) germinoma is a rare tumor, and the optimal treatment remains unknown. We evaluated the clinical outcomes of treatment of BG germinoma in pediatric patients in Taiwan.

METHODS

We retrospectively reviewed the medical records of 34 children with BG germinoma who were treated with radiotherapy (RT) at Taipei Veterans General Hospital between 1989 and 2016. The median follow-up time is 8.3 years (1.8-25.2 years). Survival was analyzed using the Kaplan-Meier estimate. Univariate Cox proportional-hazards models were used to identify the potential risk factors.

RESULTS

Only four patients (11.8%) experienced recurrence and all successfully underwent salvage therapy. One patient (2.97%) died due to suspected radiotherapy (RT)-related sarcoma in the scalp. The 2-, 3-, and 5-year DFS rates were 91.2%, 88.2%, and 79.4%, respectively; the 2-, 3-, and 5-year OS rates were 97.1%, 94.1%, and 82.4%, respectively. Focal RT showed low DFS in the Kaplan-Meier survival curves (P = .028) compared with non-focal RT (whole ventricle, whole brain, or cranial spinal area). In the univariate Cox proportional-hazards model, there was a significant difference in DFS between focal and non-focal RT (P = .03). There is no difference in DFS and OS between BG germinoma patients and non-BG germinoma patients.

CONCLUSIONS

We found an excellent DFS and OS in pediatric patients with BG germinoma treated with RT. Whole ventricle irradiation is recommended for good tumor control and low treatment-related toxicity. BG germinoma patients showed similar treatment results as germinoma patients in other common sites.

Progressive hemiparesis in a young man: Hemicerebral atrophy as the initial manifestation of basal ganglia germinoma

Basal ganglia germinomas are rare and patients are classically young Oriental males presenting with gradually progressive hemiparesis. Although early treatment with chemo-radiotherapy can be curative and significantly improve the quality of life, medical attention is often delayed. A young Chinese male experienced a 6-month history of right hemiparesis with magnetic resonance imaging findings of hemicerebral atrophy and lentiform nucleus microhemorrhage, highly suggestive and early signs of basal ganglia germinomas. No further imaging was performed until 2 years later when he was admitted for acute neurological deterioration and a repeat scan revealed a large infiltrative tumor pathologically confirmed to be a pure germinoma.

Radiologic features of primary intracranial ectopic germinomas: Case reports and literature review

RATIONALE

Germinomas are sensitive to radiation therapy and chemotherapy; therefore, correct imaging diagnosis is crucial for them. However, the imaging findings of germinomas originating from off-midline regions displayed different patterns from those originating from midline areas.

PATIENT CONCERNS

The objective of this study is to describe the radiologic features of primary ectopic germinoma. We reviewed the MR and CT findings of 12 patients with histologically proven off-midline ectopic germinomas with off-midline locations.

INTERVENTIONS

All of these patients underwent conventional MR images and 3 of them underwent diffusion images. Additional CT images were available in 3 patients. Analysis was focused on the shape and entity of tumors in images, signs of hemiatrophy, and the involvement of fibers in diffusion images.

OUTCOMES

Well-defined (8/12) and ill-defined margin masses (4/12) were identified according to the shape of the mass. Multicystic masses were seen in 11 of the 12 patients. The solid component of the tumors had a high density (3/3) with calcifications (2/3) on CT images, iso- to hypointensity in T2WI (11/12) and restricted diffusion on apparent diffusion coefficient (ADC) maps (3/3). Hemiatrophy was observed in 5 cases and progressive hemiatrophy was observed in 1 case. Other signs included mild peritumoral edema (10/12), and hydrocephalus (7/12). Additionally, infiltration of the corticospinal tract (CST) was identified on diffusion tensor imaging (DTI) (2/2).

LESSONS

The results indicate that multicysitic entities and hypointensities in solid components on T2WI and hemiatrophy are the imaging features of ectopic germinomas. DTI has potential for assessing CST involvement.

Clinical and Radiologic Features of Pediatric Basal Ganglia Germ Cell Tumors

BACKGROUND AND OBJECTIVE

Pediatric basal ganglia germ cell tumors (GCTs) represent a rare subset of tumors about which little is known. We aimed to summarize the clinical features and radiological findings of this special subgroup of GCTs.

METHODS

From January 2010 to January 2015, 12 pediatric patients with basal ganglia GCTs were treated in our hospital. The clinical features, radiologic findings, diagnosis, treatment, and outcome of these patients were analyzed retrospectively. Our institutional diagnostic principle and treatment strategy of this disease were discussed.

RESULTS

GCTs accounted for 25.5% of all the pediatric basal ganglia tumors treated in our hospital. There were 9 male and 3 female patients with a mean age of 11.5 ± 2.1 years. The most common symptom was progressive hemiparesis (n = 9, 75%). The radiologic findings showed that the lesions predominately located in caput of caudate nucleus (n = 9, 75.0%), followed by lenticular nucleus (n = 3, 25.0%). Hemiatrophy was commonly observed (n = 8, 66.7%). Eight patients were diagnosed as having germinomas, and 4 patients as having nongerminomatous germ cell tumors. During the follow-up period, preoperative neurologic dysfunctions improved in 7 patients and remained stable in 3. Two patients developed new onset of neurologic dysfunction after the treatment. Two patients suffered from tumor recurrence.

CONCLUSIONS

GCTs are not as rare as considered in pediatric basal ganglia tumors. They bear some distinctive clinical and radiologic features, which can help with the accurate diagnosis and successful management of such tumors.

Basal ganglia germinomas in children. Four clinical cases and a literature review

Basal ganglia germinomas are a specific group of intracranial germinomas. Their early diagnosis is complicated due to their atypical localization and diversity of neuroimaging and clinical signs.

MATERIAL AND METHODS

We describe 4 cases of basal ganglia germinoma in boys of 13, 14, 15, and 16 years of age. The medical history data, clinical features, neuroimaging and histological characteristics of basal ganglia germonomas, and preliminary results of the treatment are presented.

CONCLUSION

Basal ganglia germinomas are usually verified at the late stage of the disease when patients are detected with extended lesions of the basal ganglia and severe neurological and neuroendocrine deficits. This situation is due to clinical and imaging signs that are untypical of common germinomas.

Basal ganglia germinoma: MRI classification correlates well with neurological and cognitive outcome

Basal ganglia germinomas (BGG) are often associated with delayed diagnosis because of their nonspecific clinical presentation and subtle abnormalities on initial neuroimaging. Despite excellent survival, the prognostic indicators still remained unclear. From our case series, we demonstrated that the MRI classification scheme devised by Phi and colleagues is useful in predicting neurological and cognitive outcomes for patients with unilateral BGG. Subtle lesions with faint or no contrast enhancement are associated with early cerebral atrophy with progressive neurological deficits and poor cognitive outcomes. BGG along with bilateral involvement, regardless of the types of lesion, are also associated with poor neurological and cognitive outcomes.

Latency of intracranial germ cell tumors and diagnosis delay

BACKGROUND

Intracranial germ cell tumors (GCTs) frequently take an insidious clinical course before diagnosis. To date, clinical latency has been discussed in the context of germinoma in the suprasellar area and basal ganglia.

OBJECTIVE

In this study, we classified the clinical latency of intracranial GCTs into three categories and described their characteristics in order to understand the full spectrum of the phenomenon.

METHODS

In a cohort of 181 patients with intracranial GCTs, 17 patients had a delayed diagnosis of more than 3 months (90 days) from the initial brain magnetic resonance imaging to the definitive GCT diagnosis. Clinical records and radiological data of the patients were reviewed.

RESULTS

The patients with a delayed diagnosis were categorized into three groups according to their tumor location: suprasellar (nine patients), basal ganglia (six patients), and pineal (two patients). Initial symptomatology corresponded with the tumor location: central diabetes insipidus for the suprasellar group, hemiparesis for the basal ganglia group, and precocious puberty for the pineal group. The overall survival of patients with germinoma and delayed diagnosis was significantly shorter than that of patients who were diagnosed within 3 months (P = 0.002).

CONCLUSIONS

Clinical latency and delayed diagnosis are not restricted to germinomas in the suprasellar area and basal ganglia; they are canonical features of intracranial GCTs including pineal non-germinomatous GCTs. Early detection and proactive diagnosis of these tumors are required because diagnosis delay may negatively influence patient survival.

Incidental brain lesions in children: to treat or not to treat?

Central nervous system (CNS) lesions that are discovered incidentally when imaging children for problems that were unrelated to the detected lesion pose a dilemma to physicians. Because there are few data on the outcome of such cases, we retrospectively reviewed the clinical course of a group of children followed at our institution with brain lesions found incidentally on neuro-imaging. A database of all children with brain lesions followed at the University of Rochester medical center from 2000 to 2010 was reviewed. Data were obtained regarding presentation, magnetic resonance imaging (MRI) features, treatment, progression-free survival, and overall survival of children with brain lesions found incidentally. Of the 244 children with brain lesions seen over this time period, 21 (8.6%) were found to have incidentally discovered brain lesions. Of these 21 children, 12 (57%) underwent surgical resection of their brain lesions. Ten patients (48%) had symptoms considered to be unassociated with the detected lesion. Lesions were found in the cerebellum (n = 7, 33%), midline (n = 5, 24%), and cerebrum (n = 9, 43%). All lesions were ≤5 cm in diameter. Eight patients (38%) had surgery at presentation, one because of imaging features suspicious for a posterior fossae ependymoma, and the seven others because of location in the posterior fossae or brain stem. Of the remaining 13 patients, five had progression of disease on serial MRI scans: four underwent surgery and the fifth was monitored and remained stable after the initial progression stabilized. Nine of the ten patients (90%) with posterior fossae lesions underwent surgery, while only three of 11 with supratentorial lesions underwent surgery (27%) (P = 0.006). The progression free survival was 94% at 12 months (95% CI 65-99%) and 71% at 24 months (95% CI 39-88%). At a median follow-up of 32 months, the overall survival was 100%. Incidentally detected CNS lesions are usually small. The outcome for children with such lesions is excellent. Close monitoring of these patients with serial MRIs may be a safe alternative to immediate biopsy and/or resection for select patients.

Primary yolk sac tumor of bilateral basal ganglia

A primary intracranial yolk sac tumor (YST) is a type of germ cell tumor (GCT) and usually involves the pineal or suprasellar regions, as do other GCTs. Primary YST in the basal ganglia is not common, and bilateral basal ganglia involvement is even rarer. Early diagnosis is often difficult because of minimal or subtle findings without space-occupying lesions shown on neuroimaging during the early course of the disease. We report a case of primary intracranial YST encountered in the basal ganglia bilaterally and describe the clinical presentation, diagnostic problem, imaging characteristics, histopathologic features, and prognosis of the tumor. To the best of our knowledge, this is only the third reported case of primary YST confined to the basal ganglia in the literature.

Germinoma in the basal ganglia with an abnormal karyotype: case report and review of the literature

INTRODUCTION

Germ cell tumor of basal ganglia with abnormal constitutional karyotype has been rarely reported.

CASE REPORT

A 9-year-old boy presented with precocious puberty and right hemiparesis. Magnetic resonance imaging showed high intensity on T1-weighted, T2-weighted, and contrast-enhanced T1-weighted images in the left basal ganglia and ipsilateral cerebral hemiatrophy predominantly in the basal ganglia and midbrain. Germinoma in the left basal ganglia was confirmed by stereotactic biopsy and immunochemical examination. His constitutional karyotype was 46, XY, t (8; 19), (p23.1; p13.1), a novel chromosomal abnormality.

DISCUSSION

Intracranial germinoma, a potentially curable tumor, should be considered in children with nonspecific neurological symptoms, endocrinologic changes, and ipsilateral cerebral hemiatrophy on computed tomography or magnetic resonance. Investigation of chromosomal aberrations in those patients would clarify the tumorigenesis and lead to possibilities for novel disease-specific therapies.

Pathophysiological mechanism of ipsilateral cerebral and brainstem hemiatrophy in basal ganglia germ cell tumors: case report

INTRODUCTION

The basal ganglia is an uncommon location for germ cell tumors. It has been reported that basal ganglia germinomas and mixed germ cell tumors are associated with ipsilateral cerebral and brainstem hemiatrophy on presentation. Several pathophysiological mechanisms including autoimmune process and direct tumor infiltration of the thalamus or the internal capsule have been postulated to explain this association.

CASE REPORTS

The authors report two boys, aged 7 and 10, with basal ganglia germ cell tumors. Both of them presented with gradual onset of hemiparesis and had features of ipsilateral cerebral and brainstem hemiatrophy on imaging studies. They underwent chemotherapy followed by reduced dose radiotherapy with good response.

DISCUSSION

Pathophysiological mechanisms of the associated ipsilateral cerebral and brainstem hemiatrophy are discussed. The authors postulate that the gradual obliteration of the perforating arteries to the diencephalon especially the lenticulostriate arteries of the prebifurcation middle cerebral artery may be the major mechanism of the associated hemiatrophy.

Atypical basal ganglia germinoma presenting as cerebral hemiatrophy: diagnosis and follow-up with 11C-methionine positron emission tomography

OBJECTS

Some basal ganglia germinomas are difficult to diagnose in early stage of disease due to vague initial presentation without discernable mass lesion on brain imaging. We performed this study to determine the usefulness of 11C-methionine positron emission tomography (MET PET) for the diagnosis and monitoring of disease activity.

MATERIALS AND METHODS

MET PET was performed in three consecutive patients; they presented with cerebral hemiatrophy without definite mass lesions on brain image. The maximum standard tracer uptake values (max SUVs) were calculated and used for the quantitative evaluation of the abnormal MET uptake. A pathological diagnosis was made after stereotactic biopsy using MET PET/computed tomography. The max SUVs significantly decreased after treatment.

CONCLUSION

Basal ganglia germinoma should be considered in the differential diagnosis of patients with progressive hemiparesis and hemiatrophy on magnetic resonance imaging. The MET PET was useful for diagnosis, and it can be valuable in evaluation of treatment effects and monitoring for tumor recurrence.

Germ cell tumors in the basal ganglia: problems of early diagnosis and treatment

OBJECT

Intracranial germ cell tumors (GCTs) originating in the basal ganglia are rare. The authors investigated factors related to the diagnosis of these lesions as well as outcome in order to help decrease the time to diagnosis and improve treatment efficacy.

METHODS

The authors reviewed the clinical features of 142 cases of intracranial GCT in their institute. Fourteen cases of basal ganglia GCT were identified. The symptoms, neuroimaging findings, delay between symptom onset and diagnosis or treatment, initial and further treatment, and outcome were investigated.

RESULTS

Major symptoms were motor weakness and precocious puberty. Gadolinium-enhanced T1-weighted MR images showed enhancement in 8 of 11 patients examined, but only slight hyperintensity without enhancement in 2 patients. Ipsilateral peduncle and hemispheric atrophy were found in 3 and 4 patients, respectively. Cases of basal ganglia GCT were characterized by a longer delay from the initial neuroimaging examination to diagnosis compared with GCT in other regions. Five patients had aggravated hemiparesis in the extremities due to the delay in diagnosis. Despite good response to the initial therapy, 5 patients experienced recurrence; 2 of these 5 had malignant GCTs, and 3 had been treated only with chemotherapy or radiochemotherapy with insufficient radiation dose and field. Finally, the 2 patients with malignant GCTs died of the disease, and 1 died of aspiration pneumonia due to dissemination around the brainstem.

CONCLUSIONS

Early diagnosis requires MR imaging with administration of contrast medium in young patients presenting with motor weakness and/or precocious puberty. Serial neuroimaging studies should be performed if any tiny lesion is detected in the basal ganglia. Since insufficient treatment resulted in early recurrence, radiation therapy with adequate dose and field is essential.

Inherent diagnostic and treatment challenges in germinoma of the basal ganglia: a case report and review of the literature

Among intracranial germinomas, basal ganglia germinomas represent a specific clinical and anatomical entity. Based on an unusual case of a basal ganglia germinoma in a 13-year-old Caucasian male, we highlight the diagnostic challenges and discuss treatment considerations in this disease.

Bilateral germinoma of the basal ganglia

Germinoma arising in the bilateral basal ganglia is exceedingly rare, with only five cases reported to date. Owing to non-specific clinical findings and the frequent presence of ill-defined abnormalities without a definite tumor mass on neuroimaging, the diagnosis can be difficult. We describe a case in which magnetic resonance spectroscopy (MRS) findings suggested a tumor and supported the decision to perform biopsy of the lesion.

Limited-field radiation for bifocal germinoma

PURPOSE

To report the incidence, characteristics, treatment, and outcomes of bifocal germinomas treated with chemotherapy followed by focal radiation.

METHODS AND MATERIALS

This was a retrospective review. Inclusion criteria included radiologic diagnosis of bifocal germinoma involving the pineal and neurohypophyseal region, no evidence of dissemination on spinal MRI, negative results from cerebrospinal fluid cytologic evaluation, and negative tumor markers.

RESULTS

Between 1995 and 2004, 6 patients (5 male, 1 female; median age, 12.8 years) fulfilled the inclusion criteria. All had symptoms of diabetes insipidus at presentation. On MRI, 4 patients had a pineal and suprasellar mass, and 2 had a pineal mass associated with abnormal neurohypophyseal enhancement. All patients received chemotherapy followed by limited-field radiation and achieved complete remission after chemotherapy. The radiation field involved the whole ventricular system (range, 2,400-4,000 cGy) with or without a boost to the primary lesions. All patients remain in complete remission at a median follow-up of 48.1 months (range, 9-73.4 months).

CONCLUSIONS

This experience suggests that bifocal germinoma can be considered a locoregional rather than a metastatic disease. Chemotherapy and focal radiotherapy might be sufficient to provide excellent outcomes. Staging refinement with new diagnostic tools will likely increase the incidence of the entity.