CNS germinoma in a boy with simple virilizing 21-hydroxylase deficiency and precocious puberty

A 6 year-old boy presented with peripheral precocious puberty and was diagnosed as having simple virilizing 21-hydroxylase deficiency based on clinical features and elevated 17-hydroxyprogesterone levels on ACTH stimulation. He was managed with glucocorticoids and mineralocorticoids. Two years later he presented with features of CNS involvement in the form of seizures and raised intracranial pressure with rapid progression of puberty. Contrast enhanced CT scan of brain showed an intraventricular tumor with cerebrospinal fluid cytology suggestive of germinoma. Serum and CSF levels of human chorionic gonadotropin (hCG) and alphafetoprotein (AFP) were elevated, confirming the diagnosis of germinoma.

Testicular sperm extraction in azoospermic patients with gonadal germ cell tumors prior to chemotherapy--a new therapy option

BACKGROUND

In view of the high cure rates in patients with testicular germ cell tumors (TGCT), increasing clinical importance is attached to protection of fertility. Long-term infertility due to cytostatic therapy may be expected in more than 50% of the patients at a cumulative dose of cisplatin > 0.6 g/m2. The standard procedure for fertility protection in cancer patients includes cryopreservation of ejaculated spermatozoa. Considering that some patients have tumor-induced azoospermia, we examined the usefulness of testicular sperm extraction before therapy.

METHOD

A survey of the literature served as a basis for investigating biological and clinical aspects of the impact of chemotherapy on male fertility. A study of our patient population also enabled us to explore the option of extracting sperm from the contralateral healthy testis prior to treatment in 14 azoospermic patients with testicular germ cell tumors.

RESULTS

We were able to successfully recover haploid germ cells in 6/14 testicular biopsies from azoospermic patients with testicular germ cell cancer prior to treatment. Maturation arrest was found in 3/14 cases and Sertoli-cell-only syndrome in the rest. None of the patients had secondary healing or a treatment delay because of the testicular biopsy.

CONCLUSION

Since the post-therapeutic fertility status is difficult to predict in cancer patients, we think that TESE should be regarded as a general option prior to cancer treatment and offered to azoospermic cancer patients. New guidelines should be established in this connection.

Persistent Mullerian duct syndrome presenting with bilateral intra-abdominal gonadal tumours and obstructive uropathy

Persistent Mullerian duct syndrome is a rare, autosomal recessive intersex disorder characterized by the presence of completely developed Mullerian duct derivatives in an otherwise normally virilized male with a 46, XY karyotype. We discuss a rare presentation of this disorder, bilateral gonadal tumours with obstructive uropathy, and its management, together with a review of the literature.

Cerebral germinoma with hemiatrophy of the brain: report of three cases

BACKGROUND

The authors report three cases of cerebral germinoma that occurred in young adults with unusual presentation.

METHOD

All three patients presented with hemiparesis and were treated at Seoul National University. A histological diagnosis of germinoma was made by a stereotactic biopsy in all three cases.

FINDINGS

Magnetic resonance (MR) images showed that their tumors were located in the internal capsule and thalamus, and were associated with ipsilateral cerebral hemisphere and brain stem atrophy. The hemiparesis slowly progressed and this was accompanied by a haemorrhagic cyst in each patient.

INTERPRETATION

Clinical diagnosis was not easy because of the unusual clinical presentations and atypical MR imaging findings. It is suggested that cerebral germinoma should be included in the differential diagnosis of a haemorrhagic mass which is associated with cerebral atrophy in the thalamus, basal ganglia, or internal capsule, especially in adolescents or young adults.

Pure word deafness in two patients with subcortical lesions

We report two patients with pure word deafness (PWD) with tumour in the III ventricle region with obstructive hydrocephalus. A diagnosis of PWD was made in these two patients in view of impaired verbal comprehension in the presence of adequate hearing, intact acoustic stapedius reflex and well preserved environmental sound perception. Return of verbal comprehension following the radiation therapy observed is probably due to the reduction of the tumour mass and the release of thalamocortical auditory pathways from its compressive effect. Our findings support the hypothesis of the presence of discrete auditory pathways for mediation of verbal and non-verbal stimuli independently.

Cutaneous mastocytosis associated with a mixed germ cell tumour of the ovary: report of a case and review of the literature

A 10-year-old girl with a mixed germ cell tumour of the ovary, treated by surgery and chemotherapy, developed cutaneous mastocytosis approximately 8 months after starting chemotherapy. This is the sixth report of a germ cell tumour associated with mastocytosis. c-kit receptor point mutations, including Asp816Val and Val560Gly were absent in a biopsy specimen obtained from lesional skin.

Precocious puberty in children with tumours of the suprasellar and pineal areas: organic central precocious puberty

During the past 11 y, 115 children younger than 8/9 y of age (female/male) with tumours of the suprasellar or pineal areas were followed in our clinic to study the incidence of precocious puberty. In addition, type of central lesion, clinical characteristics and gonadotropic secretion were studied in order to elucidate the different mechanisms of gonadal activation. A control group of 21 patients with idiopathic precocious puberty and a control group of 10 age-matched patients with suprasellar tumours without precocious puberty were also studied. Precocious puberty associated with organic central lesions was found at diagnosis in 30 patients (26%), in 9 out of 48 patients with glial cell tumours (18.7%), 6 out of 9 patients with germ cell tumours (66.6%), 11 out of 11 patients with hypothalamic hamartomas (100%) and in 4 out of 4 patients with subarachnoid cysts or arachnoidocele (100%). Precocious puberty was not found in any of 36 patients with craniopharyngioma. With the exception of one patient with pineal germinoma, all lesions were localized to the suprasellar area. In all patients with hypothalamic hamartoma, precocious puberty was diagnosed before 4 y of age, while in most patients with the other lesions, it was diagnosed after this age. Height SDS, weight increase and advancement of bone age were similar in both idiopathic and organic central precocious puberty. Maximal LH responses to GnRH in idiopathic and organic central precocious puberty were similar except for germ cell tumours. Patients with suprasellar tumours without precocious puberty had lower maximal LH (but not FSH) responses to GnRH, with the exception of germ cell tumours. In the latter, elevation of serum beta-hCG indicates that this gonadotropin was responsible for gonadal stimulation. In hypothalamic hamartomas, the prepubertal hiatus in the activity of the GnRH pulse generator was absent. The mechanism of this failure in the inactivation of GnRH is unknown. Data suggest that in glial cell tumours and in subarachnoid cysts, an unknown factor, probably secreted by the tumours, advances the tempo of GnRH maturation. Therefore, the aetiology of organic central precocious puberty is multiple and is directly related to location and type of lesion.

CONCLUSION

This clinical information suggests that the onset of puberty is not the result of the disruption of a putative pulse generator inhibitory influence but the consequence of secretion of stimulatory substances by the lesions.

Gonadotropin releasing hormone-independent precocious puberty in a 5 year-old girl with suprasellar germ cell tumor secreting beta-hCG and alpha-fetoprotein

A 5 year-old girl presented with typical features of isosexual precocity with breast and pubic hair development (Tanner stage 3) and menarche, following a few months history of hirsutism of the back and thighs. Stimulation testing revealed GnRH-independent precocious puberty, tertiary hypothyroidism, hyperprolactinemia and mild testosteronemia. The ovaries in ultrasound examination were prepubertal. Tumor markers beta-hCG and AFP were markedly elevated and a 2.5 x 1.5 cm suprasellar germ cell tumor (GCT) was visualized by MRI. Combined chemotherapy followed by radiotherapy resulted in normalization of pubertal features along with estrogen and marker levels. Our observations support the possibility of hCG-dependent precocious puberty (PP) in girls caused by suprasellar hCG-secreting tumor. We emphasize the need of diagnostic management of hCG-dependent PP not only in boys, but also in girls, especially when they present even slight features of androgenization. We hypothesize that the rarity of isosexual PP in girls with hCG-secreting suprasellar GCT results not only from the lower occurrence of these tumors in girls than in boys, but above all from a rare simultaneous concomitant incidence of both high tumor aromatase activity and hCG secreting potency.

Ventriculoscope tract recurrence after endoscopic biopsy of pineal germinoma

Recurrence along an endoscope tract has been described after endoscopic biopsy and resection of malignant tumors arising in multiple organ systems. We describe a case of tract recurrence following the ventriculoscopic biopsy of a central nervous system tumor. A retrospective review of the patient's clinical course, radiology and pathology was undertaken to formulate a case report. A 14-year-old boy was treated with endoscopic third ventriculostomy and endoscopic biopsy of a pineal germinoma associated with hydrocephalus. Persistent hydrocephalus required repeat third ventriculostomy. The patient subsequently received focal external beam radiotherapy. Seventeen months after the first third ventriculostomy, a routine MRI revealed a 2-cm enhancing mass in the ventriculoscope tract. This was removed via a right frontal craniotomy. Again the pathology was germinoma. Serum and CSF markers were negative at initial presentation and at the time of recurrence. The potential for tract recurrence and CSF dissemination should be considered following the endoscopic biopsy of pineal germ cell tumors as this could affect the extent of radiotherapy and/or chemotherapy.

Erythropoietin in urologic oncology

OBJECTIVES

The use of erythropoietin (EPO) for the treatment of anemia associated with urological malignancies is not well defined. The rate of anemia is dependent on the type of cancer and on the different types of treatment. Only with a substantial risk for blood transfusion is substitution treatment by EPO justified. Additionally, the long-term risks of blood transfusions have to be balanced against the costs of EPO treatment.

METHODS

Different experts have reviewed the literature on anemia and EPO regarding the four main tumor entities.

RESULTS/CONCLUSIONS

In prostate cancer, EPO treatment may be justified before radical prostatectomy and in patients with advanced, hormone-refractory disease. In bladder cancer, significant treatment-related anemia mainly occurs in patients who have to undergo radical cystectomy and in patients who will be treated with polychemotherapy for metastatic disease. Patients with renal cell carcinoma rarely suffer from anemia and thus are usually not candidates for EPO treatment. Testis cancer patients only have a substantial risk for blood transfusions if they belong to the intermediate or poor prognosis group according to IGCCCG or if they need salvage chemotherapy or salvage surgery. However, in testis cancer patients EPO treatment should generally be preferred to blood transfusions since cure rates are excellent and thus the potential risks of transfusion-related infections are significant.

Membranoproliferative glomerulonephritis associated with a mixed-cell germinal ovary tumor

We describe a patient with membranoproliferative glomerulopathy associated with a mixed-cell germinal ovary tumor (embryonal and dysgerminoma components). Advanced renal failure ensued without remission of nephrotic syndrome after surgery. Five other cases of ovary tumor associated with glomerulopathy and reported in the literature are reviewed. The association between membranoproliferative glomerulonephritis and mixed-cell germinal ovary tumor has not been previously reported.

Gastrointestinal presentation of germ cell malignancy

OBJECTIVES

To summarize monoinstitutional experience with gastrointestinal (GI) presentations of germ cell malignancy and to review recent medical literature on this issue.

METHODS

Retrospective review of 5 cases with advanced germ cell malignancy (testicular 2 and retroperitoneal 3) and involvement of the upper GI tract and a comparison with published observation.

RESULTS

In 4 patients the duodenum and in 1 patient the distal part of the esophagus were involved in germ cell malignancy. In 3 patients grade 3 or grade 4 anemia represented the principle initial symptom. Ulceration of the upper GI tract was in 1 case complicated by an aortoduodenal fistula with rupture of the aorta. This patient and 2 other cases needed emergency surgery due to GI hemorrhage before and/or during the initial phase of chemotherapy. Our observations compare well with the literature, showing the need of multimodality therapy of these complications.

CONCLUSION

In young males with a malignant tumor in the upper GI tract, the diagnosis of germ cell malignancy should be considered. Treatment of this condition requires a multimodality approach, not rarely including emergency surgery. Though these patients often belong to a poor-prognosis group, our results and the literature review show that long-term survival is possible using modern treatment principles. In particular, the risk of GI hemorrhage, during the initial phase of therapy, should not be overseen.

[Clinical presentation, treatment, and follow-up of 32 patients with a primary intracranial germinoma, registered during the previous 15 years in the Dutch Pathological-Anatomical National Automated Archive (PALGA)]

OBJECTIVE

Evaluation of clinical presentation, treatment and follow-up of patients with intracranial germinoma in the Netherlands.

DESIGN

Retrospective.

METHOD

The case histories of 32 patients with histologically verified intracranial germinoma, registered in the period 1983-1999 in the Pathological Anatomical Nationwide Automated Archive (PALGA), were studied. Fifty of the 59 registered patients were found of whom 6 had no germinoma. Informed consent was obtained from 32 of the 44 patients with respect to studying their medical records for age, symptoms at presentation, diagnostic investigations, presence of tumour markers, treatment and follow up.

RESULTS

The patient group consisted of 23 men and 9 women aged 6 to 35.6 years (mean: 17.3) and was subdivided with respect to their tumour localization. In patients with pineal localization symptoms of increased intracranial pressure and eye movement disorders were most prominent, whereas in patients with suprasellar localization endocrine disorders prevailed. Thirty-one patients were treated with radiotherapy, one with combined radiotherapy and chemotherapy and one surgically. Twenty-six patients had remained disease free after a median follow-up of 39 months (range: 0-144 months). One patient developed an intracranial embryonal carcinoma and another a testis seminoma. Two patients died because of recurrences. Two other patients died of causes not directly related to the germinoma.

CONCLUSION

At the time of this study 84% of all patients treated with radiotherapy were disease-free. Although the percentage patients who had recovered after treatment (surgical and radiotherapy) was high, many patients either already had or subsequently developed neurological and endocrinological deficiencies.

Thickened pituitary stalk on magnetic resonance imaging in children with central diabetes insipidus

Magnetic resonance imaging (MRI) has revealed isolated pituitary stalk thickening (PST) in certain cases of idiopathic or secondary central diabetes insipidus (DI) due to infiltrative processes. Twenty-six children with DI and PST underwent cerebral MRI at the age of 8 +/- 4 years and were followed (n = 25) by clinical and MRI evaluation for 5.5 +/- 3.6 and 3.0 +/- 2 years, respectively, but given no treatment other than hormonal substitutive therapy. Patients were subdivided into groups according to the etiology of the DI: germinoma (n = 4), Langerhans' histiocytosis (n = 5) or 'idiopathic' DI with PST (n = 17). Complete anterior pituitary evaluation in 24 of the 26 patients revealed that 14 children were suffering from associated growth hormone deficiency and 7 had multiple hormone deficiencies. At the first MRI evaluation, pituitary stalk enlargement varied from 2.2 to 9.0 mm. The anterior pituitary gland was found to be normal (n = 12), small (n = 8) or enlarged (n = 6). At the final evaluation, a change in MRI features had occurred in 16 patients: morphological and/or signal changes in the PST (n = 16; 6 of whom showed an increase in PST) and changes in anterior pituitary gland size (n = 8; 3 of whom had increased and 5 had decreased). The presence of a growing suprasellar mass with a progressively enlarging pituitary stalk was demonstrated in the 6 patients who had shown increased pituitary stalk enlargement 1.8 +/- 1.6 years after the first MRI. In 4 of these patients, a diagnosis of germinoma was made 1.3 +/- 0.6 years after PST identification by MRI at the onset of DI, but the other 2 patients showing a suprasellar mass were still categorized as 'idiopathic' at the final clinical evaluation performed 7.8 and 12.3 years after DI onset. In 10 patients (all but 1 with Langerhans' histiocytosis, showing 'idiopathic' DI) the pituitary stalk enlargement was diminished after 2.0 +/- 1.9 years of MRI follow-up, and there was a complete reversal of pituitary stalk enlargement in 5 patients. We conclude that the natural history of 'idiopathic' isolated central DI with PST is unpredictable. Although germinoma should always be considered during the first 3 years of follow-up in patients presenting isolated DI with PST by repeated investigations every 3-6 months, it remains an infrequent etiology, affecting only 15% of cases in our study.

[Clinicopathological study of the testicular microlithiasis]

PURPOSE

Testicular microlithiasis (TM) is a relatively rare condition characterized by calcific concref1p4 within the seminiferous tubules. Little has been reported on the incidence or the clinical implication of TM among Japanese. To address the problem, we evaluated pathologic specimens from biopsies and orchiectomies, of testes with various conditions.

MATERIALS AND METHODS

Pathologic specimens of the testes of 200 cases, 56 from orchiectomy and 144 from testicular biopsy, were investigated.

RESULTS

The pathological diagnosis of TM was confirmed in seven (3.5%) cases, four of which were associated with germ cell tumors and the other three were obtained from testicular biopsies performed for examination of infertile men. Of the 41 patients with germ cell tumors, four (9.8%) were found to have TM, and another three (2.5%) were identified among 122 patients with infertility. The prevalence of TM is significantly higher in specimen with germ cell tumors than those without germ cell tumors (p < 0.05).

CONCLUSIONS

Although TM is rarely encountered, this condition is relatively often accompanied by testicular malignancy. Further investigation would be fundamental to ascertain the relationship between TM and testicular malignancy.

A large pseudolesion in the left lobe of the liver caused by inferior vena caval obstruction secondary to metastatic retroperitoneal lymphadenopathy

A rare case with a large pseudolesion in the left lobe of the liver observed on early phase of incremental dynamic computed tomography (CT) caused by inferior vena caval obstruction is presented. Decreased portal perfusion due to increased volume of systemic venous inflow into the left lobe via paraumbilical venous system may be its underlying hemodynamic change. The etiology of this pseudolesion was successfully confirmed by conventional CT with intravenous contrast medium injection via superficial vein of lower extremity.

A case of jejunal intussusception with gastrointestinal bleeding caused by metastatic testicular germ cell cancer

BACKGROUND/AIM

We report an unusual case of metastatic testicular germ cell tumor with its unusual presentation.

METHOD

A patient presented to the San Joaquin General Hospital with gastrointestinal bleeding and obstruction and a testicular mass is described. The patient's clinical course is followed and the literature reviewed.

RESULTS

The patient presented with jejunal intussusception due to metastatic testicular cancer. He was treated with orchiectomy and bowel resection followed by postoperative chemotherapy.

CONCLUSION

This case illustrates the need to consider metastatic small-bowel obstruction and/or intussusception in patients presenting with testicular mass and abdominal pain.

Comparative tolerability of chemotherapy regimens for germ cell cancer

Germ cell tumours, even at an advanced stage, represent a unique model of malignant curable disease since >80% of patients are expected to be cured after appropriate therapy: surgery and radiotherapy in early stages, and chemotherapy and surgery in advanced stages. In advanced stages, serum tumour marker levels as well as extrapulmonary (brain, liver and bone) visceral metastases are the most important prognostic factors that affect treatment modalities. 'Gold standard' regimens for germ cell cancer currently include etoposide plus cisplatin with (BEP) or without (EP) bleomycin. In patients with good risk disease (90% cure rate), the optimal regimen of chemotherapy should combine the best efficacy and the least toxicity. As a result of randomised trials, 3 regimens can be currently recommended: (i) 4 cycles of EP; (ii) 4 cycles of BEP (with etoposide 350 mg/m2 per cycle); or (iii) 3 cycles of BEP (with etoposide 500 mg/m2 per cycle). In patients with poor risk disease, 4 cycles of BEP (with etoposide 500 mg/m2 per cycle) allow a disappointing cure rate of 50%. The long term toxicity of these regimens (gonadal toxicity and secondary malignancies) appears to be negligible and clearly does not challenge current standard strategies.

A rare simultaneous presentation of testicular mixed germ cell tumor with a contralateral testis torsion

We report a rare case of a 27-year-old man presenting with an acute scrotum with simultaneous occurrence of testicular tumor and contralateral torsion. Preoperative imaging demonstrated the testicular missed torsion, yet findings were equivocal with regard to the testicular tumor. On scrotal exploration the left testis was found to be ischemic due to threefold rotation. The right testis was not identifiable, being composed of numerous necrotic lesions. Frozen section suggested malignancy, hence high right orchiectomy was performed. Histologic examination of the right testis showed mixed germ cell tumor, containing all the subtypes. To our knowledge no similar case has been reported.

Hematologic disorders associated with primary mediastinal nonseminomatous germ cell tumors

BACKGROUND

The association between primary germ cell tumors of the mediastinum (the space between the lung pleura that contains the heart and other chest viscera) and hematologic malignancies has been described by retrospective analysis of patients treated at individual clinical centers. To better characterize the risk of hematologic disorders in patients with extragonadal germ cell tumors and to describe the clinical and biologic features of the disorders, we studied an unselected population in a large, international, multicenter database.

METHODS

Six hundred thirty-five patients treated at 11 centers in the United States and Europe from 1975 through 1996 were evaluated retrospectively.

RESULTS

A hematologic disorder was observed in 17 patients with germ cell tumors. All cases developed among the 287 patients with primary mediastinal nonseminomatous germ cell tumors, giving an incidence rate in this group of 2.0% (95% confidence interval [CI] = 1.1%-3.1%) per year over a median follow-up time of 3 years. The risk of developing hematologic disorders was statistically significantly increased in patients with primary mediastinal nonseminomatous germ cell tumors in comparison with the age-matched general population (standardized incidence ratio = 250; 95% CI = 140-405). The median time to onset of hematologic neoplasia was 6 months (range, 0-47 months), and the median survival after diagnosis of the hematologic disorder was 5 months (range, 0-16 months) (two-sided P<.0001, comparing survival from the time of diagnosis of the germ cell tumor of patients with and without hematologic disorders).

CONCLUSION

In our study, approximately one in 17 patients with primary mediastinal nonseminomatous germ cell tumors was affected by a hematologic disorder, whereas no cases were seen among 334 patients with other extragonadal germ cell tumors. The hematologic disorder had a statistically significant impact on prognosis, with none of the 17 reported patients surviving for more than 2 years.