Primary intracranial germ cell tumor. Pathologic study of 51 patients

Extended focal radiotherapy of 30 Gy alone for intracranial synchronous bifocal germinoma: a single institute experience

OBJECTS

To evaluate the disease characteristics and treatment outcomes for patients with intracranial synchronous bifocal germinomas treated with extended focal irradiation alone.

METHODS

Between January 1996 and March 2007, seven patients (three males and four females) with intracranial synchronous bifocal germinomas treated at Taipei Veterans General Hospital were reviewed. The median age at diagnosis was 14 years (range, 11-28 years). Four patients had surgery before radiotherapy. All patients underwent extended focal irradiation encompassing the whole ventricle system with a total radiation dose of 30 Gy (2 Gy daily). No patient received scheduled systemic chemotherapy before or after radiotherapy. Disease characteristics, treatment outcomes, and the impact of lesion numbers (single vs. bifocal) on survivals were investigated.

RESULTS

With a median follow-up time of 49 months (range, 20-66 months), the 2- and 5-year survival rates were both 100%. After treatment, all patients had good performance without recurrence. No severe complication was observed. In comparison, the overall survival (OS, p = 0.475) and the disease-free survival (DFS, p = 0.537) rates were not significantly different between bifocal- and single-lesion groups. Lesion numbers did not affect both OS and DFS. In addition, the incidence of neuraxial seeding was not higher in patients with bifocal germinomas as compared to those with single lesion.

CONCLUSIONS

Intracranial germinomas are extremely radiosensitive. Young patients with synchronous bifocal germinomas could be successfully treated with extended focal 30-Gy radiotherapy alone. The therapeutic advantage using this regimen needs to be further evaluated with larger sample size and longer follow-up time.

Mixed germ cell tumors in septum pellucidum after radiochemotherapy of suprasellar germinoma: de novo metachronous or recurrent neoplasms?

INTRODUCTION

Mixed germ cell tumors (GCTs) consisting of a germinoma and a mature teratoma in the septum pellucidum have never been described previously; the patient we present here is the first reported example.

CASE REPORT

This case involves an 18-year-old man who presented with abnormal behavior, impairment in recent memory, and emotional change. Five years ago, he received five cycles of chemotherapy using cisplatin and ectoposide and 24G of local radiotherapy for clinical diagnosis of suprasellar germinoma in another hospital. The tumor was then completely resolute. Magnetic resonance imaging in our hospital revealed a large fatty mass located primarily in the septum pellucidum and some portions of the corpus callosum; a heterogeneous enhancing tumor was observed in the surrounding area. The second tumor was completely removed. The histological diagnosis was mixed GCTs containing the component of a germinoma and a mature teratoma.

CONCLUSION

This case is characterized by a second GCT occurring at a different site and with a different histological type, long after complete resolution of suprasellar germinoma. Although it is very difficult to draw conclusions about the correlation between the first and second GCTs, neurosurgeons should always pay attention to the pathological variety and dynamic pathological changes in GCTs once they start to examine and treat them.

[Germ-cell tumors of the central nervous system in childhood: retrospective study of 13 patients]

BACKGROUND AND PURPOSE

Germ cell tumors (GCT) of the central nervous system are rare (2% of all brain tumors in children). Although originating from germ cells, GCT cover a spectrum of different tumors with different management and prognosis, depending on whether they secrete tumor markers or not. The aim of this study is to present a series of children with GCT and comment on overall management practices.

METHODS

We retrospectively reviewed 13 children under the age of 18 years (nine boys and four girls), treated in the same institution between 1986 and 2006 for one or more primitive GCT of the central nervous system.

RESULTS

Median age at diagnosis is 12.9 years (7-17 years). Tumor markers (alpha foetoprotein [alphaFP], human chorionic gonadotrophin [betaHCG]) were assessed 11 times in blood as well as cerebrospinal fluid (CSF). Tumors were located as follows: pineal region (10 cases), hypothalamus (eight cases), basal ganglia (one case) and corpus callosum (one case). Six were bifocal (pineal region and hypothalamus). Clinical signs were mostly dominated by diabetes insipidus and intracranial hypertension. Seven children required surgery for hydrocephalus. Tumor markers were positive in three cases and these children subsequently received chemotherapy followed by radiotherapy, except one child. Eventually, the three patients with positive markers required surgery because of a residual lesion. The eight other patients had a stereotactic biopsy for diagnosis. At the end of follow-up, treatment morbidity appears to be low and neither death nor recurrence was observed. Mean follow-up is 8.85 years (2-20 years).

CONCLUSIONS

The prognosis of cerebral GCTs in children is excellent because of their pronounced chemo- and radiosensitivity. Surgery is crucial for diagnosis in the event of negative markers, or if there is evidence of residual tumor with normalization of tumor markers at the end of chemotherapy. Tumor markers must be monitored to check the diagnosis and for follow-up. The place of tumor biopsy during endoscopic third ventriculostomy (performed if hydrocephalus is present) is still debated.

Germinoma involving the basal ganglia in children

BACKGROUND

Germinoma originating in the basal ganglia is rare, and the majority of reported papers have been from Japan. In a collection of the first 500 cases of primary brain tumors in children in Taipei Veterans General Hospital, six pure germinomas with tissue diagnosis situated in this location.

MATERIALS AND METHODS

We reviewed the clinical features, neuroimaging studies, tumor markers, management, and outcome of these six patients.

RESULTS

All of them were boys. The median age of onset of symptoms was 9.7 years. They uniformly presented with hemiparesis. The average duration of symptoms before surgical management was 1 year. One patient had bilateral basal ganglia tumors. Serum beta-human chorionic gonadotropin levels was elevated (128 mIU/ml) in one patient. Longitudinal neuroimaging studies in four patients clearly showed that the tumor arose as a tiny lesion at the lenticular nucleus. Five patients had cysts within tumors. Five patients received partial, subtotal, to total resection. One patient had stereotactic biopsy of the tumors. Postoperative primary adjuvant therapies included radiotherapy, chemotherapy alone, and combined chemotherapy and radiotherapy. Five patients survived, and one patient died of radiation-induced sarcoma with median follow-up period of 13.7 years. Local recurrence was observed in all of three patients after solitary postoperative chemotherapy.

CONCLUSIONS

The lenticular nucleus is a significant locus for germinomas and can be bilateral. Although rarely reported in Western countries, it does exist in Taiwan as well. Treatment of germinomas in this specific location is similar to germinoma in other intracranial locations.

Granulomatous tissue response in germinoma, a diagnostic pitfall in endoscopic biopsy

We report a case of a 24-year-old man with a right thalamic germinoma that initially mimicked a granulomatous inflammation, compatible with neurosarcoidosis based on clinical symptoms, imaging results and histology of an endoscopically navigated biopsy. A second biopsy, prompted by clinical course, and performed openly from parieto-lateral revealed the underlying germinoma, obscured in the first biopsy by a granulomatous tissue response, particularly at the tumor edge. The present case highlights granulomatous inflammatory tissue response on the tumor edge of germinoma as a tumor-immanent diagnostic challenge. This diagnostic problem is aggravated by stereotactic and endoscopic approaches. We conclude that granulomatous inflammation in a specimen obtained by biopsy of a midline lesion should always be considered for the differential diagnosis of germinoma. Stereotactic and endoscopic surgery should sample several different target points within the lesion. Because of tumor heterogeneity of germinoma, the open biopsy approach is advantageous compared to endoscopic or stereotactic techniques for germinoma and should be considered if a germinoma is in the differential diagnosis and if allowed by the clinical situation.

Pure pineal germinomas: analysis of gender incidence

OBJECTIVE

Pure pineal germinomas have been rarely reported in girls. Gender incidence and differences of pure pineal germinomas are not well known. The authors report a series of pure pineal germinoma and its gender characteristic is reviewed.

METHODS AND RESULTS

Of a total of 50 germ cell tumors operated on between 1988 and 2004 we found 26 cases (median age at diagnosis, 12 years) of pineal germ cell tumors. Of these, 14 cases (male/female ratio: 13/1) were pure pineal germinomas, and 12 cases (male/female ratio: 12/0) were non-germinoma germ cell tumors. In pure pineal germinomas, the main clinical presentations were intracranial hypertension and cranial nerve dysfunction. Imaging studies disclosed a homogeneous type of tumor (n = 10) and associated hydrocephalus (n = 6). Cases were managed with biopsy and subsequent radiation therapy and chemotherapy. After a follow up of 10 years, pure germinoma cases have no neurological deficits and tumor recurrence. The literature on gender incidence of pure pineal germinomas is analyzed and possible causes are discussed.

CONCLUSIONS

Although rare, pure pineal germinoma can be found in female subjects. On the basis of the literature review, the male/female ratio in cases of pure pineal germinoma is between 5:1 and 22:1 (mean 14:1). In our series, the male/female ratio was 13:1.

Gamma knife radiosurgery for intracranial mature teratoma—long-term results and review of literature

BACKGROUND

The purpose of this report is to present long-term outcomes of gamma knife radiosurgery for intracranial mature teratoma after debulking surgery.

METHODS

Three patients with intracranial mature teratoma had initial target volumes of 5.4, 18.7, and 5.1 cm(3), respectively, and were treated by gamma knife radiosurgery between 1993 and 2004. Marginal doses of 17, 12.5, and 13.5 Gy, respectively, were delivered to the tumors at isodose levels of 50%, 50%, and 62%, respectively. The first patient received radiosurgery after surgical removal and conventional radiotherapy. The second patient received similar management, including surgery and radiotherapy, with tumor recurrence. Two additional operations and subsequent radiosurgery were performed on this patient. Based on the favorable results of the first 2 patients, we performed radiosurgery instead of conventional radiotherapy after subtotal surgical removal in the last patient. By reviewing literatures concerning the therapeutic modalities and the long-term results of our 3 patients, we discuss the role of radiosurgery in treating intracranial mature teratoma.

RESULTS

A follow-up period of 121, 89, and 31 months, respectively, demonstrated tumor volume reduction rates of 70%, 89%, and 48%, respectively. No evidence of further tumor progression and no radiosurgery-related complication or morbidity was noted. The school performances of the affected children are all above average.

CONCLUSIONS

Gamma knife radiosurgery provides a safe and effective alternative as the adjuvant treatment of intracranial mature teratoma after surgical debulking. Previous conventional radiotherapy does not alter final tumor control. Radiosurgery should be considered when residual tumor growth continues with no related symptoms or evaluations of tumor markers during follow-up.

Pineal region teratoma with high serum and CSF alpha-fetoprotein levels

We report a patient with an immature teratoma of the pineal region with high levels of alpha-fetoprotein (AFP) in serum and cerebrospinal fluid. This is very rare and to the best our knowledge, the second case reported in the literature.

Primary pediatric brain tumors: statistics of Taipei VGH, Taiwan (1975-2004)

BACKGROUND

The purpose of the current study was to investigate a hospital series of 986 cases of primary pediatric brain tumors in Taiwan.

METHODS

The authors reviewed the database of primary pediatric brain tumors in patients < 18 years of age collected in Taipei Veterans General Hospital (Taipei VGH) from 1975 to May 2004. Age and gender distribution, location, and classification of brain tumors were analyzed. Intracranial tumors with diagnostic imaging were included. Nontumoral lesions, cysts, and vascular malformations were excluded.

RESULTS

The mean age of these 986 patients was 7.8 years, and the male to female ratio was 1.4:1. Supratentorial (including pineal-quadrigeminal) located tumors (58.3%) was predominant to infratentorial tumors (41.1%). In these series, 886 patients had either histologic diagnosis (842 patients) or clinical diagnosis (44 patients). The most common 5 categories of tumors were astrocytic tumors (31.1%), germ cell tumors (14.0%), medulloblastomas (13.3%), craniopharyngiomas (8.3%), and ependymal tumors (5.8%). Atypical teratoid/rhabdoid tumors (AT/RTs), a rare but highly malignant tumor, were 2.1%. The high incidence of primary intracranial germ cell tumors correlated with reported series from Japan and Korea. For the remaining 100 patients without diagnostic classifications, the majority were most likely astrocytic tumors in brain stem.

CONCLUSIONS

The authors analyzed a large hospital series of primary brain tumors in children. Both histologically verified and unverified tumors were recruited to avoid selective bias. Although it was not a study of a population-based brain tumor registry, it could still be representative of primary pediatric brain tumors in Taiwan.

Cerebral composite atypical teratoid/rhabdoid tumor and yolk sac tumor in the frontal lobe of an infant. Case report

A 1-year-old male infant presented with a rare cerebral composite tumor consisting of atypical teratoid/rhabdoid tumor (AT/RT) with epithelial and mesenchymal components and yolk sac tumor (YST) with Schiller-Duval bodies. He was admitted to our medical center with a 2-month history of right hemiparesis. Computed tomography and magnetic resonance imaging revealed a large, intra-axial solid tumor with a cyst in the left frontal lobe. Total resection of the tumor was performed. Histological examination showed two different main growth patterns: solid sheets of undifferentiated polygonal cells and a few rhabdoid cells with rosette structures and rhabdomyoblastic cells; and reticular or papillary structures with occasional Schiller-Duval bodies in a myxoid matrix. The immunohistochemical and electron microscopy findings indicated composite AT/RT and YST. Initial total resection of the tumor was subsequently followed by local recurrence, hydrocephalus, and spinal metastasis. Despite adjuvant chemotherapy, the patient died 9 months after admission. AT/RT is a recently established entity of the central nervous system. The present case of composite AT/RT and YST in the frontal lobe indicates the poor prognosis of such tumors.

Intérêt de la chimiothérapie néoadjuvante dans le traitement des séminomes purs intracérébraux : expérience de l'hôpital du Val-de-Grâce

Optimal management of intracranial germinomas remains controversial. Focal irradiation to the primary tumor followed by prophylactic craniospinal radiotherapy represents the traditional treatment resulting in excellent long-term survival but potential late effects. To decrease late effects related to extensive fields of radiotherapy, combined chemotherapy and irradiation has been tested with reduced volumes and doses of radiation therapy. We report our experience about four patients successfully treated by neoadjuvant chemotherapy with carboplatin and etoposide followed by radiotherapy delivering 26 to 36 Gy to the whole brain and 36 to 50 Gy to the initial tumor volume.

CNS germinoma with elevated serum human chorionic gonadotropin level: clinical characteristics and treatment outcome

PURPOSE

The prognostic significance of human chorionic gonadotropin (HCG) level in central nervous system germinoma remains controversial. The purpose of this study was to compare clinical characteristics and prognosis of germinoma patients with normal and high HCG titers in the serum.

METHODS AND MATERIALS

We undertook a multi-institutional retrospective analysis of 103 patients with central nervous system germinoma whose serum HCG and/or beta-HCG level had been measured before treatment between 1984 and 2002. All patients had been treated with radiation therapy either alone (n = 66) or in combination with chemotherapy (n = 37) with a median dose of 47.8 Gy.

RESULTS

HCG and/or beta-HCG level in the serum was high in 39% of all patients. The proportion of HCG-producing tumors was higher in the lesions at the basal ganglia than in the lesions at the other sites. No correlation was found between tumor size and HCG level, but there seemed to be a weak correlation between size and beta-HCG. The 5- and 10-year survival rates were 96% and 94%, respectively, in both patient groups with normal and high HCG (p = 0.99). The 5- and 10-year relapse-free survival rates were 87% and 82%, respectively, in patients with normal HCG level and were both 87% in patients with high HCG (p = 0.74). Also, no other patient-, tumor-, or treatment-related factors seemed to influence the prognosis of the patients.

CONCLUSION

Serum HCG level does not seem to influence patient prognosis when treated with sufficient doses of radiation. Relationship between tumor size and site and HCG level should be investigated further.

Pineal gland lesions: a cytopathologic study of 20 specimens

BACKGROUND

Pineal gland lesions are rare, with only a few cytologic descriptions occurring in the literature, according to the authors' knowledge. The current article describes the cytopathologic characteristics of 20 such lesions with discussion of differential diagnoses.

METHODS

Cytologic material was obtained either by fine-needle aspiration biopsy (FNAB) under stearotactic radiologic guidance or by touch imprinting (TI) at the time of frozen sectioning. The 20 specimens include pineoblastoma (five specimens), pineocytoma (four specimens), astrocytoma (three specimens), germ cell tumor (three specimens), meningioma (one specimen), epidermoid cyst (three specimens), and pineal cyst (one specimen). Smears were stained with Diff-Quik and with Papanicolaou and hematoxylin and eosin stains. In selected specimens, immunoperoxidase (IPOX) stains were performed on cell block sections using synaptophysin, neuron-specific enolase, placental alkaline phosphatase, glial fibrillary acidic protein, leukocyte common antigen, cytokeratins, and human chorionic gonadotropin antibodies.

RESULTS

Several cytomorphologic characteristics unique to each lesional category with occasional overlapping features were observed. The unique features included the following: small, hyperchromatic, round to oval cells with frequent rosetting (pineocytoma), with a few specimens in addition showing hypercellularity, crowding, mitoses, and necrosis (pineoblastoma); pleomorphic round cells in a fibrillary background (astrocytoma); large polygonal cells with prominent nucleoli and clear cytoplasm (germ cell tumor); spindled fibroblastic cells (meningioma); anucleate squames and mature squamous cells (epidermoid cyst); and small uniform polygonal cells (pineal cyst). When necessary, IPOX studies supported the morphologic diagnoses.

CONCLUSIONS

FNAB and TI cytology were found to provide a rapid and reliable diagnosis of pineal lesions. This is particularly important when dealing with minute amounts of tissue material. Both techniques appeared to provide equally good cytomorphology on smears. IPOX studies played an important complementary role in difficult cases when performed on cell blocks.

OCT4 immunohistochemistry is superior to placental alkaline phosphatase (PLAP) in the diagnosis of central nervous system germinoma

OCT4 is an 18-kDa POU-domain transcription factor encoded by the POU5F1 gene. Also known as OCT3, OTF3, and POU5F1, OCT4 is involved in the initiation, maintenance, and differentiation of pluripotent and germline cells during normal development. It is expressed in mouse and human embryonic stem and germ cells but absent from all differentiated somatic cell types in vitro and in vivo. OCT4 has been detected in primary testicular germ cell tumors with pluripotent potential: seminoma and embryonal carcinoma. We investigated: 1) whether a similar pattern of expression is present in primary intracranial germinomas; and 2) how OCT4 compares with placental alkaline phosphatase (PLAP) in terms of specificity and sensitivity as a potential diagnostic tool. We examined histologic sections from 25 cases of germinoma in which paraffin blocks with sufficient material were available. All cases were reviewed and sections from 32 different blocks were obtained and immunostained for OCT4 and PLAP. Additionally, 49 primary and metastatic brain tumors that may be potentially confused with germinoma, either clinically or histologically, were investigated for OCT4 expression. All but one germinoma were pure (ie, lacking other germ cell components). Intense and often diffuse nuclear staining was detected in 100% of germinomas. PLAP immunoreactivity was detected in 23 of 25 cases and was absent in the remaining 2 cases. The intensity of OCT4 immunostaining was significantly better than that of PLAP. None of the 49 control cases, which included glioblastoma multiforme, pineoblastoma, pituitary adenoma, malignant lymphoma, metastatic melanoma, capillary hemangioblastoma, meningioma, schwannoma, and a variety of metastatic carcinomas showed immunoreactivity for OCT4. Our study demonstrates that OCT4 is a highly specific and sensitive immunohistochemical marker for primary intracranial germinomas. OCT4 should be part of immunoperoxidase staining panels in which germinoma enters the differential diagnosis.

Clinical management of primary central nervous system germ cell tumors

Despite excellent long-term results for patients with germinoma treated with radiation therapy, the potential for late effects makes the treatment controversial. On the other hand, most patients with non-germinomatous tumors treated by conventional treatment with surgery and radiation therapy fail to survive longer than 3 years. After combination chemotherapy with cisplatin was confirmed to be effective in gonadal germ cell tumors, germ cell tumors of the brain became candidates for chemotherapy. The author reviews several prospective phase II studies that are being investigated to assess the effect of combination chemotherapy and radiation therapy for germ cell tumors. The aim of these studies is to reduce the volume and dose of radiation therapy for germinoma and prolong the survival of patients of non-germinomatous tumors. For germinoma, a trial with chemotherapy alone failed, with a high rate of recurrence, but Japanese and European trials with reduced-dose chemotherapy and a smaller volume of radiation therapy have resulted in high event-free survival (EFS) rates. Ongoing phase II studies with combined chemotherapy and radiation therapy for non-germinomatous tumors will result in a 5-year survival rate of greater than 50%, which is better than that achieved by radiation therapy alone.

MRI and CT findings of neurohypophyseal germinoma

OBJECTIVE

Magnetic resonance (MR) imaging and computed tomography (CT) findings of neurohypophyseal germinoma have not previously been described in detail. The purpose of the present study was to establish the spectrum of MR imaging and CT findings in neurohypophyseal germinomas.

MATERIALS AND METHODS

MR and CT images of 13 consecutive patients (seven males, six females; mean age: 15 years; range: 6-31 years) with neurohypophyseal germinoma were retrospectively analyzed. The diagnosis had been made either histologically (n=8) or clinically according to established criteria (n=5). All patients had been examined using MR imaging and CT before treatment.

RESULTS

On MR imaging, infundibular thickening (up to 16 mm) was observed in all 13 cases. Hyperintensity of the posterior pituitary on T1-weighted image was absent in all 13 cases (100%) and 12 of the 13 displayed central diabetes insipidus. Ten germinomas (77%) were isointense to cerebral cortex on T1-weighted image, but variable intensities were exhibited on T2-weighted image. MR images revealed intratumoral cysts in six cases (46%), most of which demonstrated intra-third ventricular extension. Eleven of the 13 cases (85%) revealed hyperdense solid components on unenhanced CT. Calcification was absent in all cases (100%).

CONCLUSION

Infundibular thickening, absence of the posterior pituitary high signal on T1-weighted image, lack of calcification and hyperdensity on unenhanced CT are common imaging features of neurohypophyseal germinoma.

A case of sudden death from primary intracranial germinoma complicated by microvascular disease of the heart

A coroner's autopsy conducted on an 11.5-year-old girl, with a history of hypopituitarism, manifesting as growth hormone deficiency associated with short stature, demonstrated the presence of an undiagnosed hypothalamic intracranial germinoma, showing hypophyseal and mesencephalic invasion, together with histological evidence of microvascular (small coronary artery) disease of the heart. The substantive, or primary, cause of her sudden death was clearly the intracranial germinoma, which was acutely haemorrhagic and necrotic. However, it is postulated that there might be an, as yet, undescribed association between this malignancy and the pathogenesis of the coronary microvascular disease; the latter being deemed, in this instance, to be a contributory cause of death.

Radiotherapy to primary CNS germinoma: how large an irradiated volume is justified for tumor control?

Between 1990 and 1999, there were 30 primary central nervous system (CNS) germinoma patients who received radiotherapy (RT) as treatment. Of these, 23 are male and 7 are female patients, with a median age of 16 years. The treatment field of RT included whole neuraxis in 10, whole brain in 8 and local tumor site in 12 patients; the median dose delivered to the whole neuraxis being 3060 cGy, with 3060 cGy to the whole brain and 5040 cGy to the tumor site. Chemotherapy was prescribed in 9 patients. The median time on follow-up for survivors is 73 months. There were 7, out of a total of 30 patients, who suffered treatment failure. Five of twelve patients (41.6%) who received partial brain RT failed in the brain, with no difference in the rate between patients with or without chemotherapy, and only 2 of 18 patients (11.1%) who received whole brain or whole neuraxis RT failed in the brain (p = 0.053). None of 5 spinal seeding patients failed in the spine and only one failed in the brain after whole neuraxis RT, one patient without whole neuraxis RT (5%) failed in the spine. In summary, partial brain RT will have higher probability of intracranial relapse, and sparing the spinal RT will not result in more spinal failure, whole brain RT would be sufficient for tumor control on primary CNS germinoma.

Suprasellar germ cell tumours: specific problems and the evolution of optimal management with a combined chemoradiotherapy regimen

OBJECTIVE

Suprasellar germ cell tumours are rare, and there are few series of patients outlining the problems in diagnosis and management, and providing clear guidelines for optimal therapy. We have therefore reviewed our own series of 11 such patients who were managed in a joint endocrinology/clinical oncology setting.

PATIENTS AND DESIGN

A retrospective case review assessment of all patients seen within a given time. Clinical, biochemical and radiological findings were reviewed, the types of therapy administered noted, and the responses to treatment analysed.

RESULTS

In the years 1977-2001, 11 patients with suprasellar (SS) germ cell tumours (GCT) were seen (germinomatous : nongerminomatous = 8 : 3). SSGCT had an approximately equal sex incidence (M : F, 6 : 5), in contrast to pineal tumours, the commonest site of origin of intracranial GCT and which occur predominantly in men. The median age at presentation was 20 years (range 6-49 years) with a median duration of symptoms before diagnosis of 17 months (range 1-35 months). Polyuria was the commonest presenting symptom (10 patients). Diabetes insipidus occurred in all patients, as did partial or complete anterior pituitary failure. Visual failure was present in 55% of cases. Anorexia, weight loss and disturbed thirst sensation were also common. Positron emission tomography scanning was occasionally useful in the evaluation of suprasellar tumours/pituitary stalk lesions deemed too risky to biopsy. A "central nervous system-friendly" chemoradiotherapy regimen comprising vincristine, etoposide and carboplatin and differential daily dose irradiation, usually administered using a partial transmission block technique, produced a 5-year survival of 100% with low morbidity. Treatment did not correct previously abnormal endocrine function although it did improve vision in three of six patients.

CONCLUSIONS

We therefore emphasize the use of techniques other than biopsy in the diagnosis of these patients, note the problems in the management of their fluid control, and highlight the favourable response to a combined chemotherapy-radiotherapy protocol.

Production of human chorionic gonadotropin-beta subunit associated with an osteolytic meningioma. Case report

An osteolytic meningioma in a 36-year-old woman was accompanied by elevated serum levels of human chorionic gonadotropin-beta subunit (beta-HCG), which returned to normal after removal of the tumor. Light microscopy examination demonstrated a transitional meningioma. Immunohistochemical analysis revealed that the tumor cells had a positive reaction for beta-HCG. This case illustrates the possibility that meningioma may be associated with clinically detectable secretion of beta-HCG. To the authors' knowledge, this is the first case in which meningioma has been shown to secrete beta-HCG. The authors believe that meningioma should be considered in the differential diagnosis of choriocarcinoma, embryonal cell tumor, germinoma, and metastatic ovarian tumor associated with elevated levels of beta-HCG.

Intracranial germ cell tumors: a retrospective study of 44 children

This 16-year retrospective study review sought to determine the factors influencing prognosis and treatment results of all patients with primary intracranial germ cell tumors treated at our hospital who were younger than 17 years of age at the time of diagnosis. A total of 44 patients were treated during the study period, including 32 males and 12 females with a male:female ratio of 2.67:1. The median age at diagnosis was 12 years and 5 months of age (range = 2-16 years). The 44 intracranial germ cell tumors consisted of 27 pure germinomas (61.4%) and 17 nongerminomatous germ cell tumors, including 10 mixed germ cell tumors (22.7%), three yolk sac tumors (7.8%), two immature teratomas (4.5%), and two choriocarcinomas (4.5%). Univariate analysis of prognostic factors using Kaplan-Meier survival estimates revealed that only histologic tumor type was correlated with outcome (P < 0.005). The projected 5-year overall survival and event-free survival rate of patients with germinomas vs those with intracranial germ cell tumors were 92.6%, 92.6% vs 47.3%, and 42.1%, respectively. Our analysis suggests that radiation involving the spinal axis has limited usefulness in patients with intracranial germ cell tumor, although better results have been obtained for germinomas using radiotherapy in this study.

Late recurrence of pineal germinoma

BACKGROUND

Cerebral germinomas and their occasional recurrences can usually be cured by irradiation, chemotherapy, or a combination of the two treatment modalities. Late recurrences, as in our case, are distinctly rare.

CASE DESCRIPTION

This patient presented at age 24 with a calcified tumor in the pineal area. The radiological diagnosis was germinoma. No tissue diagnosis was obtained. Radiation therapy was given, and there was a complete response. The patient's symptoms reappeared 13 years later. Imaging studies revealed a lesion in the anterior corpus callosum. A germinoma was diagnosed by stereotactic biopsy. Because of complications attributed to the initial course of radiation therapy, no further radiation was given. Five courses of chemotherapy resulted in a partial remission lasting six months. The patient later died because of massive tumor progression with intracerebral, intraventricular, cerebellar, and meningeal dissemination.

CONCLUSIONS

As this case illustrates, exceptional recurrences of cerebral germinomas may appear even many years after adequate initial treatment with radiation and chemotherapy.

Pathology of pineal region tumors

Various histological types of tumors arise in the pineal region. The most common tumors are pineal parenchymal tumors and germ cell tumors. Pineal parenchymal tumors are divided into pineocytoma, pineal parenchymal tumor with intermediate differentiation and pineoblastoma. Pineocytomas are well-differentiated tumors and retain the morphological and immunohistochemical features of pineal parenchymal cells. Lobular architectures and pineocytomatous rosettes are also typical features. In contrast, pineoblastomas are embryonal tumors resembling primitive neuroectodermal tumors (PNET). However, pineoblastomas are distinct from PNET in other sites due to their exhibiting photosensory differentiation including Flexner-Wintersteiner rosettes and fleurettes. Although pineal cysts are tumor-like lesions, and not true neoplasms, they are occasionally difficult to distinguish from pineocytoma and astrocytoma. From the therapeutic aspect, a precise differential diagnosis is critical. The pineal region is the most common site of the brain in which germ cell tumors occur. Germinoma, teratoma, embryonal carcinoma, yolk sac tumor and choriocarcinoma are encountered, and the latter three types of tumors usually constitute elements of mixed germ cell tumors. The morphological and immunohistochemical features of intracranial germ cell tumors are very similar to those of gonadal germ cell tumors, although there are some differences in germinoma. Pineal germinoma may exhibit carcinomatous differentiation. Other types of tumors are occasionally observed, including fibrillary and pilocytic astrocytoma, glioblastoma, ependymoma, melanoma, meningioma and so on. Metastatic pineal tumors are also rare. The most common site of origin for pineal metastasis is the lung.

Delayed resolution of intracranial germinoma after radiotherapy: a preliminary study of the correlation between histology and magnetic resonance imaging

A central nervous system germinoma is curable in most cases by radiotherapy, and most of the tumor mass disappears promptly after 20-30 doses. However, some germinomas take a longer period to vanish completely from magnetic resonance imaging (MRI) or computed tomography (CT) scans. In such cases, the tumor may contain components such as teratoma. The aim of this study was to clarify the nature of the persistence of some germinomas. Five cases of histologically verified germinoma in which radiotherapy was performed to treat residual tumor were selected. The doses of focal radiotherapy and whole brain radiotherapy were 10-20 Gy and 20-34 Gy, respectively. In these cases, correlation was made between the degree of persistence of the tumor when assessed by MRI and the amount of interstitial content, as determined by histology. The histological evaluation, using hematoxylin-eosin stain, silver impregnation and Azan staining was carried out independently of clinical information. The tumor vanished soon after radiotherapy in three cases, but 3-15 months passed before the tumor completely vanished from the MRI scans in the other two cases. The histology of the cases in which the tumor disappeared rapidly was predominantly of large tumor cells and only small amounts of reticulin. However, in the persistent tumors, large amounts of reticulin and vascular components were present. Thus, it is proposed that tumors with a large parenchymal component disappear soon after radiotherapy, whereas tumors composed mainly of interstitial component persist. Long-standing enhancement seen on MRI or CT scans of patients with an intracranial germinoma is indicative of a large amount of interstitial component in the tumor.

Teratomas of the central nervous system: treatment considerations based on 34 cases

OBJECT

The optimum clinical management of central nervous system (CNS) teratomas, particularly postsurgical adjuvant therapy, is still unclear, partly as a result of the tumors' low incidence. In this study the authors analyze 34 cases of CNS teratomas so that they may adequately indicate management of these lesions.

METHODS

The median age of the 34 patients was 13 years. Twenty-seven patients treated between 1970 and 1991 were retrospectively reviewed. Four of these 27 patients died as a result of radical surgery; each of them had a teratoma involving the hypothalamus. After initial treatment, which included radiation therapy, 20 patients (48%) had died. In all seven cases of mature teratomas there was no recurrence. In two cases of immature teratomas in which there was complete surgical resection there was recurrence; however, salvage therapies were effective. Seven of eight patients with highly malignant teratomas died; for these patients salvage therapies, including repeated radiation and chemotherapy, failed. Seven patients who presented with CNS teratomas between 1992 and 1996 received adjuvant chemotherapy and radiation therapy according to a prospective study protocol. All seven patients were free from recurrence with a 70 to 100% Karnofsky Performance Scale score at a median follow-up period of 41 months. Patients with CNS teratomas rarely responded completely to chemotherapy or radiation therapy; an effective adjuvant therapy produced a partial response at best.

CONCLUSIONS

Because teratomas show various responses to adjuvant therapy, a misdiagnosis of their histological subtype will lead to inadequate therapy. A diverse therapeutic protocol based on histological diagnosis is necessary to plan appropriate management. Treatment recommendations are discussed in detail in the article.

Hereditary persistence of alpha-fetoprotein. Case report and review of the literature

Persistently elevated alpha-fetoprotein (AFP) levels of 24 to 30 micrograms/ml (normal < 10 micrograms/ml) were found in a 38-year-old healthy man. Subsequently, AFP was found to be elevated in another five out of 13 family members within three generations. The pedigree is consistent with an autosomal dominant inheritance pattern. No discernible disease and no functional abnormality appears to be associated with this clinically benign disorder which has been recorded in the literature on four occasions to date. The reported AFP levels in these other cases ranged from 18 to 198 micrograms/ml. Physiologically, AFP is mainly produced in the liver and the yolk sac of human fetuses more than four weeks old, with peak values of up to 4 mg/ml at 12 to 16 weeks of gestation. After birth, AFP levels usually fall, within eight to 12 months, to a very low concentration of < 10 micrograms/ml and persist at low levels throughout life. However, AFP levels can rise above normal in both children and adults in distinct conditions and diseases which will be discussed. Hereditary persistence of alpha-fetoprotein (HPAFP) should be considered in both children and adults with unexplained and persistent elevation of AFP e.g., those screened for hepatocellular carcinoma or diagnosed for germ cell tumor. It should also be recognized in AFP screening for neural tube defects or Down's syndrome during pregnancy. Hereditary persistence of AFP can be easily confirmed by analyzing AFP levels in family members.

An attempt to treat pediatric intracranial alphaFP and betaHCG secreting germ cell tumors with chemotherapy alone. SFOP experience with 18 cases. Société Française d'Oncologie Pédiatrique

PURPOSE

Intracranial alphaFP and betaHCG secreting germ cell tumors have a very poor prognosis with local treatment alone. Because of efficacy of chemotherapy in extracranial forms, we tried in the SFOP (Société Française d'Oncologie Pédiatrique) to treat them with chemotherapeutic treatment exclusively.

PATIENTS AND METHODS

Eighteen patients (10 alphaFP, 2 betaHCG, 6 alphaFP and betaHCG secretion) were enrolled from January 1988 to December 1992. After biological diagnosis patients were to receive 6 cycles of chemotherapy (vinblastine bleomycin - carboplatin or etoposide - carboplatin/ifosfamide - etoposide). After completion of chemotherapy, surgery was to be performed in case of residual tumor. Focal radiation was only to be delivered in case of viable residual tumor.

RESULTS

All patients had biological remission and tumor reduction. Fifteen patients were treated according to the protocol by chemotherapy alone (13) or chemotherapy and radiation of residue (2). Twelve of the 13 non irradiated patients relapsed, 8 in local and/or regional area, 3 in cerebrospinal area and 1 in undeterminated area with mild elevation of markers except in one case. Six patients are alive in second complete remission after chemotherapy and/or surgery and then a consolidation treatment with radiation and/or high dose chemotherapy (5) or craniospinal radiation (1). Three patients received radiation after 2 or 3 cycles of chemotherapy as protocol violations and didn't relapse. Thus, 12 patients out of the 18 patients are alive with a median follow up of 68 months. All but 1 had focal radiation as part of treatment. No toxic death was observed.

CONCLUSION

Although survival rate is noteworthy (66%), these tumors were not curable with this conventional chemotherapy alone and focal radiotherapy should be part of the treatment.

Possible common origin of alpha-fetoprotein- and human chorionic gonadotropin--secreting cells in intracranial germ cell tumor. Case report

A primary intracranial germ cell tumor in a 16-year-old boy secreted both alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG). The tumor, located in the right thalamus, contained germinomatous, trophoblastic, and endodermal sinus components. To identify AFP- and HCG-secreting cells, germ cells from the surgical specimen were cultured in vitro. These cultured cells secreted AFP and HCG for 10 weeks, and immunohistochemical studies showed that some of the cells secreted both AFP and HCG. These findings suggest that multipotential germ cells migrate to the encephalic region and may become germ cell tumors containing various types of tissue.

Case report: pineocytoma in a male Fischer 344 rat

An enlarged pineal gland was observed in a 112-wk-old male Fischer 344 rat from the low-dose treatment group in a 2-yr bioassay. Formalin-fixed, paraffin-embedded sections of the gland were stained with hematoxylin and eosin along with the immunohistochemical biomarkers synaptophysin, placental alkaline phosphatase, glial fibrillary acidic protein, and vimentin. Based on its histomorphological features and on positive staining with synaptophysin, the lesion was diagnosed as a malignant pineal gland parenchymal cell tumor or pineocytoma of incidental origin.

[The unmasking of secondary adrenal insufficiency and central diabetes insipidus by a highly febrile acute Hantaan virus infection]

CASE REPORT

A 32-year-old obese patient was admitted to our hospital as an emergency with very severe abdominal pain. Routine examinations initially failed to establish a diagnosis. The patient then went on to develop a high fever that was associated with polydipsia and polyuria. Serological studies revealed an acute infection with the Hantaan virus. Laboratory investigations showed hypofunction of the anterior and posterior lobes of the pituitary, with complete absence of ACTH, which was caused by two germinomas located intracranially.

CONCLUSION

The clinical symptoms had thus been the result of acute secondary insufficiency of the adrenal cortex, which was unmasked by the acute, highly febrile Hantaan viral infection.

Primary intracranial germ cell tumors: a clinical analysis of 153 histologically verified cases

The authors analyzed 153 cases of histologically verified intracranial germ cell tumors. The histological diagnosis was germinoma in 63 patients (41.2%), teratoma in 30 (19.6%), and other types of tumors in 60 patients (39.2%). The patients were treated by a consistent policy of surgical removal with histological verification followed by radiation therapy with or without chemotherapy. The 10- and 20-year survival rates of patients with pure germinoma were 92.7% and 80.6%, respectively. The 10-year survival rates of patients with mature teratoma and malignant teratoma were 92.9% and 70.7%, respectively. Patients with pure malignant germ cell tumors (embryonal carcinoma, yolk sac tumor, or choriocarcinoma) had a 3-year survival rate of 27.3%. The mixed tumors were divided into three subgroups: 1) mixed germinoma and teratoma; 2) mixed tumors whose predominant characteristics were germinoma or teratoma combined with some elements of pure malignant tumors; and 3) mixed tumors with predominantly pure malignant elements. The 3-year survival rates were 94.1% for the first group, 70% for the second group, and 9.3% for the third group, and the differences were statistically significant. Twenty-six patients with malignant tumors received chemotherapy that consisted of cisplatin and carboplatin combinations with or without radiation therapy. However, chemotherapy was not significantly more effective than radiation therapy alone. From these treatment results, the authors classified tumors into three groups with different prognoses and proposed a treatment guideline appropriate for the subgroups.

Prognosis of intracranial germinoma with syncytiotrophoblastic giant cells treated by radiation therapy

PURPOSE

The limited information in the literature suggests that intracranial germinoma with syncytiotrophoblastic giant cells (STGC) producing human chorionic gonadotropin (HCG) is associated with a higher recurrence rate compared with pure germinoma producing no HCG. To determine whether the poorer prognosis for germinoma with STGC is an inevitable finding, we retrospectively analyzed data for our patients.

METHODS AND MATERIALS

Data were analyzed for 44 patients who had pretreatment examination of HCG titers in the serum and/or cerebrospinal fluid (CSF) and underwent radiotherapy between 1978 and 1993. The diagnosis of germinoma was made histologically in 19 patients and clinically in 25 according to the established criteria. The treatment volume was the primary tumor site in 9 patients, the cerebrospinal axis in 29, and other in 6. The median follow-up period was 90 months.

RESULTS

Twenty (45%) of the 44 patients had elevated HCG titer. The abnormal HCG levels ranged from 4.9 to 189 mIU/ml (median: 18 mIU/ml) in serum and 8.2 to 660 mIU/ml (median: 26 mIU/ml) in CSF. No difference was found between the two groups in any patient or treatment characteristics including tumor size and incidence of CSF dissemination. The mean radiation dose to the primary tumor site was 46.4 Gy for pure germinoma and 47.5 Gy for germinoma with STGC. The 10-year survival and relapse-free survival rates were both 100% for the patients with germinoma with STGC and both 89% for those with pure germinoma. Among these patients, only two with pure germinoma developed recurrence.

CONCLUSIONS

Our data suggest that the prognosis of intracranial germinoma with STGC treated with adequate radiation therapy does not differ from that of pure germinoma. Our current policy of delivering 40-45 Gy for tumors < 4 cm in diameter seems to be a reasonable treatment for germinoma with STGC.

Stereotactic management of lesions of the pineal region

OBJECTIVE

The relevance of the computed tomography-guided stereotactic approach for the management of lesions of the pineal region is analyzed.

METHODS

In a retrospective analysis conducted between 1985 and 1993, the risk profile, the diagnostic accuracy, and the therapeutic relevance of the stereotactic approach in 106 patients was studied. Survival analysis was used to assess the reliability of the stereotactically obtained diagnosis in terms of follow-up observation.

RESULTS

A histological diagnosis was obtained in 103 of the 106 patients. In three patients, a conclusive diagnosis could not be established because of intraoperative complications. One lesion was misdiagnosed as a pineocytoma instead of a pineoblastoma. Two of the 106 patients died; 9 patients experienced perioperative morbidity. In 38 patients, the stereotactic approach was also useful for therapy. Cyst aspiration and/or internal drainage was performed in 18 patients with symptomatic cystic lesions, and radiosurgical treatment with use of interstitial 125iodine was performed in 16 patients with low-grade tumors and in 4 patients with solitary metastases. In 12 patients, the obtained tissue diagnosis was the basis for deferring additional therapy. In 43 patients with germ-cell tumors, pineoblastomas, or malignant gliomas, a stereotactic biopsy was the starting point for additional radiotherapy/chemotherapy. Open tumor resection played a minor role (five patients).

CONCLUSION

The stereotactic approach to the pineal region is a relatively safe procedure in experienced hands. The diagnosis obtained by computed tomography-guided stereotactic biopsy is a valid basis for treatment decisions. Long-term follow-up observation of the benign lesions is necessary for a definite confirmation of diagnostic accuracy.

Two unusual recurrences of intracranial germinoma

Two recurrent cases of intracranial suprasellar germinoma, with relapses at 55 and 16 months, respectively, after the end of primary therapy strongly effective against pure germinoma, are presented. Human chorionic gonadotropin beta subunit was elevated in the cerebrospinal fluid and in the serum in both patients at the time of recurrence but not before. This and resulting treatment failures suggest that there were also other, more resistant elements within the primary tumor, which have not been identified in biopsy specimens. The problem of adequate diagnosis and its impact on patients' survival are discussed.

Mixed germ-cell tumor of the brain. Pathologic study of six autopsy cases

Intracranial mixed germ-cell tumors are rare. We describe the findings from six autopsies of patients with these tumors. The patients were all young at presentation (mean age, 16 years), and five of the six were male. Headache, vomiting, polyuria and diplopia were common symptoms. Radiographic evaluation demonstrated a mass on the midline of the brain. The patients were treated mainly with radiation, but survival (mean, 3.7 years) was not as long as predicted. At autopsy, the tumors occupied most of the ventricular spaces, and ranged from being well-circumscribed to invasive. All tumors contained both germinoma components and nongerminomatous germ-cell tumor components. Because the distribution of these components was not homogenous, at least two sections were necessary for the diagnosis. Immunoreactivity for placental alkaline phosphatase was found in all tumors. Immunostaining for human chorional gonadotropin, alpha-fetoprotein and carcinoembryonic antigen was usually associated with abnormally high serum levels of these tumors markers in life. A number of the cells in both kinds of tumor components expressed proliferating cell nuclear antigen, probably reflecting the intense malignant potential.

Intracranial germ-cell tumours--treatment results and residuals

There is only sparse information about the development of children after successful treatment for intracranial germ-cell tumours. Between January 1981 and June 1992, 26 children with intracranial germ-cell tumours were treated in the University Hospital Hamburg-Eppendorf. We report on treatment results, long standing residuals and the "quality of life" of these patients. The long-term event-free survival was 88% for the germinomas and 43% for the malignant teratomas. Of the patients 58% had no relevant functional neurological deficits and 37% had mild impairment. Only 1 patient with metastatic disease was severely handicapped. Six patients showed neuro-endocrine dysfunction. All of them had suprasellar/hypothalamic lesions and all received successful substitution therapy. As to neuropsychological functions, 53% of the patients had no or only mild disturbances. The most affected function was speed of information processing. Of the children 69% were able to proceed with their education at the same level as before therapy. The overall self-assessment revealed good results in 75% of the patients.

CONCLUSION

After surgical removal and radiation therapy long-term survival of intracranial germinomas amounts to 88%. Despite craniospinal axis radiation severe residuals are rare and a good quality of life is common. In malignant teratomas treatment regimens including chemotherapy are much less successful.

Radiotherapy of intracranial germinomas

Between 1980 and 1992, 32 patients with intracranial germinomas were treated with radiation. All patients were confirmed histopathologically prior to treatment. Of the 32 intracranial germinomas reviewed, 14 were located in the suprasellar region, 12 in the basal ganglia and thalamus, four in the pineal, and two in both the pineal and suprasellar regions. Three patients had subarachnoid seeding. Craniospinal irradiation was undertaken for 29 patients. The median dose of 54 Gy was delivered to the tumor bed, 36 Gy to the whole brain and 24 Gy to the spinal axis. Five and 10-year survival rates were 96.9 and 96.9%, respectively. Local control was achieved in all patients except one who died of persistent tumor after 2 months following radiotherapy. No intracranial recurrence or spinal metastasis were found. Tumor site did not relate to the prognosis. One patient developed severe intellectual deterioration, three patients had vertebral growth impairment. The present study confirms the excellent result with radiotherapy alone for patients with germinomas.

Familial neurofibromatosis 1 with germinoma involving the basal ganglion and thalamus

Intracranial germinoma associated with neurofibromatosis 1 (NF-1) has never been documented previously. We report a case of familial NF-1 with a germinoma involving the right basal ganglion and thalamus. A 12-year-old boy presented with multiple café-au-lait spots and a family history of neurofibromatosis in his mother, one of two siblings, and his maternal grandfather. His intracranial lesion was subtotally resected. Histologically, it was a pure germinoma. Serum alpha-feto protein and beta-human chorionic gonadotropin levels were within the normal range. Postoperative myelographic examination and cerebrospinal fluid cytology study showed no evidence of subarachnoid seeding. The patient received postoperative combination chemotherapy resulting in complete response and clearance of the residual tumor. Although this finding of an intracranial germinoma in a patient with familial NF-1 may be coincident, it is suggestive of a potential genetic predisposition. Longitudinal evaluation for the possibility of neoplasm, especially germ cell tumor, in basal ganglion lesions in NF-1 patients is necessary.

Intracranial teratoma with multiple fetuses: pre- and post-natal appearance

An intracranial teratoma in which six distinct dysmorphic fetuses were included was studied at autopsy. Karyotopic studies showed a normal chromosomal number in the child and the same karyotype in the three tumoral parts were examined. This is the second tumor of this type reported.

Combination chemotherapy with vinblastine, bleomycin, cisplatin, and etoposide (VBPE) in children with primary intracranial germ cell tumors

We have treated 13 children with primary intracranial germ cell tumors with the combination of vinblastine, bleomycin, cisplatin, and etoposide, the so-called VBPE regimen in the past seven years at one institution. The clinical diagnosis of these children were: three germinomas, seven non-germinomatous germ cell tumors, and three recurrent non-germinomatous germ cell tumors without previous chemotherapy. Of this group, three germinomas and three non-germinomatous germ cell tumors were treated primarily with VBPE plus radiotherapy. All of them responded completely, and were free of tumor. Primary VBPE regimen without radiotherapy was used in another four non-germinomatous germ cell tumors. After six courses of VBPE regimen, only one of the four patients achieved complete response for 30 months. VBPE regimen was used as salvage chemotherapy in three recurrent non-germinomatous germ cell tumors without previous chemotherapy. After six courses of VBPE regimen, two had complete response for 58+ months and 78+ months respectively. We concluded that in newly-diagnosed intracranial non-germinomatous germ cell tumors, the combination of chemotherapy VBPE regimen and radiotherapy led to good results. Primary chemotherapy with VBPE alone was not adequate for the treatment of non-germinomatous germ cell tumors. However, VBPE regimen might be one of the salvage therapies for recurrent germ cell tumors without chemotherapy before relapse.

Immunohistochemical characterization of 'small, lymphoid-like cell populations' within germinomas: immunologic and molecular approaches to diagnosis

Little is known to date about the biological and molecular characteristics of 'small lymphoid cells' within intracranial germinomas. Frozen sections from three germinoma specimens were evaluated immunohistochemically in order to identify phenotypic markers expressed on human lymphoid cells as well as intercellular adhesion molecules. In addition, T-cell receptor (TCR) variable alpha- and beta-chain mRNA expression was analyzed by polymerase chain reaction (PCR). The small cells stained faintly with anti-CD5 in two specimens, but were negative for the T cell specific markers, CD2, CD3, CD7, and CD8. In addition, these cells were weakly positive for CD11b (Mac-1) and CD54 (ICAM-1), but were negative for lymphocyte-specific CD11a (LFA-1) and CD11c (p150,95). No TCR V alpha or V beta gene expression was detected by PCR within these germinoma specimens. The small cells of germinomas with the cytologic appearance of lymphocytes are not derived from T-cells or other lymphocytic lineages.

Precocious puberty in a girl with an hCG-secreting suprasellar immature teratoma. Case report

Although precocious puberty is common in boys with human chorionic gonadotropin (hCG)-secreting brain tumors, it is extremely rare in girls. The authors describe a 6-year-old girl with an hCG-secreting suprasellar immature teratoma who presented with diabetes insipidus, increased intracranial pressure, and precocious puberty. On admission, breast budding was observed. The serum hCG level was 1230 mIU/ml. Both luteinizing hormone (LH) and follicle-stimulating hormone (FSH) remained below detectable levels, even after gonadotropin-releasing hormone stimulation. Serum estrogen and androgen were moderately elevated. After chemotherapy, breast budding disappeared with normalization of serum hCG. It has been believed that hCG does not produce precocious puberty in girls in the absence of FSH, and this has been used as an explanation for the rarity of precocious puberty in girls with hCG-secreting brain tumors. However, it has also been reported that hCG has not only LH activity but also intrinsic, although weak, FSH-like activity. In the present case, this FSH-like activity was considered to have played a role in the development of precocious puberty. It is speculated that a very high level of serum hCG can produce precocious puberty in girls. The rarity of intracranial germ-cell tumors with a high potential of hCG secretion may be one of the reasons why hCG-induced precocious puberty is uncommon in girls.

Radiation therapy of pineal region tumors: 25 new cases and a review of 208 previously reported cases

PURPOSE

Malignant pineal region tumors are rare neoplasms arising in midline structures of the brain. This report analyzes the influence of histology, tumor location, radiation dose, treatment volume, age and cerebrospinal fluid findings on freedom from relapse, freedom from spinal relapse and survival.

METHODS AND MATERIALS

Patient and treatment parameters of 25 cases of pineal region tumors managed at Stanford University are presented, and an additional 208 published cases were reviewed. Univariate and multivariate analysis were performed to delineate parameters predictive of freedom from relapse, freedom from spinal relapse, and survival for all 233 patients.

RESULTS

The 5- and 10-year freedom from relapse for Stanford patients was 63% and 46%, respectively. The 5- and 10-year survival for Stanford patients was 67% and 61%, respectively. The 5- and 10-year freedom from relapse for the total 233 cases was 66% and 61%, respectively. The 5- and 10-year survival for all patients was 74% and 68%, respectively. For the entire group, biopsy confirmed germinoma and non-biopsied tumors had superior freedom from relapse compared to non-germinoma germ cell tumors (p = 0.03, p = 0.005, respectively). Non-biopsied patients had improved survival compared to non-germinoma germ cell tumors (p = 0.004). Pineal parenchymal tumors had worse freedom from relapse compared to non-biopsied patients (p = 0.04). For patients with suprasellar tumors, germinomas were associated with improved freedom from relapse compared to non-germinoma germ cell tumors (p = 0.02). Simultaneous pineal and suprasellar tumors had superior survival compared to solitary tumors of pineal (p = 0.04), suprasellar (p = 0.03), or third ventricle location (p = 0.03). Twenty-two patients (9.4%) developed isolated spinal relapse. Five- and 10-year spinal relapse rates for all patients were 11% and 13%. Survival after spinal relapse was 19%. Pineal parenchymal tumors had lower freedom from spinal relapse compared to non-biopsied patients (p = 0.001). For tumors located in the pineal gland, germinomas and pineal parenchymal tumors had lower freedom from spinal relapse than did non-biopsied patients (p = 0.006, p = 0.004, respectively). Pineal germinomas had lower freedom from spinal relapse than germinomas with suprasellar location (p = 0.04). Univariate and multivariate analysis identified tumor histology as the most significant predictor of freedom from relapse, freedom from spinal relapse and survival.

CONCLUSION

Histologic type had the greatest impact on outcome. Treatment recommendations should be based on assessment of histologic type and extent of disease.