Alphafetoprotein and human chorionic gonadotropin determination in cerebrospinal fluid. An aid to the diagnosis and management of intracranial germ-cell tumors

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.

Long-term survival of a patient with primary sellar choriocarcinoma with pulmonary metastases: a case report

Extracranial metastasis is an unusual complication of most types of primary intracranial tumor. Approximately one-third of reported cases of primary intracranial choriocarcinoma have been associated with pulmonary tumor metastasis. The prognosis of such patients has been uniformly fatal. This report describes a probable long-term survivor of primary intracranial choriocarcinoma wit pulmonary metastasis. The patient had a complete response to combination chemotherapy with cisplatin, etoposide, and bleomycin and is surviving free of disease >3 years from diagnosis.

Human chorionic gonadotrophin immunoactivity in cystic intracranial tumours

BACKGROUND AND OBJECTIVE

With regard to intracranial tumours, elevated hCG in CSF or serum has been considered to be specific for germ-cell tumours. Recently however, elevated hCG has also been shown to be present in cyst fluid and CSF of patients with craniopharyngiomas. While germ-cell tumours are generally non-cystic, the aim of our study was to determine the significance of hCG in cystic intracranial lesions.

DESIGN

In a prospective study, hCG immunoactivity and subunits of hCG were measured in cyst fluid, CSF, and serum of patients harbouring intracranial cyst lesions.

PATIENTS AND MEASUREMENTS

hCG immunoactivity was measured in cyst fluid and serum samples of 42 patients. CSF samples were available from 12 patients with craniopharyngiomas. In order to fully characterize the hCG immunoactivity, we used immunoradiometric assays for total hCG activity (measuring both intact hCG and the free beta-subunit of hCG), and those specific for intact, dimeric hCG (hCG), free beta-subunit of hCG (hCG beta) and free alpha-subunit. Furthermore, immunostaining of tumour tissue was performed using monoclonal antibodies directed against the free beta-subunit of hCG.

RESULTS

Total hCG immunoactivity was markedly elevated in cyst fluid of all 17 craniopharyngiomas (range 36.7-4558 IU/I; normal < 5 IU/I). Moderately elevated levels of hCG in cyst fluid were detected in three of four pituitary adenomas, in two metastases from lung cancer and in two arachnoid cysts. hCG beta was detected in cyst fluid from all hCG positive cysts, while specific determination of intact (dimer) hCG and alpha-subunit mostly yielded negative results. No hCG immunoactivity was found in cystic gliomas, meningiomas or haemangioblastomas. hCG was elevated in CSF of two patients with craniopharyngiomas, but no hCG immunoactivity was detected in any serum sample. Subtle immunostaining of epithelial cell groups was shown in five of ten craniopharyngiomas. Clear immunostaining for hCG beta was also found in scattered epithelial cells of one pituitary adenoma.

CONCLUSIONS

hCG immunoactivity in cystic intracranial lesions is due mainly to hCG beta. Measurement of hCG immunoactivity in cyst fluid can be helpful in the differential diagnosis of intracranial cystic lesions, if surgery is restricted to cyst decompression and no histology is available. High levels suggest a craniopharyngioma.

Treatment of intracranial nongerminomatous malignant germ cell tumors producing alpha-fetoprotein

We treated 10 patients with intracranial nongerminomatous malignant germ cell tumors producing alpha-fetoprotein between 1969 and 1992. Two patients were treated with radiotherapy (RT) only (RT group), and three were treated with RT and cisplatin plus vinblastine plus bleomycin therapy with or without surgery (cisplatin plus vinblastine plus bleomycin group). The most recently treated five patients received cisplatin plus etoposide (PE) therapy with or without RT and/or surgery (PE group). The level of alpha-fetoprotein in serum was elevated in all 10 patients. In the PE group, PE therapy consisted of cisplatin (20 mg/m2) and etoposide (60 mg/m2) daily for 5 days (one course) given two or three times at 4-week intervals and then once every 4 months; the patients received three to six courses (mean, 4.2 courses). In the RT group (n = 2), one patient died 3 months after diagnosis and the other died at 12 months. In the cisplatin plus vinblastine plus bleomycin group (n = 3), complete remission was obtained in one patient, but the other two patients died 12 and 24 months after diagnosis. In contrast, in the PE group (n = 5), complete remission was obtained in all patients who are all currently alive without recurrence, at 35 to 71 months (average, 53.6 mo) after diagnosis. The results indicate that multidisciplinary treatment including combination chemotherapy with cisplatin and etoposide with or without surgery and/or RT is highly effective in the treatment of patients with alpha-fetoprotein-producing intracranial nongerminomatous malignant germ cell tumor.

Paradoxical response of a pineal immature teratoma to combination chemotherapy

A case of primary intracranial germ cell tumour is reported in a 5-year-old Chinese boy who presented with symptoms and signs of increased intracranial pressure. Computed tomography (CT) scan of the brain revealed a multicystic tumour over the pineal region. Stereotactic biopsy yielded enteric epithelium and isolated cells with hyperchromatic nuclei and high nuclear-to-cytoplasmic ratio, suggesting the diagnosis of an immature teratoma. Grossly elevated serum and cerebrospinal fluid (CSF) levels of alpha-fetoprotein and mildly elevated levels of beta human chorionic gonadotrophin suggested the simultaneous presence of embryonal tissues. Combination chemotherapy with cisplatin, etoposide, and bleomycin resulted in a gradual but complete normalisation of the serum and CSF tumour markers. Paradoxically, the patient's consciousness deteriorated and repeat CT scan after 3 months of treatment showed that the tumour was actually increasing in size. Complete surgical removal was attempted and histologic sections of the specimen revealed only mature teratomatous tissues. The child is now well and remains disease-free with minimal left hemiparesis 12 months after completion of treatment. This case illustrates the importance of combined neoadjuvant chemotherapy and surgery in the management of intracranial non-germinomatous germ cell tumour harbouring both germ cell and teratomatous components, while monitoring of both biochemical and radiological parameters are necessary in assessing the clinical behaviour of mixed germ cell tumours.

MR findings of pineal yolk sac tumor in a patient with testicular embryonal carcinoma

Magnetic resonance imaging features of a rare pineal region yolk sac tumor found in a 31-year-old man with a history of previously treated embryonal cell carcinoma of the testicle are presented. No specific magnetic resonance imaging features that definitely differentiate yolk sac tumor from other pineal region tumors could be found. However, in individuals with a previously established testicular germ cell tumor, a metastatic or secondary primary germ cell tumor should be suspected when there is a newly diagnosed pineal region mass. Serum tumor markers are helpful in confirming the diagnosis of a germ cell tumor.

Management of pineal non-germinoma germ cell tumor with residual teratoma and normal alpha-fetoprotein

A 16-year-old white male presented with multiple abnormal extraocular movements secondary to an enhancing pineal tumor. Subtotal resection of the lesion revealed a mixed malignant germ cell tumor. The preoperative serum alpha-fetoprotein (AFP) was markedly elevated at 155 IU/L. The patient subsequently received radiotherapy and adjuvant chemotherapy consisting of cisplatin rotating monthly with vincristine and cyclophosphamide, with dramatic tumor regression and return of AFP to normal. Eighteen months later the persistence of a substantial tumor mass despite a normal AFP raised concern for residual active tumor. Histological examination of the resected lesion revealed benign teratoma and fibrous tissue. Repeat management of mixed malignant germ cell tumors, which demonstrate a persistent mass following an initial response to treatment.

Long-term survival in malignant intracranial germ-cell tumors: a report of two cases and a review of the literature

The authors report the successful treatment of two cases of malignant germ-cell tumor. A 12-year-old patient with a pineal immature teratoma and increase of alpha-fetoprotein serum levels was treated with total excision and cisplatin, vinblastine, and bleomycin (PVB) in combination given twice. One year later, he had a recurrence of tumor in the right occipital lobe, which was totally removed, and yolk sac tumor was verified. As subsequent adjuvant chemotherapy, PVB was given in four courses over 1.5 years, together with one course of cisplatin-etoposide (PE) therapy. The patient is well 5 years and 9 months after the first operation. In the second case, a 19-year-old patient with a pineal mixed germ-cell tumor, composed of germinoma, yolk sac tumor, and embryonal carcinoma, was treated with total excision, followed by four courses of PVB therapy and one of PE. She has done well in the 4.5 years since the initial treatment. Thus, aggressive extirpation of the lesion and subsequent combination chemotherapy using cisplatin and other multiple drugs, given in at least four courses over 1.5 years, even if tumor markers return to within normal limits, might provide successful treatment for malignant germ-cell tumors.

Serum proteolytic activity during the growth of C6 astrocytoma

Tumor growth is dependent on the ability of neoplastic cells to induce angiogenesis. Blood-vessel remodeling requires the reconstruction of the nonfibrous proteins and type IV collagen components of the basement membrane. This study has assessed the influence of the growth of C6 astrocytoma cells in the rat spheroid implantation model on serum general protease and type IV collagenase activity. The results demonstrate that general protease activity increased in serum, reaching maximum values on Day 6 and Day 13 following spheroid implantation, and that type IV collagenase activity increased in serum, obtaining maximum values on Day 8 and Day 15. The measurement of serum proteolytic activity may be of value in the detection of recurrent tumors.

Controversy pertaining to therapeutic modalities for tumors of the pineal region: a worldwide survey of different patient populations

The management of tumors of the pineal region differs between Western countries and Japan. This paper reports on a worldwide survey of individual experience and regimens for treating pineal region tumors in different patient populations. Fifteen pediatric neurosurgeons from nine different countries participated in the survey, and a total of 408 pineal region tumors were evaluated. Determination of tumor histology as an initial procedure was strongly supported by the majority of neurosurgeons in North and Central America and Europe (group A), whereas all but one from Asia and Egypt (group B) emphasized initial application of the radiation test. The analysis of patient populations clearly revealed racial differences in tumor type which explain this discrepancy. Germinoma, the most radiosensitive tumor, constituted 43-70% (mean: 53.7%) of tumors in group B, followed by teratoma, pineoblastoma, and others, whereas in group A the incidence of germinoma was only 21-44% (mean: 34.7%), followed by a variety of tumors, such as astrocytoma, pineoblastoma, etc. The age distribution among intracranial germ cell tumors (GCT) obtained from data from the Brain Tumor Registry in Japan also demonstrated clear differences in the incidence of tumor types in different age groups in Japan: while germinoma constituted 70-84% of GCT in patients between the ages of 15 and 35 years, the incidence was much lower before 15 years and after 35 years, being 24% of tumors under 4 years and 34% of tumors after 40 years of age. The therapeutic regimen for pineal region tumors should depend on the patient population concerned, because of the differences relating to race and age distribution.

Neurosurgical experience with tumours of the pineal region at Clinica Puerta de Hierro

The clinicopathological experience with 50 cases of pineal region tumours at Clinica Puerta de Hierro is presented. In this series, 88% of the patients were evaluated by CT-scan. Pineal region tumours make up approximately 0.7% of the intracranial expansive processes in the Spanish population. The largest group of lesions appearing in this localization is that of the germinomas (38%), followed by nontumoural lesions (20%) and tumours generally considered to be of the vicinity, such as meningiomas, gliomas and metastases (18%), tumours of the pineal parenchyma (14%), and non-germinoma germinal tumours (10%). In our series, in addition to an intracranial hypertension syndrome, an ophthalmological and, to a minor degree, an endocrinological syndrome predominate in germ-cell tumours, with a cerebellar syndrome appearing in gliomas of the pineal region. All the patients in the series diagnosed as having a germinoma and treated by irradiation are alive, and free of disease, after follow-up ranging from 2 to 20 years (mean: 8 years). The experience obtained with the present series supports the opinion that, in radiosensitive tumours, surgical resection adds no therapeutic benefit to treatment with radiotherapy alone. We suggest that when dealing with a tumour of the pineal region, CT-scan and clinical assessment now permit an initial selection of patients susceptible to surgery as a first therapeutic option, indicating those patients who, because they are considered to have either a "probable germinoma" or a "tumour of uncertain diagnosis", should undergo stereotaxic biopsy or trial radiotherapy and, only when this has proved a failure, should be subjected to open surgery.

Malignant pineal teratomas: a report on three patients and the case for craniospinal irradiation following chemotherapy

Malignant pineal teratomas carry a poor prognosis. We describe a long-term survivor after chemotherapy and craniospinal irradiation, and another who achieved only transient disease control with chemotherapy and cranial irradiation. Spinal cord spread occurred in first patient and long-term survivors have been reported following surgery and craniospinal irradiation alone, suggesting a role for craniospinal irradiation following chemotherapy.

Pineal and CNS germ cell tumors: Royal Marsden Hospital experience 1962-1987

A retrospective analysis has been made of all patients with pineal and CNS germ cell tumors who were treated at The Royal Marsden Hospital between 1962-1987. A total of 67 new cases were seen: 17 had initial histological verification of tumor type and the remainder were tested for radiosensitivity with a dose of 20 Gy following a shunting procedure. Patients with germ cell or radiosensitive tumors were treated with a uniform policy of whole neuraxis radiotherapy giving 50 Gy to the local tumor and 30 Gy to the remaining brain and spinal cord. Nonresponding lesions continued with local fields to a dose of 50 Gy. Patients were divided into three groups (a) germinoma and radiosensitive tumours, 34 cases; (b) malignant teratoma, 12 cases; (c) non-germ cell, 21 cases. Median follow-up is 83 months (range 2-246 months). Overall and cause specific actuarial 5/10 year survival were for group 1, 81.7%/69.4% and 86.5%;/86.5%; group 2, 18.2%/18.2% and 18.2%/18.2%, and group 3, 64.3%/46.8% and 64.3%/52.6%, respectively. No patient in group 1 treated during the last 12 years has recurred. Univariate analysis of factors at presentation, showed that neurological performance status (p less than .001) as well as tumor type (p less than .001) correlated with outcome. Recurrence was confined to the primary site in only 1 of 4 patients in group 1 compared to 6 of 9 patients in group 2 and 9 of 10 patients in group 3. No isolated spinal recurrence occurred in group 1 patients. A total of eight patients have received platinum containing chemotherapy for recurrence (6 cases) or adjuvant therapy (4 cases). Germinomas appear to respond better than teratomas, all of which have recurred rapidly following initial partial response. Shunting and radiosensitivity testing remains the treatment of choice for tumors compatible with germinoma. Craniospinal irradiation is associated with low morbidity providing spinal growth is complete and is recommended in older patients as salvage following spinal recurrence is unsatisfactory. Aggressive combined modality approaches with surgery, radiotherapy and chemotherapy need to be investigated to improve results in CNS teratoma.

Germ cell tumors of the thalamus and the basal ganglia

Two cases of germ cell tumors (GCTs) of the basal ganglia are presented and 40 previously reported cases are reviewed. The incidence of GCTs of the basal ganglia and thalamus was estimated as less than 14% of all intracranial GCTs. All patients except for two (95%) were male, aged 7-19 years. The clinical course was usually slow. The major symptoms were hemiparesis, mental deterioration such as dementia or character change, precocious puberty, diabetes insipidus, oculomotor palsy, speech disturbance, and hemianopsia. Signs of intracranial hypertension did not occur until the late stages of the disease. The plain CT finding was characterized by an irregularly defined, slightly high-density area frequently accompanied by central low-density areas without significant mass effect. The tumors showed mild to moderate and nonhomogeneous contrast enhancement. An ipsilateral cerebral hemiatrophy was often found. MR images demonstrated the corresponding findings. GCTs of the basal ganglia had a high possibility of containing components other than germinoma such as choriocarcinoma, endodermal sinus tumor, and embryonal carcinoma. Thus, tumor markers in the serum, CSF, or cyst fluid were frequently positive. With recent refinement of microsurgical techniques as well as immunohistochemical study and measurements of tumor markers of serum, CSF, and cyst fluid, major resections of tumor, accurate pretreatment histologic diagnosis, and early determination of the specific types of this tumor appear to be readily possible. This is essential for effective treatment of patients not only with radiosensitive germinoma, but also those with radioinsensitive nongerminoma variants and a combination of them located in this region.

Malignancy markers in the cerebrospinal fluid

The specificity and sensitivity of malignancy marker determinations in cerebrospinal fluid (CSF) are often insufficient. Even at the subclinical stage of the disease the marker should be present. The effect of therapy should be monitored and relapses noted. Thus high standards of methodology are required. There are many substances that may indicate a malignant process in the central nervous system. However, there are many pitfalls in their determination. Malignant cells may occur in CSF via processes involving leptomeningeal structures such as metastases and leukaemia, but primary brain tumours seldom show cells in CSF. Human chorionic gonadotrophin and alpha-fetoprotein determinations assist in the early detection of cerebral germ cell tumours and of relapses, even in the subclinical stage. Desmosterol may aid in the diagnosis of medulloblastomas and malignant gliomas and in monitoring therapy. Putrescine levels are elevated in CSF of patients with medulloblastoma and correlate with the clinical state, and serial analyses may reveal relapses. Fibronectin, when determined in CSF at the time of diagnosis, appears to be of great significance for the prognosis of acute lymphoblastic leukaemia. Ferritin and beta-2-microglobulin may help in some well-defined conditions. Brain-specific proteins and antibodies to them are non-specific markers whereas tumour-specific antigens and growth factors may be more significant.

Placental alkaline phosphatase as a tumor marker for primary intracranial germinoma

A sensitive enzyme-linked immunosorbent assay (ELISA) was used in a retrospective study of placental alkaline phosphatase (PLAP) levels in serum, cerebrospinal fluid (CSF), and intratumoral cyst fluid in primary intracranial germinoma. The ELISA showed no cross-reactivity with intestinal alkaline phosphatase except in very high concentrations, after samples had been heat-treated. Three patients with germinoma were studied for serum PLAP levels and in all the levels were elevated (3.78, 0.52, and 2.11 IU/liter). Two of the germinoma patients were studied for PLAP levels in the CSF, and both had elevated levels (0.83 and 9.83 IU/liter). The intratumoral cyst fluid in one case of germinoma was tested for PLAP and the level was found to be very high (603 IU/liter). These PLAP levels decreased concomitantly with the reduction in tumor size during irradiation. Serum PLAP levels were measured in 40 control adult male individuals and in the CSF of 20 nonpregnant patients with subarachnoid hemorrhage. The upper normal limits were 0.20 and 0.11 IU/liter in the serum and the CSF, respectively. All PLAP levels measured in the serum of patients with various brain tumors were 0.18 IU/liter or less. This study strongly suggests that PLAP is a clinically useful tumor marker for primary intracranial germinoma.

Pineal region tumors in children

The authors believe that the preferred treatment for pineal region tumors in children requires definitive surgery with a histological diagnosis and that a conservative approach consisting of shunting and radiation therapy no longer seems to be appropriate. The results are reported of a retrospective review of the presentation, treatment, and outcome of 36 children under the age of 18 years treated between 1974 and 1986. Eleven children had germinomas (two-cell type), seven had astrocytomas, and the remaining 18 had 15 histologically different tumor types. Surgery was performed on 30 patients; there were no deaths, but a 10% rate of persistent morbidity was found. The median follow-up period was 4 years. Nine (82%) of 11 patients with germinomas are alive without evidence of recurrence; one child died from recurrent tumor in the pineal region and another is presently being treated for recurrent tumor of the spinal cord. Six (86%) of the seven patients with astrocytoma are well after biopsy and radiation therapy. Of the remaining 18 children, five (28%) died from tumor progression. The cerebrospinal fluid (CSF) tumor markers alpha-fetoprotein and beta-human chorionic gonadotropin were helpful in determining the presence of malignant germ-cell tumors, particularly those with a poor prognosis. Magnetic resonance imaging was useful for diagnosis and for planning the operative approach. Magnetic resonance images showed the presence of pineal region tumors in four children with hydrocephalus who had no evidence of tumor on computerized tomography scans. Because the great variety of tumor types found in the pineal region must be treated in different ways and because improved microsurgical and stereotaxic surgical techniques have made mortality and morbidity rates acceptably low, a biopsy diagnosis should be obtained in all patients. Preoperative assessment of CSF tumor markers and cytology is useful for the identification of patients who have a poor prognosis.

Diagnosis and treatment of pineal tumours. Kyoto University experience (1941-1984)

Our current policy for the treatment of pineal tumours is presented, based upon our experience of 139 cases of pineal tumours in a period of 44 years from 1941 through 1984. First of all, it should be emphasized that germinomas are extremely radiosensitive and are treated successfully by radiotherapy alone. Accordingly, the treatment of choice for germinomas would be radiotherapy without surgery, if the diagnosis could be made confidently by the modern armamentarium of investigations, including CT, cerebrospinal fluid cytology and serum level of tumour markers, such as alphafetoprotein and human chorionic gonadotropin. When the diagnosis of germinoma is suspected although not straightforward, CT is reexamined after a trial of diagnostic radiation of 20 Gy. If the tumour size has not been reduced at all, it is unlikely that the tumour is a germinoma and surgery should be considered for removal as well as establishment of the histological diagnosis.

Primary intracranial germ-cell tumors. A retrospective analysis with special reference to long-term results of treatment and the behavior of rare types of tumors

Thirty cases of primary intracranial germ-cell tumors were reviewed with reference to the effect of treatment. Histologically, there were 23 pure germinomas, while the remaining tumors had more unusual histology; 3 of these were teratomas, and 4 germ-cell tumors with the admixture of yolk sac tumor (YST) or embryonal carcinoma (EMC). Three of these rare cases are presented. The performed surgery and radiotherapy, seemed adequate for pure germinomas, and all these cases lived tumor-free after an observation time of 13 to 139 months although 4 patients developed intellectual retardation or cerebral dullness after radiotherapy. Four cases with YST and EMC elements, indicated by the elevation of AFP and HCG values in serum, were resistant to radio- and chemotherapy and developed, despite surgically total removal of the tumor, intra- or extracranial metastases. A review of the literature is included.

Neoadjuvant chemotherapy for newly diagnosed germ-cell tumors of the central nervous system

A neoadjuvant (preradiotherapy) chemotherapy regimen consisting of either cyclophosphamide alone (60 to 80 mg/kg) or a modified multidrug regimen (vinblastine, bleomycin, cyclophosphamide, and cisplatin) was administered to 15 newly diagnosed patients with histologically confirmed, fully staged, primary germ-cell tumors (GCT's) of the central nervous system (CNS). There were 11 patients with germinomas and four with non-germinoma malignant GCT's. There were six females and nine males, whose median age was 13 years (range 4 months to 24 years). Seven germinoma patients (64%) had disseminated disease. For the germinoma patients, the subsequent radiotherapy dose was modified based on the response to the neoadjuvant chemotherapy, and craniospinal radiotherapy was given only to those with disseminated CNS disease at diagnosis. Ten of the 11 germinoma patients had complete disappearance of all evaluable disease after two courses of chemotherapy (cyclophosphamide in eight and multidrug in three) and one had a partial response. The planned dose of radiotherapy to the primary tumor was reduced from 5500 to 3000 rads, and the craniospinal dose was lowered from 3600 to 2000 rads. Ten patients remain in continuous disease-free remission 20+ to 89+ months after diagnosis (median follow-up period 47 months). All four patients with non-germinoma GCT's received the multidrug regimen, and two fo three patients with evaluable disease had a partial response. High-dose regional and craniospinal radiotherapy was administered thereafter, but only two patients remain in their first remission. Previously untreated germinoma is a highly chemosensitive disease and the neoadjuvant treatment strategy permits the identification of active chemotherapy regimens in newly diagnosed patients. Patients who have complete responses to neoadjuvant chemotherapy tolerate a significant radiotherapy dose reduction without compromising long-term survival, thereby allowing a reduction of some of the late effects of therapeutic radiation. Germinomas tend to disseminate early in the course of the disease and a pre-therapy staging evaluation permits individualized radiotherapy treatment planning.

Pathobiology of intracranial germ-cell tumors: immunochemical, immunohistochemical, and electron microscopic investigations

In an attempt to clarify the pathobiology of intracranial germ-cell tumors, we studied 56 patients with these tumors, both clinically and pathologically. Our evaluations included immunochemical, immunohistochemical, and electron microscopic observations. Thirty tumors originated in the pineal region, ten in the suprasellar region, nine in the basal ganglia, and two in other regions. Five had double sites of origin. Histologically, there were 39 germinomas, six teratomas, four embryonal carcinomas, two choriocarcinomas and five mixed tumors. Among tumors tested immunochemically, serum carcinoembryonic antigen (CEA) was positive in 3.4%, serum alpha-fetoprotein (AFP) in 25.8%, and serum human chorionic gonadotropin (HCG) in 32.1%. In CSF, CEA was positive in 14.3%, AFP in 26.3%, and HCG in 75%. One third of germinomas were positive for serum HCG, and 88.9% for CSF HCG. One half of teratomas were positive for CEA of CSF. In immunohistochemical testing, the positive rates for CEA, AFP, HCG, and placental alkaline phosphatase (PLAP) were 26.9%, 11.5%, 24.1%, and 55.6%, respectively. Most teratomas were positive for CEA and the reactions were prominent in gland-like structures. HCG-positive syncytial cells were found in three germinomas and two embryonal carcinomas as well as in choriocarcinomas. The majority of germinomas were positive for PLAP and the reactive sites were tumor cell membranes and cytoplasm. On electron microscopy, germinomas were least differentiated, followed in order by embryonal carcinomas, choriocarcinomas, and teratomas. Further clinical and pathological studies will be necessary for a better understanding of the biology of these tumors.

Intracranial embryonal carcinoma and precocious puberty

A boy aged 7.5 years presented with precocious onset of secondary sexual characteristics and symptoms and signs of neurological dysfunction. A CT brain scan demonstrated a suprasellar mass lesion. The elevated beta-hCG and alpha-fetoprotein concentrations in cerebrospinal fluid and in serum were consistent with a diagnosis of intracranial embryonal carcinoma, although histological diagnosis was not available. The tumour markers beta-hCG and alpha-FP should be looked for in all children with precocious puberty presenting with midline brain tumours.

Pineal germinoma: diagnosis, treatment and tumor response

We report the case of pineal germinoma in a 25 year old man. The neurological signs and symptoms were insidious in onset; Parinaud syndrome allowed a topical diagnosis, confirmed by CT scan. Computerized Tomography and CSF cytological examination were of the utmost importance to diagnosis and treatment and it confirmed the success of radiotherapy.

Pineal region tumours of childhood

In Germany, the relative frequency of pineal region tumours seems to be much higher than hitherto assumed. At the University Hospital Hamburg, from 1980-1985 17 children with pineal region tumours were encountered amongst 102 children with CNS tumours. Two-cell-type germinoma is the most frequent pineal region tumour. Cerebrospinal fluid cytology is highly successful in identifying this germ cell tumour. Surgical removal has become a reasonably safe procedure in the treatment of pineal region tumours and was successful in all 10 cases so treated. In addition, our patients with two-cell-type germinomas received craniospinal axis radiation. All children, treated by both surgical removal and craniospinal axis radiation are so far relapse-free and are functioning on a pretreatment level.

Epidermoid tumor of the pineal region

The authors report a case of a successfully removed epidermoid tumor of the pineal region. It became possible to diagnose this kind of cyst when the contrast medium injected during ventriculography penetrated inside the tumor, thus delineating its lamellae.

Pineocytomas of childhood. A reappraisal of natural history and response to therapy

Pineocytomas are pineal parenchymal tumors composed of differentiated cells histologically similar to those of the mature pineal gland. Little is known about the incidence, pattern of growth, or response to treatment of pineocytomas. Between 1975 and 1985, six children with pineocytomas were treated at our institution, and pineocytomas constituted 11% of all newly diagnosed pineal region tumors. The clinical, radiographic, and pathologic features of these six patients with pineocytomas are presented. Initial treatment for these children included craniospinal plus supplemental local radiotherapy (three), local radiotherapy alone (one), or radiation therapy plus adjuvant chemotherapy (two). Four of six patients had tumor recurrence a median of two years after diagnosis. Three patients had leptomeningeal dissemination, one at the time of diagnosis and two following therapy. Our findings suggest that: biopsy is necessary to distinguish pineocytomas from other pineal region tumors; radiation therapy alone is inadequate; and these tumors are aggressive in the pediatric population, with a high propensity for leptomeningeal dissemination.

An immunohistochemical study of intracranial germ cell tumours

Histologically verified intracranial tumours, mainly germ cell tumours of the pineal and suprasellar regions, were studied immunohistochemically using anti-serum of alpha fetoprotein (AFP), human chorionic gonadotropin (HCG), carcinoembryonic antigen (CEA), human placental lactogen (HPL), pregnancy specific beta-1 glycoprotein (SP-1), glial fibrillary acidic protein (GFAP), S-100 and neuron specific enolase (NSE). In germinomas, HCG positive cells were occasionally demonstrated in cells presenting as syncytiotrophoblastic giant cells (STGC), and GFAP and S-100 positive cells were found in the surrounding gliotic lesions. Teratomas were positive for CEA in their epithelial components. Endodermal sinus tumours were positive for AFP, choriocarcinomas for HCG and SP-1, and embryonal carcinomas for AFP, HCG and SP-1. HCG and SP-1 positive cells were demonstrated in STGC. As for the relationship between serum AFP level and tissue localization, many cases presenting a serum AFP level exceeding 220 ng/ml were positive for AFP in tumour tissue.

Immunosuppressive acidic protein in patients with brain tumours: a preliminary report

The present investigation was conducted to document the serum concentrations of immunosuppressive acidic protein (IAP) in patients with intracranial tumours utilizing the single radial immunodiffusion method. Among 46 pre-operative patients, elevated serum levels of IAP were found in nine of 16 patients with gliomas, six of nine patients with metastasis, and two of 21 patients with non-glial, histologically benign intracranial tumours. The mean value of serum IAP in glial or metastatic tumours was found significantly higher than that of either non-glial or normal individuals. It was postulated that serum IAP levels could correlate with a grade of anaplasia and malignancy of the tumour. And it was also of note that serum IAP levels appeared to have a tendency to decrease in response to the treatment. In addition, serum IAP levels were found correlated with the clinical condition and course of disease as evaluated by performance status and erythrocyte sedimentation rate. Therefore, it was suggested that measurement of serum IAP could be, at least in part, useful in validating the histologic analysis of brain tumours, in following responses to treatment when used as a tumour indicator, and in monitoring the progress of the disease in patients in terms of performance status.

Mixed germ-cell tumor of the pineal region. Case report

The case is presented of a 15-year-old boy with a mixed nongerminomatous germ-cell tumor of the pineal region associated with elevated cerebrospinal fluid and serum levels of the beta subunit of human chorionic gonadotropin. Treatment consisted of initial subtotal resection followed by radiotherapy and systemic chemotherapy with cisplatin, vinblastine, and bleomycin. The patient is alive without evidence of tumor 37 months after his initial diagnosis. A literature review of intracranial embryonal carcinoma and choriocarcinoma provided the rationale for a combined-modality approach to this otherwise lethal neoplasm.

Chemotherapy with cisplatin for AFP-secreting germ-cell tumors of the central nervous system

Therapeutic results in 17 cases of alpha-fetoprotein (AFP)-secreting tumors of the central nervous system are reported. Twelve of the patients were male and five female. The patients' ages ranged from 5 years to 25 years (mean 13.6 years). The tumors originated in the pineal region in 10 cases, in the suprasellar region in four cases, and in both regions in one case; of the other two tumors, one originated in the basal ganglia and one in the sacrococcygeal region. Extraneural metastases or subarachnoid dissemination occurred in seven cases. Increased AFP titer in the serum or cerebrospinal fluid was verified in 13 cases. The patients were divided into two groups: those treated before (Group A) and those treated after (Group B) the introduction in 1980 of cisplatin as a chemotherapeutic agent. All seven Group A patients died, even after extensive therapy consisting of surgery, radiotherapy, and chemotherapy (ACNU or adriamycin) in some of the cases. The mean survival time following diagnosis for Group A was 23.7 months. Six of the 10 Group B patients died an average of 25.8 months after diagnosis; however, the other four were still alive and well an average of 25.3 months after diagnosis. The tumors responded well to chemotherapy consisting of cisplatin either alone or combined with bleomycin and vinblastine. The initial response rate to treatment in Group B was 100% and five cases had a complete remission, verified by computerized tomography or the serum AFP level. Once the tumor recurred, the response to cisplatin was markedly decreased. It is suggested that an effective therapy must still be sought for recurrent tumors.

A malignant mixed germ cell tumor originating from the pituitary gland with a suprasellar extension: a case report

A case of an intracranial tumor in a 26-year old woman with symptoms of hypopituitarism, and visual disturbance is presented. The primary site has been verified by the clinical presentations and the hormonal and the neurological studies as originating from the pituitary gland with extension to the suprasellar area. Histologically, the tumor contains elements that demand its interpretation as a malignant teratoma. In a tumor marker study, the aFP level was elevated, suggestive of an endodermal sinus tumor component. We report this case as a mixed germ cell tumor originating from the pituitary gland with a suprasellar extension and a malignant transformation from a benign component.

Tumours in the pineal and supra-sellar region. A review of clinical manifestations and managements

The records of 14 patients with a tumour in the pineal or supra-sellar region seen at The Norwegian Radium Hospital, Oslo between 1973-1980 have been studied retrospectively. The problems with a widely accepted classification are discussed, as well as the choice of treatment (surgery versus radiation) and the indications for local or total CNS radiation. All patients should start radiation treatment to a local field with a generous margin. After 20 Gy a CT scan should be performed. A marked reduction in tumour size indicate a radiosensitive tumour (germ cell tumour or pineoblastoma) and the radiation field should be extended to total CNS who receives 30 Gy. No change on CT scan after 20 Gy indicate a tumour of glial origin or pineocytoma, the radiation should then continue with a local field to 50 Gy.

Central neural antigens: detection and diagnostic application

During the last few years, methods have been developed which permit practical use of biochemical research on the nervous system. In the central nervous system, proteins have been identified for astrocytes (glial fibrillary acidic protein and vimentin) and oligodendroglia (myelin basic protein and other glycoproteins). For certain classes of nerve cells, the neurofilament proteins and neuron-specific enolase (a glycolytic isoenzyme) have been identified. Detection of some of these substances in body fluids is possible via radioimmunoassays (RIA) and in tissue sections using the peroxidase-antiperoxidase immunohistochemical method.

Elevation of carcinoembryonic antigen in cerebrospinal fluid among patients with meningeal carcinomatosis

The concentration of carcinoembryonic antigen (CEA) in cerebrospinal fluid (CSF) was determined by using an enzyme immunoassay for 204 patients with various nonneoplastic neurologic disorders, 8 patients with systemic infectious diseases, 19 patients with systemic neoplastic diseases without involvement of the nervous system, and 35 patients with neoplastic neurologic disorders. The highest CEA level in CSF among patients without neoplastic neurologic disorders was 0.6 ng/ml. Of 35 patients with neoplastic neurologic disorders, 10 had CEA levels in CSF that exceeded 0.6 ng/ml, the highest level being 70.5 ng/ml. All 10 patients had carcinomas. Among 14 patients with neoplastic meningitis, 5 of 8 patients with meningeal carcinomatosis had elevated CEA concentrations. Although the efficacy of the assay for CEA in CSF must be compared with that of other laboratory tests such as cytologic examination and the assay for beta-glucuronidase--and any potentially false-positive results should be ruled out by determination of the serum CEA level--the CEA concentration in CSF can be used as an adjunctive diagnostic procedure for detection of meningeal carcinomatosis.

Normal and malignant neural cells: a comprehensive survey of human and murine nervous system markers

Tumor-associated neural markers are finding increased application in diagnostic histopathology and in the development of brain tumor therapy. The major cell-type-specific markers and monoclonal antibodies that identify murine and human neural cells are reviewed in this study. Monoclonal antibodies, raised against fetal and adult neural tissue, neuroectodermal tumor tissue, or cell line immunogens which recognize epitopes on brain tumors are comprehensively described including antigens common to the nervous, hematopoietic, and immune systems. The clinical application of neural cell markers and monoclonal antibodies for the diagnosis, localization, and treatment of neuroectodermal tumors is reviewed.

Primary germinoma of the brain. Immunocytochemical demonstration of tumour cells in the cerebrospinal fluid

A patient is presented, who developed a suprasellar tumour. Stereotactical biopsy of the tumour revealed the diagnosis of a dysgerminoma. Immunocytochemical examination of the CSF showed neoplastic cells staining for human chorionic gonadotropin and for alpha-fetoprotein. The authors stress the possibility to diagnose primary intracranial germ cell tumours without operation.