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

Primary intracranial choriocarcinoma: MR imaging findings

PICCC is the rarest, most malignant primary intracranial GCT. The purpose of this study was to describe and characterize the MR imaging findings in a series of 7 patients (6 males and 1 female; mean age, 11.9 years) with pathologically proved PICCC in our institution from 2004 to 2009. All tumors were located within the pineal (n = 6) or suprasellar (n = 1) regions. On T2-weighted MR imaging, the lesions appeared markedly heterogeneous with areas of both hypointensity and hyperintensity reflecting the histologic heterogeneity, including hemorrhage, fibrosis, cysts, or necrosis. Heterogeneous (n = 7), ringlike (n = 4), and/or intratumoral nodular (n = 3) enhancement was noted on T1-weighted images with gadolinium. These MR imaging findings, combined with patient age and serum β-HCG levels, may prove helpful in distinguishing PICCC from the more common primary brain tumors, thereby avoiding biopsy of this highly vascular tumor.

Management of primary intracranial germ cell tumors

Primary intracranial germ cell tumors are rare and usually localized in the pineal and the suprasellar regions. They are divided into the following histologic types: germinoma, teratoma (mature, immature, malignant), choriocarcinoma, embryonal carcinoma, endodermal sinus tumor (yolk sac tumor), and mixed tumors. Clinically, they are manifested with ocular signs or signs of obstructive hydrocephalus. Localized germinomas are treated with radiation therapy and exhibit a relatively good prognosis. Chemotherapy is reserved for disseminated germinomas. Mature teratomas are treated with surgery. The rest of germ cell tumors are managed with various combinations of surgery, chemotherapy, and radiotherapy depending on the tumor type. If the tumors secrete beta-human chorionic gonadotrophin (hCG) or alpha-fetoprotein (FP), these tumor markers can be used to accurately monitor response to treatment. Prognosis is best for germinomas and mature teratomas and worst for choriocarcinomas and embryonal carcinomas.

Management of primary intracranial germinomas: diagnostic surgery or radical resection?

Because intracranial germinomas are readily curable with radiation and chemotherapy or radiation therapy alone, the role of radical surgery has become debatable. This study assesses the optimum degree of surgical resection for intracranial germinomas. Twenty-nine patients who underwent surgery for germinoma were retrospectively analyzed (male/female ratio 27:2, median age 18 years). Among these 29 patients there were 10 solitary pineal, seven solitary neurohypophyseal/hypothalamic, and 12 multifocal or disseminated tumors. Biopsy samples were obtained in 16 patients (stereotactically in eight, transsphenoidally in four, and via frontotemporal craniotomy in four). Partial resection was attained in five patients (via a frontotemporal approach in three and occipitotranstentorially in two). Gross-total resection was achieved via an occipitotranstentorial route in eight patients with pineal masses. After surgery, 10 patients were treated with radiotherapy alone, and 19 received radiation and chemotherapy; complete remission was achieved in all 29 patients. The overall tumor-free survival rate was 100% at a median follow-up period of 42 months. There was no significant difference in outcome related to the extent of surgical resection. Postoperative neurological improvement was seen in only two patients, whereas transient postoperative complications, mainly upgaze palsy, were observed in six. One patient experienced a slight hemiparesis, bringing the surgical morbidity rate to 3% (one of 29). It is concluded that radical resection of intracranial germinomas offers no benefit over biopsy. The primary goal of surgery should be to obtain a sufficient volume of tumor tissue for histological examination. If there is strong evidence of germinoma on radiological studies, biopsy samples should be obtained. When a perioperative histological diagnosis of pure germinoma is made during craniotomy, no risk should be taken in continuing the resection.