Suprasellar germinomas

Endonasal surgery for suprasellar germ cell tumors: two cases and review of the literature

Germ cell tumors are rare malignant tumors frequently located in the suprasellar region. Definitive treatment is chemotherapy and radiation. However, in some circumstances, surgery is indicated for biopsy or resection. There are limited reports of the role of the endonasal endoscopic approach (EEA) in the management of this tumor. We present two cases in which EEA was utilized for successful management of germ cell tumor. The most challenging aspect of germ cell tumor management for the treating physician is knowing the proper indications for surgery. In this paper, we highlight two specific instances, namely diagnosis and tumor refractory to chemoradiation. Given the suprasellar location, EEA is an ideal approach.

Combined chemotherapy and radiation therapy for central nervous system germ cell tumors: preliminary results of a Phase II study of the Japanese Pediatric Brain Tumor Study Group

The authors conducted a multiinstitutional phase II study to establish a postsurgical combined chemotherapy and radiation therapy regimen for patients with primary germ cell tumors of the brain. After surgical debulking of the tumor and histological verification, patients were divided into three therapeutic groups: good prognosis, intermediate prognosis, and poor prognosis. Patients received two kinds of chemotherapy (three courses) prior to receiving radiation therapy: carboplatin-etoposide combination ([CARB-VP]: carboplatin 450 mg/m(2) on Day 1, etoposide 150 mg/m(2) on Days 1-3) or ifosphamide-cisplatin-etoposide combination ([ICE]: ifosphamide 900 mg/m(2), cisplatin 20 mg/m(2), and etoposide 60 mg/m(2) on Days 1-5). Patients in the good prognosis group (those with germinomas) were treated with CARB-VP followed by local radiation therapy (24 Gy). Patients in the intermediate prognosis group received CARB-VP followed by local radiation therapy (50 Gy); they received five additional chemotherapy treatments. Patients in the poor prognosis group received ICE followed by whole craniospinal radiation therapy; they also received five additional chemotherapy treatments. Eighty-two patients were evaluated. For the 56 patients with germinomas, a 93% rate of complete remission after treatment was achieved. The remission rate was 76% for 21 patients in the intermediate prognosis group, and no recurrence was detected during a median follow-up period of 2.6 years. In the group of five patients with poor prognosis, the disease in three patients progressed during chemotherapy or radiation therapy and they died within 6 months. There were no serious complications in the surviving patients. The authors found their treatment protocols to be currently effective for patients with germinomas and those with an intermediate prognosis.

Pathological features of intracranial germinomas with reference to fibrous tissue and granulomatous change

Intracranial germinomas are accompanied occasionally by a significant granulomatous change and abundant fibrous tissue, and this has made their pathological diagnosis difficult. However, the incidence of the granulomatous reaction and the presence of fibrous tissue together with their clinical characteristics in intracranial germinomas have not been fully investigated. Twenty-four germinomas, none of which had received preoperative treatment, were clinicopathologically examined. The location of the tumor was the pineal region (5 cases), the suprasellar region (13 cases), multiple lesions (2 cases), the basal ganglia region (1 case), and other regions (3 cases). Histologically, the germinomas could be divided into two types: (1) type A (18 cases) consisted mainly of large neoplastic cells and small lymphocytes, showing a two-cell pattern; (2) type B (6 cases) consisted predominantly of fibroinflammatory tissues containing occasional neoplastic cells (5/6 cases) and, rarely, neoplastic cells (1/6 cases). Perioperatively, two-cell-pattern germinomas (type A) were characterized as soft tumors and fibroinflammatory germinomas (type B) as hard tumors. Thus, the fibroinflammatory type B accounted for 25% of the intracranial germinomas. Although there were no topographical and clinical differences between the two types, we conclude that immunohistological studies to detect neoplastic germ cells are warranted in cases of small stereotactic biopsies of hard type B tumors.

Neurohypophyseal granulomatous germinoma invading the right cavernous sinus: case report and review of the literature

We encountered a rare case of neurohypophyseal germinoma with a prominent granulomatous reaction, which invaded the right cavernous sinus. The neuroimaging and histopathology features in this case were unique, distinguishing it from other types of suprasellar lesions. A 13-year-old boy presented with loss of appetite and polyuria; both symptoms were present for 1 year, and headache, general fatigue and blurred vision present for the prior 2 months. On admission, neurological examination indicated bitemporal hemianopsia and optic atrophy. Endocrinological exam showed panhypopituitarism. Tumor markers such as alpha-fetoprotein, human growth hormone, carcinoembryonic antigen, and placental alkaline phosphatase were negative. Brain CT revealed a suprasellar tumor with calcification. MR T(1)-weighted and T(2)-weighted images showed the tumor to be isointense to normal brain parenchyma and to be enhanced densely. The tumor also involved the right cavernous sinus, so that a biopsy was performed by the transsphenoidal approach. On pathologic examination of the specimen, typical large tumor cells with lymphocytic cell infiltration and prominent granulomatous reaction were observed. Neurohypophyseal granulomatous germinoma was diagnosed. Radiotherapy was performed with a total dose of 51 Gy and the tumor shrank remarkably. The patient returned to school under hormone replacement therapy.

Intrasellar germinoma treated with low-dose radiation

A radiation dose lower than what had previously been recommended was given to a case of intrasellar germinoma in a 17-year-old patient who suffered from migraine-like headache for 2 years, amenorrhoea for 3 months and a body-weight loss of 10 kg over 4 months. Baseline assessment of pituitary hormone reserve was within the lower limits of the normal range, except for an elevated serum prolactin level (PRL). Magnetic resonance imaging (MRI) showed an abnormal, slightly enhanced mass in the pituitary fossa, extending along the pituitary stalk and to the hypothalamus. Transsphenoidal removal of the intrasellar part of the tumour was performed and microscopic sections of the surgical specimens revealed a pure germinoma. Adjunctive radiation therapy (RT) was given 3 weeks after surgery. A total dose of only 27 Gy was delivered to this patient. The patient's menstrual cycles resumed in 4 months. Repeated MRI follow-up showed no recurrence of the tumour.

Combined chemotherapy and radiation therapy for CNS germ cell tumors--the Japanese experience

Among intracranial germ cell tumors, nongerminomatous tumors have proved refractory to conventional treatment with surgery and irradiation. The median survival is less than 2 years. Since 1983, chemotherapy has been delivered in Japan as an adjuvant therapy in patients with intracranial nongerminomatous germ cell tumors. Based on our clinical experience, we undertook a multi-institutional phase II study to establish post-surgical combined chemotherapy and radiation therapy for primary germ cell tumors in the brain. We adopted carboplatin-etoposide (CARB-VP) or cisplatin-etoposide (PE) combination chemotherapy for patients with germinomas and those with tumors that placed them in the intermediate prognosis group, and ifosphamide-cisplatin-etoposide (ICE) for patients with tumors that placed them in the poor prognosis group. One hundred and twelve patients were evaluated. Among patients with germinoma (n = 75), the rate or complete remission after combination therapy was 92.0%; it was 67.8% for patients in the intermediate prognosis group (n = 28). Tumor recurrence was noted in 9 patients with germinoma and 2 patients in the intermediate prognosis group. Of 9 patients with a poor prognosis, 4 experienced disease progression during treatment and died within 10 months. There were no serious complications attributable to the combination therapy. Our treatment protocols are effective for patients with germinomas and those with an intermediate prognosis.

Intramedullary spinal teratoma presenting with urinary retention: case report and review of the literature

OBJECTIVE AND IMPORTANCE

Intramedullary tumors affect a small but significant segment of patients with spinal cord tumors. Intramedullary teratomas are rare entities that are usually located in the sacrococcygeal region. Although some reports claim that diagnostic studies can exactly predict the nature of intramedullary tumors, this case report demonstrates the lack of preoperative diagnostic specificity. Therefore, the aim of surgery should be radical extirpation whenever possible.

CLINICAL PRESENTATION

A case report of a thoracolumbar intramedullary teratoma is presented. This young male patient displayed urinary retention and motor deficits. Computed tomographic and magnetic resonance imaging examination revealed an intramedullary tumor; however, the exact nature of the tumor could not be determined preoperatively. The literature concerning these tumors is extensively reviewed.

INTERVENTION

During surgery, a multicystic tumor was found at the base of the filum terminale, which was resected as far as possible.

CONCLUSION

It is concluded that surgery should be the first choice for treatment. More aggressive teratomas are found in intramedullary locations, especially in children, emphasizing the importance of radical tumor resection. The use of adjuvant chemo- or radiotherapy should be explicitly substantiated for the nonbenign teratoma group.

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.

Reduction of the radiation dose for intracranial germinoma: a prospective study

Intracranial germinoma has usually been treated with radiation doses of 50 Gy or more, but it is unclear whether such doses are actually necessary to cure this radiosensitive tumour. At our institution, the standard radiation dose for intracranial germinoma was 60 Gy in the 1960s, but the dose has prospectively been reduced stepwise to 40-45 Gy. In this paper, the treatment outcome was assessed in 84 patients (47 with histologically confirmed disease and 37 diagnosed clinically in the post-computerised tomography era) enrolled in both prospective and retrospective series. The 5 and 10 years survival rates for all 84 patients were 88% and 83% respectively, and the corresponding relapse-free survival rates were 88% and 85%. The 10-year relapse-free survival rate was 88% for 31 patients receiving 19-47 Gy (median 42 Gy) to the primary tumour, 92% for 28 patients receiving 48-52 Gy (median 50 Gy), and 83% for 25 patients receiving 54-62 Gy (median 60 Gy), and there was no significant difference among the three groups. In-field local recurrence only developed in one patient who received 40 Gy over a protracted period and one patient who received 60 Gy. A tumour size < 3 cm and treatment in the post-computerised tomography era were associated with a better prognosis according to univariate analysis, while age, sex, tumour site, treatment volume, the radiation dose to both the primary and the spinal cord and the extent of surgical resection did not influence the prognosis. In contrast, none of these factors had a significant influence in multivariate analysis. In conclusion, intracranial germinomas < or = 4 cm in size can usually be cured with 40-45 Gy of radiation, thus avoiding the major adverse effects of brain irradiation.

CNS germinomas: curable tumours in two adolescents

Two cases of central nervous system germinoma are described which highlight the various presentations of this tumour in different anatomical locations. The first case is that of a 15 year old boy with a suprasellar germinoma who presented with the classical triad of diabetes insipidus, visual disturbance and hypopituitarism. The need for full hormonal evaluation and replacement therapy is stressed. In the second case a 14 year old boy with pineal germinoma presented with features of raised intracranial pressure, Parinaud's syndrome and normal anterior pituitary function. Both cases were treated with corticospinal irradiation which resulted in regression of the tumours. Follow up has now been for over 4 years with no sign of recurrence.

Third ventricle germinoma after total removal of intrasellar teratoma. Case report

A unique case is presented of a third ventricle germinoma developing 3 years after total removal of an intrasellar teratoma. The third ventricle germinoma was not considered to be a recurrence or dissemination of the mature intrasellar teratoma but to have been transformed from multicenter germ cells present in the midline of the brain with different temporal development. The relevant literature is reviewed and the problems of management of patients with germ-cell tumors are discussed.

Magnetic resonance imaging of neurohypophyseal germinomas

The authors reviewed magnetic resonance (MR) images in seven cases of germinoma in the hypothalamoneurohypophyseal axis (HNA). The intrasellar portions were clearly identified in six germinomas. Two small germinomas of these six were located only in the neurohypophysis. The major parts of the four large germinomas were located below the optic chiasm, and the large intrasellar portions were demonstrated. The remaining one small germinoma was localized from the pituitary stalk to the third ventricular floor. These findings strongly suggest that the primary site of germinomas in the HNA is the neurohypophysis. In the four large germinomas, the tumor shape was similar to that of pituitary adenoma. The authors believe that age (limited to first three decades), symptoms (diabetes insipidus), MR findings (absence of normal hyperintense signal of the posterior pituitary on T1-weighted (T1WI) images, and homogeneous hypointensity to the pons on T1WI images/isointensity on T2-weighted images are important in differential diagnosis.

Intracranial germ-cell tumors in children

All patients with confirmed intracranial germ-cell tumors treated at the Hospital of Sick Children during the period January, 1952, to December, 1989, were reviewed. Of the 51 tumors reviewed, 16 were located in the suprasellar region, 32 in the pineal region, and three in both the pineal and the suprasellar regions. Forty-nine patients underwent surgical resection which was total in seven and partial in 20, and consisted of a biopsy in 22. Two patients were managed on the basis of serum and cerebrospinal fluid markers. Surgical tools such as the operating microscope, the ultrasonic surgical aspirator, and the laser beam allowed safe debulking and removal of the deep-seated tumors in the pineal region. There were no operative deaths in the 36 patients treated since 1972, who included 23 with pineal tumors. Twenty-five patients with germinomas received radiotherapy and had a 5-year survival rate of 85.1%. Thirteen patients with non-germinoma germ-cell tumors received radiotherapy and had a 5-year survival rate of 45.5%. On the basis of this review, the authors recommend resection of pineal and suprasellar germ-cell tumors in order to firmly establish an accurate histological diagnosis to guide the extent of adjuvant therapy. In the case of a pure germinoma without evidence of dissemination, adjuvant therapy consists only of local radiotherapy. On the other hand, for malignant non-germinoma germ-cell tumors, adjuvant therapy must include chemotherapy as well as craniospinal axis radiotherapy.

Postoperative chemotherapy for primary intracranial germ cell tumor

Two children with primary intracranial mixed germ cell tumors are described who were successfully treated by partial resection of the tumor followed by sequential combination chemotherapy without radiation therapy. The chemotherapy consisting of VP-16 and cisplatin alternating with vincristine, methotrexate, and bleomycin resulted in apparent complete response after 6 to 7 months of treatment. Disease-free remission has continued 30-34 months off therapy. A small residual mass in one patient continues to decrease in size on magnetic resonance imaging and is presumed to represent postsurgical change rather than malignant tumor. This report demonstrates that chemotherapy may be effective in primary germ cell tumors of the suprasellar and pineal regions and could be considered for primary treatment instead of radiotherapy.

[Primary mediastinal seminoma]

Primary mediastinal seminoma is an uncommon lesion and should be included in the differential diagnosis of mediastinal tumors. Symptoms and signs may not be clear and in most cases the diagnosis is made by sternotomy or thoracotomy. Our recommendation is that patients with primary mediastinal seminoma should undergo curative resection or reductive surgery. Curative resection should be followed by radiation therapy. Chemotherapy with cisplatin-containing combinations should be reserved for patients who have metastases at the time of diagnosis.

Suprasellar germinomas in childhood. A reappraisal

Germinomas in childhood may arise in both the suprasellar and pineal region, and outcome has been reported to be worse for suprasellar germinomas with a 5-year survival rate of 20% as compared to 60% for pineal germinoma. To determine the factors impacting on outcome, the results of a uniform treatment approach were evaluated and included primary surgical debulking (PSD) and systemic craniospinal axis radiation (CSRT) for suprasellar germinomas. Between 1976 and 1985 ten consecutive patients (seven females, three males) with the pathologically confirmed diagnosis of suprasellar germinoma were treated. Outcome was compared to four male patients with pineal germinoma treated over the same time period and series of patients reported in the literature. At diagnosis the mean age of patients with suprasellar germinoma was 13.9 years (range, 8.9 to 9.4 years). Symptoms were present for a mean of 18 months (range, 2 to 72 months) prior to diagnosis and included diabetes insipidus, anterior pituitary dysfunction, decreased vision, headache, vomiting, and diplopia. Staging studies, including myelography (n = 4) and cerebrospinal fluid cytology (n = 7), disclosed dissemination in only one child. Surgical treatment included biopsy in three cases, partial resection in five, and total resection in two; no permanent postsurgical complications were noted. The mean radiation therapy dose to the tumor site was 4953 cGy (range, 4400 to 5250 cGy) and to the spine 3354 cGy (range, 3000 to 4000 cGy). Patients were followed for a mean period of 5.1 years (range, 1.9 to 10.5 years). One patient with SG who did not receive treatment initially developed a pineal tumor after diagnosis; she was treated with PSD and CSRT and is asymptomatic 5 years later. All the remaining patients are alive and remain disease-free. Surgical resection and CSRT results in excellent disease control for children with suprasellar germinomas, and outcome is similar to those patients with pineal germinoma.

Primary retroperitoneal pure choriocarcinoma. Two long-term complete responders from a rare fatal disease

Extragonadal germ cell tumors may have a worse prognosis than germ cell tumors of gonadal origin, even when tumor bulk and extent of dissemination are equal. Primary retroperitoneal pure choriocarcinoma is one of the least common subgroups of the extragonadal germ cell tumors and has previously appeared to have the worst prognosis. Two new case reports on the treatment and follow-up of two patients with primary retroperitoneal pure choriocarcinoma are discussed. Both patients are disease-free at 24 and 81 months, respectively. After aggressive primary multiagent drug therapy for primary retroperitoneal pure choriocarcinoma, a favorable prognosis may be anticipated.

Suprasellar germ cell tumors in the dog: a report of five cases and review of the literature

Suprasellar germ cell tumors were identified in five young adult to middle-aged dogs. Clinical signs included depression, mydriasis, ptosis and visual deficit. At necropsy large extramedullary masses were found on the ventral surface of the rostral brain stem. Histologically four were characterized by sheets and nests of moderately pleomorphic round cells resembling seminoma, admixed with larger vacuolated cells, glandular formations with secretory material, and occasional foci of squamous differentiation. The fifth case was more homogeneous, with germinomatous elements predominating. Immunohistochemical examination of three tumors revealed positive staining for alpha fetoprotein. Although only one case showed intracranial metastasis, these tumors were considered malignant due to the marked local invasion and destruction. The veterinary literature is reviewed, and we propose that two tumors previously reported as craniopharyngioma be reclassified as germ cell tumors. One other tumor previously reported as an unclassified suprasellar tumor was identified, which also demonstrated features of a germ cell tumor.

Intracranial germ-cell tumors: natural history and pathogenesis

The natural history of primary intracranial germ-cell tumors (GCT's) is defined from 389 previously published cases, of which 65% were germinomas, 18% teratomas, 5% embryonal carcinomas, 7% endodermal sinus tumors, and 5% choriocarcinomas. Intracranial GCT's display specificity in site of origin. Ninety-five percent arise along the midline from the suprasellar cistern (37%) to the pineal gland (48%), and an additional 6% involve both sites. The majority of germinomas (57%) arise in the suprasellar cistern, while most nongerminomatous GCT's (68%) preferentially involve the pineal gland (p less than 0.0001). The age distribution of afflicted patients is unimodal, centering with an abrupt surge in frequency in the early pubertal years; 68% of patients are diagnosed between 10 and 21 years of age. Nongerminomatous GCT's demonstrate an earlier age of onset than do germinomas (p less than 0.0001). Prolonged symptomatic intervals prior to diagnosis are common in germinomas (p = 0.0007), in suprasellar GCT's (p = 0.001), and among females (p = 0.02). Parasellar germinomas commonly present with diabetes insipidus, visual field defects, and hypothalamic-pituitary failure. Nongerminomatous GCT's present as posterior third ventricular masses with hydrocephalus and midbrain compression. Germ-cell tumors may infiltrate the hypothalamus (11%), or disseminate to involve the third ventricle (22%) and spinal cord (10%). Among a subpopulation of 263 conventionally treated patients, two factors were of prognostic significance: 1) histological diagnosis; germinomas were associated with significantly longer survival than nongerminomatous GCT's (p less than 0.0001); and 2) staging of the extent of disease; this emphasizes the ominous character of involvement of the hypothalamus (p = 0.0002), third ventricle (p = 0.02), or spinal cord (p = 0.01). Specific recommendations regarding the necessity of histological diagnosis and staging of the extent of disease are made in light of modern chemotherapeutic advances. The pathogenesis of GCT's may be revealed by their specificity of origin within the positive (suprasellar cistern-suprachiasmatic nucleus) and negative (pineal) regulatory centers for gonadotropin secretion within the diencephalon. The abrupt rise in age distribution at 10 to 12 years suggests that the neuroendocrine events of puberty are an "activating" influence in the malignant expression of these embryonal tumors.

Intrasellar germinoma associated with hyperprolactinemia

We report two young adult patients with hyperprolactinemia and neuroendocrine deficits due to predominantly intrasellar germinomas. In both cases the diagnosis of germinoma was confirmed histologically after transsphenoidal surgery. This very rare type of tumor may be intrasellar and it may mimic prolactinoma or craniopharyngioma. Dynamic testing of pituitary function and computed tomography scanning are of value in the early detection of this malignant but radiocurable lesion.

Pineal region tumors: analysis of treatment results

This article represents a review of 32 patients with pineal region tumors seen and treated at the University of Michigan Medical Center from January 1950 to December 1980. All patients presented with manifestations of increased intracranial pressure: limitation of the upward gaze (Parinaud's syndrome), hydrocephalus and a mass in the posterior aspect of the third ventricle. The tumor was demonstrated by pneumoencephalography, ventriculography, angiography or CT scans. Ventricular decompression was performed in all patients. Eighteen of the 32 patients (56%) had a histological diagnosis of germinoma, one patient had a diagnosis of hamartoma; no histological diagnosis was obtained in the remainder of the patients. Twenty-seven patients received post-operative irradiation. Irradiation dosage ranged between 30 and 55 Gy. The overall 10 year survival for evaluable patients was 16/24 (67%). The low incidence of spinal cord metastasis in these patients does not justify routine use of spinal irradiation.

Ventriculoperitoneal shunt metastasis of a pineal germinoma

Metastasis of pineal germinoma to the peritoneal cavity via the patient's ventriculoperitoneal shunt represents an unusual complication of this rare tumor. We report such a case with autopsy correlation of the abdominal CT findings. CT accurately delineated the extent of the metastatic mass and revealed associated complications including biliary tract obstruction, thrombosis of the inferior vena cava and a small amount of ascitic fluid. Since this tumor is very sensitive to radiotherapy and chemotherapy, the need for early detection of such metastasis is apparent. Possible implications with respect to the management of these patients are considered.

Transsphenoidal surgery of intrasellar germinomas. Report of two cases

Two patients with diabetes insipidus, hypopituitarism, and an enlarged sella turcica underwent a transsphenoidal operation for the treatment of intrasellar germinomas. Successful transsphenoidal treatment of such neoplasms has not been reported previously. The cases indicate that the diagnostic possibility of intrasellar germinoma should be considered in young patients with combined diabetes insipidus and hypopituitarism, even when the sella is markedly expanded.

Suprasellar germinoma. Unresolved problems in diagnosis, pathogenesis, and management

A suprasellar germinoma, initially thought to be granulomatous diencephalitis of uncertain cause, responded following chloramphenicol and methicillin treatment both by clinical and radiographic criteria and was not diagnosed until a third biopsy was performed. Analysis of this case and review of the literature lead to the conclusion that adequate diagnostic workup of such lesions requires that biopsy be extensive enough to include the central core as well as the granulomatous reaction that surrounds such tumors. Furthermore, since the degree of inflammation may fluctuate, regression does not mean that the lesion is not neoplastic in origin. In the present instance, the correct diagnosis could have been made earlier if the beta-chain of human chorionic gonadotropin had been measured in spinal fluid.

Intrasellar mixed germ-cell tumor. Case report

✓ The case of a 19-year-old male with a pluripotential teratoma arising in the pituitary gland is presented. The clinical, radiological, and pathological aspects of this case are discussed. This case demonstrates that intracranial germinal tumors can arise from the pituitary gland as well as from the infundibular and pineal regions.

[Late medullary metastasis of suprasellar germinoma: report of a case]

Paciente operado de tumor intramedular que evoluiu para o óbito, cuja necrópsia revelou presença de germinoma intramedular e germinoma supra-selar remanescente de tratamento cirúrgico e radioterápico realizado 11 anos antes. São discutidas a etiologia e a conduta cirúrgica e radioterápica.

Endocrine aspects and tumoral markers in intracranial germinoma: an attempt to delineate the diagnostic procedure in 14 patients

This work outlines the endocrine abnormalities associated with intracranial germinomas (14 patients before treatment). Diabetes insipidus of various intensity was present in all cases. Adipsia is often present as well. In six patients, the first neuroradiologic examination after the onset of DI was normal. Growth hormone secretion was deficient in 11 of 13 patients. Abnormalities of TSH response to TRH were present in nine of ten (four insufficient and five exaggerated responses to TRH). Anterior pituitary dysfunction could not be predicted by the tumor site as determined by radiologic criteria. Tumoral markers have also been studied. Elevated plasma tumoral markers were found in four patients of 11 studied. Tumoral germinoma cells were present in CSF in five patients of ten, in one of them before radiologic confirmation. Pertinent endocrine evaluation and search for tumoral markers was of great value in systematic follow-up of patients with central diabetes insipidus, and could lead to early diagnosis and treatment of the tumor.

Measurements of the volume and density of intracerebral tumors by CT following therapy

For the interpretation of curative measures in patients with cerebral tumors CT is of increasing importance. The therapeutic effects can be demonstrated by close follow-up studies without any of the disadvantage of invasive neuroradiological methods. Our investigations of 125 patients with cerebral tumors are based on volume and density determinations. The CT studies of removed or inoperable tumors followed by radiation and/or cytostatic therapy prove that the best results follow a combination of both. In the present cases however, if CT proves postoperatively, at the end of radiation or at the beginning of the application of cytostatics that there is a residual mass, a complete remission cannot be obtained.

Primary retroperitoneal seminoma

In a retrospective review (1950-1975) of the Mayo Clinic experience with seminomas (483 cases), twelve patients (2.5%) were found to have a retroperitoneal seminoma without evidence of testicular involvement. The mean age was 47 years (range, 31-67). Eleven patients were treated by radiation alone, with doses ranging from less than 2,000-5,800 rads. Seven patients are alive with a median follow-up of six years. The median survival of the five that died is ten months. Good prognostic factors are typical histopathology and an encapsulated tumor. Poor prognostic factors are atypical histopathology, a nonencapsulated tumor, a symptomatic abdominal mass and a nonfunctioning kidney at the time of diagnosis. Although the review includes few patients, it seems reasonable to suggest irradiation of the tumor bed and para-aortic lymph nodes to a minimum dose of 2,000 rads. Prophylactic treatment of the mediastinum and supraclavicular lymph nodes should be considered if one or more of the poor prognostic factors are present.

Primary mediastinal seminoma

Primary mediastinal seminoma is a rare germ cell neoplasm histologically identical to testicular seminoma. Thirteen patients have been treated with definitive megavoltage radiotherapy at the Stanford University Medical Center, Division of Radiation Therapy, between 1961 and 1976. Doses ranged from 2500 rads over five weeks to 6000 rads over seven weeks. Actuarial survival at ten years is 69% with relapse-free survival of 54%. No patient receiving greater than 4700 rads to the primary lesion had local or systemic relapse. Patterns of relapse and recommendations for diagnostic evaluation are discussed. Primary megavoltage irradiation to the mediastinum and neck with a dose of 4500 to 5000 rads over five to six weeks is appropriate treatment.

An ultrastructural study on germinoma cells

Germinoma cells were ultrastructurally studied in 17 cases composed of 8 cases with testicular seminoma, 3 cases with ovarian dysgerminoma, 4 cases with intracranial germinoma and one case with mediastinal germinoma. The tumor cells were generally polyhedral in shape, and has frequently a cytoplasmic process, occasionally a long process like a pseudopod. Regarding several components of the cytoplasm, most of the tumor cells in all but few cases had varying numbers of glycogen granules and fatty droplets, some of tumor cells in all but few cases had annulate lamellae, junctional apparatuses and microvilli, while stacks of rER or large autolysomes were observed in some of the tumor cells in several cases. In some of the seminoma cells and dysgerminoma cells observed were one or more of 4 types of intranuclear pseudoinclusions. Definite differences among germinoma cells associated with their originating sites were not recognized except for a few features of the nucleus.

Congenital anophthalmia associated with intracranial germinoma

A 14-year-old boy with anophthalmia presented evidence of hypothalamic dysfunction. He was found to have a third-ventricular germinoma, probably pineal. This case is interesting in view of a previous case report of the association of anophthalmia and a germ-cell tumor (teratoma), and suggests a possible causal relationship between this malformation and germ-cell neoplasms, bith of which probably arise early in development.

Primary intracranial endodermal sinus tumor. Case report

Endodermal sinus tumor (yolk sac carcinoma), a germinal neoplasm, is rarely primary in the cranial cavity. The authors add a third case with the tumor located in the anterior third ventricular (suprasellar) region to the literature. Seventeen previously reported intracranial cases, mostly in the pineal region, are briefly reviewed.

[A comparative clinical and pathological study on the classification and prognostic features of 57 thymomas. I. Microscopy and ultrastructural pathology (author's transl)]

Fifty-seven thymomas, defined as neoplasms of the epithelial-reticular framework cells of the thymus, were assessed in respect to histologic type, inclusive of there ultrastructural aspects. The median age of the 57 patients was 40.4 years, with a range of 2 1/2--72 years. All neoplasms were located in the anterior mediastinum. The tumours in 40 cases were encapsulated and without invasion of adjacent tissue or implants (equal to non-invasive thymomas). The tumors in 17 cases were invasive of adjacent tissue, particularly mediastinal pleura, pericard and trachea. Six of 57 patients (equal to 10.5%) with thymomas have had a thoracic and supraclavicular lymph node metastasis, and osteolytic metastases in the vertebrae and sternum. Thirty-seven (equal to 64.9%) were so-called lympho-epithelial, 7 (equal to 12.3%) pure epithelial, 4 (equal to 7.0%) atypical (or anaplastic) with granulomatous focuses, 3 (equal to 5.3%) carcinoid and one (equal to 1.8%) seminomatous tumors. One patient have had a thymic cyst as a tumor-like conditions of the thymus, and four patients (equal to 7.0%) have had a thymo-lipoma. The histologic type of thymoma had no proof value in predicting prognosis with the exception of the so-called atypical or anaplastic thymoma. The fine structural aspects of thymomas and the fine structural differential diagnosis of anterior mediastinal tumors are discussed.

Pineal and suprasellar germinomas. Results of radiation treatment

The results of radiation treatment of 52 patients with a tumor in the pineal region or a suprasellar germinoma are analyzed. The overall 5-year survival rate was 59%. Ten patients in whom initial biopsy confirmed pineal germinoma were all alive 2 to 121 months from diagnosis, although two developed meningeal seeding at 2 and 7 months. Twelve of 15 patients 25 years old or younger with an unbiopsied tumor in the pineal region were alive 12 to 225 months after irradiation, with a 5-year survival rate of 81%. In comparison only five of 16 patients older than 25 years with a pineal region tumor survived, a 5-year survival rate of 37%. This marked age dependence in survival rates was attributed to a high proportion of germinomas in the younger patients and gliomas in the older patients.

Extrapyramidal disorder with pineal germinoma. Case report

Space-occupying lesions of the basal ganglia are a rare cause of extrapyramidal dysfunction in children. Metastatic pineal germinoma in both basal ganglia produced dystonia in a 12-year-old boy. The literature is reviewed. Extrapyramidal manifestations in the child are compared with previously reported cases of basal ganglia neoplasms.

Ectopic pinealoma. Report of a case and remarks on the treatment

A case of ectopic pinealoma is reported. It presented with the clinical triad of visual disturbances of the chiasmatic type, diabetes insipidus, hypothalamic-hypophyseal impairment, and with enlargement of the sella turcica on roentgenographic examination. The patient is alive and well eight years after incomplete removal followed by radiation treatment. It is felt that this is the correct treatment for such lesions, rather than radiation treatment alone as apparently favoured in other reports. The diagnostic and therapeutic points supporting such an opinion are discussed.

Multiple germ cell tumors: reports of 3 cases, 1 with 3 primary lesions

Tumors may develop in both testes, either concomitantly or sequentially. We herein report 3 cases of bilateral testicular neoplasms. One patient had concomitant seminomas of the testes and another had sequential germ cell tumors separated by an 11-year interval. The third patient is an unusual case in that he had bilateral testicular germ cell tumors diagnosed concomitantly 8 years after irradiation of an extragonadal, histologically proved, seminoma in the mediastinum. Evidence suggests that all 3 sites, each testis and the mediastinum, were primary lesions. Standard methods of therapy should be used in the treatment of malignancies.

Intracranial dysgerminomas

We have reported three cases of intracranial dysgerminoma. The origin of these tumors has been controversial for a long time. It is now accepted that they develop from germ cells. The diagnosis is often difficult to confirm because of the varity of signs. If their origin is now accepted, the best way to deal with these lesions is still controversial. They can be macroscopically removed if they are in the pineal region. Such treatment is not possible for suprasellar tumors. Since these tumors can metastasize, radiation should be administered as soon as a pathological diagnosis is obtained. It is our belief that it should be administered to the whole spinal axis.