Atypical teratomas of the pineal and hypothalamus

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.

Extraneural metastases of paediatric brain tumours

A survey of published cases of extraneural metastases of primary brain tumours in children under the age of 18 years revealed 245 cases; 60.7% occurred in boys and 27.3% were directly related to the placing of a shunt. The most common entities leading to extraneural metastases were medulloblastomas (56.3%), germinomas (9.8%), glioblastomas (6.9%), ependymomas (3.7%) and pilocytic astrocytomas (2.9%). While medulloblastomas were frequent among non-shunt-related metastases (69.4%), germ cell tumours were most common among shunt-related metastases (33.3%). Metastases were encountered equally often in bone (56.3%) and visceral organs (55.5%) but were markedly rarer in lymph nodes (25.3%). Medulloblastomas showed a preference for bones (88.3% of cases), germinomas for bones (77.8%) and visceral organs (66.7%), whereas ependymomas and ependymoblastomas were more frequently found in lymph nodes and visceral organs (71.5-100%). The most frequent sites of bone metastases were the pelvis (59.3% of cases with osseous lesions), femur (54%) and vertebrae (46%). Medulloblastomas preferentially spread into pelvis, femur and vertebrae, whereas germ cell tumours mainly involved pelvis, femur and ribs and glioblastomas vertebrae and pelvis. Most frequent sites of lymph node metastases were cervical (45.8% of cases with nodular lesions) and thoracic (31.3%) with 54% of children suffering from medulloblastomas and 7.9% from germ cell tumours. The most frequent organ involved in non-shunt-related metastases were the lungs (56.5% of children with visceral lesions) followed by muscle/soft tissue (26.9%), pleura (16.4%), skin (14.9%) and liver (13.4%). Among shunt-related cases, the peritoneum was the most frequent site (86.6% of children). The mean interval between primary brain tumour and occurrence of metastasis was 22.1 months with particularly grave outcomes among medulloblastomas, non-germinomatous germ cell tumours and glioblastomas (85.5-100% deceased children), whereas 60% of children suffering from germinomas were still alive at the time of reporting.

Radiation therapy for histologically confirmed primary central nervous system germinoma

PURPOSE

To evaluate survival and patterns of recurrence in patients with primary central nervous system germinoma treated with radiation therapy.

METHODS AND MATERIALS

Data regarding 48 patients with histologically confirmed, primary central nervous system germinoma were reviewed. All had been operated on at the Mayo Clinic between the years 1935 and 1993. Thirty-two patients (67%) were treated since 1973. The study group included 39 males and 9 females, with a median age at diagnosis of 17 years (range, 6-42 years). Twelve patients (25%) were treated with craniospinal axis irradiation, 11 (23%) received whole-brain irradiation without spinal axis irradiation, and 24 (50%) underwent partial-brain irradiation. Treatment volumes were unknown in one patient. The median dose to the primary tumor was 44.00 Gy (range, 7.44-59.40 Gy). The median follow-up was 5.5 years (range, 4 months to 37 years).

RESULTS

Actuarial 5-year and 10-year survival for the entire study group of patients was 80%. There was a trend toward improved survival in patients treated after 1973 (introduction of computed tomography) with 5-year and 10-year survival of 91% vs. 63% in prior years (p = 0.07). For the group of 31 patients treated since 1973 with known treatment volumes, the spinal axis failure rate at 5 years was 49% for patients treated with partial brain fields (11 patients) vs. 0% for those having undergone whole brain (10 patients) or craniospinal axis (10 patients) irradiation (p = 0.007). The rate of brain failure was also significantly higher in patients receiving less than whole-brain irradiation; at 5 years, 45% of the patients treated with partial-brain fields had intracranial recurrence of disease compared to 6 % of patients treated with craniospinal axis or whole-brain irradiation (p = 0.01). Among the 32 modern era patients, the rate of brain failure was higher in patients who received doses less than 40 Gy (median dose, 48.55 Gy; range, 30.60-59.40 Gy) to the primary tumor (5-year brain failure rate 52% vs. 11%, p = 0.002).

CONCLUSION

The long-term survival of patients with histologically proven CNS germinoma treated with radiation is excellent. Whole-brain or craniospinal axis irradiation appears to result in fewer spine and brain failures than does partial-brain irradiation. Furthermore, the administration of doses greater than 40 Gy to the primary tumor is associated with better local control.

Metachronous ovarian dysgerminoma after a suprasellar germ-cell tumor treated by radiation therapy. Case report

A case of suprasellar germ-cell tumor in a 9-year-old girl who later developed ovarian dysgerminoma is reported. The clinical course of the case is described and a double-primary tumor, rather than metastasis from either tumor to the other, is suggested by the authors to explain the oncogenesis in this patient. The authors strongly encourage that patients with intracranial germinoma be examined for associated extraneural lesions before, as well as after, the completion of the initial therapy.

Testicular seminoma in a patient with pineal germinoma

A case is reported of a 30 year old man with a testicular seminoma. He had presented 16 years previously with a pineal germinoma, followed two years later by intracranial metastases. This is an unusual occurrence of double pathology in the germ cell line.

Successful treatment of recurrent malignant germ cell tumors: report of two cases

We report two patients with recurrent malignant germ cell tumors who were successfully treated with radiation therapy and cisplatin combination chemotherapy. Patient 1, who had a suprasellar mixed yolk sac tumor, had been free of tumor for 3.5 years after cisplatin/vinblastine/bleomycin combination chemotherapy alone but showed a recurrent tumor in the pineal region. In Patient 2, who had a pineal alpha-fetoprotein-producing tumor, recurrent tumors appeared in the lateral ventricle 3 years after the tumor was controlled by radiation and cisplatin/vinblastine/bleomycin therapy. They were treated successfully again by radiation therapy, followed by cisplatin and etoposide combination therapy, and they have been free of tumor for 5.5 and 7 years after recurrence, respectively. The total dose of cisplatin in both patients exceeded 1,000 mg/m2, which would have contributed to the control of the recurrent tumors. Anterior pituitary dysfunction observed in Patient 1 did not improve, even after tumor disappearance by chemotherapy, suggesting severe damage to the neurohypophysis by direct invasion of the tumor.

Intracranial germ cell tumor mimicking anorexia nervosa

A previously healthy seventeen-year-old boy developed loss of weight, poor appetite, and aversion to food. Physical examination being normal, anorexia nervosa was suspected. Thirteen months later a CT scan revealed a mass in the third ventricle histologically proven to be a malignant teratoma. To our knowledge anorexia nervosa is only extremely rarely the presenting feature of intracranial germ cell tumors.

Intratubular germ cell neoplasia in testicular teratomas and epidermoid cysts. Correlation with prognosis and possible biologic significance

The clinicopathologic features of 4 testicular teratomas in infants, 13 testicular epidermoid cysts in adults, and 8 pure teratomas in adults were compared. Intratubular germ cell neoplasia (ITGCN, carcinoma in situ) was observed in 88% of the teratomas in adults; 63% of the patients in this group had metastases and 37% died. No ITGCN was observed in infant testes with teratomas or adult testes with epidermoid cysts; all of the neoplasms in the latter two groups behaved as benign tumors. ITGCN is associated with malignant potential (P = 0.0004; Fisher's exact test). These tumors comprise a spectrum of clinicopathologic entities that probably reflect differences in pathogenesis.

Hypothalamic and basal forebrain germinoma presenting with amnesia and hyperphagia

Patients harboring primary intracranial germinomas usually have had Parinaud's syndrome and hydrocephalus (with pineal tumors) or hypopituitarism, visual loss, and diabetes insipidus (with suprasellar tumors) at presentation. The few reported cases of verified intraparenchymal hypothalamic germinomas all have been in prepubertal males with progressive neurologic deficits, altered levels of consciousness, or clinically apparent panhypopituitarism. The subject of this report was an endocrinologically normal, primiparous 24-year-old woman who presented with hydrocephalus followed by worsening anterograde amnesia and hyperphagia despite having a functioning ventriculoatrial shunt. Computed tomography scanning and magnetic resonance imaging demonstrated an anterior hypothalamic, thalamic, and basal forebrain mass, which stereotactic biopsy proved to be a germinoma. Intraaxial germinomas restricted to the anterior hypothalamus or thalamus rarely have been reported. The clinical features of the current patient may be unique.

Cerebral germinomas and Klinefelter syndrome. A review

Patients with Klinefelter syndrome appear to be predisposed to the development of extragonadal cerebral germinomas. A case of a pineal region germinoma in a boy 15 years of age with Klinefelter syndrome is documented in this article. In view of three other cases of cerebral germinomas associated with Klinefelter syndrome in the literature, a hypothesis for this predisposition is suggested.

Germinoma in the cerebellopontine angle

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Pineal germinoma with widespread extracranial metastases

A case of primary pineal germinoma with widespread extracranial metastasis in a 36-year-old man is presented. A clinical work-up revealed bilateral pleural effusions, ascites, and metastatic lesions involving the lung. Cytology and electron microscopic study of the pleural and ascitic fluid and of the fine needle aspiration material revealed metastatic germinoma. Although the cytologic features were not distinct from those of anaplastic carcinoma, they were distinguishable from those of glial neoplasms, lymphoma, and sarcoma. The computed tomography findings, elevated human chorionic gonadotropin level, and electron microscopic features contributed significantly to the diagnosis of extracranial metastasis of the pineal germinoma. Metastatic spread most likely occurred via the ventriculoperitoneal shunt.

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.

Extraneural metastases from primary pineal tumors. Review of the literature

Extraneural metastases from primary pineal tumors are extremely rare: only 15 such cases could be found in th literature. Another case is presented of a 10-year-old boy who developed multiple pulmonary and skeletal metastases from a presumed primary pineal germinoma. The incidence and pathogenesis of distant dissemination in the different types of pineal tumors are discussed, with special comment on the controversial role of the direct surgical approach and shunting of cerebrospinal fluid.

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.

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.

Suprasellar germinoma with probable extracranial metastases

A case of metastasizing suprasellar germinoma (ectopic pinealoma) in a prepubertal part-Polynesian female is presented, and the histological features of the tumour are described. Review of the literature had disclosed 11 previous reports of extraneurally metastasizing pineal germinoma. The present case appears to be the first recorded instance of extraneural metastases from an intracerebral germinoma where the primary tumour mass is situated outside the pineal gland.

The management of pineal area tumors: a recent reappraisal

This study concerns our experience with 22 pineal area tumors from 1972 through 1977. Eleven identified tumors included: three gliomas, three pineoblastomas, two endodermal sinus tumors, one germinoma, one epidermoid, and one metastasis. Three others were presumptively germinomas. Twelve cases were treated by means of radiation and shunting if necessary. Eight patients had pineoblastomas and 2, endodermal sinus tumors. Death occurred in spite of radiologic evidence of radiation response. Cerebrospinal fluid (CSF) cytology was positive in 2 of 7 cases involving potentially disseminating tumors and negative in 2 cases involving spinal metastases. We conclude that radiation response and CSF cytology are insufficient to determine optimum treatment. Direct operations, which were not associated with mortality or serious morbidity were most useful for providing a tissue diagnosis.

Endodermal sinus tumor of the pineal region

Two cases of endodermal sinus tumor of the pineal region are reported and compared with 16 others in the literature. The preponderance of neoplasms occurs in boys, usually in their second decade. The diagnosis is usually established within three months of the onset of non-specific symptoms of an intracranial mass. Treatment with operation or radiotherapy alone is inadequate. Most patients have died within two years, some with widespread intradural metastases. The one individual who has survived five years was treated with both operation and radiotherapy.

Pathological survey of intracranial germinoma and pinealoma in Japan

Pathologic survey was performed on 43 cases of intracranial germinoma and 12 cases of pinealoma. The present study suggests that, in Japan, the incidence of teratoma groups including germinoma is remarkably higher than that in U.S. and Europe, whereas the rate of true pinealoma is lower. Using ultrastructural, enzyme-histochemical, and fluorescence-histochemical methods for a few surgical specimens, a strong similarity between intracranial germinoma (so-called "pinealoma" with a two-cell pattern) and seminoma and dysgerminoma was confirmed. The true pinealoma could be classified as pineoblastoma and pineocytoma, according to the degree of pineocyte differentiation of the tumor cells, and as "neuroblastoma-like" and "pineal-like" on the basis of the histologic architecture.

Tumors of the pineal and suprasellar region: Childrens Cancer Study Group treatment results 1960--1975: a report from Childrens Cancer Study Group

Tumors of the pineal and suprasellar region form a rare and interesting group of lesions with germinomas accounting for over 50% of all lesions in this anatomic region. The Brain Tumor Committee of Childrens Cancer Study Group (CCSG) recently surveyed all CCSG member institutions to determine treatment parameters and assess the techniques. A total of 140 patients were seen during the period from 1960 to 1975; 118 patients were evaluable, having adequate treatment records. One hundred and one patients were less than 30 years of age with a 2:1 male predominance. Thirty-six of the 57 biopsied patients (63%) were found to have germinomas. The survival of patients in the germinoma group (72%) was comparable to that of the patients without biopsy (71%). The overall survival rate for all patients (biopsied and unbiopsied) was 65% with follow-up times ranging from 2 to 15 years. Nine patients developed spinal cord metastases (8%), two of whom also had simultaneous primary recurrence; none of these patients had received adjunctive spinal irradiation.

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.

Case report and ultrastructural study of intracranial embryonal carcinoma

A case of a primary intracranial embryonal carcinoma, the first with ultrastructural study, is reported. The tumor was associated with precocious puberty in a 6 1/2-year-old female. Characteristic embryoid bodies were present. At the ultrastructural level three cell types were noted: undifferentiated, differentiated, and intermediate types. The undifferentiated showed scanty cytoplasmic organelles and numerous free polysomes, while the differentiated cells contained well-developed mitochondria, Golgi apparatus, rough endoplasmic reticulum, and some contained secretory granules. The intermediate cells possessed dilated and irregularly-shaped mitochondria but still retained large numbers of free polysomes. The authors suggest that intracranial germ cell tumors be named in conformity with germ cell tumors in other sites, and that terms such as "ectopic pinealoma" and "atypical teratoma of the pineal" be used no longer.

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.

Pathognomonic aspect of germinoma on CT scan

Bilateral visual impairment, associated with amenorrhea, diabetes insipidus and mental deterioration were observed in a 28 year old woman. CT scan revealed bilateral symmetrical infiltrative processes surrounding the ventricular system, which was confirmed by postmortem examination. Histologically the lesion was a germinoma.

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.

Computed tomography of tumors of the pineal region

Eight pathologically proven cases of pineal region tumors examined by computed tomography (CT) were found upon reviewing 11,000 consecutive CT studies at the Massachusetts General Hospital. The CT scan findings of the eight cases are described and related to a pathological classification of pineal tumors.

Results of irradiation of tumors in the region of the pineal body

The clinical findings and results of radiation treatment in 14 patients with tumors in the region of the pineal body are presented. The neurologic signs and symptoms improved significantly in 11 patients (79 per cent). The survival rate for five years or more was 50 per cent. Radiation therapy as the primary method of treatment is discussed.

Radiology of suprasellar ectopic pinealoma

The radiographic and clinical findings in twenty-three recently reported cases of suprasellar ectopic pinealoma are reviewed and three previously unreported cases are described. It is concluded that suprasellar calcification is extremely rare; enlargement of the sella turcica was present in approximately 20 to 30 per cent, none demonstrated elevation of the anterior cerebral artery. Pneumography may show a smooth or irregular filling defect in the anterior part of the third ventricle. In one of the new cases there was an isotope uptake in the suprasellar region. The differential diagnosis and other clinical data are also discussed.

Chemosis, proptosis and amaurosis in a 19-year-old male

An ectopic pinealoma was excised in 1966 and the patient received radiotherapy postoperatively. The patient developed diabeted insipidus, hypopituitarism, chemosis, proptosis, and loss of vision in the left eye. The left eye was enucleated in 1974 and a large orbital mass was found to contain malignant cells consistent with the diagnosis of germinoma. The orbital mass was in all likelihood a metastasis from the original focus of the tumor.

Evolution of a primary intrasellar germinomatous teratoma into a choriocarcinoma. Case report

A case of intrasellar teratoma with a germinal structure in a 10-year-old girl is described. A few months after intracranial surgery the tumor differentiated into a choriocarcinoma and finally spread to multiple cerebral, pulmonary, and renal metastases. In the course of choriocarcinomatous evolution, very high urinary levels of luteinizing gonadotropin (HCG) developed, but there was no clinical or anatomical evidence of precocious puberty.

Embryonal carcinoma in the cerebellum. Case report

✓ A cerebellar embryonal carcinoma in a 5-year-old child is reported. The tumor was well encapsulated and completely removed. Postoperative radiation was given. The patient is alive and healthy.