Spinal intradural primary germ cell tumour--review of literature and case report

Brain and Spinal Tumors Originating from the Germ Line Cells

Primary central nervous system germ cell tumors (CNS GCTs) are part of the GCTs in children and adults. This tumor entity presents with geographic variation, age, and sex predilection. There are two age peaks of incidence distribution at the first few months of life and in adolescence. CNS GCTs are heterogeneous in histopathological subtypes, locations, and tumor marker (AFP, β-hCG) secretions. In the WHO CNS tumor classification, GCTS are classified as germinoma and nongerminomatous GCT (NGGCT) with different subtypes (including teratoma). Excluding mature teratoma, the remaining NGGCTs are malignant (NGMGCT). In teratoma, growing teratoma syndrome and teratoma with somatic-type malignancy should be highlighted. The common intracranial locations are pineal region, neurohypophysis (NH), bifocal pineal-NH, basal ganglia, and cerebral ventricle. Above 50% of intracranial GCTs (IGCTs) present obstructive hydrocephalus. Spinal tumors are rare. Age, locations, hydrocephalus, and serum/CSF titer of β-hCG correlate with clinical manifestations. Delayed diagnosis is common in tumors arising in neurohypophysis, bifocal, and basal ganglia resulting in the increasing of physical dysfunction and hormonal deficits. Staging work-up includes CSF cytology for tumor cells and contrast-enhanced MRI of brain and spine for macroscopic metastasis before treatment commences. The therapeutic approach of CNS GCTs integrates locations, histopathology, staging, tumor marker level, and therapeutic classification. Treatment strategies include surgical biopsy/excision, chemotherapy, radiotherapy (single or combination). Secreting tumors with consistent imaging may not require histopathological diagnosis. Primary germinomas are highly radiosensitive and the therapeutic aim is to maintain high survival rate using optimal radiotherapy regimen with/without chemotherapy combination. Primary NGNGCTs are less radiosensitive. The therapeutic aim is to increase survival utilizing more intensive chemotherapy and radiotherapy. The negative prognostic factors are residue disease at the end of treatment and serum or CSF AFP level >1000 ng/mL at diagnosis. In refractory or recurrent NMGGCTs, besides high-dose chemotherapy, new therapy is necessary. Molecular profiling and analysis help for translational research. Survivors of pediatric brain tumors frequently experience cancer-related cognitive dysfunction, physical disability, pituitary hormone deficiency, and other CNS complications after cranial radiotherapy. Continuous surveillance and assessment may lead to improvements in treatment protocols, transdisciplinary interventions, after-treatment rehabilitation, and quality of life.

Primary Extramedullary, Extradural Cervical Spine Seminoma

While extragonadal seminomas resulting in spinal cord compression are rarely reported in the literature, most have been treated with surgical decompression followed by radiation therapy. In this report, we present the unique and interesting case of a 38-year-old man who initially presented as an outpatient with a chief complaint of axial neck pain and lateral thoracic wall pain. After an extensive malignancy workup, he was diagnosed with a primary cervical spine seminoma and was treated with a C6-T1 laminectomy with posterior spinal instrumentation from C5 to T2. He has since undergone chemotherapy with cisplatin, vinblastine, and bleomycin, and at 24-month follow-up, he remains asymptomatic with no signs of recurrent disease.

Successful treatment of mixed yolk sac tumor and mature teratoma in the spinal cord: case report

Primary spinal germ cell tumors are rare, and spinal nongerminomatous germ cell tumors represent an even rarer subset for which no standard therapy has been established. The authors report the case of a 24-year-old woman with multifocal primary spinal germ cell tumors scattered from T-12 to L-5 that consisted of yolk sac tumor and mature teratoma. After diagnostic partial resection, the patient was treated with 30 Gy of craniospinal irradiation and 30 Gy of local spinal irradiation, followed by 8 courses of chemotherapy based on ifosfamide, cisplatin, and etoposide (ICE). Salvage surgery was also performed for residual mature teratoma components after the third course of ICE chemotherapy. Chemotherapy was continued after the operation, but ifosfamide was entirely eliminated from the ICE regimen because severe myelosuppression was observed after previous courses. The patient remains recurrence free as of more than 5 years after the completion of chemotherapy. This case suggests that this treatment strategy is an effective option for primary spinal yolk sac tumor.

Primary extramedullary spinal germinoma: case report and review of the literature

The authors describe a case of a purely primary extramedullary spinal germinoma in a young Chinese male. Primary spinal germinoma is extremely rare tumor. Currently, less than 30 histologically verified spinal germinoma cases have been reported previously, mostly involving Asian of Japanese descent. This 24-year-old male suffered from progressive low back pain radiating to both legs. Magnetic resonance imaging showed a well-demarcated, intradural extramedullary mass at the level of L2 and L3. The lesion was totally removed and was confirmed as a germinoma. Upon histological verification of the tumor, he was treated successfully with radiotherapy and adjuvant chemotherapy. This report also reviews the literature pertaining to primary spinal germinoma. Except for 16 cases with intramedullary lesions and five cases with both intra- and extramedullary tumors, there were only three previously reported cases of extramedullary spinal germinomas, all initially presenting with sausage-like lesions. To the authors' knowledge, it is thought to be the first case of such a tumor, roughly round in shape and extramedullary location. Although rare, primary spinal germinoma do occur and should be included in the differential diagnosis of spinal tumors. Aggressive malignant behavior has been reported and close follow-up is necessary.

Intramedullary Spinal Cord Germinoma: A Case Report and Review of Literature

Primary spinal cord germinomas are an extremely rare group of tumors, most commonly reported as single cases in young Japanese adults. They usually present as intramedullary lesions located in the thoracic and thoracolumbar spine. The importance of preoperative diagnosis lies in the fact that by using radiotherapy and chemotherapy, even without surgery, a good cure rate can be achieved in patients with spinal cord germinoma. These tumors, however, demonstrate unspecific imaging characteristics, and only some secrete tumor markers. Therefore, a diagnosis of these lesions before biopsy or resection with pathohistologic examination can be difficult. We present a case of a 28-year-old white man with intramedullary spinal cord germinoma. The tumor was resected completely with electrophysiological monitoring, without a biopsy and frozen section analysis. Postoperative radiotherapy also was part of the treatment. The patient has had no relapse 4.5 years after diagnosis; however, significant neurologic deficits remain. Although not as frequent in white patients, germinoma should be considered as differential diagnosis in cases of young adult patients with intramedullary tumor in the thoracic or thoracolumbar spine. Therefore, spinal mass surgery should commence with a biopsy and intraoperative frozen section analysis. In this way, attempting a gross total resection becomes unnecessary. With an approach of intraoperative biopsy and frozen section analysis, a considerable amount of postoperative neurologic deficits can be reduced.

Treatment strategies and long-term outcomes for primary intramedullary spinal germinomas: an institutional experience

Primary intramedullary germinomas are very rare tumors in the spinal cord. This study presented a series of 11 patients with histologically proven primary intramedullary spinal germinomas. Their clinical and radiological findings, treatment records and long-term outcomes were reviewed. There were four male and seven female patients with a mean age of 27.1 years. Because germ cell tumors were suspected by frozen-section biopsy, gross total resection was unattempted. Partial resection was performed in four cases, while biopsy was performed in seven cases. Postoperatively, carboplatin and etoposide chemotherapy combined with low dose radiotherapy (30.6 Gy) to local spine was performed in seven cases, followed by radiotherapy alone (40 Gy) in four cases. All 11 patients had a complete response to either combination treatment or single radiotherapy, and the mass effect on the spinal cord vanished. The mean follow-up period was 75.4 months. At the last follow-up, the symptoms were improved in 10 cases and the current status of one patient was unchanged. The postoperative follow-up magnetic resonance imaging showed no recurrence or dissemination in any of the patients. Primary intramedullary germinomas are amenable to adjuvant radiochemotherapy and low dose radiation with etoposide and carboplatin chemotherapy is recommended. When combination therapy cannot be performed, relatively high doses of radiotherapy are advised, and radiation to the craniospinal axis may be unnecessary. A good clinical outcome after combination therapy or radiotherapy alone can be expected, and the risk of long-term recurrence and dissemination is low.

A rare case of multifocal intramedullary germinoma in cervical spinal cord

STUDY DESIGN

Case report.

OBJECTIVES

We present for the first time a patient with multifocal intramedullary cervical spinal cord germ cell tumors with elevated serum alpha-fetoprotein (AFP).

SETTING

Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.

METHODS

A 19-year-old girl experienced numbness in her right leg 10 months before diagnosis. The numbness gradually became severe and extended up to the thorax. Magnetic resonance imaging (MRI) visualized several intramedullary masses with intensive enhancement and extensive peritumoral edema in the spinal cord at the C3-T1 vertebral body levels. Administration of methylprednisolone caused no treatment effect. The largest mass, which was located at the T1 level inside the normal spinal cord and confirmed by naked eye observation, was completely extracted under a microscope. Postoperative pathological examination demonstrated the so-called 'two-cell pattern,' which is typical of germinoma with placental alkaline phosphatase expression. The serum level of AFP was 64.50 ng ml(-1) (normal range: 0-5 ng ml(-1)). The residual tumor was eliminated through radiation therapy (local 30 Gy) following surgery. Afterward, the patient's neurological deficits were improved but not resolved.

RESULTS

Six years after surgery, no recurrence was encountered and the patient remained stable.

CONCLUSION

Radiotherapy is the salvage therapy for spinal cord germinoma. Steroids were of no therapeutic value in the treatment of intramedullary spinal cord germinoma.

Primary spinal germ cell tumors: a case analysis and review of treatment paradigms

Objective. Primary intramedullary spinal germ cell tumors are exceedingly rare. As such, there are no established treatment paradigms. We describe our management for spinal germ cell tumors and a review of the literature. Clinical Presentation. We describe the case of a 45-year-old man with progressive lower extremity weakness and sensory deficits. He was found to have enhancing intramedullary mass lesions in the thoracic spinal cord, and pathology was consistent with an intramedullary germ cell tumor. A video presentation of the case and surgical approach is provided. Conclusion. As spinal cord germinomas are highly sensitive to radiation and chemotherapy, a patient can be spared radical surgery. Diverse treatment approaches exist across institutions. We advocate biopsy followed by local radiation, with or without adjuvant chemotherapy, as the optimal treatment for these tumors. Histological findings have prognostic value if syncytiotrophoblastic giant cells (STGCs) are found, which are associated with a higher rate of recurrence. The recurrence rate in STGC-positive spinal germinomas is 33% (2/6), whereas it is only 8% in STGC-negative tumors (2/24). We advocate limited volume radiotherapy combined with systemic chemotherapy in patients with high risk of recurrence. To reduce endocrine and neurocognitive side effects, cranio-spinal radiation should be used as a last resort in patients with recurrence.

Intratumoral hemorrhage because of primary spinal mixed germ cell tumor presenting with atypical radiological features in an adult

BACKGROUND CONTEXT

Germ cell tumors are known to arise in the central nervous system, usually in the intracranial regions. However, primary spinal mixed germ cell tumors are extremely rare.

PURPOSE

This is the first reported case of intratumoral hemorrhage because of a primary spinal mixed germ cell tumor consisting of germinoma and immature teratoma in the conus medullaris of an adult patient that presented with rapid changes on magnetic resonance image (MRI). We report this rare case and discuss the clinical manifestations of an intramedullary spinal mixed germ cell tumor in adult.

STUDY DESIGN

A case report.

METHODS

A 42-year-old woman experienced buttock numbness, and a spinal cord tumor was observed on the conus medullaris on MRI. The patient was scheduled for an operation in 1 month, but she developed sudden-onset neurologic deterioration. Rapid progression of the tumor was observed on follow-up MRI. The tumor was removed by emergency surgery and was identified as a primary mixed germinoma and immature teratoma.

RESULTS

The patient received adjuvant chemotherapy and radiotherapy after gross total resection. The neurologic deficit of the patient was relieved, and recurrence of the tumor was not observed 26 months after the surgery.

CONCLUSIONS

We present this rare case and emphasize the necessity of precise diagnosis and early treatment of primary spinal germ cell tumor. Close observation on MRI is required after surgery, and adjuvant chemotherapy and radiotherapy should be considered according to the pathologic features.

Mature teratoma of the spinal cord in adults: An unusual case

Intraspinal mature teratomas rarely occur in adults. The present study describes an unusual case of adult intradural mature teratoma, which was completely resected. A 22-year-old female presented with an intermittent pinching pain in the lower right shank that had lasted for three months. Magnetic resonance imaging (MRI) results indicated a multicystic mass extending from the T12 to L2 vertebrae, and the tumors were certified as teratomas by a histopathological examination. The level of pain experienced by the patient was improved following the surgery. The present study also compared the literature concerning adult intradural mature teratoma, summarized the basic clinical characteristics and theory of origin of adult intradural mature teratoma and reviewed the available treatments for this disease.

Effective radiotherapy cured cauda equina syndrome caused by remitted intracranial germinoma depositing

Cauda equina syndrome (CES) in children is very rare and can permanently disable. A remitted intracranial germinoma depositing on the spinal cord, leading to CES, has never been reported. We discuss the case of a 10-year-old girl who presented with sudden ataxia, low back pain, sensory deficits of the left lower extremity, and difficulty urinating and defecating 7 months after totally remitted intracranial germinoma postintracranial surgery and cranial irradiation. Magnetic resonance imaging (MRI) of the brain and spine showed multiple intradural extramedullary homogeneous masses from the cervical to lumbar levels, compressing the conus medullaris and cauda equina. After emergent craniospinal irradiation, the patient's neurologic symptoms dramatically subsided. A remitted intracranial germinoma depositing on her spinal cord could be the cause of CES. Early identification and a proper craniospinal irradiation may halt the progression of symptoms.

Primary intramedullary spinal germ cell tumors

BACKGROUND

Intramedullary spinal germ cell tumors are rare lesions, with germinomas being the most common variant.

METHODS

To date, there have been 23 reports of primary intramedullary germ cell tumors described in the literature, the vast majority occurring in Japanese patients.

RESULTS

We present a case of a nonmetastatic intramedullary germ cell tumor in a 28-year-old Caucasian woman.

CONCLUSIONS

Characteristics of intramedullary germ cell tumors are summarized, and the current role for surgery and adjuvant radiation and chemotherapy are discussed.

Spinal epidural teratoma: review of spinal teratoma with consideration on the pathogenesis: case report

BACKGROUND AND IMPORTANCE

Of the 170 cases of teratomas in the spinal canal reported in the English literature, only 13 were spinal epidural teratomas (SETs). We present a case of SET, review the characteristics of SETs in comparison with spinal intradural teratomas (SITs), and investigate the pathogenesis of spinal teratoma.

CLINICAL PRESENTATION

A 17-month-old boy visited our clinic with paraparesis. A multicystic mass was noted in the left epidural space from T8 to T10 and the left paraspinal area. Complete resection of the tumor, including the paraspinal portion, was accomplished by laminoplastic laminotomy. The tumor was well encapsulated and filled with heterogeneous contents. The tumor was suspected to originate from the left T9 root.

CONCLUSION

On histopathological examination, the tumor was found to be a mature teratoma. The clinical characteristics of SETs and SITs show similarities in age, male preponderance, location, associated anomalies, and pathology. SETs and SITs are probably 2 different types of a single disease entity. Pluripotent somatic cell from the Hensen's node and caudal cell mass is the probable origin of spinal teratoma. However, originating from misplaced primordial germ cell could not be excluded.