Combined radiosurgery and external radiotherapy of intracranial germinomas

Microsurgical Management of Pineal Region Tumors

BACKGROUND

Pineal tumors are rare, and the pineal region is a challenging surgical location for neurosurgeons. The present study aimed to investigate the effects of microsurgical management in patients with pineal region tumors and explore probable factors associated with preoperative hydrocephalus, postoperative hydrocephalus remission, and prolonged hospital length of stay (LoS).

METHODS

A retrospective study of patients with pineal region tumors who underwent microsurgical management at the First Affiliated Hospital of Soochow University (Jiangsu, China) between 1 January 2010 and 31 October 2022 was conducted.

RESULTS

Data from 36 patients were included in this study. The top 5 common symptoms included headache (58%), dizziness (44%), double vision (22%), vomiting (19%), and nausea (14%). Patients with a lower Karnofsky Performance Score (KPS), younger age, and larger maximum tumor diameters were more vulnerable to preoperative hydrocephalus. Preoperative hydrocephalus also led to a prolonged postoperative LoS (P = 0.021). Patients with a lower KPS score (P = 0.020) or larger maximum tumor diameters (P = 0.045) were more likely to achieve postoperative remission of hydrocephalus. Most postoperative complications led to increased hospital LoS.

CONCLUSIONS

Microsurgical resection of pineal tumors yielded favorable long-term outcomes. Patients with a lower KPS score, younger age, and larger maximum tumor diameters were more vulnerable to preoperative hydrocephalus and prolonged LoS. Patients with a lower KPS score or larger tumor diameter were likely to achieve significant remission of hydrocephalus after tumor resection.

Diagnostic radiation-induced regression of a metastatic primary intracranial germinoma: a case report

Pineal region germinomas are sensitive to radiotherapy. Standard neurosurgical management involves obtaining a tissue biopsy and to relieve the often accompanying obstructive hydrocephalus. We present a patient with a suspected hyper-radiosensitive metastatic primary intracranial germinoma where computed tomography scanning resulted in tumor regression before radiotherapy could be administered.

A rare case report and literatures review on primary germinoma in cerebellar hemisphere

OBJECT

Primary intracranial germinoma is a rare intracranial lesion which accounts for approximately 0.5-2% of all intracranial tumors. Generally, primary intracranial germinoma occurs in the midline structures of the central nervous system of a pediatric patient. Only four cases of primary cerebellar germinomas with poor prognosis have been previously reported. The object of this paper is to introduce a case of germinoma originating from cerebellar hemisphere and to discuss its clinical features.

METHODS

This paper reported an 8-year-old boy who was diagnosed to have cerebella inflammatory granuloma during hospitalization and then discharged without any operation. However, the follow-up MRs revealed that the lesion became larger. Therefore, the boy was hospitalized again and underwent a gross total resection of lesion. According to pathological examination, the final diagnosis was confirmed as germinoma.

RESULTS

Chemo- and radiotherapy were followed and so far, the patient showed good recovery without any recurrence and metastasis.

CONCLUSION

Primary cerebellar germinoma has been rarely described in previous literatures. In this paper, a primary cerebellar germinoma was reported and its clinical features and treatments were discussed. The tumor's significant shrinkage by CT- scan was firstly reported and maybe this would provide a valuable hint for the diagnosis and treatment on the intracranial germinomas in children.

Regression of Pineal Lesions: Spontaneous or Iatrogenic? A Case Report and Systematic Literature Review

BACKGROUND

Tumors arising from the pineal region account for approximately 1% of intracranial neoplasms. We present a case of a previously healthy 5-year-old boy with an acute onset of headache. A magnetic resonance imaging (MRI) scan showed a pineal mass with aqueduct compression. The patient was scheduled for tumor resection. An endoscopic third ventriculostomy was performed in advance for the treatment of hydrocephalus. Afterwards, MRI showed a relevant regression of the pineal mass without specific treatment. Consequently, surgery was cancelled and further MRI follow-up showed a regression of the mass and a constant tumor mass over a period of 30 months. Spontaneous regression of malignant tumors is a rare phenomenon with an incidence of 1 of 60,000-100,000 cases. Only a few cases with spontaneous regression of pineal tumors have been reported.

METHODS

We performed a systematic literature review according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines on spontaneously regressing pineal lesions and found 13 cases in the literature.

RESULTS

Six hypotheses for explaining tumor regression were found, comprising treatment with steroids, effects of diagnostic irradiation, treatment of hydrocephalus, pineal apoplexy, surgical trauma, and immunologic mechanisms. None of these mechanisms was evidentiary. However, in all reported cases, some kind of treatment (e.g. treatment of hydrocephalus, application of steroids, and so on) has been performed before tumor regression.

CONCLUSIONS

The clinician has to bear in mind that regression of pineal tumors might be triggered by use of steroids, for example, and in cases of improvement of the patient's presenting symptoms, new MRI scans should be performed.

Microsurgical resection of pineal region tumors

The extensive variety of possible histologic subtypes makes it imperative to establish a tissue diagnosis in patients with pineal region tumors. Management decisions regarding adjuvant therapy, prognosis, and follow-up strategies vary with the histologic diagnosis. Specialized surgical and stereotactic techniques have evolved to provide the neurosurgeon with an array of safe and effective options for obtaining a tissue diagnosis. Advanced microsurgical techniques combined with improved preoperative management and postoperative critical care methods have made aggressive surgical resection a mainstay of management. Aggressive surgical resection has resulted in excellent long-term prognoses for nearly all patients with benign tumors and a large percentage of patients with malignant tumors. However, pineal region surgery remains fraught with potential pitfalls, and these favorable results are dependent on an advanced level of surgical expertise.

Optimal treatment for intracranial germinoma: can we lower radiation dose without chemotherapy?

PURPOSE

To review the effectiveness of reduced-dose and restricted-volume radiation-only therapy in the treatment of intracranial germinoma and to assess the feasibility of reducing or eliminating the use of chemotherapy.

METHODS AND MATERIALS

Between January 1996 and March 2007, a retrospective analysis was performed that included 38 patients who received either reduced radiation alone (30 Gy for 26 patients) or reduced radiation with chemotherapy (n = 12 patients). All 38 patients received extended focal (including whole-ventricle) irradiation and were followed up until February 2008. Overall survival (OS) and relapse-free survival (RFS) rates were calculated. Variables associated with survival were evaluated by univariate Cox proportional hazards regression.

RESULTS

Median follow-up was 62.4 months (range, 10.1-142.5 months). The total 5-year OS rate was 93.7%. The 5-year OS and RFS rates for patients receiving radiation only were 100% and 96.2%, respectively. The rates for those receiving radiation plus chemotherapy were 83.3 % and 91.7%, respectively (not statistically significant). No predictive factor was significantly associated with the OS or RFS rate. Chemotherapy had no significant effect on survival but was associated with a higher incidence of treatment-related toxicity.

CONCLUSIONS

A further decrease in the radiation dose to 30 Gy with whole-ventricle irradiation is sufficient to treat selected patients with intracranial germinoma. Wide-field irradiation or chemotherapy should be avoided as these methods are unnecessary. Thus, reduction of the radiation dose to 30 Gy may be feasible, even without chemotherapy.

Role of stereotactic radiosurgery and fractionated stereotactic radiotherapy in pediatric brain tumors

Brain tumors are the most common solid tumor in childhood. Surgery and/or fractionated radiotherapy are conventional treatment modalities. Stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (FSRT) are advanced radiation therapy techniques that have been frequently used in adults with brain tumors but they are less frequently used in pediatric patients. SRS and FSRT can potentially add to the armamentarium against brain tumors in children. This article will review the role of SRS and FSRT in the management of pediatric brain tumors.

Role of Gamma Knife surgery in the management of pineal region tumors

Object

Increasingly, radiosurgery is used to treat pineal region tumors, either as a primary treatment or as an adjunct to conventional radiation therapy. The authors report their experience with Gamma Knife surgery (GKS) for the treatment of pineal region tumors.

Methods

The authors retrospectively reviewed the charts of all patients undergoing GKS at their institution between 1997 and 2005. Seventeen patients underwent GKS for nonmetastatic tumors of the pineal region. All patients were treated using Leksell Gamma Plan treatment planning software (versions 4.12::5.34). The mean treatment volume was 7.42 cm3 (range 1.2–32.5 cm3). Prescribed doses ranged from 12 to 18 Gy. All doses were prescribed to the 50% isodose line. Independent neuroradiologists reviewed all follow-up imaging studies for evidence of progression of disease.

Results

One patient (Case 10) died 6 days after GKS. Mean clinical and imaging follow-up in the remaining 16 cases was 31 months. Local control was established during a mean neuroimaging follow-up period of 31 months (range 1–95) in 16 patients (100%). In 2 of these 16 patients (one with an anaplastic astrocytoma, the other with a primitive neuroectodermal tumor), leptomeningeal and spinal spread of tumor developed despite control of the pineal lesions. There were no new neurological deficits attributable to GKS. Three patients died (including the one who died 6 days after GKS) during the follow-up period.

Conclusions

Excellent control of pineal region brain tumors can be obtained with GKS when it is used in conjunction with surgery, conventional radiation therapy, or both. Patient survival and quality of life can be optimized through the use of multimodal treatment, including surgery, conventional radiation therapy and/or radiosurgery, and chemotherapy, when applicable.

Pure pineal germinomas: analysis of gender incidence

OBJECTIVE

Pure pineal germinomas have been rarely reported in girls. Gender incidence and differences of pure pineal germinomas are not well known. The authors report a series of pure pineal germinoma and its gender characteristic is reviewed.

METHODS AND RESULTS

Of a total of 50 germ cell tumors operated on between 1988 and 2004 we found 26 cases (median age at diagnosis, 12 years) of pineal germ cell tumors. Of these, 14 cases (male/female ratio: 13/1) were pure pineal germinomas, and 12 cases (male/female ratio: 12/0) were non-germinoma germ cell tumors. In pure pineal germinomas, the main clinical presentations were intracranial hypertension and cranial nerve dysfunction. Imaging studies disclosed a homogeneous type of tumor (n = 10) and associated hydrocephalus (n = 6). Cases were managed with biopsy and subsequent radiation therapy and chemotherapy. After a follow up of 10 years, pure germinoma cases have no neurological deficits and tumor recurrence. The literature on gender incidence of pure pineal germinomas is analyzed and possible causes are discussed.

CONCLUSIONS

Although rare, pure pineal germinoma can be found in female subjects. On the basis of the literature review, the male/female ratio in cases of pure pineal germinoma is between 5:1 and 22:1 (mean 14:1). In our series, the male/female ratio was 13:1.

Stereotactic radiosurgery for brain tumors in pediatric patients

Brain tumors represent the most common solid tumor in children. Fractionated radiation therapy has been an important treatment modality in the multi-disciplinary management of these tumors. Stereotactic radiosurgery is the precise delivery of a single fraction of radiation and has been an important treatment option for adult brain tumor patients. Although the use of stereotactic radiosurgery in pediatric brain tumors is much less frequent, it represents an important alternative for patients with recurrent, surgically inaccessible or radioresponsive tumors. This article will review the results and logistical issues of this modality in the management of pediatric brain tumors.

Stereotactic gamma radiosurgery for pineal and related tumors

The role of gamma knife radiosurgery as an additional therapy after conventional treatments for pineal and related tumors was studied in 30 of 33 tumors with a mean follow-up of 23.3 months. Overall results showed that a complete response was obtained in 8 cases (26.7%) and the response rate was 73.3%. However, tumor progression was found in 8 cases (26.7%), of whom 7 (23.3%) died as a consequence. Germinoma and pineocytoma showed higher response and control rates (100%), and neither progression nor death occurred after gamma knife treatment. Germinoma with syncytiotrophoblastic giant cells (STGC) has been thought to have an intermediate prognosis. Two of our cases showed a partial response and another progression. Malignant germ cell tumor and pineoblastoma showed unfavorable responses and prognosis, with the response and progression rates both being 50%. Gamma knife radiosurgery was the initial treatment in three pineal tumor cases without a histological diagnosis, and one complete and two partial responses were obtained. Gamma knife radiosurgery is expected to be an effective and novel approach to pineal and related tumors, not only as an adjuvant but also as an initial treatment.

Spontaneous regression of a germinoma in the pineal body after placement of a ventriculoperitoneal shunt

The authors report a case in which a germinoma in the pineal body displayed spontaneous regression after placement of a ventriculoperitoneal (VP) shunt. Spontaneous regression of malignant tumors is extremely rare, occurring in only one of 60,000 to 100,000 patients. Although in rare cases spontaneous regression is known to occur in patients with testicular seminomas, only one case of spontaneous regression of a primary pineal germinoma has so far been reported. In the present case a 17-year-old man presented with headache. A tumor in the pineal body and acute hydrocephalus were revealed by head computerized tomography (CT) and magnetic resonance (MR) imaging, and VP shunt placement was performed. Computerized tomography scanning of the head was performed four times during a 2-week period following the operation, and the patient was temporarily discharged to return to school. At the time of discharge, CT scanning demonstrated no change in the size of the tumor. Two months later, the patient was readmitted to the hospital to undergo surgery. At that time, head MR imaging revealed regression of the tumor. The pathological diagnosis of the lesion was germinoma. The patient underwent three courses of chemotherapy, during which carboplatin and etoposide were administered, in addition to a 24-Gy dose of radiotherapy. No manifestations of nerve impairment were noticed, and the patient was observed on an outpatient basis. The authors think that the factors involved in tumor regression included the effects of the VP shunt, the effects of radiation absorbed during head CT scanning, and the role of the patient's own immune response. However, no conclusion has been reached concerning the actual cause.

Primary meningeal melanocytoma of the pineal region. Case report

A unique case of a meningeal melanocytoma located in the pineal region is presented. This 48-year-old man presented with a round pineal region tumor that caused triventricular hydrocephalus and exhibited slow clinical progression. During surgery a black encapsulated tumor was found and totally removed. On histopathological examination, the tumor proved to be a meningeal melanocytoma. In this report cell culture data are presented and the relevant literature is reviewed. The problems of histopathological diagnosis and management of patients with melanocytomas are also discussed.

Linear accelerator radiosurgery in the management of brain tumours

Radiosurgery is an increasingly popular method for treating a variety of intracranial tumours. A great deal of treatment data has been accumulated suggesting that radiosurgery may be the treatment of choice for small acoustic schwannomas. Moreover, radiosurgery promises excellent tumour control and minimal risk in the treatment of small meningiomas in risky surgical locations such as the cavernous sinus. Radiosurgery offers superior local control rates for many metastatic neoplasms and has promise as an adjuvant 'boost' technique in certain malignant gliomas. This article presents a brief description of the linear accelerator, LINAC, radiosurgical technique, followed by a review of the more common applications of stereotactic radiosurgery in the treatment of intracranial neoplastic disease.

Spontaneous regression of a residual pineal tumor after resection of a cerebellar vermian germinoma

A case of multiple intracranial germ cell tumor in which a pineal tumor regressed spontaneously after resection of the cerebellar mass is reported. Immunohistochemical staining of the cerebellar mass showed that most of the infiltrating lymphocytes were positive for CD3 and CD8. The anti-Ki-67 monoclonal antibody MIB-1 staining of the resected tumor revealed a high MIB-1 positivity ratio (36.1%) among the large tumor cells, and TUNEL staining demonstrated that positivity in up to 6% of the tumor cells. Possible mechanisms responsible for this spontaneous regression including immunological responses and apoptosis induced by T lymphocytes are discussed.

Pineal region tumors and the role of stereotactic biopsy: review of the mortality, morbidity, and diagnostic rates in 370 cases

OBJECTIVE

It is classically considered that the morbidity and mortality rates are greater for stereotactic biopsies of pineal region tumors, compared with tumors in other regions. However, to date, the number of cases studied in the literature has been insufficient to evaluate these parameters and compare them with the morbidity and mortality rates for stereotactic biopsies of tumors located elsewhere.

METHODS

With the aim of evaluating these parameters, we reviewed 370 stereotactic biopsies of pineal region tumors, from 15 French neurosurgical centers. We statistically verified the absence of heterogeneity of the different French centers with regard to diagnostic, mortality, and morbidity rates. In contrast, statistical heterogeneity was clearly seen for the large stereotactic biopsy series (for all tumor locations) in the literature.

RESULTS

The mortality rate was 1.3% (5 patients of 370), and 3 patients suffered severe neurological complications. This study is the first to clearly demonstrate that the mortality, morbidity, and diagnostic rates for stereotactic biopsies are not different in the pineal region.

CONCLUSION

Our conclusion is that stereotactic biopsy must remain a main diagnostic modality for tumors of the pineal region.

Radiotherapy of intracranial germinomas

Between 1980 and 1992, 32 patients with intracranial germinomas were treated with radiation. All patients were confirmed histopathologically prior to treatment. Of the 32 intracranial germinomas reviewed, 14 were located in the suprasellar region, 12 in the basal ganglia and thalamus, four in the pineal, and two in both the pineal and suprasellar regions. Three patients had subarachnoid seeding. Craniospinal irradiation was undertaken for 29 patients. The median dose of 54 Gy was delivered to the tumor bed, 36 Gy to the whole brain and 24 Gy to the spinal axis. Five and 10-year survival rates were 96.9 and 96.9%, respectively. Local control was achieved in all patients except one who died of persistent tumor after 2 months following radiotherapy. No intracranial recurrence or spinal metastasis were found. Tumor site did not relate to the prognosis. One patient developed severe intellectual deterioration, three patients had vertebral growth impairment. The present study confirms the excellent result with radiotherapy alone for patients with germinomas.

Pineal region tumours treated with interstitial brachytherapy with low activity sources (192-iridium)

Three patients with tumours of the pineal region underwent interstitial Ir-192 brachytherapy. Histological diagnoses were obtained in all patients, by stereotactic biopsy and included one germinoma, one mixed pineoblastoma/pineocytoma, and one astrocytoma grade III. Our approach to pineal region neoplasms is first to decide whether stereotactic biopsy or surgery should be performed. When a pineal lesion is thought to be benign on the basis of imaging, such as benign teratoma, surgery is performed to resect the entire lesion. When a definitive diagnosis is not possible, stereotactic biopsy is performed to obtain a histological diagnosis for treatment planning, using a Brown-Roberts-Wells (BRW) stereotactic apparatus with computed tomography (CT) or magnetic resonance imaging (MRI). When a lesion is malignant and localized, stereotactic implantation of catheters for interstitial brachytherapy is performed simultaneously. Radioactive Ir-192 seeds are inserted into the catheters and maintained for 5-10 days to give 36 Gy of irradiation at the tumour periphery. Sequential CT scans and MRI after treatment revealed tumour disappearance in two patients with germinoma and high grade astrocytoma and tumour reduction in the patient with mixed pineoblastoma/pineocytoma. No significant morbidity or mortality occurred in any of these patients after stereotactic biopsy and brachytherapy. The technique and the advantages of this therapeutic approach to selected pineal region tumours are described and discussed.

Complete disappearance of giant intracranial germinoma after irradiation

Intracranial germinomas are lesions with a varying, rather benign growth potential, and account for only 0.3 to 1.5% of all brain tumors. About 70% of the patients with these tumors are between 10 and 21 years of age at diagnosis. Germinomas are radiosensitive and respond well also to chemotherapy. The case of a 22-year-old male patient with a giant primary intracranial germinoma originating in the pineal region is presented. Clinical signs and symptoms are described together with neuroradiological, light-microscopic, and immunohistochemical findings. The tumor was irradiated with a total dose of 46 Gy and disappeared completely already after an effective tumor dose of 30 Gy. No recurrence was seen during a follow-up of three years. The patient's quality of life could be preserved and a complete cure was achieved.

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.

The short-term effect of low-dose radiation on intracranial germinoma. A pathologic study

A correlative pathologic and imaging (computed tomography and magnetic resonance imaging) study is reported of a pineal germinoma in a 35-year-old man who died unexpectedly of massive pulmonary embolism on the 8th day during the course of radiation therapy after receiving a total dose of only 1600 cGy. A histologic study of the entire lesion in serial sections revealed no viable tumor cells. The tumor bed was composed of stromal elements with a variable degree of proliferation. The lymphocytic component of the tumor was unaffected by the radiation. This case provided a rare opportunity to show total eradication of tumor cells in a germinoma after a small dose of radiation and supports the notion, based on imaging observations, that histologically proven intracranial pure germinomas may be treated successfully with a much smaller dose of radiation than previously thought.

Stereotactic diagnosis and treatment of pineal region tumours and vascular malformations

Diagnosis and treatment of tumours and vascular malformations in the region of the pineal gland continue to challenge the neurosurgeon's skill. Due to vital vascular and brain structures in the region, microsurgical removal of such masses is often impossible. During the past nine years, we have managed 47 patients with pineal region mass lesions using stereotactic techniques for diagnosis and treatment. In order to determine further therapeutic options, 15 patients underwent stereotactic biopsy of pineal region tumours. In all patients, the histologic diagnosis obtained served to direct further therapy. Thirty-two patients were treated with stereotactic radio-surgery for pineal region tumours or vascular malformations. During the follow-up period, one patient underwent delayed microsurgical resection of a midbrain angiographically occult vascular malformation. No other patient required microsurgical intervention after a stereotactic procedure. In all 47 patients, no significant morbidity or mortality occurred after stereotactic biopsy or radiosurgery. Empiric treatment of pineal region tumours with fractionated radiation therapy is no longer warranted. Image-guided stereotactic technology provides a safe method to accurately diagnose and effectively treat selected pineal region masses. After definitive histologic diagnosis is established, proper treatment may be instituted. Options for treatment include stereotactic radiosurgery for selected tumours and vascular malformations, microsurgical resection of benign tumours or fractionated external beam radiation therapy for malignant germ cell and glial tumours. Stereotactic surgery should be the first option in the diagnosis and therapy of pineal region masses.

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.