Suprasellar embryonal carcinoma which developed ten years after local radiation therapy for pineal germinoma

Fast-developing fatal diffuse leptomeningeal dissemination of a pineal germinoma in a young child: a case report and literature review

BACKGROUND

Intracranial germinomas are uncommon and constitute less than 1% of all intracranial tumors. They usually arise in the midline of the brain, most commonly in the pineal region. Pineal germinomas tend to spread through the cerebrospinal fluid (CSF). However, pineal germinomas with fast-developing diffuse subarachnoid/leptomeningeal dissemination are extremely rare, especially in young children.

METHODS

The case of a 4-year-old boy with a pineal germinoma who died of diffuse subarachnoid/leptomeningeal dissemination 1 month after radiotherapy is reported. A PubMed search with specific key terms was used to review cases of pineal germinomas with metastasis.

RESULTS

The patient presented with a two-week history of worsening headache, visual disturbances and nonprojectile vomiting. Parinaud's sign was positive on physical examination. Head computed tomography (CT)/magnetic resonance imaging (MRI) revealed a lesion in the pineal region with eccentric calcification and obvious supratentorial hydrocephalus. Pineal germinoma was suspected. A ventriculoperitoneal (VP) shunt followed by focal radiotherapy ameliorated the headaches and visual disturbances. The patient was discharged home without further treatment due to financial difficulties. One month after discharge, he was readmitted due to worsening headache, vomiting and lethargy. MRI showed a decrease in the size of the pineal lesion but revealed a diffuse leptomeningeal enhancement including the sulcus, basal cistern, prepontine cistern, and supravermian cistern. The patient's condition deteriorated rapidly, and he died 26 hours after readmission. The characteristics of pineal germinomas with metastasis are reported based on a review of the literature.

CONCLUSIONS

Metastases in pineal germinomas predominately occur in adolescents or young adults, most commonly as spinal "drop metastases." Dissemination usually develops several years after the initial tumor diagnosis and has a relatively good clinical prognosis. However, fast widespread subarachnoid/leptomeningeal dissemination and sudden death may occur in a young child before salvage treatment, as in the presented case.

Intracranial germinoma: clinical and MRI findings in 56 patients

INTRODUCTION

Intracranial germinoma is a rare malignant tumor, only constituting 0.5-2.0% of all primary intracranial tumors. It usually occurs in children and young adults, it is highly sensitive to radiotherapy or/and chemotherapy, and is potentially curable without operation. To make correct pre-operative diagnosis and spare surgical intervention, we retrospectively reviewed 56 patients in our hospital, and presented clinical findings and MRI characteristics.

MATERIALS AND METHODS

We reviewed medical records and magnetic resonance imaging (MRI) of 56 patients. Information regarding sex, age at diagnosis, clinical presentation, duration of symptom, and associated neurologic deficits was noted. The tumor location, number of metastasis, size, margin, involved tissues, and characteristics of signal intensity on MRI were analyzed by two experienced radiologists, respectively.

RESULTS

In the series, 57% of intracranial germinoma was located in pineal region, 32% in suprasellar region, and 9% in basal ganglia region. One patient was found germinoma with synchronous lesions in pineal and suprasellar region. Sixty-three percent of patients were male in pineal region, 39% and 100%, respectively, in suprasellar region and basal ganglia region. Age at diagnosis ranged from 3 to 21 years (mean, 12.5 years) with a peak between 10 and 18 years.

CONCLUSIONS

Intracranial germinoma has some features in terms of age, sex, clinical presentation, and MRI. These features are in favor of pre-operative diagnosis and thus make for good prognosis.

Pineal germinoma

Germinomas are gonadal neoplasms that rarely occur extragonadally in the midline structures of the human body. Newly diagnosed adult cases of pineal gland germinomas are very rare since most of the cases are diagnosed in the mid teens. The estimated incidence of this tumor in western countries is between 0.4-3.4%. Typically, this tumor is diagnosed by its characteristic radiological appearance alone, supported by tumor marker(s) or by stereotactic biopsy of the tumor. We are reporting a very unique case of pineal germinoma diagnosed in an adult at our institute by cerebrospinal fluid cytology with literature review. We analyzed case reports, literature reviews, and therapy and diagnostic articles about pineal germinoma in the English literature from 1983 to 2009 through the national library of medicine, Pubmed, and OVID search engines. We used key words "pineal germinoma," "pineal gland tumor," "CNS germinoma," and "extragonodal germinomas" to search for our articles.

Dual occurrence of pineal germinoma and testicular seminoma. Case report and review of the literature

A 16-year-old male presented with obstructive hydrocephalus secondary to pineal germinoma. There have been many reported cases of abdominal metastasis of pineal germinoma after ventriculoperitoneal shunting. Endoscopic ventriculostomy was preferred in our case, thus avoiding iatrogenic peritoneal seeding, but spinal metastasis was unavoidable. Metastatic infiltration of the ventricular system and spinal meninges is the commonest mode of spread. Later, the patient underwent orchidectomy for an asymptomatic left testicular seminoma. He responded to chemotherapy, and had a complete recurrence-free remission for more than 10 years. As far as we know there are only a handful of reported cases of dual occurrence of two primary germ cell tumors (GCT), i.e. gonadal seminoma and pineal germinoma with spinal seeding. We also addressed the controversial subject of radiation versus chemotherapy in the management of patients with pineal germinomas. A review of the relevant literature and recommendations for future treatment of similar cases are discussed.

Molecular genetics of pineal region neoplasms

A large variety of mass lesions have been reported in the region of the pineal gland. Pineal parenchymal tumors and germ cell tumors (GCTs) are especially characteristic of this region. Despite their rarity, a number of excellent studies on the cytogenetics and molecular genetics of pineal parenchymal tumors and pineal region GCTs have been published. These studies draw attention to a number of distinct genomic regions recurrently involved in the various subtypes of malignancies of the pineal gland. Outcomes for tumors in this location vary widely between patients and among differing histologies. Development of novel therapies for patients with poor prognoses will depend on the acquisition of a more detailed understanding of the molecular basis associated with the etiopathogenesis of these neoplasms. We review the literature on cytogenetics, familial syndromes, animal models and molecular genetics of pineal region neoplasms.

Imaging of pineal apoplexy

The authors present 2 unusual cases of hemorrhagic pineal cysts. CT/MR imaging characteristics are shown.