Late recurrence of pineal germinoma

Molecular Pathology and Targeted Therapies for Personalized Management of Central Nervous System Germinoma

Intracranial germinomas are rare tumours, usually affecting male paediatric patients. They frequently develop in the pineal and suprasellar regions, causing endocrinological disturbances, visual deficits, and increased intracranial pressure. The diagnosis is established on magnetic resonance imaging (MRI), serum and cerebrospinal fluid (CSF) markers, and tumour stereotactic biopsy. Imaging techniques, such as susceptibility-weighted imaging (SWI), T2* (T2-star) gradient echo (GRE) or arterial spin labelling based perfusion-weighted MRI (ASL-PWI) facilitate the diagnosis. Germinomas are highly radiosensitive tumours, with survival rates >90% in the context of chemoradiotherapy. However, patients with resistant disease have limited therapeutic options and poor survival. The aim of this review is to highlight the genetic, epigenetic, and immunologic features, which could provide the basis for targeted therapy. Intracranial germinomas present genetic and epigenetic alterations (chromosomal aberrations, KIT, MAPK and PI3K pathways mutations, DNA hypomethylation, miRNA dysregulation) that may represent targets for therapy. Tyrosine kinase and mTOR inhibitors warrant further investigation in these cases. Immune markers, PD-1 (programmed cell death protein 1) and PD-L1 (programmed death-ligand 1), are expressed in germinomas, representing potential targets for immune checkpoint inhibitors. Resistant cases should benefit from a personalized management: genetic and immunological testing and enrolment in trials evaluating targeted therapies in intracranial germinomas.

Ectopic germinoma in the corpus callosum with severe restrictive anorexia: case report and review of literature

Intracranial germ cell tumors are a rare group of neoplasms constituting 1% to 2% of primary intracranial tumors in North America and Europe. Germinomas of the corpus callosum are exceedingly rare, accounting for only 0.7% of all intracranial germ cell tumors. We report a case of germinoma in the corpus callosum of a 17-year-old woman with a 2-year history of personality change, anorexia, amnesia, hypersomnia, and depression. Magnetic resonance imaging (MRI) showed a well-circumscribed, heterogeneous mass measuring 2.9 × 5 × 3.1 cm, with multiple cystic areas and heterogeneous enhancement with gadolinium. It arose in the corpus callosum and extended to the fornix and frontal lobes. There was mild perilesional edema but no evidence of hypothalamus or hippocampus involvement. No spinal drop metastases were visualized on MRI. Cerebrospinal fluid and serum levels of alpha-fetoprotein, beta-human chorionic gonadotropin, carcinoembryonic antigen, and placental alkaline phosphatase (PLAP) were all normal. Immunohistologic staining of tumor cells was positive for OCT3/4, PLAP, and CD117 and negative for CD30 and GPC3. Radiotherapy led to a substantial decrease in tumor size. This is a case of germinoma arising in the corpus callosum that presented clinically with an eating disorder manifested as restrictive anorexia.

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.

Ectopic intracranial germinoma

Intracranial ectopic germinomas are often associated with synchronous midline disease. Germinomas involving the corpus callosum are exceedingly rare. The reported imaging appearance is not as varied as one might expect and a review of the literature reveals a few common imaging features amongst most ectopic lesions, including cyst formation. We report a 24-year-old man with panhypopituitarism. Neuroimaging revealed three enhancing lesions involving the pituitary infundibulum, the pineal region, and a parenchymal lesion involving the genu of the corpus callosum. The described ectopic mass, a parenchymal lesion, was associated with small peripheral cysts. Stereotactic biopsy and histopathological evaluation revealed this mass to be a germinoma. Following chemotherapy and radiation therapy, there was near-total resolution of the intracranial disease. Preoperative imaging plays an important role, not only in delineating the extent of disease, but also in assisting in generating an appropriate differential diagnosis. Germinomas in the corpus callosum are exceedingly rare but should be considered in the differential of any young patient with a characteristic cystic and solid intra-axial mass.

MRI and MR spectroscopy findings of the evolution of an intracranial germinoma: A case report

Intracranial germinomas (IG) are rare tumors that typically occur in the pineal gland and suprasellar region of the brain. IG can be successfully treated with radiation therapy and its recurrence is rare. The present study reports the case of a patient with IG involving the pineal and suprasellar regions. The patient was treated with radiotherapy, achieving significant remission. However, recurrence was discovered 10 months later. The patient was subsequently treated with chemotherapy and radiotherapy, resulting in gradual remission. The patient had recovered 2 months later and was in good health. The entire evolution process, including magnetic resonance (MR) imaging and MR spectroscopy findings, are described herein. The present case suggests that MR spectroscopy may be useful for monitoring the effects of treatment.

Tumores de células germinativas intracranianos na infância: avaliação de 14 casos

Este estudo avalia o diagnóstico, a terapia e a sobrevida de 14 pacientes com tumor de células germinativas intracraniano durante o período entre 1991 e 2001. Onze pacientes eram do sexo masculino e três do feminino. A média de idade do grupo foi 12,5 anos (20 dias-18 anos). Na admissão, os mais comuns sintomas foram cefaléia (10/14), vômitos (6/14) e visuais (6/14). Os tumores estavam localizados em região hipotalâmica/hipofisária em 10 casos, suprasselar em 3 casos e intraparenquimatosa em 1 caso. Histologicamente, havia 1 caso de carcinoma embrionário, 5 de germinomas, 2 de teratoma maduro, 1 de teratoma imaturo e 5 de tumores mistos. O tratamento foi variável, dependendo da histologia da lesão. Três pacientes morreram após a progressão tumoral ou recidiva e um paciente morreu devido causa não relacionada ao tumor. Os demais estão vivos e sem doença.