Metachronous neurohypophyseal germinoma occurring 8 years after total resection of pineal mature teratoma

Suprasellar teratoma to germinoma recurrence: implications for diagnosis and follow-up

Mature teratoma is a subtype of intracranial germ cell tumors (GCTs), distinguished from malignant GCTs by its benign nature and excellent prognosis. Typically, no adjuvant therapy is recommended following gross total resection (GTR). We report a case of a prepubertal girl with a suprasellar mature teratoma that recurred as a germinoma 6 months post-GTR. A 7-year-old girl presented with headache and polydipsia. Imaging revealed a suprasellar mass. The patient underwent GTR, and pathological diagnosis confirmed a mature teratoma without other GCT components. Six months later, MRI identified a newly developed suprasellar mass adjacent to the optic chiasm. A second surgery confirmed the mass as a germinoma. The patient subsequently underwent adjuvant chemotherapy combined with proton therapy, resulting in complete remission. The diagnosis of mature teratoma must be approached with caution, and thorough follow-up is imperative, particularly in cases involving female patients, prepubertal age, or non-pineal locations.

Vasospasm and subsequent stroke from paraneoplastic syndrome in a pediatric patient with an intracranial mature teratoma: a case report

Teratomas account for 18-20% of all intracranial germ cell tumors and mostly occur in the pineal region with only a few cases of pediatric sellar and suprasellar teratomas described in the literature. Here, we present a case of a child with an intracranial mature teratoma with pancreatic features causing vasospasm and subsequent stroke, found to be positive for CDKN2A-an independent variant associated with malignancy and small vessel disease leading to stroke.

Pediatric sellar teratoma - Case report and review of the literature

BACKGROUND

Intracranial teratoma represents a rare neoplasm, occurring predominantly during childhood. Characteristic symptoms depend on the location but are mainly hydrocephalus, visual disturbances, hypopituitarism, and diabetes insipidus. Initial diagnosis can be challenging due to similar radiological features in both teratomas and other lesions such as craniopharyngiomas. Gross total resection is recommended if feasible and associated with a good prognosis.

CASE DESCRIPTION

A 10-year-old girl presented with newly diagnosed growth retardation, fatigue, cephalgia and bilateral hemianopia. Further laboratory analysis confirmed central hypothyroidism and hypercortisolism. Cranial magnetic resonance imaging showed a cystic space-occupying lesion in the sellar and suprasellar compartment with compression of the optic chiasm without hydrocephalus present, suspicious of craniopharyngioma. Subsequently, an endonasal endoscopic transsphenoidal near-total tumor resection with decompression of the optic chiasm was performed. During postoperative recovery the patient developed transient diabetes insipidus, the bilateral hemianopia remained unchanged. The patient could be discharged in a stable condition, while hormone replacement for multiple pituitary hormone deficiency was required. Surprisingly, histopathology revealed conspicuous areas of skin with formation of hairs and squamous epithelia, compatible with a mature teratoma.

CONCLUSIONS

We present an extremely rare case of pediatric sellar teratoma originating from the pituitary gland and a review of literature focusing on the variation in presentation and treatment. Sellar teratomas are often mistaken for craniopharyngioma due to their similar radiographic appearances. However, the primary goal of treatment for both pathologies is to decompress eloquent surrounding structures such as the optic tract, and if applicable, resolution of hydrocephalus while avoiding damage to the pituitary stalk and especially the hypothalamic structures. If feasible, the aim of surgery should be gross total resection.

Rare sphenoid ridge intracranial mature teratoma in an adult female

Intracranially located teratomas usually involve midline brain structures. However, they rarely occur in adults. A 26-year-old woman presented with a growing intracranial mass lesion in the left sphenoid ridge without neurological deficits. Magnetic resonance imaging revealed homogenous hyperintensities without contrast enhancement. The patient underwent gross total excision of the soft, yellowish sphenoid ridge tumor with no cystic component. The surgery was uneventful, with no intraoperative complications. Histological analysis revealed a mature teratoma. She attended regular outpatient neuroradiology follow-up appointments. The present case is an unusual example of a mature teratoma with regard to location, neuroimaging appearance, macroscopic intraoperative findings, histological tumor subtype, and patient age and sex.

Pure germinoma occurring 11 years after total pineal mature teratoma removal: a case report and review of the literature

Intracranial mature teratomas have good prognoses and are usually treated by total tumor resection. We report a rare case of a germinoma that occurred 11 years after total removal of a pineal mature teratoma. A 5-year-old boy presented with headache and nausea and was diagnosed with a pineal tumor and obstructive hydrocephalus on MRI. He underwent total removal of the lesion, which was pathologically diagnosed as a mature teratoma without any other germ cell tumor components. MR images after 11 years showed a newly developed pineal tumor, which was confirmed as a germinoma after neuroendoscopic biopsy. Chemoradiotherapy resulted in complete remission, without any symptoms. This case demonstrated possible late occurrence of germinoma even after total removal of a mature teratoma had been achieved. A long-term follow-up of 10 years or more should be planned for these patients.

Extremely Late Recurrence 21 Years after Total Removal of Immature Teratoma: A Case Report and Literature Review

Immature teratoma (IMT) is normally treated by resection and adjuvant therapy. The present unusual case of recurrent germinoma occurred 21 years after total resection of pineal IMT. A 3-year-old boy presented with headache, disturbance of consciousness, and Parinaud's syndrome. Magnetic resonance (MR) imaging revealed a pineal mass lesion, and total resection of the tumor was achieved. The histological diagnosis was mature teratoma. He did not receive further treatment, and did well without recurrence for 20 years. However, he suffered headache 21 years after resection, and MR imaging revealed a homogeneously enhanced pineal mass with low minimum apparent diffusion coefficient value and proton MR spectroscopy showed a huge lipid peak. The levels of tumor markers were not elevated. Cerebrospinal fluid (CSF) cytology found atypical cells with large nuclei and irregularly shaped nucleoli. To elucidate the relationship between the primary and recurrent tumors, we reviewed the histological specimens and CSF cytology at the initial treatment and found a subset of incompletely differentiated components resembling fetal tissues in the histological specimen and atypical large cells in the CSF. Based on these radiological and histological findings, we presume that the recurrent disease was disseminated germinoma after the resection of disseminated IMT. He received chemotherapy and craniospinal radiation therapy, and the enhanced lesion and atypical cells in the CSF disappeared. This case demonstrates that disseminated IMT can be controlled for the long term without adjuvant therapy, but may recur as germinoma. Tumor dormancy may account for this unusual course.

Clinical management of teratoma, a rare hypothalamic-pituitary neoplasia

Intracranial teratomas are rare and comprise about 0.5 % of all intracranial tumours. Actually, a total of 15 cases of sellar-suprasellar teratoma have been described in the last 24 years. Although rare, hypothalamic-pituitary teratomas should be taken into account in the differential diagnosis of hypothalamic-pituitary region tumours. The current review focuses on the clinical and therapeutic management of pituitary region teratomas. Teratomas occur more frequently in children and young adults than in the older population and in males as compared to females. Symptoms at diagnosis are usually neurological defects, diabetes insipidus and hypopituitarism. Teratoma diagnosis can be suggested though neuroimaging findings. Magnetic resonance imaging remains the preferred modality for assessment of teratoma. Neuro-radiological findings of mixed-density mass, usually with mixed cystic and solid components or inclusions of teeth, fat and calcification can be suggestive. Tumour markers as beta-HCG and alpha-FP can be useful at teratoma diagnosis for distinguishing immature teratomas, mixed GCTs and mature teratomas with immature or malignant components. Optimal treatment for mature teratoma is neurosurgical excision. Radical excision is advocated as recurrence rate for a mature teratoma is extremely low in cases of complete resection and long-term outcome is excellent. During post-treatment follow-up, in cases of healing, according to tumour marker evaluation and contrasted MRI findings, hormone replacement therapy should be considered, also for secondary hypogonadism and GH deficit, with a more intense follow-up. However, as actually few evidence are available, safety data have to be confirmed also trough a surveillance study.

Successful treatment of metastatic βHCG-secreting germ cell tumor occurring 3 years after total resection of a pineal mature teratoma

Patients diagnosed with intracranial teratoma are at risk for developing a recurrent malignant germ cell tumor. We describe a 14-year-old boy initially diagnosed with a mature teratoma in the pineal region that recurred as a metastatic beta-human chorionic gonadotropin (βHCG)-secreting germ cell tumor 3 years after gross total resection. A surveillance brain MRI scan during follow-up demonstrated multiple lesions within the ventricular and subependymal area infiltrating the brain parenchyma along with concomitant elevated levels of βHCG in both the serum and cerebrospinal fluid. The patient underwent chemotherapy with PEI (cis-platinum, etoposide, ifosfamide) followed by radiation therapy according to the SIOP CNS GCT protocol. The patient is currently alive without evidence of disease 35 months after starting therapy.

CONCLUSIONS

A careful and long-term follow-up including scheduled tumor markers as well as surveillance MRI scans is required for patients with intracranial teratoma in an effort to detect and diagnose recurrent malignant disease, especially since multimodal therapy provides the potential for long-term cure.

Mature Intracranial Teratoma

Teratomas constitute a group of nongerminomatous germ cell tumors that are composed of an admixture of different tissue types representative of ectoderm, endoderm and mesoderm. Intracranial teratomas are rare, comprising approximately 0.5% of all intracranial tumors. They preferentially involve the midline structures, and occur primarily in children.

We presented an unusual case of mature intracranial teratoma with extracranial extension in a 24-year-old man who complained of headache, nausea and vomiting. The intracranial expansive lesion was localized in the left frontotemporobasal region extending into the ipsilateral orbit. The patient underwent total resection of the tumor. No adjuvant treatment was given. On gross examination, the resected tumor was lobulated, containing heterogeneous solid and cystic components. Histologic investigation revealed the presence of various fully differentiated tissues representative of the three germ cell layers, including adipose tissue, cartilage, bone, striated muscle bundles, brain tissue, respiratory epithelium and glandular structures. The diagnosis of mature teratoma was established. Follow-up at four years did not show any evidence of recurrence.

The presented case is an unusual example of mature teratoma with regards to the age of the patient and, especially, to the location of the tumor, both intraand extracranially. It is critical to recognize this rare entity by extensive sampling to rule out the presence of immature elements which may constitute only a minor part of the tumor.

Occurrence of metachronous pure germinomas long after treatment of a mixed germ cell tumor containing yolk sac tumor and germinoma

The authors report a rare case involving the occurrence of metachronous pure germinomas long after treatment of a mixed germ cell tumor (GCT) categorized as having a poor prognosis. A neurohypophysial germinoma occurred 4 years and 6 months after the initial treatment of a mixed pineal GCT containing a yolk sac tumor and a germinoma. Furthermore, intramedullary germinomas occurred 21 years after the initial treatment of the mixed GCT and 15 years after the second treatment of the neurohypophysial germinoma. The neurohypophysial germinoma was not confirmed histopathologically, but the intramedullary germinoma was histopathologically diagnosed as a pure germinoma. Serum α-fetoprotein levels at the second neurohypophysial and third intramedullary occurrences of the germinomas were less than 10 ng/ml. Therefore, no yolk sac components seemed to be contained in the tumors. The second neurohypophysial and third intramedullary germinomas might be recurrences of the germinoma component of the pineal mixed GCT, which consisted of a yolk sac tumor and a germinoma. However, it seems very unlikely that only the germinoma, categorized in the good prognosis group, would be the only one to recur. Hence, it seems plausible that both the second and the third occurrences of pure germinoma were de novo metachronous GCTs arising after the pineal mixed GCT was cured. The authors' case indicates the possibility of multicentric GCTs in the CNS.

Cerebral falx mature teratoma with rare imaging in an adult

Intracranial mature teratoma is a rare lesion in adults. Despite several intracranial mature teratomas had been reported not to be located at the midline region, no one was found to be within cerebral falx. Herein, we reported a 37-year-old female patient with an intracranial mature teratoma confined within frontal cerebral falx. Her main complaint was intermitted headache, which could not be relieved recently by taking painkiller. Excepting for mild papilledema, we did not find positive neurological signs on physical examination. CT scanning showed it was a round homogenously hypodense lesion with hyperdense signal at its rim. MRI revealed the lesion was 3.5 cm×3.6 cm×4.5 cm in volume, with uniformed hypointensity on T1WI, hyperintensity on T2WI and enhancement in the capsule. It was totally removed via inter-hemispheric approach, and we found the lesion was confined within the frontal cerebral falx. Postoperatively, it was proved histologically to be a mature teratoma. At three years of fellow up, neither neurological deficits nor recurrent sings on MRI was found. To our best knowledge, this is the first case of intracranial mature teratoma within cerebral falx.

Metachronous mature teratoma in the corpus callosum occurring 12 years after a pineal germinoma

The authors report a metachronous germ cell tumor with different histological type occurring 12 years after resection of a pineal germinoma. Histological examination of the original tumor revealed germinoma without any other component of germ cell tumor, and the patient underwent chemotherapy followed by 24 Gy of localized irradiation. Twelve years later, follow-up MR imaging showed a round mass in the genu of the corpus callosum. Two courses of chemotherapy were administered, but the tumor size remained stable. A second operation was performed and this second tumor was completely removed. The histological diagnosis was mature teratoma. The second tumor was considered as a metachronous mature teratoma rather than a recurrence of the original germinoma. To the authors' knowledge, this combination of metachronous germ cell tumor has not previously been reported in the literature

Malignant transformation of intracranial mature teratoma to yolk sac tumor after late relapse

✓ The recurrence of intracranial mature teratomas as germ cell tumors of different histological types is rarely reported. The authors describe the first case of the malignant transformation of an intracranial mature teratoma into a yolk sac tumor in a 16-year-old boy who presented with a 1-month history of anorexia and somnolence. Seven years prior to this presentation, the boy had undergone surgery for extirpation of a mature pineal teratoma. Computed tomography images obtained at his second presentation revealed a homogeneously enhanced mass within the third ventricle. The tumor was resected and the results of a histological examination were consistent with a yolk sac tumor. After resection, the patient underwent radiation therapy followed by chemotherapy with cisplatin and etoposide but died of tumor progression 15 months after his second hospitalization.

De novo germinoma in the brain in association with Klinefelter's syndrome: case report and review of the literature

BACKGROUND

There are no previous reports about de novo germ cell tumors without any past history of germ cell tumor. We describe a case of de novo cerebral germinoma in association with Klinefelter's syndrome.

CASE DESCRIPTION

A boy had undergone growth hormone therapy for dwarfism because of hypopituitarism from 10 to 17 years old. The result of karyotyping at the age of 13 was 47,XXY. Magnetic resonance images (MRI) of the brain at the age of 17 years showed no lesions. Two years later, at the age of 19, the patient noticed onset of mild right hemiparesis. MR imaging revealed the existence of a brain tumor in the left temporal lobe and hypothalamus. The patient underwent an operation and the histologic diagnosis of the lesion was germinoma. After postoperative chemotherapy and radiation therapy, the lesion disappeared and the patient was discharged uneventfully.

CONCLUSIONS

To the best of the authors' knowledge, this is the first reported case of a germ cell tumor to be de novo without any past history of other germ cell tumor and the seventh case in which it occurred in association with Klinefelter's syndrome.

Bilateral metachronous germinoma of the basal ganglia occurring long after total removal of a mature pineal teratoma: case report

OBJECTIVE AND IMPORTANCE

We report the extremely rare occurrence of a second germ cell tumor at a different site and with different histological types long after total removal of a mature pineal teratoma.

CLINICAL PRESENTATION

A 10-year-old boy who presented with headache and vomiting was admitted to our hospital. Neuroradiological studies revealed a tumor in the pineal region. The tumor was totally removed. Histologically, the tumor proved to be a mature teratoma. The patient's postoperative course was uneventful. The patient received no adjuvant therapy and was followed in the outpatient clinic. Three years later, he was readmitted with transient left upper limb weakness and vomiting. Neuroradiological studies showed a tumor in the bilateral basal ganglia.

INTERVENTION

The second tumor, which was located in the right basal ganglion, was partially removed for biopsy. Histologically, the tumor proved to be a germinoma. The patient received three cycles of combination chemotherapy consisting of carboplatin and etoposide with radiotherapy. After the second course of chemotherapy, magnetic resonance imaging studies revealed no evidence of the tumor.

CONCLUSION

The second tumor was considered to be a de novo metachronous neoplasm rather than a recurrence of the original mature teratoma. We think that if primordial germ cell groups exist along the midline of the brain, more than two primordial germ cell groups could give rise to metachronous neoplasms at different sites and with different histological types.

Intrathecal and intraperitoneal germinomas occurring 20 years after total removal of a pineal teratoma. Case report

In 1980, a 10-year-old boy was admitted to the authors' hospital with consciousness disturbance and vomiting. Computerized tomography (CT) scans revealed a pineal mass lesion and hydrocephalus. The tumor was totally removed and a ventriculoperitoneal (VP) shunt was inserted. Histological investigation of a surgical specimen revealed that it was a teratoma. Five years later, the patient was readmitted to the same institution with polyuria. Magnetic resonance (MR) imaging revealed a mass lesion in the suprasellar region. The patient received systemic chemotherapy, and the tumor disappeared; however, 2 years after the chemotherapy, MR imaging demonstrated a right lateral ventricular mass. The tumor was totally resected, and histopathological investigation revealed a teratocarcinoma. Three years after the chemotherapy, CT scanning revealed suprasellar and right lateral ventricular tumor recurrences, for which the patient received irradiation and chemotherapy. The tumors disappeared and the patient achieved complete remission that lasted longer than 10 years. On January 25, 2000, however, he noticed hip pain. Lumbar MR imaging demonstrated a spinal tumor below L-4 and also an abdominal tumor. The abdominal tumor was totally removed, and the histological findings identified it as a germinoma. The patient received systemic chemotherapy and the tumor disappeared completely. The authors believe that the suprasellar tumor was a metachronous germinoma and that it had metastasized through the intrathecal route and the VP shunt.

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.

Mature teratoma arising from the sella--case report

A 26-year-old, short statured, obese male presented with a mature teratoma located entirely within the dural confines of the sella manifesting as headaches and progressive loss of vision. He had panhypopituitarism. Magnetic resonance imaging showed a large sellar-suprasellar but entirely infradiaphragmatic tumor of varying consistency. The tumor was resected through a trans-sphenoidal route. The tumor had elevated the diaphragma sellae to a significant extent but did not pass through. Histological examination confirmed a mature teratoma.

Teratomas of the central nervous system: treatment considerations based on 34 cases

OBJECT

The optimum clinical management of central nervous system (CNS) teratomas, particularly postsurgical adjuvant therapy, is still unclear, partly as a result of the tumors' low incidence. In this study the authors analyze 34 cases of CNS teratomas so that they may adequately indicate management of these lesions.

METHODS

The median age of the 34 patients was 13 years. Twenty-seven patients treated between 1970 and 1991 were retrospectively reviewed. Four of these 27 patients died as a result of radical surgery; each of them had a teratoma involving the hypothalamus. After initial treatment, which included radiation therapy, 20 patients (48%) had died. In all seven cases of mature teratomas there was no recurrence. In two cases of immature teratomas in which there was complete surgical resection there was recurrence; however, salvage therapies were effective. Seven of eight patients with highly malignant teratomas died; for these patients salvage therapies, including repeated radiation and chemotherapy, failed. Seven patients who presented with CNS teratomas between 1992 and 1996 received adjuvant chemotherapy and radiation therapy according to a prospective study protocol. All seven patients were free from recurrence with a 70 to 100% Karnofsky Performance Scale score at a median follow-up period of 41 months. Patients with CNS teratomas rarely responded completely to chemotherapy or radiation therapy; an effective adjuvant therapy produced a partial response at best.

CONCLUSIONS

Because teratomas show various responses to adjuvant therapy, a misdiagnosis of their histological subtype will lead to inadequate therapy. A diverse therapeutic protocol based on histological diagnosis is necessary to plan appropriate management. Treatment recommendations are discussed in detail in the article.