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Karita H, Koiso T, Muroi A, Sakamoto N, Zaboronok A, Ishikawa E. Preoperatively difficult-to-diagnose medulla oblongata germinoma: A case report and literature review. Surg Neurol Int 2023; 14:366. [PMID: 37941640 PMCID: PMC10629303 DOI: 10.25259/sni_682_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/22/2023] [Indexed: 11/10/2023] Open
Abstract
Background Intracranial germinomas are rare tumors, accounting for 0.5-2% of primary intracranial neoplasms. While they typically occur in the pineal gland, suprasellar region, basal ganglia, and thalamus, germinomas arising in the medulla oblongata are exceptionally rare. Diagnosis of medulla oblongata germinoma is challenging, potentially leading to misdiagnosis and poor prognosis. Case Description We present a case of a 29-year-old man complaining of left leg numbness. Radiological findings revealed a contrast-enhanced lesion in the medulla oblongata. The patient underwent tumor biopsy, and intraoperative pathological diagnosis (IOD) suspected the diagnosis of medulla oblongata germinoma. He underwent chemoradiotherapy after confirming the diagnosis of germinoma. Intracranial germinoma arising in the medulla oblongata differs from germinomas in other locations due to its higher incidence in individuals in their 20s and a slight female predominance. Conclusion When encountering lesions in the medulla oblongata, germinoma should be considered as one of the differential diagnoses, and surgical strategies including IOD should be planned accordingly.
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Affiliation(s)
- Hiroki Karita
- Department of Neurosurgery, University of Tsukuba, Tsukuba, Japan
| | - Takao Koiso
- Department of Neurosurgery, University of Tsukuba, Tsukuba, Japan
| | - Ai Muroi
- Department of Neurosurgery, University of Tsukuba, Tsukuba, Japan
| | | | | | - Eiichi Ishikawa
- Department of Neurosurgery, University of Tsukuba, Tsukuba, Japan
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Ronsley R, Bouffet E, Dirks P, Drake J, Kulkarni A, Bartels U. Successful management of symptomatic hydrocephalus using a temporary external ventricular drain with or without endoscopic third ventriculostomy in pediatric patients with germinoma. J Neurosurg 2022; 137:807-812. [PMID: 35238528 DOI: 10.3171/2021.8.jns211443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to describe the management of hydrocephalus in a cohort of pediatric patients with germinoma. METHODS The authors conducted a retrospective chart review of patients with germinoma and symptomatic hydrocephalus treated at the Hospital for Sick Children between 2002 and 2020. Descriptive data included tumor location, CSF diversion procedure (external ventricular drain [EVD], endoscopic third ventriculostomy [ETV], ventriculoperitoneal [VP] shunt) and outcomes. The frontooccipital horn ratio (FOR) method was used to determine the presence of ventriculomegaly. RESULTS Of 39 patients with germinoma, 22 (73% male) had symptomatic hydrocephalus at diagnosis (11 pineal, 4 suprasellar, and 7 bifocal). Management of hydrocephalus included EVD (n = 5, 22.7%), ETV (n = 5, 22.7%), and combination ETV and EVD (n = 7, 31.8%), whereas 5 patients (22.7%) did not undergo surgical intervention. The median FOR at diagnosis was 0.42 (range 0.38-0.58), which correlated with moderate to severe ventriculomegaly. Carboplatin and etoposide-based chemotherapy induced fast tumor shrinkage, avoiding CSF diversion (n = 5) and resolving hydrocephalus with a transient EVD (n = 5). The median duration until EVD removal was 7 days (range 2-10 days). Two of 12 patients with EVD ultimately required a VP shunt. Kaplan-Meier overall survival was 100% and progression-free survival was 96.4% at a median follow-up of 10.4 years. CONCLUSIONS Timely initiation of chemotherapy is imperative to rapidly reduce tumor bulk in children with germinoma and limits the need for VP shunt insertions. In children in whom CSF diversion is required, hydrocephalus may be successfully managed with a temporary EVD ± ETV.
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Affiliation(s)
- Rebecca Ronsley
- 1Division of Hematology, Oncology & Bone Marrow Transplant, Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia
| | - Eric Bouffet
- 2Division of Hematology, Oncology & Bone Marrow Transplant, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Ontario; and
| | - Peter Dirks
- 3Pediatric Neurosurgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - James Drake
- 3Pediatric Neurosurgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Abhaya Kulkarni
- 3Pediatric Neurosurgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Ute Bartels
- 2Division of Hematology, Oncology & Bone Marrow Transplant, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Ontario; and
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Albiña P, Solis A, Lorenzoni J, Henny P, Manriquez M. Primary germinoma of the medulla oblongata: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21315. [PMID: 35733824 PMCID: PMC9204933 DOI: 10.3171/case21315] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 04/11/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Primary central nervous system germinomas of the medulla oblongata are extremely rare and usually have been found in young female Asian patients. The authors present an illustrative case of a patient who presented with severe medullary and posterior cord syndrome, the first South American case published to date, to the authors’ knowledge. OBSERVATIONS Initially, the radiological differential diagnosis did not include this entity. The lesion was located at the obex and exhibited a well-delineated contrast enhancement without hydrocephalus. An emergency decompressive partial resection following functional limits was performed. After histological confirmation, radiotherapy was indicated, with complete remission achieved at a 6-month follow-up. The patient, however, continued to have a severe proprioceptive disorder. The literature review identified 21 other such patients. The mean age for this location was 23 years, with a strong female and Asian origin predilection. All tumors exhibited contrast enhancement, and only one presented with hydrocephalus. LESSONS In the absence of elevated tumor markers, radiological clues such as a well-delineated, contrast-enhanced lesion arising from the obex, without hydrocephalus, associated with demographic features such as young age, female sex, and Asian heritage, should evoke a high level of suspicion for this diagnosis. Gross total resection must not be attempted, because this tumor is potentially curable with high-dose radiotherapy.
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Affiliation(s)
- Pablo Albiña
- Neuroanatomy Lab, Department of Anatomy, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Neurosurgery, Hospital Barros Luco Trudeau, Santiago, Chile
| | - Aracelly Solis
- Intensive Care Unit, National Institute of Neurosurgery Dr. Asenjo, Santiago, Chile
| | - Jose Lorenzoni
- Department of Neurosurgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pablo Henny
- Neuroanatomy Lab, Department of Anatomy, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Interdisciplinary Center for Neuroscience, NeuroUC, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; and
| | - María Manriquez
- Department of Pathology, Military Hospital of Santiago, Santiago, Chile
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Li B, Feng J, Chen L, Li Y, Wang J, Lv W, Li Y, Liu Y, Liu S, Luo S, Qiu X. Relapse pattern and quality of life in patients with localized basal ganglia germinoma receiving focal radiotherapy, whole-brain radiotherapy, or craniospinal irradiation. Radiother Oncol 2021; 158:90-96. [PMID: 33610622 DOI: 10.1016/j.radonc.2021.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 01/21/2021] [Accepted: 02/08/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE The optimal target volume in localized basal ganglia (BG) germinoma is still undetermined. Thus, based on the relapse pattern and health-related quality of life (HRQOL), we evaluated three target volumes. MATERIAL AND METHODS The clinical data of 161 patients with localized BG germinoma were included in this retrospective study. Relapse status and relapse sites after treatment were explored. HRQOL was evaluated using the Pediatric Quality of Life Inventory 4.0 (PedsQL 4.0) (≤15 years) and Short Form-36 (SF-36) (>15 years) questionnaires based on the patients' age at last follow-up. RESULTS After a median follow-up duration of 83 months (range, 20-214 months), 19 patients experienced relapse, including 15, 4, and 0 patients in the focal radiotherapy (FR) (n = 35), whole-brain radiotherapy (WBRT) plus boost (n = 109), and craniospinal irradiation (CSI) plus boost (n = 17) groups, respectively. The 5-year disease-free survival rates were 74.3%, 97.2%, and 100%, respectively (p < 0.001). Among the 15 patients who relapsed after FR, 14 had positive radiological findings, including seven (50.0%) with lesions in the periventricular area and seven (50.0%) with frontal lobe lesions. Relapse in both these areas were significantly reduced by WBRT or CSI. HRQOL data were available for 69 patients, who generally scored low. Among 38 patients evaluated by SF-36, those receiving CSI had significantly lower mental component scores than those receiving WBRT (p = 0.027) or FR (p = 0.011). CONCLUSIONS Considering both disease control and HRQOL, WBRT is the optimal target volume in our series. The relapse pattern identified in patients receiving FR is informative for further treatment volume optimization.
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Affiliation(s)
- Bo Li
- Department of Radiation Oncology, Beijing Tiantan Hospital, Capital Medical University, China; Beijing Neurosurgery Institute, Capital Medical University, China
| | - Jin Feng
- Department of Radiation Oncology, Beijing Tiantan Hospital, Capital Medical University, China
| | - Li Chen
- Department of Radiation Oncology, Beijing Tiantan Hospital, Capital Medical University, China
| | - Youqi Li
- Department of Radiation Oncology, Beijing Tiantan Hospital, Capital Medical University, China
| | - Jiayi Wang
- Department of Radiation Oncology, Beijing Tiantan Hospital, Capital Medical University, China
| | - Wenyi Lv
- Department of Radiation Oncology, Beijing Tiantan Hospital, Capital Medical University, China
| | - Yanong Li
- Department of Radiation Oncology, Beijing Tiantan Hospital, Capital Medical University, China
| | - Yanwei Liu
- Department of Radiation Oncology, Beijing Tiantan Hospital, Capital Medical University, China
| | - Shuai Liu
- Department of Radiation Oncology, Beijing Tiantan Hospital, Capital Medical University, China
| | - Shiqi Luo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China
| | - Xiaoguang Qiu
- Department of Radiation Oncology, Beijing Tiantan Hospital, Capital Medical University, China; Beijing Neurosurgery Institute, Capital Medical University, China
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Lee JW, Lim DH, Sung KW, Cho HW, Ju HY, Yoo KH, Koo HH, Kim JH, Suh YL, Shin HJ. Induction Chemotherapy Reduces Radiation Therapy Dose and Volume in the Treatment of Intracranial Germinoma: Results of the SMC-G13 Trial. Int J Radiat Oncol Biol Phys 2020; 108:649-656. [PMID: 32502506 DOI: 10.1016/j.ijrobp.2020.05.051] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 05/20/2020] [Accepted: 05/23/2020] [Indexed: 01/14/2023]
Abstract
PURPOSE We performed a prospective single-arm trial (NCT02782754) to explore the feasibility of reducing radiation therapy (RT) dose when induction chemotherapy is combined in the treatment of intracranial germinoma with beta-human chorionic gonadotropin levels <200 mIU/mL. METHODS AND MATERIALS All patients aged 3 to 35 years from November 2012 to June 2018 were eligible for this study. Four cycles of induction chemotherapy were given before RT. Carboplatin/etoposide and cyclophosphamide/etoposide regimens were used in alternation every 3 weeks. A dose of 18 Gy of craniospinal RT for metastatic tumors, whole brain RT for basal ganglia tumors, or otherwise whole ventricular RT followed by 12.6 Gy of boost RT to the primary tumor bed was administered after induction chemotherapy. The primary endpoint of this study was progression-free survival. RESULTS A total of 41 consecutive patients were enrolled (location: suprasellar in 12, pineal in 12, both suprasellar and pineal in 11, and basal ganglia in 6 patients). Eleven patients had leptomeningeal seeding. Toxicity during chemotherapy was mild, except for bone marrow suppression. Tumor status after induction chemotherapy was complete response in 33 patients and partial response in 8. All but 2 patients completed the scheduled treatment. All patients but 1 remained event free during a median follow-up of 3.4 (range, 0.3-7.0) years from diagnosis. The 1 patient experienced relapse and died of tumor bleeding. Late effects were not significant except for neuroendocrine dysfunction already present at diagnosis. Vertical growth and cognitive function were not significantly disturbed by treatment. CONCLUSIONS This study showed the feasibility of reducing RT dose/volume with induction chemotherapy in pathologically pure germinoma with elevated beta-human chorionic gonadotropin levels up to 200 mIU/mL.
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Affiliation(s)
- Ji Won Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ki Woong Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Hee Won Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hee Young Ju
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Keon Hee Yoo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hong Hoe Koo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ji Hye Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yeon-Lim Suh
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyung Jin Shin
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Yeo KK, Kayser K, Margol AS, Wong KK, Robison N, Finlay J, Dhall G. Clinical and neuropsychological outcome of pediatric non-midline central nervous system germinoma treated with chemotherapy and reduced dose/volume irradiation: The Children's Hospital Los Angeles experience. Pediatr Blood Cancer 2019; 66:e27983. [PMID: 31502379 DOI: 10.1002/pbc.27983] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/19/2019] [Accepted: 08/20/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Germ cell tumors (GCT) arising from non-midline structures (basal ganglia, thalamus, and posterior fossa) are rare. Although patients with midline (pineal and suprasellar) germinoma have excellent survival with chemotherapy and whole ventricular irradiation (WVI), germinoma in non-midline locations have traditionally been treated with craniospinal irradiation (CSI) or whole brain irradiation (WBI) to achieve similar outcomes. However, CSI and WBI are associated with significant long-term neuropsychological sequelae. METHODS We describe the clinical and neuropsychological outcomes of patients with non-midline germinoma treated at the Children's Hospital Los Angeles between 1990 and 2015. RESULTS Nine patients had basal ganglia/thalamic germinoma and one patient had a cerebellar primary. Eight patients received chemotherapy followed by reduced dose/volume irradiation, whereas two patients received chemotherapy alone as upfront therapy. One patient in the chemotherapy alone group relapsed after 4.3 years and was salvaged with CSI plus boost. The overall survival for the entire cohort was 100% at a median follow-up of 8.5 years. Neuropsychological data were available for six patients at a median of five months (baseline) and 4.2 years (follow-up) post-diagnosis. At four-year follow-up, data available revealed intact overall cognitive ability, verbal memory, and executive functioning, but persistent deficits in fine motor function. Comparison of baseline to follow-up suggests a downward trend in working memory, planning/problem-solving, verbal memory, and visuospatial integration. CONCLUSION Chemotherapy followed by reduced dose/volume of irradiation is an effective strategy resulting in long-term survival in patients with non-midline germinoma. Neuropsychological data suggest relatively minimal morbidity over time.
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Affiliation(s)
- Kee Kiat Yeo
- Children's Center for Cancer and Blood Diseases, Division of Hematology, Oncology and Blood and Marrow Transplantation, Children's Hospital Los Angeles, Los Angeles, California.,Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Kimberly Kayser
- Children's Center for Cancer and Blood Diseases, Division of Hematology, Oncology and Blood and Marrow Transplantation, Children's Hospital Los Angeles, Los Angeles, California
| | - Ashley S Margol
- Children's Center for Cancer and Blood Diseases, Division of Hematology, Oncology and Blood and Marrow Transplantation, Children's Hospital Los Angeles, Los Angeles, California
| | - Kenneth K Wong
- Children's Center for Cancer and Blood Diseases, Division of Hematology, Oncology and Blood and Marrow Transplantation, Children's Hospital Los Angeles, Los Angeles, California.,University of Southern California, Department of Radiation Oncology, Los Angeles, California
| | - Nathan Robison
- Children's Center for Cancer and Blood Diseases, Division of Hematology, Oncology and Blood and Marrow Transplantation, Children's Hospital Los Angeles, Los Angeles, California
| | - Jonathan Finlay
- The Neuro-oncology Program, Division of Hematology, Oncology and BMT, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Girish Dhall
- Children's Center for Cancer and Blood Diseases, Division of Hematology, Oncology and Blood and Marrow Transplantation, Children's Hospital Los Angeles, Los Angeles, California.,The Alabama Center for Childhood Cancer and Blood Disorders at Children's of Alabama, University of Alabama at Birmingham (UAB), Birmingham, Alabama
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Emergency irradiation with 3.4 Gy/2f in sellar/suprasellar germinoma patients with rapid visual acuity decline. Chin Med J (Engl) 2019; 132:2073-2078. [PMID: 31261204 PMCID: PMC6793780 DOI: 10.1097/cm9.0000000000000315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Rapid visual acuity (VA) decline was a common complaint in patients with sellar/suprasellar germinoma. In our hospital, 3.4 Gy/2f of emergency irradiation was applied to save patient VA and enable subsequent chemoradiotherapy. This study aimed to investigate the efficacy of emergency irradiation with 3.4 Gy/2f in patients with sellar/suprasellar germinoma who had rapid VA decline. Methods: From January 2014 to December 2017, 33 patients with sellar/suprasellar germinoma who complained of VA decline within 3 months received 3.4 Gy/2f of emergency irradiation in Beijing Tiantan Hospital. The best-corrected VA (BCVA) and mean deviation (MD) were measured. Correlations between visual function change and clinical factors, including age at diagnosis, duration of VA decline, extent of tumor regression, serum level of tumor markers, were analyzed. Results: Among 33 patients with sellar/suprasellar germinoma, the median diameter and volume of sellar/suprasellar lesions were 32 mm (range: 5–55 mm) and 12.9 cm3 (range 0.6–58.5 cm3), respectively. Data on pre- and post-emergency-irradiation BCVA were obtained in 32 patients. For the right eyes, BCVA was improved in 23 patients (71.9%), unchanged in 7 (21.9%), and worsened in 2 (6.2%); and for the left eyes, these numbers were 27 (84.4%), 4 (12.5%), and 1 (3.1%), respectively. In terms of the logarithm of the minimum angle of resolution (logarithm of the minimum angle of resolution = Log (1/BCVA) score, the improvement was significant in both eyes (P < 0.001). In terms of MD, six patients had paired data and the improvement was marginal in the right eyes (P = 0.068) and significant in the left eyes (P = 0.043). However, no clinical factor was found to have correlation with visual function improvement. Conclusion: In sellar/suprasellar germinoma patients with VA decline, 3.4 Gy/2f of emergency irradiation was effective in improving visual function.
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Hatiboglu MA, Kocyigit A, Guler EM, Nalli A, Akdur K, Sakarcan A, Ozek E, Uysal O, Mayadagli A. Gamma knife radiosurgery compared to whole brain radiation therapy enhances immunity via immunoregulatory molecules in patients with metastatic brain tumours. Br J Neurosurg 2019; 34:604-610. [PMID: 31317782 DOI: 10.1080/02688697.2019.1642445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: There is lack of data on the effect of stereotactic radiosurgery in modulation of the immune system for cancer patients with metastatic brain tumours. Therefore, we investigated the change in levels of immunoregulatory molecules after Gamma Knife radiosurgery (GKR) and whole brain radiation therapy (WBRT) in patients with brain metastases.Methods: Peripheral blood samples were collected from 15 patients who received GKR, nine patients who received WBRT for brain metastases and 10 healthy controls. Samples were obtained at three time points such as before, 1h after and 1 week after the index procedure for patients treated with GKR or WBRT. All patients' demographic data and radiosurgical parameters were retrospectively reviewed. We analyzed the change in the levels of T-lymphocyte-associated antigen 4 (CTLA-4) and programmed cell death ligand-1 (PD-L1), and cytokines such as IL-2, IL-10, IFN-γ, TNF-α after GKR and WBRT using Enzyme-linked immunosorbent assays (ELISA).Results: Baseline level of IFN-γ was found to be lower and that of PD-L1 was higher in the GKR group compared to WBRT group and healthy controls (p < 0.05 and p < 0.01, respectively). Levels of IFN-γ and IL-2 were increased (p < 0.01 and p < 0.01, respectively), while CTLA-4 and PD-L1 were decreased (p = 0.05 and p = 0.01, respectively) after GKR compared to pre-GKR levels, while there was no change after WBRT.Conclusion: GKR regulates immunoregulatory molecules towards enhancing the immune system, while WBRT did not exert any effect. These findings suggested that treatment of metastatic brain lesion with GKR might stimulate a systemic immune response against the tumour.
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Affiliation(s)
- Mustafa Aziz Hatiboglu
- Department of Neurosurgery, Bezmialem Vakif University School of Medicine, Istanbul, Turkey.,Department of Molecular Biology, Bezmialem Vakif University Beykoz Institute of Life Science and Biotechnology, Istanbul, Turkey
| | - Abdurrahim Kocyigit
- Department of Medical Biochemistry, Bezmialem Vakif University School of Medicine, Istanbul, Turkey
| | - Eray Metin Guler
- Department of Medical Biochemistry, Bezmialem Vakif University School of Medicine, Istanbul, Turkey
| | - Arife Nalli
- Department of Molecular Biology, Bezmialem Vakif University Beykoz Institute of Life Science and Biotechnology, Istanbul, Turkey
| | - Kerime Akdur
- Department of Neurosurgery, Bezmialem Vakif University School of Medicine, Istanbul, Turkey
| | - Ayten Sakarcan
- Department of Neurosurgery, Bezmialem Vakif University School of Medicine, Istanbul, Turkey
| | - Erdinc Ozek
- Department of Neurosurgery, Bezmialem Vakif University School of Medicine, Istanbul, Turkey
| | - Omer Uysal
- Department of Biostatistics, Bezmialem Vakif University School of Medicine, Istanbul, Turkey
| | - Alpaslan Mayadagli
- Department of Radiation Oncology, Bezmialem Vakif University School of Medicine, Istanbul, Turkey
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Treatment outcomes of intracranial germinoma: a retrospective analysis of 170 patients from a single institution. J Cancer Res Clin Oncol 2018; 145:709-715. [PMID: 30209611 DOI: 10.1007/s00432-018-2743-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 09/04/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To perform a retrospective analysis of patients with intracranial germinoma treated in our department to evaluate treatment outcomes and determine optimal treatment strategies. METHODS We reviewed the treatment outcomes of 170 patients with intracranial germinoma who were treated in our department from January 1996 to January 2017. The median patient age was 15 years old. Among the patients, 56 (33%) were pathologically diagnosed, and 114 (67%) were diagnosed clinically. Various radiation fields and doses were used. Cerebrospinal fluid (CSF) and serum beta-human chorionic gonadotropin (β-HCG) levels were examined before treatment in 114 patients. Endocrinological evaluation was performed in 141 patients before and after treatment. A total of 38 patients received chemotherapy prior to radiotherapy (RT). The median follow-up time was 64.5 months (range 4-260.5 months). RESULTS The 5- and 10-year overall survival (OS) rates were 94.5% and 91.3%, respectively. The relapse-free survival (RFS) rates at 5- and 10-years were 91.9% and 78.1%, respectively. Relapses occurred in 18 patients within 6 months-10 years. The spinal cord metastasis rate was 3.4% in patients with a localized lesion who did not receive spinal cord irradiation and 16.7% in patients with bifocal disease who were treated using whole ventricular irradiation (WVI) or whole brain radiotherapy (WBRT). Treatment failure did not occur in patients receiving chemoradiotherapy or in patients receiving three-dimensional conformal radiation therapy (3D-CRT)/intensity-modulated radiation therapy (IMRT). The RFS rate did not have a statistically significant correlation with the CSF/serum β-HCG level. After RT, 19.1% of the patients developed newly impaired pituitary function and required hormone replacement therapy. CONCLUSIONS WVI or WBRT+ primary boost (PB) is a sufficient irradiation field for localized intracranial germinoma, while patients with bifocal disease should undergo craniospinal irradiation (CSI), especially when treated with RT alone. CSF β-HCG is not a prognostic marker for intracranial germinomas. The treatment results of chemotherapy followed by reduced-dose RT are comparable to those of RT alone. IMRT is recommended for intracranial germinoma to improve the target volume accuracy and decrease the complications of RT.
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Gholami YH, Wilson N, James D, Kuncic Z. Toward Personalized Dosimetry with 32 P Microparticle Therapy for Advanced Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2017; 99:1029-1038. [DOI: 10.1016/j.ijrobp.2017.07.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 07/16/2017] [Accepted: 07/24/2017] [Indexed: 10/19/2022]
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Intracranial Germinoma: Systemic Chemotherapy in Addition to Dose-Reduced Radiation Therapy. Am J Ther 2017; 24:e609-e610. [DOI: 10.1097/mjt.0000000000000469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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12
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Sasmaz A, Ozkan S, Gursu MF, Sasmaz M. The hematological and biochemical changes in rats exposed to britholite mineral. Appl Radiat Isot 2017; 129:185-188. [PMID: 28869870 DOI: 10.1016/j.apradiso.2017.07.060] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 06/09/2017] [Accepted: 07/31/2017] [Indexed: 01/22/2023]
Abstract
The present study was to investigate the alteration of biochemical and hematological parameters on the rats exposed to natural radiation caused by britholite mineral (REE, Ca, Na)5 [(Si,P)O4]3(OH,F) within 15 days. Britholite was collected from Kuluncak mining area, Malatya, bearing radioactive 232Th isotope (average 2.68% ThO2), which is rare earth elements found high amounts. Britholite is toxic for the living animal and human and emits the radiation to natural surroundings about 0.8R/h due to its radioactive 232Th properties. In this study, animals were divided to two groups, one groups exposed to 232Th, the other group was served as control group. All animals were fed with same food and water during the experimental study (15 days). After 15 days, the hematologic and biochemical parameters (Na, K, Ca, P, Cl, Mg, glucose, cholesterol, HDL, LDL, albumin, Uric acid, AST, ALT, total protein, Fe, urea and creatine level and hormonal parameters (TSH, T3 and T4)) were analyzed The levels of serum triglyceride in the ionizing radiation group generated by 232Th isotope (p < 0.05) statistically significantly increased compared with control group value. Lymphocytes, TSH, T3 and T4 decreased in the ionizing radiation group generated by 232Th isotope while neutrophils increased in the ionizing radiation group generated by 232Th isotope. The rats exposed to ionizing radiation generated by 232Th isotope caused significant changes in the hematological and biochemical parameters and the most significantly alteration was observed in the thyroid hormonal levels, which might be due to high radiation doses within short time. These results should be kept in mind to maintain healthy life in people who lives in britholite mineral vicinity.
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Affiliation(s)
- Ahmet Sasmaz
- Fırat University, Department of Geological Engineering 23119 Elazig, Turkey.
| | - Suheyla Ozkan
- Fırat University, Department of Geological Engineering 23119 Elazig, Turkey
| | | | - Merve Sasmaz
- Fırat University, Department of Environmental Engineering 23119 Elazig, Turkey
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Huo L, Wang X, Allen PK, Wang L, Liao Y, Han Z, Shen L, Tu Q, Zhong M, Zhuang Y, Li J, Hong J. Predictors of long-term survival following postoperative radiochemotherapy for pathologically confirmed suprasellar germ cell tumors. Mol Clin Oncol 2014; 3:430-434. [PMID: 25798281 DOI: 10.3892/mco.2014.461] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 11/10/2014] [Indexed: 11/06/2022] Open
Abstract
The aim of this study was to evaluate the predictors of long-term survival following postoperative therapy for suprasellar germ cell tumors (GCTs). A total of 23 patients with pathologically confirmed suprasellar GCTs were reviewed between April, 1987 and October, 2008. The predictors were identified with a univariate Cox proportional hazards model and the results were used to group patients according to outcome. The overall survival (OS) and progression-free survival (PFS) rates for the good- and poor-prognosis two groups were estimated with Kaplan-Meier analysis, with log-rank tests used to assess differences between the groups. The OS rate for all patients was 82.6% at 5 and 72.9% at 10 years. Lesion size (2-4 vs. >4 cm) and pathological type (pure germinoma vs. mixed GCT) were the only significant predictors of OS (P<0.05). The OS rate for the good-prognosis group was 92.9% at both 5 and 10 years, whereas the corresponding rates for the poor-prognosis group were 66.7 and 40.0%, respectively (P=0.020). The PFS rate for the good-prognosis group was 92.9% at 5 and 85.7% at 10 years, whereas the corresponding PFS rates for the poor-prognosis group were 44.4 and 33.3%, respectively (P=0.007). Lesion size and histology predicted outcome following postoperative therapy for suprasellar GCT. Therefore, pathological diagnosis is recommended whenever possible, as histology may dictate the choice of treatment.
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Affiliation(s)
- Lei Huo
- Departments of Neurosurgery, Xiangya Hospital, Central South University, Institute of Skull Base Surgery and Neurooncology, Changsha, Hunan 410008, P.R. China
| | - Xia Wang
- Radiation Oncology, Xiangya Hospital, Central South University, Institute of Skull Base Surgery and Neurooncology, Changsha, Hunan 410008, P.R. China
| | - Pamela K Allen
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Longyun Wang
- Radiation Oncology, Xiangya Hospital, Central South University, Institute of Skull Base Surgery and Neurooncology, Changsha, Hunan 410008, P.R. China
| | - Yuping Liao
- Radiation Oncology, Xiangya Hospital, Central South University, Institute of Skull Base Surgery and Neurooncology, Changsha, Hunan 410008, P.R. China
| | - Zaide Han
- Department of Radiology, Xiangya Hospital, Central South University, Institute of Skull Base Surgery and Neurooncology, Changsha, Hunan 410008, P.R. China
| | - Liangfang Shen
- Radiation Oncology, Xiangya Hospital, Central South University, Institute of Skull Base Surgery and Neurooncology, Changsha, Hunan 410008, P.R. China
| | - Qingsong Tu
- Radiation Oncology, Xiangya Hospital, Central South University, Institute of Skull Base Surgery and Neurooncology, Changsha, Hunan 410008, P.R. China
| | - Meizuo Zhong
- Radiation Oncology, Xiangya Hospital, Central South University, Institute of Skull Base Surgery and Neurooncology, Changsha, Hunan 410008, P.R. China
| | - Yan Zhuang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jing Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jidong Hong
- Radiation Oncology, Xiangya Hospital, Central South University, Institute of Skull Base Surgery and Neurooncology, Changsha, Hunan 410008, P.R. China
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Zilbermint M, Ramnitz MS, Lodish MB, Kanaka-Gantenbein C, Kattamis A, Lyssikatos C, Patronas NJ, Quezado MM, Stratakis CA. Pituitary stalk lesion in a 13-year-old female. J Pediatr Endocrinol Metab 2014; 27:359-62. [PMID: 24129100 PMCID: PMC4727445 DOI: 10.1515/jpem-2013-0274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 08/14/2013] [Indexed: 11/15/2022]
Abstract
Germinomas presenting with a pituitary stalk lesion and panhypopituitarism are rare in children, and their definite diagnosis is challenging. An invasive diagnostic approach, such as a transsphenoidal biopsy, is often required prior to establishing a treatment regimen. A 13-year-old female presented with 1 year of secondary amenorrhea, fatigue, and progressive thirst with polyuria. Laboratory work-up revealed panhypopituitarism (central hypothyroidism, hypogonadotropic hypogonadism, adrenal insufficiency and central diabetes insipidus). α-Fetoprotein and β-human chorionic gonadotropin were not elevated in serum nor in cerebrospinal fluid. The magnetic resonance imaging (MRI) of the pituitary region showed an enhancing infundibular lesion, extending into the hypothalamus, and infiltrating the pituitary gland. A transsphenoidal biopsy of the infundibular lesion confirmed the diagnosis of germinoma (germ-cell tumor). After appropriate hormone replacement therapy, chemotherapy and low-dose radiation therapy, the patient achieved complete resolution of the pituitary stalk lesion on the MRI.
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Affiliation(s)
- Mihail Zilbermint
- Program on Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Mary S. Ramnitz
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Maya B. Lodish
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Christina Kanaka-Gantenbein
- First Department of Pediatrics, Athens University Medical School, “Aghia Sophia” Children’s Hospital, Athens, Greece
| | - Antonis Kattamis
- First Department of Pediatrics, Athens University Medical School, “Aghia Sophia” Children’s Hospital, Athens, Greece
| | - Charalampos Lyssikatos
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Nicholas J. Patronas
- Department of Diagnostic Radiology, Warren Grant Magnuson Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Martha M. Quezado
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Constantine A. Stratakis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Building 10/CRC 1-3330, 10 Center Drive, Bethesda, MD 20892, USA, Phone: +1 (301) 594-5984, Fax: +1 (301) 480-6480
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15
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Intensive chemotherapy followed by reduced-dose radiotherapy for biopsy-proven CNS germinoma with elevated beta-human chorionic gonadotropin. J Neurooncol 2014; 117:279-85. [DOI: 10.1007/s11060-014-1381-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Accepted: 01/20/2014] [Indexed: 12/23/2022]
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16
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The effect of radiation on the immune response to cancers. Int J Mol Sci 2014; 15:927-43. [PMID: 24434638 PMCID: PMC3907847 DOI: 10.3390/ijms15010927] [Citation(s) in RCA: 197] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 12/26/2013] [Accepted: 12/31/2013] [Indexed: 02/07/2023] Open
Abstract
In cancer patients undergoing radiation therapy, the beneficial effects of radiation can extend beyond direct cytotoxicity to tumor cells. Delivery of localized radiation to tumors often leads to systemic responses at distant sites, a phenomenon known as the abscopal effect which has been attributed to the induction and enhancement of the endogenous anti-tumor innate and adaptive immune response. The mechanisms surrounding the abscopal effect are diverse and include trafficking of lymphocytes into the tumor microenvironment, enhanced tumor recognition and killing via up-regulation of tumor antigens and antigen presenting machinery and, induction of positive immunomodulatory pathways. Here, we discuss potential mechanisms of radiation-induced enhancement of the anti-tumor response through its effect on the host immune system and explore potential combinational immune-based strategies such as adoptive cellular therapy using ex vivo expanded NK and T cells as a means of delivering a potent effector population in the context of radiation-enhanced anti-tumor immune environment.
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17
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Kortmann RD. Current concepts and future strategies in the management of intracranial germinoma. Expert Rev Anticancer Ther 2013; 14:105-19. [PMID: 24224870 DOI: 10.1586/14737140.2014.856268] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Radiation therapy is the backbone in the management of intracranial germinoma. In localized disease chemotherapy followed by whole brain irradiation is the present standard providing cure rates in excess of 90%. Craniospinal irradiation alone in metastatic disease provides equally excellent outcome. Chemotherapy is able to convert macroscopic to microscopic disease permitting a dose reduction to the tumor site and possibly the ventricular system and is investigated in prospective trials. Chemotherapy alone cannot replace radiotherapy as sole treatment. Whole-ventricular radiotherapy followed by a boost to tumor site without chemotherapy might be feasible. New treatment technologies such as intensity-modulated radiotherapy or proton therapy permit a dose reduction to non-target brain. Data on functional outcome are conflicting and based on small heterogeneous series only mandating prospective investigations.
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Affiliation(s)
- Rolf-Dieter Kortmann
- Department of Radiation Therapy, University of Leipzig, Stephanstr. 9a, 04103 Leipzig, Germany
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18
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Baek HJ, Park HJ, Sung KW, Lee SH, Han JW, Koh KN, Im HJ, Kang HJ, Park KD. Myeloablative chemotherapy and autologous stem cell transplantation in patients with relapsed or progressed central nervous system germ cell tumors: results of Korean Society of Pediatric Neuro-Oncology (KSPNO) S-053 study. J Neurooncol 2013; 114:329-38. [DOI: 10.1007/s11060-013-1188-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 06/23/2013] [Indexed: 11/29/2022]
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19
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Intracranial Germ Cell Tumors: Efficacy of Neoadjuvant Chemo-radiotherapy without Surgical Biopsy. Keio J Med 2011; 60:56-64. [DOI: 10.2302/kjm.60.56] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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21
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Khatua S, Dhall G, O'Neil S, Jubran R, Villablanca JG, Marachelian A, Nastia A, Lavey R, Olch AJ, Gonzalez I, Gilles F, Nelson M, Panigrahy A, McComb G, Krieger M, Fan J, Sposto R, Finlay JL. Treatment of primary CNS germinomatous germ cell tumors with chemotherapy prior to reduced dose whole ventricular and local boost irradiation. Pediatr Blood Cancer 2010; 55:42-6. [PMID: 20222020 DOI: 10.1002/pbc.22468] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate a reduced irradiation dose strategy for newly diagnosed primary central nervous system (CNS) germinomas. METHODS Twenty patients with histologically diagnosed localized pure germinoma (n = 19) or germinoma with a mature teratoma component (n = 1) received four cycles of carboplatin and etoposide at 3-week intervals. In 18 patients, chemotherapy was followed by whole ventricular irradiation to 21.6-25.5 Gy with a simultaneous integrated or sequential primary site boost to 30-30.6 Gy. Initial tumor markers for beta-human chorionic gonadotrophin (HCGbeta) and alpha-fetoprotein (AFP) were evaluated in serum and lumbar cerebrospinal fluid (CSF). Endoscopic biopsies were performed in 12 patients and partial resections in the remaining 8 patients at diagnosis. Neurocognitive function was evaluated periodically following treatment. RESULTS Eighteen of 20 patients are without evidence of residual or recurrent tumor. Both relapsing patients were subsequently determined to harbor malignant non-germinomatous germ cell tumor (NGGCT). This retrospective study shows that the Kaplan-Meier estimates of event-free survival (EFS) and overall survival (OS) at 3 years for all 20 patients were 89.5 +/- 7.1% and 100%, respectively. Neurocognitive function was well preserved in all 19 evaluable patients. CONCLUSION Chemotherapy followed by reduced dose whole ventricular and local boost irradiation appears to be effective in patients with localized pure CNS germinoma with evidence of preservation of neurocognitive function.
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Affiliation(s)
- Soumen Khatua
- Neural Tumors Program, Center for Cancer and Blood Diseases, Childrens Hospital Los Angeles, Los Angeles, California, USA.
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22
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Nakamura H, Takeshima H, Makino K, Kochi M, Ushio Y, Kuratsu JI. Recurrent intracranial germinoma outside the initial radiation field: a single-institution study. Acta Oncol 2009; 45:476-83. [PMID: 16760185 DOI: 10.1080/02841860500519778] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Between 1975 and 2005, we treated 52 newly diagnosed germinoma patients. Until 1991, patients with pure germinomas or germinomas with syncytiotrophoblastic giant cells (STGCs) received whole-brain radiotherapy only. Of the 52 patients, 30 were treated with a reduced radiation volume and combined chemotherapy; seven of these received local irradiation with 24 Gy, two received whole-brain (30 Gy) plus local irradiation (20 Gy), 16 received extended local irradiation delivered to the whole ventricles (30 Gy) plus local (20 Gy) irradiation, and five received extended local irradiation (24 Gy). Of the 30 patients treated with a reduced radiation volume and combined chemotherapy, four experienced tumor recurrence; three patients had been treated with 24 Gy of local radiotherapy and one had received extended local (30 Gy) plus local (20 Gy) irradiation in addition to chemotherapy. In these patients, the delivered radiotherapy was inadequate and the origin of the recurrent tumors was outside the radiation field. None of the patients who had received at least 24 Gy of whole ventricle radiotherapy combined with chemotherapy experienced tumor recurrence. In combination with chemotherapy, the delivery of irradiation covering the ventricles effectively reduced the incidence of tumor recurrence in patients with germinomas or germinomas with STGCs.
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Affiliation(s)
- Hideo Nakamura
- Department of Neurosurgery, Graduate School of Medical Science, Kumamoto University, 1-1-1 Honjo Kumamoto 860-8556, Japan.
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Hadziahmetovic M, Clarke JW, Cavaliere R, Mayr NA, Montebello JF, Grecula JC, Newton HB, Chang EL, Lo SS. CNS germinomas: what is the best treatment strategy? Expert Rev Neurother 2008; 8:1527-36. [PMID: 18928345 DOI: 10.1586/14737175.8.10.1527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
CNS germ cell tumors are rare primary brain malignancies. Germinomas comprise approximately two-thirds of CNS germ cell tumors. Owing to their radiosensitivity, radiotherapy has been used to treat patients with CNS germinomas, with favorable treatment outcomes. Historically, craniospinal irradiation has been used. Given the concerns over long-term toxicities associated with craniospinal irradiation, reduced volume radiotherapy with or without chemotherapy has been employed. Data on the use of different strategies in the treatment of CNS germinomas are emerging but a standard strategy has not been established. This article reviews the different strategies used in the management of CNS germinomas.
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Affiliation(s)
- Mersiha Hadziahmetovic
- Department of Radiation Oncology, The University of Texas Medical Branch, Trauma Center, 301 University Boulevard, Galveston, TX 77555-1178, USA.
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24
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Huang PI, Chen YW, Wong TT, Lee YY, Chang KP, Guo WY, Chang FC, Liang ML, Chen HH, Chiou SH, Yen SH. Extended focal radiotherapy of 30 Gy alone for intracranial synchronous bifocal germinoma: a single institute experience. Childs Nerv Syst 2008; 24:1315-21. [PMID: 18581122 DOI: 10.1007/s00381-008-0648-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Indexed: 10/21/2022]
Abstract
OBJECTS To evaluate the disease characteristics and treatment outcomes for patients with intracranial synchronous bifocal germinomas treated with extended focal irradiation alone. METHODS Between January 1996 and March 2007, seven patients (three males and four females) with intracranial synchronous bifocal germinomas treated at Taipei Veterans General Hospital were reviewed. The median age at diagnosis was 14 years (range, 11-28 years). Four patients had surgery before radiotherapy. All patients underwent extended focal irradiation encompassing the whole ventricle system with a total radiation dose of 30 Gy (2 Gy daily). No patient received scheduled systemic chemotherapy before or after radiotherapy. Disease characteristics, treatment outcomes, and the impact of lesion numbers (single vs. bifocal) on survivals were investigated. RESULTS With a median follow-up time of 49 months (range, 20-66 months), the 2- and 5-year survival rates were both 100%. After treatment, all patients had good performance without recurrence. No severe complication was observed. In comparison, the overall survival (OS, p = 0.475) and the disease-free survival (DFS, p = 0.537) rates were not significantly different between bifocal- and single-lesion groups. Lesion numbers did not affect both OS and DFS. In addition, the incidence of neuraxial seeding was not higher in patients with bifocal germinomas as compared to those with single lesion. CONCLUSIONS Intracranial germinomas are extremely radiosensitive. Young patients with synchronous bifocal germinomas could be successfully treated with extended focal 30-Gy radiotherapy alone. The therapeutic advantage using this regimen needs to be further evaluated with larger sample size and longer follow-up time.
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Affiliation(s)
- Pin-I Huang
- Radiotherapy Division, Cancer Center, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan
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Ogawa K, Yoshii Y, Shikama N, Nakamura K, Uno T, Onishi H, Itami J, Shioyama Y, Iraha S, Hyodo A, Toita T, Kakinohana Y, Tamaki W, Ito H, Murayama S. Spinal recurrence from intracranial germinoma: risk factors and treatment outcome for spinal recurrence. Int J Radiat Oncol Biol Phys 2008; 72:1347-54. [PMID: 18513888 DOI: 10.1016/j.ijrobp.2008.03.055] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Revised: 03/11/2008] [Accepted: 03/12/2008] [Indexed: 11/26/2022]
Abstract
PURPOSE To analyze retrospectively the risk factors of spinal recurrence in patients with intracranial germinoma and clinical outcomes of patients who developed spinal recurrence. METHODS AND MATERIALS Between 1980 and 2007, 165 patients with no evidence of spinal metastases at diagnosis were treated with cranial radiotherapy without spinal irradiation. The median follow-up in all 165 patients was 61.2 months (range, 1.2-260.1 months). RESULTS After the initial treatment, 15 patients (9.1%) developed spinal recurrences. Multivariate analysis revealed that large intracranial disease (>/=4 cm) and multifocal intracranial disease were independent risk factors for spinal recurrence. Radiation field, total radiation dose, and the use of chemotherapy did not affect the occurrence of spinal recurrences. Of the 15 patients who experienced spinal recurrence, the 3-year actuarial overall survival and disease-free survival (DFS) rates from the beginning of salvage treatments were 65% and 57%, respectively. In the analysis, presence of intracranial recurrence and salvage treatment modality (radiotherapy with chemotherapy vs. radiotherapy alone) had a statistically significant impact on DFS. The 3-year DFS rate in patients with no intracranial recurrence and treated with both spinal radiotherapy and chemotherapy was 100%, whereas only 17% in patients with intracranial recurrence or treated with radiotherapy alone (p = 0.001). CONCLUSION Large intracranial disease and multifocal intracranial disease were risk factors for spinal recurrence in patients with intracranial germinoma with no evidence of spinal metastases at diagnosis. For patients who developed spinal recurrence alone, salvage treatment combined with spinal radiotherapy and chemotherapy was effective in controlling the recurrent disease.
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Affiliation(s)
- Kazuhiko Ogawa
- Department of Radiology, University of the Ryukyus, Okinawa, Japan
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An Evaluation of Conformal and Intensity-modulated Radiotherapy in Whole Ventricular Radiotherapy for Localised Primary Intracranial Germinomas. Clin Oncol (R Coll Radiol) 2008; 20:253-60. [DOI: 10.1016/j.clon.2007.12.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2007] [Revised: 11/07/2007] [Accepted: 12/03/2007] [Indexed: 11/23/2022]
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Villani A, Bouffet E, Blaser S, Millar BA, Hawkins C, Bartels U. Inherent diagnostic and treatment challenges in germinoma of the basal ganglia: a case report and review of the literature. J Neurooncol 2008; 88:309-14. [PMID: 18365143 DOI: 10.1007/s11060-008-9568-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Accepted: 03/04/2008] [Indexed: 12/12/2022]
Abstract
Among intracranial germinomas, basal ganglia germinomas represent a specific clinical and anatomical entity. Based on an unusual case of a basal ganglia germinoma in a 13-year-old Caucasian male, we highlight the diagnostic challenges and discuss treatment considerations in this disease.
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Affiliation(s)
- Anita Villani
- Division of Paediatrics, The Hospital for Sick Children, Toronto, Canada
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Baussart B, Lepeintre JF, Condette-Auliac S, Dupuy M, Gaillard S. Localisation trigéminale d'un germinome intracrânien primitif. À propos d'un cas. Neurochirurgie 2007; 53:43-6. [PMID: 17337016 DOI: 10.1016/j.neuchi.2006.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2006] [Accepted: 11/24/2006] [Indexed: 12/01/2022]
Abstract
A 22-year-old man presented headache, asthenia, body weight loss and trigeminal hypoesthesia worsening quickly. Radiological analysis showed an enhanced lesion that originated from the cavernous sinus and extended into the Meckel cave, owing to the fifth cranial nerve's course. The lesion was explored by a temporo-pterional approach and was partially removed. On the basis of histological analysis and negativity of tumor marker levels in serum and cerebrospinal fluid (alpha-fetoprotein alpha, human beta-chorionic gonadotropin), a primitive non-secreting intracranial germinoma was diagnosed. Under combined chemotherapy (carboplatine, ifosfamide, etoposide) followed by focal fractionated radiotherapy delivering 40 Gy to the initial tumor volume, the outcome was excellent. Five years later, the patient was in complete clinical and radiological remission. Primitive intracranial germinomas are rare malignant tumors involving mainly pineal and hypothalamic regions. We report a case of intracranial trigeminal nerve germinoma. To the best of our knowledge, no case of primitive germinoma was previously described in this location. Aspects of diagnosis and treatment are discussed in the light of previous publishing data.
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Affiliation(s)
- B Baussart
- Service de neurochirurgie, hôpital Foch, 40, rue Worth, 92150 Suresnes, France.
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Nguyen QN, Chang EL, Allen PK, Maor MH, Ater JL, Mahajan A, Wolff JEA, Weinberg JS, Woo SY. Focal and craniospinal irradiation for patients with intracranial germinoma and patterns of failure. Cancer 2006; 107:2228-36. [PMID: 17019739 DOI: 10.1002/cncr.22246] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The authors compared the patterns of failure in patients with intracranial germinoma who were managed with either chemotherapy and focal irradiation or with craniospinal irradiation (CSI). METHODS A retrospective review was conducted on 21 patients with intracranial germinoma and treated with radiotherapy (RT) to the central nervous system at The University of Texas M. D. Anderson Cancer Center from 1981 to 2002. The study group was comprised of 13 males and 8 females with a median age at diagnosis of 19 years. Nine patients received chemotherapy prior to focal RT. Twelve patients received CSI. RESULTS The actuarial 10-year survival rate for all patients was 86%. The overall survival rate at 10 years was 89% for patients who received focal RT and 83% for patients who received CSI (P = .73). The 10-year local control rate in the brain for patients who received focal irradiation was 59% compared with 100% for patients who received CSI (P = .08). The rate of distant control in the spine at 5 years was 62% for patients who received focal irradiation and 100% for patients who received CSI (P = .04). CONCLUSIONS Although focal techniques of irradiation with chemotherapy are attractive methods that limited the volume irradiated, the strategy appeared to be associated with increased rates of failures in the brain and spine.
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Affiliation(s)
- Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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Shikama N, Ogawa K, Tanaka S, Toita T, Nakamura K, Uno T, Ohnishi H, Itami J, Tada T, Saeki N. Lack of benefit of spinal irradiation in the primary treatment of intracranial germinoma: a multiinstitutional, retrospective review of 180 patients. Cancer 2005; 104:126-34. [PMID: 15895370 DOI: 10.1002/cncr.21169] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The current study assessed the contribution of spinal irradiation to the treatment outcome of patients with intracranial germinoma. METHODS Clinical data from 180 patients with intracranial germinoma, who were treated with radiotherapy and/or chemotherapy from 1980 to 2001, were collected from 6 institutions. The patients' median age was 16 years (range, 1-47 yrs), and the male-to-female ratio was 133:47. Pathologic verification was obtained in 88 patients. A solitary tumor was seen in 129 patients, and multifocal or disseminated tumors were detected in 51 patients. The median tumor size was 2.5 cm (range, 0.6-7.0 cm). Local field and/or whole brain irradiation was performed in 114 patients, and craniospinal irradiation was performed in 66 patients. Fifty-five patients were treated with chemotherapy. The median follow-up time was 89 months (range, 3-297 mos). RESULTS Eight-year overall and event-free survival rates were 91% and 89%, respectively. The 8-year recurrence rates at the primary site, intracranial space, and the spinal space were 1%, 6%, and 6%, respectively. Cox regression analysis showed that spinal irradiation (hazard ratio, 1.050; 95% confidence interval [CI], 0.355-3.170) did not contribute to a favorable event-free survival. CONCLUSIONS Spinal irradiation did not contribute to favorable event-free survival in patients with intracranial germinoma.
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Affiliation(s)
- Naoto Shikama
- Department of Radiology, Shinshu University, School of Medicine, Matsumoto, Japan.
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Rogers SJ, Mosleh-Shirazi MA, Saran FH. Radiotherapy of localised intracranial germinoma: time to sever historical ties? Lancet Oncol 2005; 6:509-19. [PMID: 15992700 DOI: 10.1016/s1470-2045(05)70245-x] [Citation(s) in RCA: 149] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The optimum management of localised intracranial germinoma remains controversial. Cure rates for this rare CNS tumour, which arises mainly in adolescents, exceed 90% at 10 years, and limitation of treatment-related late morbidity is therefore essential. Craniospinal radiotherapy plus boost is perceived to be the gold-standard treatment, but there have been suggestions that reduced-volume radiotherapy could be adequate for cure. We reviewed publications since 1988 to compare patterns of disease relapse and cure rates after craniospinal radiotherapy, reduced-volume irradiation alone (i.e., whole-brain or whole-ventricular irradiation followed by a boost), and focal or localised irradiation alone. The recurrence rate after whole-brain or whole-ventricular radiotherapy plus boost was 7.6% compared with 3.8% after craniospinal radiotherapy, with no predilection for isolated spinal relapses (2.9% vs 1.2%). We challenge the consensus that craniospinal radiotherapy is the best treatment for localised germinomas and conclude that reduced-volume radiotherapy plus boost should replace craniospinal radiotherapy when a radiotherapy-only approach is used.
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Affiliation(s)
- S J Rogers
- Department of Neuro-Oncology and Paediatric Oncology, Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey SM2 5PT, UK
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Abstract
BACKGROUND A current focus in the treatment of intracranial germinoma is on decreasing the volume of radiotherapy. We studied the theoretical impact of selecting different target volumes and treatment techniques. PROCEDURE Retrospectively, five cases of localized germinoma were identified. Treatment plans were produced for three target volumes: involved field plans (i.e., targeting only gross disease), whole brain plans, and plans of increasing complexity targeting the ventricles (lateral-opposed, four-field and intensity-modulated (IMRT)). A second series of patients was processed similarly except that no involved field plans were produced. RESULTS When target volumes were compared, normal structures were substantially spared by ventricular irradiation but maximally spared by involved field radiation. When treatment techniques were assessed for ventricular irradiation, the greatest gain in tissue sparing occurred when switching from two to four fields. This gain was at the higher doses levels at the expense of an increased volume of tissue irradiated to lower doses. IMRT plans always spared a small additional amount of normal brain. Whole ventricular plans were compared to similar plans excluding the fourth ventricle. Whole brain dose was only improved by 4-6% by excluding the fourth ventricle. CONCLUSIONS The substitution of whole-ventricular irradiation for whole-brain irradiation can spare a significant amount of normal tissue, thus providing a theoretical advantage with respect to the risk of late effects. Ventricular irradiation is best achieved with at least a four-field 3D configuration, and optimally through an IMRT plan. Exclusion of the fourth ventricle in the target volume had only a minimal impact on normal tissue doses.
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Affiliation(s)
- David Roberge
- Department of Radiation Oncology, McGill University Health Center, Montreal, Quebec, Canada.
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Shirato H, Aoyama H, Ikeda J, Fujieda K, Kato N, Ishi N, Miyasaka K, Iwasaki Y, Sawamura Y. Impact of margin for target volume in low-dose involved field radiotherapy after induction chemotherapy for intracranial germinoma. Int J Radiat Oncol Biol Phys 2004; 60:214-7. [PMID: 15337558 DOI: 10.1016/j.ijrobp.2004.02.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2003] [Revised: 02/06/2004] [Accepted: 02/09/2004] [Indexed: 10/26/2022]
Abstract
PURPOSE We previously published a report stating that germinomas with elevated serum beta human chorionic gonadotropin (HCG-beta) had a poor relapse rate, but these findings have not been supported by a multi-institutional trial. The margin for initial gross tumor volume (GTV) before surgery and chemotherapy of the same materials was investigated by retrospective review. METHODS AND MATERIAL The 27 patients reported on in the previous paper were analyzed. The two-dimensional margin from the initial GTV to 90% of the prescribed dose of 24 Gy was 2.0 cm for a solitary lesion in the protocol. This margin was measured retrospectively without knowledge of the serum HCG-beta level. The whole ventricle field was used for patients with multifocal disease and whole central nervous system field was used for disseminated disease, respectively. RESULTS Six relapses were seen in 18 patients with solitary tumors, and were treated with the minimum margin of 1.5 cm or less to the initial GTV. Five of the 6 had initially elevated serum HCG-beta at the median of 7.4 mIU/mL, ranging from 0.7-233 mIU/mL. No relapses were seen in the 9 patients who were treated with whole ventricle or whole central nervous system field. CONCLUSIONS An inadequate margin and elevated serum HCG-beta were equally determined to be candidates that caused the poor local control. The whole ventricle is recommended as the smallest target volume for germinoma with or without elevated HCG-beta after induction chemotherapy.
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Affiliation(s)
- Hiroki Shirato
- Departments of Radiology, Neurosurgery, and Pediatrics, Hokkaido University School of Medicine, North-15 West-7, Kita-ku, Sapporo 060-8638, Japan.
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Abstract
Despite excellent long-term results for patients with germinoma treated with radiation therapy, the potential for late effects makes the treatment controversial. On the other hand, most patients with non-germinomatous tumors treated by conventional treatment with surgery and radiation therapy fail to survive longer than 3 years. After combination chemotherapy with cisplatin was confirmed to be effective in gonadal germ cell tumors, germ cell tumors of the brain became candidates for chemotherapy. The author reviews several prospective phase II studies that are being investigated to assess the effect of combination chemotherapy and radiation therapy for germ cell tumors. The aim of these studies is to reduce the volume and dose of radiation therapy for germinoma and prolong the survival of patients of non-germinomatous tumors. For germinoma, a trial with chemotherapy alone failed, with a high rate of recurrence, but Japanese and European trials with reduced-dose chemotherapy and a smaller volume of radiation therapy have resulted in high event-free survival (EFS) rates. Ongoing phase II studies with combined chemotherapy and radiation therapy for non-germinomatous tumors will result in a 5-year survival rate of greater than 50%, which is better than that achieved by radiation therapy alone.
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Affiliation(s)
- Masao Matsutani
- Department of Neurosurgery, Saitama Medical School, Saitama, Japan.
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Maity A, Shu HKG, Janss A, Belasco JB, Rorke L, Phillips PC, Sutton LN, Goldwein JW. Craniospinal radiation in the treatment of biopsy-proven intracranial germinomas: twenty-five years' experience in a single center. Int J Radiat Oncol Biol Phys 2004; 58:1165-70. [PMID: 15001260 DOI: 10.1016/j.ijrobp.2003.08.028] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2003] [Revised: 08/20/2003] [Accepted: 08/25/2003] [Indexed: 10/26/2022]
Abstract
PURPOSE The optimal treatment for intracranial germinomas remains controversial. We report on our 25-year experience using craniospinal irradiation (CSI) for this disease. METHODS AND MATERIALS Between September 1976 and May 2001, 39 patients with biopsy-proven intracranial germinomas seen at the Children's Hospital of Philadelphia/Hospital of the University of Pennsylvania received CSI. Thirteen of 36 patients (36%) had evidence of spinal dissemination. Median doses to the whole brain, primary site, and spine were 36 Gy (range, 18-44.2 Gy), 50.4 Gy (range, 44-55.8 Gy), and 30.6 Gy (range, 18-40 Gy), respectively. RESULTS With a median follow-up of 7.1 years (range: 1.5-20.2 years), there have been no documented relapses. This includes 5 patients without spinal dissemination who received 18-19.8 Gy to the craniospinal axis; for these patients, the median length of follow-up was 5.5 years (range, 1.3-6.8 years). One patient, who had no evidence of disease 12.9 years after CSI, died of unknown causes 4 months later. CONCLUSIONS Our treatment of intracranial germinomas with CSI has yielded outstanding results with no known relapses during a long follow-up period. These results must be considered when evaluating other approaches, such as chemotherapy only or local field irradiation.
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Affiliation(s)
- Amit Maity
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
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Ogawa K, Shikama N, Toita T, Nakamura K, Uno T, Onishi H, Itami J, Kakinohana Y, Kinjo T, Yoshii Y, Ito H, Murayama S. Long-term results of radiotherapy for intracranial germinoma: a multi-institutional retrospective review of 126 patients. Int J Radiat Oncol Biol Phys 2004; 58:705-13. [PMID: 14967424 DOI: 10.1016/j.ijrobp.2003.07.001] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2003] [Revised: 07/24/2003] [Accepted: 07/29/2003] [Indexed: 12/13/2022]
Abstract
PURPOSE Optimal management of radiotherapy (RT) for intracranial germinoma remains controversial. This study was conducted to evaluate the long-term results of RT in patients with these tumors. METHODS AND MATERIALS The study group consisted of 126 patients with intracranial germinoma (50 patients with pathologically verified germinoma and 76 clinically diagnosed with germinoma by clinical and neuroradiologic signs) who were treated by RT alone between 1980 and 2001. The median age at diagnosis was 17 years (range, 2-47), and various radiation doses and treatment fields were used. Serum human chorionic gonadotropin (hCG) levels were elevated in 18 patients. The median follow-up of the 114 surviving patients was 122 months (range, 13-263). RESULTS The 10-year actuarial overall survival and cause-specific survival rate for all patients was 90% and 95%, respectively. The 10-year actuarial cause-specific survival rate for patients with and without elevated hCG levels was 94%. Relapses were noted in 10 patients, 7 of whom died of the disease. No in-field relapses at primary sites were observed in 72 patients treated with total doses of 40-50 Gy. The incidence of spinal relapses was 4% (2 of 56) for patients treated with spinal irradiation and 3% (2 of 70) for those without spinal irradiation. After a median 10-year follow-up, 54 (92%) of 59 patients with tumors not involving the neurohypophyseal region and 42 (76%) of 55 patients with tumors involving the neurohypophyseal region had Karnofsky performance status scores of 90-100%. With regard to school education and occupation, 54 (92%) of 59 patients with tumors not involving the neurohypophyseal region and 39 (71%) of 55 patients with tumors involving the neurohypophyseal region were attending school or undertaking occupations. Hormonal replacement therapy was required in 50 (44%) of 114 surviving patients before RT; only 4 patients (4%), all with neurohypophyseal tumors, required hormonal replacement therapy after RT. Clinically evident severe neurocognitive dysfunctions were documented in 10 patients before RT, and no patients treated with total doses of <55 Gy developed apparent neurocognitive dysfunctions or other complications after RT. CONCLUSION RT was a curative treatment for intracranial germinoma, and elevated serum hCG levels did not affect the prognosis of patients treated by RT alone. A total dose of 40-50 Gy to adequate treatment fields was effective in preventing intracranial relapse, and the incidence of spinal relapses was too low to warrant routine spinal irradiation. Karnofsky performance status scores, educational achievement, and the ability to work were generally good, particularly in patients with tumors that did not involve the neurohypophyseal region. Because most complications, such as hormonal deficiency and neurocognitive dysfunction, were documented before RT and newly diagnosed complications after RT were infrequent, the treatment toxicity faced by germinoma patients appears to be less than anticipated.
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Affiliation(s)
- Kazuhiko Ogawa
- Department of Radiology, University of the Ryukyus, Okinawa, Japan.
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Haas-Kogan DA, Missett BT, Wara WM, Donaldson SS, Lamborn KR, Prados MD, Fisher PG, Huhn SL, Fisch BM, Berger MS, Le QT. Radiation therapy for intracranial germ cell tumors. Int J Radiat Oncol Biol Phys 2003; 56:511-8. [PMID: 12738328 DOI: 10.1016/s0360-3016(02)04611-4] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To review the combined experiences of University of California, San Francisco, and Stanford University Medical Center in the treatment of intracranial germ cell tumors (GCT) and to assess the impact of craniospinal radiation (CSI) on patterns of relapse, progression-free survival (PFS), and overall survival (OS). PATIENTS AND METHODS Ninety-three patients received radiation for newly diagnosed intracranial GCTs, including 49 germinomas, 16 nongerminomatous GCTs (NGGCT), and 28 with no biopsy. Median follow-up for surviving patients was 4.5 years (range 0.25-34). Tests for variables correlating with OS and PFS were conducted using Cox proportional hazards model. RESULTS Five-year PFS and OS rates were 60% +/- 15% and 68% +/- 14% for patients with NGGCT and 88% +/- 5% and 93% +/- 4% for those with germinoma. Of 6 patients with localized NGGCT who did not receive CSI, 1 experienced an isolated spinal recurrence but was salvaged. Of 41 patients with localized germinoma, 6 who received CSI and 35 who did not, no isolated spinal cord relapses occurred. Twenty-one patients with localized germinoma received neither CSI nor whole brain radiation. Of these, none of 18 with ventricular radiation relapsed. One of 3 patients with primary tumor radiation relapsed intracranially but had only received 11 Gy at initial treatment. On multivariate analysis, germinoma histology but not CSI correlated with improved PFS and OS. CONCLUSION CSI is not indicated in the treatment of localized germinomas. For patients with localized germinomas treated with radiation alone, we recommend ventricular irradiation followed by primary tumor boost to a total of 45-50 Gy.
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Affiliation(s)
- Daphne A Haas-Kogan
- Department of Radiation Oncology, University of California, San Francisco, CA 94143, USA.
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Tseng CK, Tsang NM, Wei KC, Jaing TH, Pai PC, Chang TC. Radiotherapy to primary CNS germinoma: how large an irradiated volume is justified for tumor control? J Neurooncol 2003; 62:343-8. [PMID: 12777088 DOI: 10.1023/a:1023391903721] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Between 1990 and 1999, there were 30 primary central nervous system (CNS) germinoma patients who received radiotherapy (RT) as treatment. Of these, 23 are male and 7 are female patients, with a median age of 16 years. The treatment field of RT included whole neuraxis in 10, whole brain in 8 and local tumor site in 12 patients; the median dose delivered to the whole neuraxis being 3060 cGy, with 3060 cGy to the whole brain and 5040 cGy to the tumor site. Chemotherapy was prescribed in 9 patients. The median time on follow-up for survivors is 73 months. There were 7, out of a total of 30 patients, who suffered treatment failure. Five of twelve patients (41.6%) who received partial brain RT failed in the brain, with no difference in the rate between patients with or without chemotherapy, and only 2 of 18 patients (11.1%) who received whole brain or whole neuraxis RT failed in the brain (p = 0.053). None of 5 spinal seeding patients failed in the spine and only one failed in the brain after whole neuraxis RT, one patient without whole neuraxis RT (5%) failed in the spine. In summary, partial brain RT will have higher probability of intracranial relapse, and sparing the spinal RT will not result in more spinal failure, whole brain RT would be sufficient for tumor control on primary CNS germinoma.
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Affiliation(s)
- Chen Kan Tseng
- Department of Radiation Oncology, Chang Gung Memorial Hospital Linkou, Taoyuan, Taiwan.
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Regueiro C. Tratamiento de los tumores germinales intracraneales y otros tumores de la región pineal. Neurocirugia (Astur) 2003. [DOI: 10.1016/s1130-1473(03)70549-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Buatti JM, Friedman WA. Temporary ventricular drainage and emergency radiotherapy in the management of hydrocephalus associated with germinoma. J Neurosurg 2002; 96:1020-2. [PMID: 12066901 DOI: 10.3171/jns.2002.96.6.1020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors used an alternative strategy to avoid shunt placement for hydrocephalus associated with germinoma, and the ensuing complications. METHODS Between 1998 and 2000, five patients presenting with germinomas of the pineal area and symptomatic obstructive hydrocephalus were treated with a novel strategy. On arrival, they underwent ventriculostomy placement and one of several surgical procedures to obtain tissue for diagnosis. Within several days of the initial diagnosis, stereotactically guided fractionated radiotherapy was started. All patients experienced rapid tumor shrinkage and resolution of hydrocephalus, allowing discontinuation of external ventricular drainage without the need for permanent shunting of cerebrospinal fluid. To date, follow up reveals 100% radiographically and clinically confirmed tumor control. CONCLUSIONS Prompt resolution of hydrocephalus and absence of complications make this a potentially valuable therapy for control of germinomas and their symptoms.
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Affiliation(s)
- John M Buatti
- Department of Radiation Oncology, University of Iowa, Iowa City, USA
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Aoyama H, Shirato H, Ikeda J, Fujieda K, Miyasaka K, Sawamura Y. Induction chemotherapy followed by low-dose involved-field radiotherapy for intracranial germ cell tumors. J Clin Oncol 2002; 20:857-65. [PMID: 11821471 DOI: 10.1200/jco.2002.20.3.857] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To investigate the efficacy of chemotherapy followed by low-dose involved-field radiotherapy for the treatment of intracranial germ cell tumors (GCTs). PATIENTS AND METHODS Thirty-three patients with GCTs, including 16 pure germinomas, 11 human chorionic gonadotropin-beta (HCG-beta)-secreting germinomas, three mixed GCTs composed of immature teratomas plus germinomas (IMT/G), and three highly malignant mixed GCTs, were treated. Etoposide and cisplatin (EP) were used for the treatment of solitary pure germinomas, and ifosfamide, cisplatin, and etoposide (ICE) were used for the treatment of other GCTs. The dose schedule was 24 Gy for germinomas and 40 to 54 Gy for other GCTs. An involved-field set-up was used except for highly malignant GCTs, in which craniospinal irradiation was used. The median follow-up was 58 months (range, 18 to 102 months). RESULTS Disease-related, overall, and relapse-free survival rates at 5 years were 100%, 93%, and 69% for all patients, 100%, 100%, and 86% for patients with pure germinomas, and 100%, 75%, and 44% for patients with HCG-beta-secreting germinomas, respectively. All six patients with nongerminomatous GCTs were alive at the last follow-up. All eight relapses (one pure germinoma, five HCG-beta-secreting germinomas, and two IMT/G), except one in a course of salvage treatment, were salvaged and free of disease at the last follow-up. No decline was observed in the full-scale, verbal, or performance intelligence quotient at 12 to 51 months after the treatment in 11 patients. CONCLUSION Our results support an excellent prognosis after EP and ICE regimens followed by radiotherapy. Dose and volume can be reduced to 24 Gy in 12 fractions and involve a field set-up after EP chemotherapy for the treatment of pure germinomas.
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Affiliation(s)
- Hidefumi Aoyama
- Department of Radiation Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Shibamoto Y, Sasai K, Oya N, Hiraoka M. Intracranial germinoma: radiation therapy with tumor volume-based dose selection. Radiology 2001; 218:452-6. [PMID: 11161161 DOI: 10.1148/radiology.218.2.r01ja08452] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To prospectively investigate whether intracranial germinomas, except large ones, can be cured with radiation doses lower than 50 Gy and to determine 10-year follow-up results. MATERIALS AND METHODS Between 1985 and 1995, 38 patients with intracranial germinoma diagnosed histologically or with established criteria were enrolled. Total radiation doses to the primary tumor site were 36 Gy after total removal, 40 Gy for tumors less than 2.5 cm in diameter, 45 Gy for those 2.5-4.0 cm, and 50 Gy for those greater than 4.0 cm, with 1.6-1.8-Gy daily fractions. Patients underwent irradiation of the primary tumor site or cerebrospinal axis (20-24 Gy), depending on findings at diagnosis. No chemotherapy was allowed. RESULTS All patients completed radiation therapy. Thirty-five patients were treated according to protocol, and three with relatively slow tumor regression or presence of a cyst received additional radiation (5-7 Gy, 50-52 Gy total). Ten-year overall and relapse-free survival rates were 91% and 95%, respectively. Two patients developed meningeal dissemination, but none had local failure. Treatment complications included chordoma in one patient and internal carotid artery occlusion in another. No treatment-related decline of performance status was observed in the other patients. CONCLUSION All tumor volume-based radiation doses were effective, without risk of local failure. Intracranial germinoma 4 cm or less in diameter can be cured with doses of 40-45 Gy. Investigation of further dose reduction seems worthwhile. Radiation therapy alone with these doses should be compared with ongoing chemotherapeutic protocols plus low-dose (24-30-Gy) irradiation in future studies.
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Affiliation(s)
- Y Shibamoto
- Departments of Oncology, Institute for Frontier Medical Sciences, Kyoto University, Sakyo-ku, Kyoto 606-8507, Japan.
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Shibamoto Y, Sasai K, Kokubo M, Hiraoka M. Salvage radiation therapy for intracranial germinoma recurring after primary chemotherapy. J Neurooncol 1999; 44:181-5. [PMID: 10619503 DOI: 10.1023/a:1006367316168] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Systemic chemotherapy has been increasingly used in the primary treatment of intracranial germinoma. However, the recurrence rate seems to be very high after treatment with chemotherapy alone. We used radiation to treat 5 patients harboring intracranial germinoma that recurred following primary chemotherapy. They had received systemic chemotherapy (4 with cisplatin plus etoposide and 1 with adriamycin, vincristine, cyclophosphamide, prednisolone, and cisplatin) 7-24 months before referral. All patients were treated with conventional radiotherapy directed to the primary tumor site or the craniospinal axis with a dose to the primary site ranging from 39.6 to 47.0 Gy (mean, 42.6 Gy). Response to radiation of all the recurrent tumors was good and all tumors disappeared on diagnostic imaging below the dose of 24 Gy. All patients are alive without further recurrence at 61-129 months after salvage radiotherapy. Germinomas recurring after primary chemotherapy do not seem to have acquired cross resistance to radiotherapy. They can usually be cured by standard radiation therapy with 40-47 Gy.
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Affiliation(s)
- Y Shibamoto
- Department of Oncology, Institute for Frontier Medical Sciences, Kyoto University, Japan.
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Kitamura K, Shirato H, Sawamura Y, Suzuki K, Ikeda J, Miyasaka K. Preirradiation evaluation and technical assessment of involved-field radiotherapy using computed tomographic (CT) simulation and neoadjuvant chemotherapy for intracranial germinoma. Int J Radiat Oncol Biol Phys 1999; 43:783-8. [PMID: 10098433 DOI: 10.1016/s0360-3016(98)00488-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To investigate the importance of preirradiation mental and endocrinological evaluation, and the effectiveness of involved-field radiotherapy following neoadjuvant chemotherapy. METHODS AND MATERIALS Following etoposide and cisplatin with or without ifosfamide, 13 patients with nondisseminated disease received involved-field irradiation of 24 Gy in 12 fractions within 3 weeks and 2 patients with disseminated germinoma received 24 Gy craniospinal irradiation (CSI). CT simulation was used to cover the tumor bed. RESULTS Full-scale intelligence quotient (IQ) tests given at the time of the initial radiotherapy showed less than 90 in 7 of 11 patients who had tumors involving the neurohypophyseal region, but the 4 patients who had solitary pineal tumors showed higher scores. Panhypopituitarism was observed in 9 patients with tumors involving the neurohypophyseal region. All patients are alive without disease, with a median follow-up period of 40 months. No in-field relapse was noted after the involved-field radiotherapy. One patient experienced a recurrence outside of the planning target volume. CONCLUSION Decline of neurocognitive and endocrine functions were often seen in patients with tumors involving the hypophyseal region, but not in patients with solitary pineal germinoma before radiotherapy. Involved-field radiotherapy using 24 Gy is effective with the help of CT simulation and neoadjuvant chemotherapy.
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Affiliation(s)
- K Kitamura
- Department of Radiology, Hokkaido University School of Medicine, Sapporo, Japan
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