Successful management of symptomatic hydrocephalus using a temporary external ventricular drain with or without endoscopic third ventriculostomy in pediatric patients with germinoma

Long-term outcome of cerebrospinal fluid diversion in patients with intracranial germinoma at Ramathibodi Hospital

INTRODUCTION

Intracranial germinoma has a favorable prognosis with modern therapies, but the long-term outcome of cerebrospinal fluid (CSF) diversion for its associated hydrocephalus has been rarely focused on.

PURPOSE

To evaluate the long-term success of CSF diversion methods-endoscopic third ventriculostomy (ETV) versus ventriculoperitoneal (VP) shunt-in intracranial germinoma patients.

METHODS

Only pure intracranial germinomas with obstructive hydrocephalus and a minimum follow-up duration of 24 months were retrospectively reviewed. Their demographics, as well as pre-and postoperative data, were recorded. Patients were stratified into the ETV and the non-ETV groups and subsequently compared to determine the longevity and morbidity related to the procedures. Factors associated with the failure of CSF diversion were examined.

RESULTS

From 1993 to 2022, eighty-three pathologically confirmed intracranial germinomas were identified. Excluding four cases of mixed pathology, eight with incomplete data, and two with insufficient follow-up, we enrolled 69 eligible patients for analysis. Among them, forty-three cases with obstructive hydrocephalus were classified into the ETV (n = 22) and non-ETV (n = 21) groups. No intraoperative or immediate postoperative complications occurred. With a median follow-up of 101 months (IQR 77.75-139.75), the ETV group had no failures. In the non-ETV cohort (median follow-up 144 months (IQR 97-210)), two VP shunt cases (9.5%) required revision due to blockage, and two patients (9.5%) experienced transient over-drainage. These 4 patients were without long-term difficulty despite short-term cumbersome events. No significant factors predicting CSF diversion failure were identified. To date, all 43 patients are alive without metastases, maintaining a good quality of life.

CONCLUSION

This study highlights ETV as a preferred CSF diversion method in pure intracranial germinoma, achieving 100% success without morbidity. Apart from simultaneous biopsy, avoiding a separate operation, this approach eliminates shunt-related complications, ensuring long-term quality of life in patients with extraordinary prognoses from modern chemo- and radiotherapy.

Diagnosis and Management of Pineal Germinoma: From Eye to Brain

Pineal germinomas can be very complex in terms of presentation, diagnosis, and management. This review attempts to simplify this complexity in an organized manner, addressing the anatomic relationships that provide the basis for the uniqueness of pineal germinoma. Ocular findings and signs and symptoms of elevated intracranial pressure are the keys to suspecting the diagnosis and obtaining the necessary imaging and cerebrospinal fluid studies. Other symptoms can suggest spread beyond the pineal region. Surgery may only be needed to obtain tissue for a definitive diagnosis, as germinoma is highly responsive to chemotherapy and focused radiation therapy. Hydrocephalus, usually related to tumor obstruction of the cerebral aqueduct, may also need to be addressed. Outcome for pineal germinoma is usually excellent, but relapse can occur and may require additional intervention. These issues are detailed in this review.

Feasibility of treating pediatric intracranial germ cell tumors in a middle-income country: The Jordanian experience

BACKGROUND

Pediatric intracranial germ cell tumors (iGCT) are rare, with limited data available from Arabic countries.

METHODS

We retrospectively reviewed the medical charts of children <18 years diagnosed with iGCT at King Hussein Cancer Center/Jordan (January 2003 to December 2020) for clinical characteristics, treatment, and morbidities.

RESULTS

Sixteen patients had germinoma; median age was 6.9 years and median symptoms duration 8 months. Nine tumors were suprasellar, five pineal, and two bifocal. Four were metastatic. Eight patients had slightly elevated beta subunit human chorionic gonadotropin and 11 patients had resection/biopsy. Fifteen patients received chemotherapy; mostly carboplatin (450 mg/m² )/etoposide, which had low toxicity. All patients received radiotherapy (different doses and fields). At median follow-up of 7.7 years, one tumor recurred (progression-free survival: 91% ± 8%). Twelve patients who continued follow-up had stable visual and endocrine deficits to their initial presentation. Five finished or are finishing diploma and seven had poor school performance (four left school). Six patients were diagnosed with nongerminomatous germ cell tumor; median symptom duration was 1 month. Three tumors were pineal, two suprasellar, and one at quadrigeminal plate. Three were metastatic. Five tested patients had high tumor markers and four had resection/biopsy. All patients received chemotherapy, and then five received craniospinal radiation. Two patients are alive, two died with tumor progression, one died in remission with electrolyte imbalance, and one developed leukemia and died with septic shock.

CONCLUSIONS

We achieved excellent survival in treating germinoma using a feasible protocol for low middle-income countries. However, patients encountered significant morbidities exacerbated by delayed diagnosis and unnecessary surgical interventions despite abnormal tumor markers. Raising awareness on iGCT symptomatology and diagnosis may help limit these morbidities.