Intrasellar mixed germ-cell tumor. Case report

A 23-year-old female with a mixed germ cell tumor of the pituitary infundibulum: the challenge of differentiating neoplasm from lymphocytic infundibuloneurohypophysitis-a case report and literature review

The pathologic spectrum of diseases that infiltrate the pituitary infundibulum includes a broad variety of clinical entities. There are significant differences in the prevalence of these etiologies depending on the age of presentation. Lymphocytic infundibuloneurohypophysitis (LINH) predominates over other causes of infundibular disease in adults over age 21. Differentiating LINH from other causes of infundibular disease can be difficult because the various etiologies often have similar clinical presentations and radiologic imaging characteristics. We report the first case in an adult of a mixed germ cell tumor comprised of germinoma and embryonal cell carcinoma infiltrating the pituitary infundibulum. In our case, a 23-year-old female was initially misdiagnosed as having LINH. She presented with panhypopituitarism and diabetes insipidus, which is the most common initial presentation in both entities. The two diagnoses are difficult to distinguish based on MRI imaging, CSF findings, and histopathological examination. Our case demonstrates the need for close follow-up of patients with isolated lesions of the pituitary infundibulum and reinforces the need for biopsy of an infundibular lesion when progression of disease is demonstrated. In our case, biopsy with comprehensive immunohistochemical staining was the sole means of making a definitive diagnosis.

Sellar and suprasellar mixed germ cell tumor mimicking a pituitary adenoma

Germ cell tumors (GCT) are a heterogeneous group of lesions whose origin is not well established. Several cases of primary intrasellar germinomas have been reported, however non-germinomatous GCT have rarely been described. We report the case of a young adult male patient with a mixed GCT that presented with a sellar tumor with suprasellar extension. The patient seeked medical attention because of seizures and magnetic resonance imaging evidenced a tumor of the sellar region. Hyperprolactinemia was also present and dopamine agonist therapy was started. As there was a rapid tumor growth and the patient had concomitant central diabetes insipidus and elevated testosterone levels, a GCT was suspected and confirmed by elevated serum concentration of β-human chorionic gonadotrophin. Patient underwent surgical resection of the tumor and histopathological examination confirmed the diagnosis of a mixed GCT. Chemotherapy was initiated, followed by conventional radiotherapy. In conclusion, although pituitary adenomas respond for the vast majority of sellar tumors, concomitant symptoms such as central diabetes insipidus and rapid tumor growth should raise the suspicion of a diverse diagnosis. The present report intend not only to show a rare case of sellar and suprasellar mixed GCT but also to remind clinicians that if laboratory findings do not fit into patient's diagnosis (such as high testosterone levels in our patient), then the diagnosis should be reviewed.

Mature teratoma arising from the sella--case report

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

Immature teratoma originating from the pituitary gland: case report

OBJECTIVE AND IMPORTANCE

Recently, it has been suggested that the primary site of suprasellar germinomas is the neurohypophysis, but nongerminomatous germ cell tumors originating from the pituitary gland have been rarely reported.

CLINICAL PRESENTATION

A 27-year-old man presented with panhypopituitarism, bitemporal hemianopsia, and mild right oculomotor nerve paralysis. Diabetes insipidus was not observed. The tumor was shown by magnetic resonance imaging to extend and invade bilateral cavernous sinuses, sellar and clival dura mater, and the sphenoid sinus mucosa.

INTERVENTION

Transsphenoidal removal yielded a diagnosis of immature teratoma. Serum alpha-fetoprotein was prominently elevated. Magnetic resonance imaging and surgical findings of the superiorly displaced residual pituitary gland strongly suggest the pituitary origin of this rare tumor.

CONCLUSION

In contrast to the neurohypophyseal germinomas, nongerminomatous malignant germ cell tumors originating from the pituitary gland tend not to be associated with diabetes insipidus and thus mimic adenomas. Evaluation of the tumor markers is necessary in young patients with cavernous sinus syndrome and invasive pituitary tumors with heterogeneous intensity revealed by magnetic resonance imaging.

Displacement of the normal pituitary gland by sellar and juxtasellar tumours: surgical-MRI correlation and use in differential diagnosis

We compared the position of the normal pituitary gland as estimated by gadolinium (Gd)-DTPA-enhanced MRI, with its position at surgery in 40 patients with intra- and juxtasellar tumours: 22 pituitary adenomas, 4 craniopharyngiomas, 7 meningiomas, 2 germinomas, and 5 Rathke cleft cysts. In 37 of these, the normal gland showed more intense contrast enhancement than the adjacent tumour, from which it could be differentiated by Gd-DTPA-enhanced MRI, especially in the sagittal plane. The direction of displacement of the normal pituitary gland correlated well with tumour type, so that its position proved helpful in the differential diagnosis. The normal gland was typically displaced superiorly by pituitary adenomas, inferiorly by craniopharyngiomas, and anteriorly by germinomas. It showed variable displacement by Rathke cleft cysts, and was not usually displaced by meningiomas.

Germ cell tumor in the hypothalamo-neurohypophysial region: clinical features and treatment

Twenty-one patients with germ cell tumors (17 germinomas and 4 teratomas) involving the hypothalamic-neurohypophysial (HN) region were reviewed retrospectively. Eleven patients were males and 10 females, and their ages ranged from 7 to 45 years (average 18.5 years). Diabetes insipidus was the initial and the most prominent symptom in most germinomas; in teratomas the most prominent symptom was visual disturbance. Fifteen patients with germinomas were treated by radiotherapy, and 4 with teratomas were treated by surgical resection alone. Two recent germinoma patients with extensive CSF dissemination were treated with systemic chemotherapy consisting of anticancer platinum drugs and etoposide, which resulted in a complete disappearance of the tumors. Patients with germinoma treated after the introduction of CT scanning had a greatly improved mortality rate, and their actual survival rate was 87.5% over 10 years. On the basis of this review, the authors consider that diagnosis at an early stage of the disease and chemotherapy, which can be an effective therapeutic alternative to radiation therapy, may improve not only the mortality rate but also the quality of life of patients with HN germ cell tumors.

Magnetic resonance imaging of neurohypophyseal germinomas

The authors reviewed magnetic resonance (MR) images in seven cases of germinoma in the hypothalamoneurohypophyseal axis (HNA). The intrasellar portions were clearly identified in six germinomas. Two small germinomas of these six were located only in the neurohypophysis. The major parts of the four large germinomas were located below the optic chiasm, and the large intrasellar portions were demonstrated. The remaining one small germinoma was localized from the pituitary stalk to the third ventricular floor. These findings strongly suggest that the primary site of germinomas in the HNA is the neurohypophysis. In the four large germinomas, the tumor shape was similar to that of pituitary adenoma. The authors believe that age (limited to first three decades), symptoms (diabetes insipidus), MR findings (absence of normal hyperintense signal of the posterior pituitary on T1-weighted (T1WI) images, and homogeneous hypointensity to the pons on T1WI images/isointensity on T2-weighted images are important in differential diagnosis.

Intracranial mixed germ cell tumor with syncytiotrophoblastic giant cells and precocious puberty

A 9-year-old male patient developed a germ cell tumor in the right basal ganglia which secreted beta-human chorionic gonadotropin (beta-HCG) and caused precocious puberty. Histology and immunohistochemical staining for placental alkaline phosphatase (PLAP), alpha-fetoprotein (alpha-FP), and beta-HCG showed a mixed population of neoplastic germinocytes, embryonal carcinoma, and syncytiotrophoblastic giant cells (STGC). Immunohistochemical double-staining for alpha-FP and beta-HCG revealed that these two markers were produced by different subsets of cells. Expression of the proliferation marker Ki-67 showed a growth fraction of 53% for the neoplastic germinocytes and embryonal carcinoma cells, but only 21% for the STGC.

Suprasellar germ cell tumors in the dog: a report of five cases and review of the literature

Suprasellar germ cell tumors were identified in five young adult to middle-aged dogs. Clinical signs included depression, mydriasis, ptosis and visual deficit. At necropsy large extramedullary masses were found on the ventral surface of the rostral brain stem. Histologically four were characterized by sheets and nests of moderately pleomorphic round cells resembling seminoma, admixed with larger vacuolated cells, glandular formations with secretory material, and occasional foci of squamous differentiation. The fifth case was more homogeneous, with germinomatous elements predominating. Immunohistochemical examination of three tumors revealed positive staining for alpha fetoprotein. Although only one case showed intracranial metastasis, these tumors were considered malignant due to the marked local invasion and destruction. The veterinary literature is reviewed, and we propose that two tumors previously reported as craniopharyngioma be reclassified as germ cell tumors. One other tumor previously reported as an unclassified suprasellar tumor was identified, which also demonstrated features of a germ cell tumor.

A malignant mixed germ cell tumor originating from the pituitary gland with a suprasellar extension: a case report

A case of an intracranial tumor in a 26-year old woman with symptoms of hypopituitarism, and visual disturbance is presented. The primary site has been verified by the clinical presentations and the hormonal and the neurological studies as originating from the pituitary gland with extension to the suprasellar area. Histologically, the tumor contains elements that demand its interpretation as a malignant teratoma. In a tumor marker study, the aFP level was elevated, suggestive of an endodermal sinus tumor component. We report this case as a mixed germ cell tumor originating from the pituitary gland with a suprasellar extension and a malignant transformation from a benign component.

Germinoma of the pituitary gland; a report of two cases

Intracranial germinomas are usually situated in the pineal, but sometimes they arise in the infundibular region of the third ventricle (ectopic pinealoma) and may rarely extend down into the pituitary fossa. Two cases of germinoma arising within the pituitary gland and presenting with hypopituitarism, are described; no report of any similar cases could be found.

Primary intracranial germ-cell tumors. A clinicopathological study of 14 cases

Fourteen cases of primary intracranial germ-cell tumors are presented. Histologically, there were eight germinomas, three teratomas, and three germ-cell tumors of more than one histological type. Immunohistochemical studies revealed alpha-fetoprotein in yolk-sac tumor components in two cases and beta human choriogonadotropin in syncytiotrophoblastic giant cells in one case. One teratoma contained an unusual pleomorphic sarcomatous portion with features of early myoblastic differentiation. Comparison of intracranial with gonadal germ-cell tumors shows that the same subtypes are found in both locations with comparable incidence and similar biological behavior. The detailed World Health Organization classification of testicular germ-cell tumors should be applied to the histopathological classification of intracranial germ-cell tumors. Despite the critical location of intracranial germ-cell tumors, a good outcome can be achieved by optimal surgical excision. A primary microsurgical approach provides a histopathological diagnosis, which is indispensable for the proper choice of postoperative management.