Primary intramedullary spinal cord germinoma. Case report

Primary extramedullary spinal germinoma: case report and review of the literature

The authors describe a case of a purely primary extramedullary spinal germinoma in a young Chinese male. Primary spinal germinoma is extremely rare tumor. Currently, less than 30 histologically verified spinal germinoma cases have been reported previously, mostly involving Asian of Japanese descent. This 24-year-old male suffered from progressive low back pain radiating to both legs. Magnetic resonance imaging showed a well-demarcated, intradural extramedullary mass at the level of L2 and L3. The lesion was totally removed and was confirmed as a germinoma. Upon histological verification of the tumor, he was treated successfully with radiotherapy and adjuvant chemotherapy. This report also reviews the literature pertaining to primary spinal germinoma. Except for 16 cases with intramedullary lesions and five cases with both intra- and extramedullary tumors, there were only three previously reported cases of extramedullary spinal germinomas, all initially presenting with sausage-like lesions. To the authors' knowledge, it is thought to be the first case of such a tumor, roughly round in shape and extramedullary location. Although rare, primary spinal germinoma do occur and should be included in the differential diagnosis of spinal tumors. Aggressive malignant behavior has been reported and close follow-up is necessary.

Intramedullary Spinal Cord Germinoma: A Case Report and Review of Literature

Primary spinal cord germinomas are an extremely rare group of tumors, most commonly reported as single cases in young Japanese adults. They usually present as intramedullary lesions located in the thoracic and thoracolumbar spine. The importance of preoperative diagnosis lies in the fact that by using radiotherapy and chemotherapy, even without surgery, a good cure rate can be achieved in patients with spinal cord germinoma. These tumors, however, demonstrate unspecific imaging characteristics, and only some secrete tumor markers. Therefore, a diagnosis of these lesions before biopsy or resection with pathohistologic examination can be difficult. We present a case of a 28-year-old white man with intramedullary spinal cord germinoma. The tumor was resected completely with electrophysiological monitoring, without a biopsy and frozen section analysis. Postoperative radiotherapy also was part of the treatment. The patient has had no relapse 4.5 years after diagnosis; however, significant neurologic deficits remain. Although not as frequent in white patients, germinoma should be considered as differential diagnosis in cases of young adult patients with intramedullary tumor in the thoracic or thoracolumbar spine. Therefore, spinal mass surgery should commence with a biopsy and intraoperative frozen section analysis. In this way, attempting a gross total resection becomes unnecessary. With an approach of intraoperative biopsy and frozen section analysis, a considerable amount of postoperative neurologic deficits can be reduced.

Treatment strategies and long-term outcomes for primary intramedullary spinal germinomas: an institutional experience

Primary intramedullary germinomas are very rare tumors in the spinal cord. This study presented a series of 11 patients with histologically proven primary intramedullary spinal germinomas. Their clinical and radiological findings, treatment records and long-term outcomes were reviewed. There were four male and seven female patients with a mean age of 27.1 years. Because germ cell tumors were suspected by frozen-section biopsy, gross total resection was unattempted. Partial resection was performed in four cases, while biopsy was performed in seven cases. Postoperatively, carboplatin and etoposide chemotherapy combined with low dose radiotherapy (30.6 Gy) to local spine was performed in seven cases, followed by radiotherapy alone (40 Gy) in four cases. All 11 patients had a complete response to either combination treatment or single radiotherapy, and the mass effect on the spinal cord vanished. The mean follow-up period was 75.4 months. At the last follow-up, the symptoms were improved in 10 cases and the current status of one patient was unchanged. The postoperative follow-up magnetic resonance imaging showed no recurrence or dissemination in any of the patients. Primary intramedullary germinomas are amenable to adjuvant radiochemotherapy and low dose radiation with etoposide and carboplatin chemotherapy is recommended. When combination therapy cannot be performed, relatively high doses of radiotherapy are advised, and radiation to the craniospinal axis may be unnecessary. A good clinical outcome after combination therapy or radiotherapy alone can be expected, and the risk of long-term recurrence and dissemination is low.

Primary spinal germ cell tumors: a case analysis and review of treatment paradigms

Objective. Primary intramedullary spinal germ cell tumors are exceedingly rare. As such, there are no established treatment paradigms. We describe our management for spinal germ cell tumors and a review of the literature. Clinical Presentation. We describe the case of a 45-year-old man with progressive lower extremity weakness and sensory deficits. He was found to have enhancing intramedullary mass lesions in the thoracic spinal cord, and pathology was consistent with an intramedullary germ cell tumor. A video presentation of the case and surgical approach is provided. Conclusion. As spinal cord germinomas are highly sensitive to radiation and chemotherapy, a patient can be spared radical surgery. Diverse treatment approaches exist across institutions. We advocate biopsy followed by local radiation, with or without adjuvant chemotherapy, as the optimal treatment for these tumors. Histological findings have prognostic value if syncytiotrophoblastic giant cells (STGCs) are found, which are associated with a higher rate of recurrence. The recurrence rate in STGC-positive spinal germinomas is 33% (2/6), whereas it is only 8% in STGC-negative tumors (2/24). We advocate limited volume radiotherapy combined with systemic chemotherapy in patients with high risk of recurrence. To reduce endocrine and neurocognitive side effects, cranio-spinal radiation should be used as a last resort in patients with recurrence.

Intratumoral hemorrhage because of primary spinal mixed germ cell tumor presenting with atypical radiological features in an adult

BACKGROUND CONTEXT

Germ cell tumors are known to arise in the central nervous system, usually in the intracranial regions. However, primary spinal mixed germ cell tumors are extremely rare.

PURPOSE

This is the first reported case of intratumoral hemorrhage because of a primary spinal mixed germ cell tumor consisting of germinoma and immature teratoma in the conus medullaris of an adult patient that presented with rapid changes on magnetic resonance image (MRI). We report this rare case and discuss the clinical manifestations of an intramedullary spinal mixed germ cell tumor in adult.

STUDY DESIGN

A case report.

METHODS

A 42-year-old woman experienced buttock numbness, and a spinal cord tumor was observed on the conus medullaris on MRI. The patient was scheduled for an operation in 1 month, but she developed sudden-onset neurologic deterioration. Rapid progression of the tumor was observed on follow-up MRI. The tumor was removed by emergency surgery and was identified as a primary mixed germinoma and immature teratoma.

RESULTS

The patient received adjuvant chemotherapy and radiotherapy after gross total resection. The neurologic deficit of the patient was relieved, and recurrence of the tumor was not observed 26 months after the surgery.

CONCLUSIONS

We present this rare case and emphasize the necessity of precise diagnosis and early treatment of primary spinal germ cell tumor. Close observation on MRI is required after surgery, and adjuvant chemotherapy and radiotherapy should be considered according to the pathologic features.

Primary intramedullary spinal germ cell tumors

BACKGROUND

Intramedullary spinal germ cell tumors are rare lesions, with germinomas being the most common variant.

METHODS

To date, there have been 23 reports of primary intramedullary germ cell tumors described in the literature, the vast majority occurring in Japanese patients.

RESULTS

We present a case of a nonmetastatic intramedullary germ cell tumor in a 28-year-old Caucasian woman.

CONCLUSIONS

Characteristics of intramedullary germ cell tumors are summarized, and the current role for surgery and adjuvant radiation and chemotherapy are discussed.

Primary intramedullary spinal cord germinoma

A 21-year-old woman presented with an intramedullary spinal cord germinoma and a history of gait disturbance and elimination disorder. Magnetic resonance (MR) imaging demonstrated two isolated lesions, one located within the medulla between T9 and T11, and another at the cauda equina (L2 to L3 levels). After partial reduction of the intramedullary mass, histological findings revealed that the tumor was typical germinoma. Further MR imaging revealed no evidence of intracranial germinoma. Combined chemotherapy (carboplatin and etoposide) and whole spine radiation were performed. Follow-up MR imaging showed that the enhanced mass at the L2-L3 levels had disappeared. No recurrence of the tumor has been detected 3 years after the operation, and no dissemination into the cranial area was detected. Cisplatin and etoposide chemotherapy combined with radiotherapy is recommended for primary spinal germinoma, and is effective for inhibition of both tumor dissemination and recurrence.

A rare case of a simultaneously detected suprasellar and intramedullary spinal cord germinoma

We report the case of a 28-year-old man who presented with the sole complaint of lumbago. Spinal magnetic resonance imaging (MRI) revealed a solitary, well-defined intramedullary mass at the L1-L2 level typical of a primary spinal cord germinoma. However, cranial magnetic resonance imaging (MRI) showed a concomitant lesion in the suprasellar region. This article describes a rare case of simultaneously detected intracranial and intramedullary spinal cord germinoma and its possible etiopathology.

Primary intramedullary spinal cord germinoma: diagnostic challenge and treatment strategy

Two patients presented with primary intramedullary spinal cord germinoma (PISCG). Neither diagnosis was correct at initial evaluation, and both underwent surgical verification of the tumor. Based on the histological diagnosis, both patients were treated successfully by combination of chemotherapy and radiotherapy. These cases illustrate the unexpected occurrence of PISCG and treatment strategy.

Spinal intradural primary germ cell tumour--review of literature and case report

BACKGROUND

Primary spinal cord germ cell tumour is a rare tumour. We herein review the tumour characteristics, associated risk factors, treatment policy, and patterns of failure of primary intradural germ cell tumour.

METHOD

We conducted a PUBMED search using a combination of keywords such as "spinal germ cell tumor," "germinoma," "extradural," "intradural," "intramedullary," "extramedullary," and identified 19 cases of primary spinal germ cell tumour. Clinical features, pathologic characteristics, and treatment details of these patients including status at follow-up were noted from respective case reports. We also describe a case of a young Indian patient of intradural extramedullary germ cell tumour treated with a combination of surgery, chemotherapy, and radiotherapy.

FINDINGS

The median age at presentation was 24 years. The most common location of the tumour was thoracic (40%). Beta-HCG overproduction was noted in 40% of the patients. Most patients were treated with a combination of surgery, radiation therapy, and systemic chemotherapy. Median follow-up was 16.5 months. Recurrence was observed in 10% of the patients, all in beta-HCG over-producing tumours. The illustrative case was a 28-year male, presenting with pain in lower back and both lower limbs for 2 months. Magnetic resonance imaging spine showed an inhomogeneous hyperintense soft tissue mass at L(2)-L(4) spinal level. He was treated with complete surgical excision and four cycles of chemotherapy with BEP regimen following a histological diagnosis of non-seminomatous germ cell tumour. Palliative irradiation to the lumbar spine was given on progression at 3 months. The patient eventually succumbed to his condition, due to compressive transverse myelitis possibly due to cervical cord metastasis.

CONCLUSION

Limited surgery followed by upfront radiation therapy and adjuvant chemotherapy is the optimal management of this rare group of tumour. Omission of radiation therapy from the treatment armamentarium might engender local recurrence and spinal dissemination at first failure.

Concurrent chemoradiotherapy for primary cervical spinal cord germinoma

We report a rare case of primary intramedullary germinoma in the cervical spine of a 39-year-old woman without evidence of intracranial or disseminated disease. The germinoma was treated by a biopsy and follow-up concurrent chemoradiotherapy. This is the only reported case of primary spinal cord germinoma for which concurrent chemoradiotherapy was given. Furthermore, this is only the second reported case of histologically documented primary intramedullary cervical spinal cord germinoma. The patient was disease-free and there was near-complete resolution of the pre-operative neurological deficits at the 20-month follow-up examination.

MR imaging of primary spinal germinoma: a case report and review of the literature

Germinomas in the central nervous system (CNS) are uncommon tumors and occur usually in the pineal or suprasellar regions. Primary spinal germinoma is extremely rare. Here we reported a rare case of an extramedullary germinoma in a young adult who presented with progressive paraparesis and retention of stool and urine. The MR image features with their differential diagnoses were discussed along with literature review of all previously reported 22 cases.

Intramedullary spinal cord germinoma--2 case reports

BACKGROUND

Primary intramedullary spinal cord germinoma is very rare. We encountered 2 patients with primary intramedullary spinal cord germinoma. We describe herein our comprehensive management system for CNS germinoma, including intramedullary spinal cord germinoma, along with a review of the literature. This is the first report to describe successful application of ICE chemotherapy for intramedullary germinoma.

CASE DESCRIPTIONS

A 16-year-old adolescent girl (case 1) experienced lumbago and subsequently noticed gait disturbance that aggravated gradually. On admission, paraparesis and urinary retention were noted. Magnetic resonance imaging demonstrated marked cord swelling between T9 and T12, with slight enhancement in the spinal cord. Astrocytic tumor was initially suspected, and partial removal was performed. However, pathologic examination identified germinoma. Successful treatment with ICE chemotherapy and radiotherapy was implemented, with no evidence of recurrence apparent at 48 months postoperatively. A 34-year-old woman (case 2) presented with paraparesis and sensory disturbance. Magnetic resonance imaging demonstrated cord swelling between T8 and T10, with slight Gd-DTPA enhancement. Because the lesion did not respond to steroid pulse therapy, spinal cord tumor was suspected and biopsy was performed. Pathologic examination verified primary germinoma of the spine. Successful treatment with ICE chemotherapy and radiotherapy was implemented with no exacerbation of neurologic deficits. No evidence of recurrence was apparent at 36 months postoperatively.

CONCLUSION

Correct diagnosis of very rare primary intramedullary spinal cord germinoma is important, because these patients can be treated successfully using chemo- and radiotherapy without neurologic deterioration.

METASTASIS TO THE CONUS MEDULLARIS

OBJECTIVE

Metastasis from lung cancer to the conus medullaris has never been reported in the English literature, although three cases have appeared in the French and Japanese literature. Our case report is unique because the patient presented with a lumbar radiculopathy, an atypical presentation that was found to be caused by metastasis from lung cancer to the conus medullaris. A critical review of the pertinent literature related to metastatic neoplasms to the conus medullaris is also presented.

CLINICAL PRESENTATION

We report the case of a 54-year-old man who presented with an L5 radiculopathy and was initially found to have a small disc herniation at L4–L5 on magnetic resonance imaging scans, which was ruled out as the case of his initial symptoms. In 3 weeks, the symptoms progressed with the development of urinary incontinence and right leg weakness. A magnetic resonance imaging scan of the lumbar spine showed a tumor at the conus medullaris.

INTERVENTION

The patient underwent a laminectomy with removal of the tumor. Pathological examination of the tumor showed infiltrating differentiated adenocarcinoma. A 2.5 cm lung mass in the right middle lobe with surrounding adenopathy was found on a computed tomographic scan of the chest. The patient died 4 months later from systemic involvement and progression of his lung disease.

CONCLUSION

This case report illustrates the rare presentation of a lumbar radiculopathy caused by a metastatic tumor to the conus medullaris. This was the first presentation for the diagnosis of lung cancer in this patient.

Unusual primary secreting germ cell tumor of the spine. Case report

The authors describe a young man with a rare primary spinal germ cell tumor that secreted beta-human chorionic gonadotropin. The tumor was resected, and six courses of adjuvant chemotherapy consisting of cisplatin, bleomycin and etoposide were administered together with irradiation to the craniospinal area. An additional dose of radiation was delivered to the tumor site after the first four chemotherapy sessions. The patient was well without any neurological deficit or iatrogenic sequela 33 months after diagnosis. The occurrence of this rare tumor located primarily in the spine warrants attention in pathological studies of spinal tumors in young patients.

Mixed germinoma and choriocarcinoma in the intramedullary spinal cord: case report and review of the literature

Primary germinomas in the spinal cord are very rare with only 15 cases published previously. In this case a 22-year-old woman with urinary incontinence, lumbago, and bilateral leg pain and weakness was found to have a solid tumor in the conus medullaris between the L1 and L2 vertebral bodies. Serum HCG was elevated without pregnancy. The pathological diagnosis was mixed germinoma and choriocarcinoma of the intramedullary spinal cord. She received craninospinal irradiation and three courses of chemotherapy and is currently asymptomatic with no evidence of recurrence and metastasis 22 months after surgery. To our knowledge, this is the first case report of a patient with a primary mixed germinoma and choriocarcinoma of the intramedullary spinal cord. The previous 15 cases of primary spinal cord germinoma have been reviewed for comparison.

Aggressive spinal germinoma with ascending metastases

We report the case of a 28-year-old young man who presented with progressive paraparesis and urinary incontinence. Initial spinal MR scans showed a sausage-like lesion that extended between L1 and S2. At surgery, an encapsulated intradural extramedullary tumor was removed en bloc. The initial histopathological diagnosis was ependymoma. The tumor recurred locally to double its original size only 4 months later. After second surgery, 5,100 cGy of local spinal radiation was given since the pathologist believed that the new tumor exhibited anaplastic features. Subsequently tumor recurred at T6-10 levels and later in the right parasellar region. Surgery was undertaken for both recurrences and radiation to whole spine and to whole brain respectively followed surgery. At 11 months after the initial presentation, a new tumor was diagnosed at T11-T12 levels. After fifth surgery, chemotherapy with cisplatin, doxorubicin and vincristine was started. At this stage, review of all five surgical specimens by an outside neuropathologist was considered crucial. The new and correct histological diagnosis was germinoma. A new chemotherapy regimen targeted for germinoma was then started. The patient remains alive with no evidence of disease at 22 months after initial presentation. Primary spinal germinomas are exceedingly rare. A review of the literature revealed only 14 biopsy-proven spinal germinoma cases. Our case is clearly unique in aggressivity of the tumor, a feature often unexpected for germinomas. This case proves that the dissemination risk may be very serious for germinomas and that the craniospinal radiation may be a more secure treatment mode.

A tumor in the medulla oblongata producing beta-HCG and AFP

A 23 year-old woman presented with dysarthria, hoarseness, dysphasia, ataxia and dyspnoea. MRI showed a mass of heterogeneous intensity at the dorsal medulla oblongata. Laboratory studies revealed high serum alpha-fetoprotein (AFP) and beta-subunit human chorionic gonadotropin (beta-HCG) levels. No other tumours were found on systemic investigation. An intracranial non-germinomatous germ cell tumour (NGGCT) was strongly suspected. The patient received combination chemotherapy using ifosfamide, cisplatin, and etoposide and local irradiation to a total of 52 Gy. Serum AFP and beta-HCG levels normalized after four cycles of chemotherapy and she became asymptomatic apart from mild postural hypotension. A follow-up MRI showed only a tiny residual lesion in the medulla oblongata, which has been stable for more than three years. Surgical resection should be carefully considered in patients with brainstem tumours with elevation of serum tumour markers as chemo- and radiotherapy may be effective for brainstem NGGCT.

Intramedullary Cervical Spine Germinoma: Case Report

OBJECTIVE AND IMPORTANCE:

We report an extremely rare case of primary intramedullary germinoma in the cervical spinal cord arising in an 18-year-old man who had not undergone previous surgery or irradiation.

CLINICAL PRESENTATION:

The patient had a 2-month history of intermittent neck pain and a 4-week history of bilateral hand paresthesias and weakness. A magnetic resonance imaging scan demonstrated a heterogeneous cervical spine lesion with marked contrast enhancement extending from C3 to C6.

INTERVENTION:

The patient underwent a cervical laminotomy with tumor resection, and pathological examination revealed the tumor to be a germinoma. He recovered well from the surgery with minimal neurological deficits. A postoperative magnetic resonance imaging scan of the brain and spinal cord did not show any other tumors. In addition, imaging studies of the mediastinum, testes, and the rest of the body also did not demonstrate any other tumors. The patient received local radiation as well as three courses of chemotherapy.

CONCLUSION:

To our knowledge, this is the first report of an intramedullary cervical spine germinoma with confirmed tissue diagnosis. Although extremely uncommon, the possibility of germinoma should be included in the differential diagnosis for primary intramedullary spinal cord tumors.

Primary intramedullary spinal cord germinoma: case report

We describe an 18-year-old male with an intramedullary spinal cord germinoma in whom the diagnosis was made two years after onset of a progressive myelopathy. Spinal cord germinomas are rare, most having been described in young Japanese adults. They often respond well to radiotherapy. A unique feature of this case was the prolonged time interval between onset of the patient's symptoms and ability to visualize the mass radiographically. A further interesting finding was the infiltrative nature of the tumor surrounding residual spinal cord neurons.

Intramedullary spinal cord germinoma: case report and review of the literature

A 33-year-old man with an intramedullary spinal cord germinoma was treated successfully with partial resection, combined chemotherapy with carboplatin and etoposide, and reduced-dose local-field radiation therapy. The authors believe this is the first case without syncytiotrophoblastic giant cells so treated. The literature is reviewed, and the appearance, radiologic and histopathologic features, and treatment of germinomas are discussed.

A case of intramedullary spinal cord tumor producing human chorionic gonadotropin

We experienced a case of a persistent trophoblastic disease associated with gradually progressive Brown-Sequard syndrome, which was found to be due to a primary intramedullary spinal cord germinoma with syncytiotrophoblastic giant cells (STGC). We performed both chemotherapy and radiotherapy on separate occasions. Although the chemotherapy appeared to be ineffective, radiotherapy resulted in the disappearance of spinal cord lesions for four years. We reported a case of intramedullary spinal cord germinoma with STGC for which radiotherapy was a better therapeutic modality.

Germ cell tumors of the central nervous system originating from non-pineal regions: CT and MR features

CT and MR findings were retrospectively reviewed in 12 patients with germ cell tumors originating from the non-pineal regions. Cystic or necrotic components were seen in 6 patients. Of 4 germinomas, 2 showed mixed density on the CT. The MR signal intensity of the tumor was non-specific. Of 8 germinomas, 4 were inhomogeneously enhanced on postcontrast CT and T1-weighted MR images. CT and MR features of germinomas originating from non-pineal regions frequently differ from those of germinomas originating from the pineal region. The mass of the tumor often appeared cystic and inhomogeneously enhanced following contrast infusion.

Hemangioblastomas and other uncommon intramedullary tumors

Astrocytoma and ependymoma make up 90% of intramedullary tumors between them. However, a host of less common tumors form the remaining 10%: these include hemangioblastomas, subependymomas, gangliogliomas and other neuronal variants, metastases from extraneural cancers, and a host of other lesions that typically occur intracranially but which present on rare occasions in the intramedullary location. Most neurosurgeons will encounter the unusual tumors of the spinal cord described in this review only a few times during their professional careers, but it is nevertheless important to recognize the distinct radiological and intraoperative features of those for which significant series of patients have been accumulated. Metastases and germinomas aside, the other neoplasms described here are relatively benign in their clinical and histological behavior, and can be meaningfully resected by careful microsurgical technique.

Metastatic spinal intramedullary germinoma with elevated cerebrospinal fluid chorionic gonadotropin: a case report

We treated a patient whose unusual recurrent germinoma illustrates the diagnostic value of measuring human chorionic gonadotropin beta subunit (HCG-beta) in cerebrospinal fluid (CSF) and serum. A 25-year-old man with a suprasellar germinoma and ventricular dissemination was treated successfully with systemic chemotherapy and cranial irradiation. Six years later he developed progressive numbness and weakness in both upper extremities. Magnetic resonance imaging (MRI) disclosed an intramedullary spinal cord tumor in the cervical region. The CSF concentration of HCG-beta was elevated and exceeded that in serum. After completion of systemic chemotherapy and spinal irradiation, symptoms subsided and the tumor was no longer evident on MRI. Based on the patient's history and the rapid response of the tumor to treatment, the spinal cord tumor was considered a metastatic intramedullary spinal germinoma representing CSF dissemination via the central canal.

A rare case of extramedullary spinal cord germinoma

A rare case of spinal cord germinoma in a 20-year-old Japanese female is presented. The tumor was detected at the level of T11 and L3 by myelography. Histological findings of the resected tumor were identical to germinoma, which is characterized by polygonal tumor cells, lymphocytic infiltrate, and granuloma. Tumor cells and lymphocytes reacted with antibodies for placental alkaline phosphatase and CD45, respectively. A few multinucleated giant cells, negative immunohistochemically for human chorionic gonadotropin were also seen. The present case is the 10th case of spinal cord germinoma and is thought to be the first case of such a tumor located extramedullary. Diagnosis of such a rare tumor in an unusual location needs proper histological, ultrastructural and immunohistochemical evaluation.