Parinaud «plus» syndrome in a patient with dysgerminoma

CLINICAL CASE

A 33-year-old male diagnosed with Parinaud's syndrome, exotropia and post-papillary oedema optic atrophy in his left eye. A pineal germinoma was diagnosed after performing neuroimaging scans and a stereotactic biopsy. He was treated with chemotherapy and radiotherapy, showing a complete pathological response. The Parinaud's syndrome persists one year after diagnosis and the patient has refused to have strabismus surgery.

DISCUSSION

Parinaud's syndrome consists of a supranuclear vertical gaze palsy resulting from damage to the midbrain tectum. The involvement of adjacent structures leads to the «Parinaud-plus» syndrome. When a Parinaud's syndrome is accompanied by diplopia («Parinaud-plus» syndrome), extension of the injury into adjacent areas must be considered.

Bifocal intracranial germinoma: a retrospective analysis of treatment outcomes in 20 patients and review of the literature

PURPOSE

Bifocal germinoma (BFG) is a rare intracranial neoplasm for which the choice of radiation therapy (RT) field is controversial. Some believe that BFG represents disseminated disease requiring craniospinal irradiation (CSI), whereas others believe that BFG represents localized disease and advocate for more limited fields.

METHODS AND MATERIALS

We analyzed 20 BFG patients at our institutions with classic bifocal lesions (pineal gland and suprasellar region). In addition, we identified 60 BFG patients from the literature. The RT fields, use of chemotherapy and extent of disease were recorded and analyzed for each patient.

RESULTS

There were 55 patients with bifocal lesions only (Group I), and 25 with bifocal lesions plus ventricular and/or CSF positive disease (Group II). The 5-year progression-free survival was 95% for Group I and 80% for Group II. In Group I, there were no failures in patients receiving CSI (n = 11), two spinal failures in those treated with more limited RT fields without chemotherapy (n = 17), and one spinal failure with chemotherapy (n = 23). In Group II, there were no failures in patients receiving CSI (n = 11), but four spinal failures were observed in patients receiving more limited RT fields with chemotherapy (n = 13); 1 patient who received whole-brain RT without chemotherapy experienced failure in the spine and brain.

CONCLUSIONS

CSI is associated with excellent PFS in BFG. In Group I BFG patients, omission of spinal irradiation appears to be a reasonable approach, especially when chemotherapy is used. Patients with Group II BFG are best treated with CSI.

Strategy of combined treatment of germ cell tumors

The histopathological entity 'germ cell tumor' (GCT) encompasses a number of histological subtypes. Pineal GCTs can be grossly divided into three categories: those with a good, intermediate, and poor prognostic. Germinoma and mature teratoma are curable and classified into the good prognostic group, whereas embryonal carcinoma, yolk sac tumor, and other highly malignant neoplasms leave patients with a dismal prognosis. There are other types of GCT that have an intermediate prognosis, such as immature teratoma. Only mature teratomas are curable by surgical resection alone; the other types require adjuvant therapy. To plan a surgical strategy, then eurosurgeon has to acquire enough knowledge of the effect of adjuvant therapies and biological behavior of the GCTs. Germinoma can be cured by low-dose radiotherapy in combination with chemotherapy, and nowadays needs only to be biopsied. Other tumors, such as highly malignant tumors need a sophisticated combination therapy that includes surgery, craniospinal radiation therapy, and intensive chemotherapy. An appropriate neoadjuvant therapy prior toradical surgical removal will remarkably reduce the surgical risk. The goal of treatment should be tightly focused on the reduction of posttreatment sequelae, including surgical morbidity, and not on a complete microsurgical resection.

Management of central nervous system germinoma: proposal for a modern strategy

With the development of diagnostic, radiologic, and therapeutic modalities, strategies for management of central nervous system (CNS) germinoma are changing gradually. The author advocates that typical germinomas can be diagnosed based on their typical clinical and radiological findings, together with slight elevation of beta-human chorionic gonadotropin levels in the serum and/or cerebrospinal fluid (CSF) and quick response to radiation or chemotherapy. Radiation therapy has been the standard treatment for CNS germinoma until recently. Germinomas 4 cm or less in diameter can be cured with radiation doses of 40-45 Gy. Regarding the treatment volume, an individualized approach is recommended and a focal radiation field covering at least major parts of the ventricular system is recommended if no CSF dissemination is present and CSF cytology is negative. Such irradiation is best given by intensity-modulated radiation therapy. Systemic chemotherapy with reduced doses (24-30 Gy) of radiation has to some extent been successful, but longer follow-up periods are necessary to draw conclusions regarding the superiority of this treatment over standard-dose radiation therapy. CNS germinoma patients should be completely cured with minimum morbidity, probably by employing appropriate doses of chemotherapy and intensity-modulated radiation therapy in the future.

Recurrent intracranial germinoma along the endoscopic ventriculostomy tract. Case report

The authors report a case of a recurrent intracranial germinoma along the site of an endoscopic third ventriculostomy (ETV) after complete local tumor control using 3D conformal radiation therapy. A 13-year-old girl presented with sudden left upward gaze limitation for 4 days. A pineal region tumor and obstructive hydrocephalus were noted on magnetic resonance (MR) images. An ETV and tumor biopsy procedure were performed, which revealed the lesion to be a germinoma. The patient's visual symptoms and hydrocephalus disappeared postoperatively. Chemotherapy using cisplatin, etoposide, vincristine, and cyclophosphamide was initiated on postoperative Day 10. An MR image obtained 10 weeks after surgery and 2 weeks after chemotherapy revealed a significant (> 50%) reduction of the lesion. Radiation therapy was administered at 50.4 Gy to the target and 36 Gy to the periphery. Ten months after surgery, an MR image revealed further shrinkage of the tumor mass. One year after surgery, follow-up MR imaging demonstrated a small mass lesion at the entry site of the ETV, measuring 1.0 x 1.4 x 1.5 cm. An operation was performed to remove the small lesion, and pathological findings revealed it to be of the same histology as the primary tumor.

Biochemotherapy with standard chemotherapies plus the pineal hormone melatonin in the treatment of advanced solid neoplasms

It is known since many years that the pineal hormone melatonin (MLT) may play anticancer activity through several mechanisms, including antiproliferative and immunostimulating effects. Moreover, it exerts an important antioxidant action. Therefore, MLT could be useful in the treatment of human neoplasms, either alone or in association with chemotherapy. The present study was performed to evaluate the influence of a concomitant MLT administration on efficacy and toxicity of several chemotherapeutic combinations in metastatic solid tumor patients, suffering from non-small cell lung cancer (NSCLC) or gastrointestinal tumors. The study included 370 patients who were randomized to receive chemotherapy alone or chemotherapy plus MLT (20 mg/day orally in the evening every day). NSCLC patients received cisplatin (CDDP) plus etoposide or CDDP plus gemcitabine. Colorectal cancer patients were treated with oxaliplatin plus 5-fluorouracil (5-FU), or weekly CPT-11 or 5-FU and folates (FA). Finally, gastric cancer patients received CDDP, epirubicin, 5-FU and FA or weekly 5-FU plus FA. The overall tumor regression rate achieved in patients concomitantly treated with MLT was significantly higher than that found in those treated with chemotherapy alone. Moreover, the 2-year survival rate was significantly higher in patients concomitantly treated with MLT. These results confirm in human the anticancer therapeutic properties of the pineal hormone MLT, which may enhance the efficacy of the standard anticancer chemotherapies.

Pre-radiation chemotherapy with response-based radiation therapy in children with central nervous system germ cell tumors: a report from the Children's Oncology Group

BACKGROUND

This Phase II study was designed to determine response to chemotherapy and survival after response-based radiation (RT) in children with CNS germ cell tumors.

PROCEDURE

Children with germinomas and normal markers received cisplatin 100 mg/m(2) + etoposide, alternating with vincristine + cyclophosphamide (CPM) 2 g/m(2)/d, for four cycles. Children with nongerminomatous tumors or with abnormal markers received doubled doses of cisplatin and CPM. For germinoma patients in complete response (CR), RT was decreased from 50.4 to 30.6 Gy. High-risk patients received neuraxis RT: 50.4 Gy local + 30.6 Gy neuraxis in CR; 54 Gy local + 36 Gy if less than CR.

RESULTS

Of 12 germinoma patients, 4 had cerebrospinal fluid (CSF) human chorionic gonadotropin (HCG) 6.9-21 mIU/ml. Of 14 nongerminomatous patients, HCG in serum or CSF was >50 mIU/ml in 9, alpha-fetoprotein (AFP) abnormal in 9. Four germinoma patients attained CR, six PR, one SD, one not evaluable after resection. Two nongerminomatous patients had CR, three PR, three SD, one PD, four not evaluable after resection; one inadequately treated patient had progressive disease (PD). Both PD patients died; one SD patient died during a seizure. Eleven germinoma patients are PF at median 66 months; one patient in CR refused RT, had PD at 10 months, received RT, and was PF at 56 months. Eleven of 14 nongerminomatous patients were PF at median 58 months.

CONCLUSION

Response (germinoma, 91%; nongerminomatous, 55%) and survival are encouraging after this regimen plus response-based RT.

Trilateral retinoblastoma

BACKGROUND

Trilateral retinoblastoma (TRB) is a syndrome consisting of unilateral or bilateral hereditary retinoblastoma (Rb) associated with an intracranial neuroblastic tumor. Although its incidence is low, the prognosis is very poor. This article reports four cases of TRB and discusses the role of neuroimaging screening for early detection.

PROCEDURE

From January 1986 to December 2003, 470 children with Rb were admitted to the Pediatrics and Ophthalmology Departments, A C Camargo Hospital, São Paulo, Brazil.

RESULTS

There were four patients with pineoblastoma, two of whom had a positive familial history. The age at diagnosis of Rb was 4, 6, 10, and 24 months while the age of diagnosis of TRB was 10, 25, 57, and 72 months. One patient presented TRB at initial diagnosis of Rb. Three patients had bilateral disease and all of them had one eye enucleated, followed by chemotherapy and/or external beam radiation therapy (EBRT). One child with unilateral disease was only submitted to enucleation. In spite of intensive treatment, all patients died with progressive disease within 7, 8, 12, and 12 months after diagnosis of TRB.

CONCLUSIONS

Early diagnosis as well as new therapeutic approaches are needed to achieve better results.

Late intrathoracic relapse of pineal germinoma connected to intraspinal canal

Extraneural metastases of intracranial germinoma are rarely reported. The authors describe the first case of metastatic lung germinoma of the thoracic spine. A 27-year-old man presented with right shoulder pain and right upper limb weakness. He had a history of repetitive radiation therapy - nine (whole-abdomen; 15Gy), 12 (whole brain; 30Gy, whole spine 42Gy) and 14 years ago (local; 32Gy) - for abdominal metastasis, temporal and fourth ventricle metastasis and spinal dissemination and metastatic pineal germinoma, respectively. Magnetic resonance imaging revealed a lung mass invading the thoracic spine that was diagnosed as a germinoma by tumor biopsy. He was treated by irradiation with 54Gy and two cycles of chemotherapy with cisplatin and etoposide. He did not have any sign of tumor eight years later.

Childhood pineoblastoma: experiences from the prospective multicenter trials HIT-SKK87, HIT-SKK92 and HIT91

OBJECTIVE

To analyze the outcome of children with pineoblastoma (PB), treated within the prospective multicenter trials HIT-SKK87, HIT-SKK92 and HIT91 of German-speaking countries.

PATIENTS

We report on 11 children suffering from PB. Five children younger than 3 years of age received chemotherapy after surgery until eligible for radiotherapy (HIT-SKK87 and HIT-SKK92). Five of six children older than 3 years were treated after surgery with immediate chemotherapy and craniospinal irradiation, and one child received maintenance chemotherapy after postoperative radiotherapy (HIT91).

RESULTS

Five of the six older children are still alive in continuous complete remission (CCR) with a median overall survival (OS) and progression free survival (PFS) of 7.9 years. Five of these six HIT91 patients responded to postoperative chemotherapy and radiotherapy. The only patient with tumor progression during initial chemotherapy achieved complete remission with radiotherapy and is alive. In contrast, all five young children died of tumor progression after a median OS of 0.9 years (PFS 0.6 years). They had either metastatic disease (M1) and/or postoperative residual tumor. Response to postoperative chemotherapy was lower than in the older age group, and only one of these children received radiotherapy.

CONCLUSIONS

Combined chemotherapy and radiotherapy were feasible and effective in the older age group, leading to prolonged remissions in five of six children. Tumor biology may be more aggressive in younger children with PB, who presented more frequently with high-risk features at diagnosis and had poorer response rates to neoadjuvant postoperative chemotherapy. More intensified treatment regimens may be needed for young children with PB.

Postoperative adjuvant treatment for pineal parenchymal tumour of intermediate differentiation

Pineal parenchymal tumour of intermediate differentiation (PPTID) in adults is rare and a treatment strategy for this condition has not yet been established. We present a case of an elderly patient treated with postoperative adjuvant therapy using radio- and chemotherapy. This 60-year-old man presented with a 3-month history of memory disturbance, gait instability and double vision. Computed tomography and magnetic resonance imaging demonstrated a mass in the pineal region that suggested a malignant tumour. Partial removal of the tumour was undertaken via the right occipital transtentorial approach. The histological diagnosis was PPTID. Postoperative radio- and chemotherapy were administered, with a good response. Little is known about the clinical behaviour of PPTID in adults. Our treatment plan indicates one effective option for the management of such tumours.

Impact of surgery, chemotherapy and irradiation on long term outcome of intracranial malignant non-germinomatous germ cell tumors: results of the German Cooperative Trial MAKEI 89

Malignant non-germinomatous intracranial germ cell tumors (MNGGCTs) are a heterogenous group of neoplastic lesions. Their treatment concept follows a multimodal concept that may include tumor resection for local tumor control, craniospinal irradiation to cover leptomenigeal tumor spread and chemotherapy to eliminate systemic tumor dissemination. A Platinum-based chemotherapy proven to be highly effective in testicular and non-testicular malignant germ cell tumors in adults as well as in children has also been chosen for intracranial sites. While therapeutic concepts have been thoroughly evaluated for children and adolescents with extracranial nongonadal GCTs, no such detailed long term follow-up data are available for intracranial MNGGCTs. This paper reports on the long-term outcome of 41 patients with intracranial malignant non-germinomatous GCTs enrolled into the German prospective protocol MAKEI 89. The analysis focuses on the impact of surgery, radio- and chemotherapy.

PATIENTS AND METHODS

Between January 1989 and January 1994, 41 patients with malignant intracranial non-germinomatous GCTs were registered. Patients were compared in respect to protocol (n = 27) and non-protocol treatment (n = 14). Estimated were with chi (2) and Fisher exact test the impact of surgery, chemotherapy and irradiation on outcome.

RESULTS

The estimated (Kaplan-Meier) 5-year event free survival (EFS) of patients treated according to protocol recommendations was 0.59 +/- 0.06 (n = 27), compared to an EFS of 0.37 +/- 0.33 for patients with different treatments (n = 14) (p = 0.70, log-rank). The 5-year relapse-free survival rate (RFS) was 0.74 +/- 0.06 in protocol patients and 0.38 +/- 0.33 in non-protocol patients (median observation time of 112 months after diagnosis for surviving patients) (p = 0.14, log-rank). Surgery, complete or incomplete had no significant impact on survival (p = 0.12). Radiotherapy, in terms of craniospinal irradiation had a significant influence on survival (p = 0.035) as well as a cumulative cisplatin dose >/= 400 mg/m (2) (p = 0.002).

CONCLUSION

Cisplatin chemotherapy and craniospinal irradiation with tumor boost are of significant influence on long term survival in patients with MNGGCTs. The exclusion of major surgery at diagnosis using modern advances in neurosurgery or related tumor resection after neoadjuvant chemotherapy will allow a further reduction of treatment related mortality and long lasting morbidity. The analysis reveals that, given effective treatment, intracranial malignant non-germinomatous GCTs should not longer carry a poor prognosis.

Pineal Parenchymal Tumours: I

Pineocytoma and pineoblastoma are now recognised as a spectrum of the same disease. Three cases of pineocytoma (grade I-II) are presented, in which platinum-based chemotherapy was used with some success, either as part of primary therapy or at the time of relapse. With the recent reclassification of pineal parenchymal tumours into a grade I-IV continuum, the place of chemotherapy, previously only well-established in pineoblastoma, is discussed.

High-dose chemotherapy with autologous stem-cell rescue in children and adults with newly diagnosed pineoblastomas

PURPOSE

We evaluated the usefulness of a treatment regimen that included high-dose chemotherapy (HDC) with autologous stem-cell rescue (ASCR) in patients with newly diagnosed pineoblastoma (PBL).

PATIENTS AND METHODS

Twelve patients with PBL were initially treated with surgery and induction chemotherapy. All but two patients underwent radiotherapy. Subsequently, all patients received HDC using cyclophosphamide (CTX) + melphalan (MEL) or busulfan (Bu) + MEL regimens and ASCR.

RESULTS

A total of six children and six adults with median ages of 4.2 (range, 0.3 to 19.8 years) and 23 years (range, 23 to 43.7 years), respectively, were treated according to this strategy. Four patients had metastatic disease confined to the neuraxis. Five of 12 patients (42%) had a complete tumor resection at diagnosis. Ten patients received radiotherapy at median doses of 36.0 and 59.4 Gy to the neuraxis and pineal region, respectively. Eleven patients received HDC with CTX + MEL, and one patient received BU + MEL followed by ASCR. Nine patients are alive with no evidence of disease recurrence at a median of 62 months from diagnosis (range, 28 to 125 months), including three patients with metastatic disease and two infants who did not receive any radiotherapy. Three patients have died of progressive disease at 19, 32, and 37 months from diagnosis, respectively. The actuarial 4-year progression-free and overall survivals are 69% (95% confidence interval [CI], 39% to 99%) and 71% (95% CI, 43% to 99%), respectively.

CONCLUSION

The use of HDC in addition to radiotherapy seems to be an effective treatment for patients with newly diagnosed pineoblastoma.

[Usefulness of melatonin in the diagnostics and therapy of pineal gland and brain neoplasms]

Melatonin or N-acetyl-5-methoxytryptamine is mainly produced by pineal gland and exhibits characteristic diurnal rhythm of synthesis and secretion with the highest levels at night and low levels during a day. For several years the knowledge of pineal gland and its hormone was rather poor. It was last years when knowledge of the role of melatonin in health and different diseases was developed. Nowadays we are aware that melatonin plays important role in diagnosis and therapy of several diseases, and may be helpful factor also in neurosurgery. Author presents the review of the present knowledge on the role of melatonin in diagnosis of pineal region pathology and treatment of brain tumors.

Successful treatment of extracranially metastasized pineal gland germinoma with high-dose methotrexate

Germinoma of the pineal gland is a rare disease usually confined to the brain which responds well to radiotherapy. Spinal seeding occurs in approximately 4% of cases and distant metastases are extremely rare. We report on a 27-year-old female with an intracranially metastasized pineal gland germinoma, meningeal carcinomatosis and distant bone metastases. Treatment was initiated with intrathecal methotrexate (MTX) and continued with high-dose intravenous MTX. The therapy was very well tolerated apart from reversible hepatic toxicity requiring a dose reduction. The patient was in complete remission after three courses followed by two consolidation cycles; the patient has now been in continuous complete remission for more than 22 months. This is the first report to show that MTX is a potent drug in treating pineal gland germinoma. Long-term side effects of radiotherapy such as reduced mental function or hypopituitarism can probably be avoided. Single-agent high-dose MTX may provide high efficacy with limited adverse effects, especially at a more advanced tumor stage with spinal seeding and extracranial disease.

Influence of phenytoin on the disposition of irinotecan: a case report

Irinotecan (CPT-11), a water-soluble topoisomerase I inhibitor, is metabolized by carboxylesterase enzymes to form an active metabolite, SN-38. Recent studies have shown that irinotecan also undergoes oxidative metabolism by the P450 isozyme CYP3A4, leading to the formation of a minor inactive metabolite, 7-ethyl-10-[4-N-[(5-aminopentanoic acid)-1-piperidino]-carbonyloxy-camptothecin (APC). The elucidation of this metabolic pathway suggests the potential for drug interactions when irinotecan is administered with other inducers or substrates of CYP3A4. In this report, the authors summarize the pharmacokinetic profile of irinotecan and its major metabolites with and without concomitant phenytoin administration in an individual patient. These studies revealed that concomitant phenytoin administration resulted in a marked decrease in the systemic exposure to irinotecan and SN-38 and an increase in the exposure to APC. The area under the curve of irinotecan and SN-38 decreased by 63% and 60%, respectively; the area under the curve of APC increased by approximately 16%. Further detailed pharmacokinetic studies of irinotecan in patients receiving concomitant therapy with enzyme-inducing anticonvulsants are required so that rational dosing recommendations can be provided for this patient population.

Spontaneous regression of a germinoma in the pineal body after placement of a ventriculoperitoneal shunt

The authors report a case in which a germinoma in the pineal body displayed spontaneous regression after placement of a ventriculoperitoneal (VP) shunt. Spontaneous regression of malignant tumors is extremely rare, occurring in only one of 60,000 to 100,000 patients. Although in rare cases spontaneous regression is known to occur in patients with testicular seminomas, only one case of spontaneous regression of a primary pineal germinoma has so far been reported. In the present case a 17-year-old man presented with headache. A tumor in the pineal body and acute hydrocephalus were revealed by head computerized tomography (CT) and magnetic resonance (MR) imaging, and VP shunt placement was performed. Computerized tomography scanning of the head was performed four times during a 2-week period following the operation, and the patient was temporarily discharged to return to school. At the time of discharge, CT scanning demonstrated no change in the size of the tumor. Two months later, the patient was readmitted to the hospital to undergo surgery. At that time, head MR imaging revealed regression of the tumor. The pathological diagnosis of the lesion was germinoma. The patient underwent three courses of chemotherapy, during which carboplatin and etoposide were administered, in addition to a 24-Gy dose of radiotherapy. No manifestations of nerve impairment were noticed, and the patient was observed on an outpatient basis. The authors think that the factors involved in tumor regression included the effects of the VP shunt, the effects of radiation absorbed during head CT scanning, and the role of the patient's own immune response. However, no conclusion has been reached concerning the actual cause.

Long-term survival following extra-neural metastasis from a pineoblastoma

A young woman presented with a pineoblastoma treated initially with whole neuraxis radiotherapy. She had biopsy confirmed metastatic disease to the left lateral pelvis which was treated on 2 separate occasions, and biopsy confirmed metastatic disease to the subcutaneous tissues of the left thigh. She currently remains well 8 years after the primary diagnosis and 6 years after the first systemic relapse.

Outcome for children with supratentorial primitive neuroectodermal tumors treated with surgery, radiation, and chemotherapy

BACKGROUND

The outcome of a child with a primitive neuroectodermal tumors arising supratentorially (SPNET) is not well characterized and may differ from the outcome of a patient with a histologically similar cerebellar tumor (medulloblastoma [MB]). Recently, 5-year progression free survival rates as high as 80% have been reported for children with MB treated with craniospinal radiation (CRT) and chemotherapy including cisplatin, lomustine (CCNU), and vincristine (VCR).

METHODS

The authors reviewed the outcome of 22 consecutive patients age 3 years and older (mean age, 10 years; range, 3-18 years) with SPNET who were treated at the study institutions between 1981 and 1996. Tumor location included was 13 pineal, 6 cortical, and 3 thalamic or suprasellar. Five patients had disease dissemination at diagnosis. All patients underwent surgery and staging, followed by CRT and chemotherapy with cisplatin, CCNU, and VCR.

RESULTS

Of the 22 patients, 13 had developed disease progression and 10 had died at the time of last follow-up. Overall progression free survival (PFS) was 47% +/- 11% at 3 years and 37% +/- 11% at 5 years. There was a significant difference in PFS between patients with localized disease versus those with disseminated disease (P = 0.04). There was no statistical association between tumor location and survival. Although not significant (P = 0.21), there was a trend toward better survival of those patients with complete or near-complete resection compared with those with partial resection or biopsy.

CONCLUSIONS

The results of the current study demonstrate that the outcome for children with SPNET treated with radiation and chemotherapy appears worse than for children with MB treated with identical therapy. This suggests that there may be biologic differences between supratentorial and infratentorial primitive neuroectodermal tumors, thus requiring refinements in treatment.

Mixed germ cell tumour of the pineal region: a case report

An intracranial mixed germ cell tumour with germinoma and teratoma components is reported. The patient presented with parinaud's syndrome and precocious puberty. The treatment involved partial surgical debulking followed by whole brain radiotherapy (4500 cGY in 25 fraction over 5 weeks) and chemotherapy (consisting of cisplatin and etoposide). Post treatment MRI showed no residual lesion. The controversies in the management are discussed.

The role of chemotherapy in intracranial germinoma: a case report

BACKGROUND

The case of a 29-year-old man with histologically proven simultaneous germinoma (seminoma) of the pineal gland and a stage I embryonal carcinoma of the testis is reported. An intradural metastatic lesion from the pineal germinoma was diagnosed at the level of the first thoracic vertebra. Treatment, after inguinal orchiectomy, was chemotherapy only, rather than conventional radiotherapy for the pineal germinoma.

METHODS

Therapy consisted of bleomycin (B), etoposide (E) and cisplatin (P). MRI was used to assess the effectiveness of BEP chemotherapy.

RESULTS

A complete remission of the pineal gland germinoma and the epidural metastasis was documented after two cycles of BEP chemotherapy and after 15 months of follow-up the patient remains free of relapse.

DISCUSSION

The pathogenesis of simultaneously occurring germinoma of the pineal gland and embryonal cell carcinoma of the testis is discussed. The choice of therapy in these circumstances is a matter of debate and the good result of chemotherapy alone in this patient suggest that primary chemotherapy may be the therapy of choice in patients with pineal germinomas.

Hyperfractionated craniospinal radiation therapy for primitive neuroectodermal tumors: results of a Phase II study

PURPOSE

To report the results of a Phase II study of hyperfractionated craniospinal radiation therapy, with and without adjuvant chemotherapy for primitive neuroectodermal brain tumors (PNETs) and malignant ependymomas.

METHODS AND MATERIALS

Newly diagnosed PNET or malignant ependymomas were treated with hyperfractionated craniospinal radiation therapy. The primary tumor site was treated to a dose of 72 Gy, with 30 Gy given to the rest of the craniospinal axis. The fraction size was 1.0 Gy, given twice a day. Patients with poor risk factors also received adjuvant chemotherapy with CCNU, cisplatin, and vincristine. Patients had follow-up for survival, time to tumor progression, and patterns of relapse.

RESULTS

A total of 39 patients (21 males/18 females) were treated between March 12, 1990 and October 29, 1992. The median age was 16 years (range 3-59 years). Tumor types included 25 medulloblastomas, 5 pineoblastomas, 5 cerebral PNETs, 1 spinal cord PNET, and 3 malignant ependymomas. Twenty cases were staged as poor-risk and received adjuvant chemotherapy following radiation. Three-year progression-free survival (PFS) was 60% and 63% for poor-risk and good-risk patients, respectively. Overall 3-year survival for these groups was 70% and 79%, respectively. For the 25 patients with medulloblastoma, there were 16 good-risk and 9 poor-risk patients. Three-year PFSs were 63% and 56%, respectively. The 5-year survival for good-risk medulloblastoma was 69% with 43.7% of these patients having failures outside the primary site.

CONCLUSIONS

Survival in patients with good-risk medulloblastoma was no better than that seen in previous studies with single-fraction radiation, and the rate of failure outside the primary site is excessive. Those with poor-risk features had comparable survival to that seen in patients with good risk factors, but these patients were treated with chemotherapy, and the role that hyperfractionated radiation played in their outcome is uncertain.

Combination chemotherapy (cisplatin, vinblastin) and low-dose irradiation in the treatment of pineal parenchymal cell tumors

Pineal parenchymal cell tumors (PPCTs) with or without metastasis into the lumbar region by way of the cerebrospinal fluid were treated successfully with combination chemotherapy using cisplatin, vinblastin, and bleomycin (PVB) or cisplatin and vinblastin (PV) and low-dose irradiation (25 approximately 30 Gy). Our series included a case of pineoblastoma, two cases of mixed pinocytoma/pineoblastoma, and a case of pineocytoma, compared to which the data held by the All Japan Brain Tumor Registry (AJBTR) included information on 47 cases pineocytoma and 20 of pineoblastoma. All our patients have survived, with scores of 90% or over on Karnofsky's performance scale, for 2-12 years of follow-up so far; however, the 5-year survival rates of the patients recorded by AJBTR were 83% for pineocytoma treated with radiation and 43% without radiation; and 42% for pineoblastoma treated with radiation and 50% without radiation. Incomplete or varied chemotherapeutic regimens used in different medical centers to treat PPCTs precluded an evaluation such as was made by AJBTR. Our results suggested that combination chemotherapy with low-dose back-up radiotherapy may be the treatment of choice for primary or recurrent disease with or without dissemination in PPCTs.

Histologically confirmed pineal tumors and other germ cell tumors of the brain

BACKGROUND

This study examined the outcome of patients with histologically confirmed pineal region tumors.

METHODS

One hundred thirty-five patients with histologically confirmed pineal tumors and other germ cell tumors of the brain were evaluated retrospectively. The pineal parenchymal tumors (PPTs) included 15 pineoblastomas (PB), 2 mixed PPTs, 4 PPTs with intermediate differentiation, and 9 pineocytomas. The germ cell tumors included 48 germinomas, 26 mixed germ cell tumors, 11 mature teratomas, 9 immature teratomas, 6 malignant teratomas, 2 yolk sac tumors, and 3 choriocarcinomas. Patients were treated with various combinations of chemotherapy, radiotherapy, and surgery. The duration of follow-up ranged from 0.25 to 37.3 years, with a median follow-up of 5.3 years.

RESULTS

The 5-year patient survival rate was 86% for those with mature teratomas; 86% with pineocytomas; 80% with germinomas; 67% with immature teratomas; 49% with PPTs, excluding pineocytomas; 38% with mixed germ cell tumors; and 17% with other germ cell histologies (P = 0.0001). The delivery of > 44 Gray (Gy) to germinomas and > 50 Gy to PPTs and nongerminomatous germ cell tumors (NGGCTs) other than mature and immature teratomas was associated with improved survival. A greater extent of resection was associated with a higher rate of survival in all patients with NGGCTs. The administration of chemotherapy was associated with improved survival in those patients with NGGCTs other than mature and immature teratomas.

CONCLUSIONS

Prognosis was dependent on tumor type. Obtaining a tissue diagnosis made it possible to tailor therapy according to tumor type and potentially improve the survival of patients. Survival was dependent on the dose of radiation administered to patients with PPTs, germinomas, and NGGCTs other than mature and immature teratomas. More extensive resection and the use of chemotherapy were also associated with improved survival in subgroups of patients with NGGCTs. Treatment recommendations are described in detail in the article.

Treatment of patients with pineoblastoma with high dose cyclophosphamide

The outcome for patients with pineoblastoma has historically been very poor, with most patients dying of disseminated disease despite irradiation. Furthermore, the low incidence of this tumor has hindered progress toward defining better treatment strategies. Here we report the activity and toxicity of cyclophosphamide administered as a single agent at a dose schedule of 2 g/m2/day for 2 successive days at monthly intervals for a maximum of four courses. Eight patients were evaluated, six newly diagnosed and two recurrent. Amongst the six newly diagnosed patients, there were three patients demonstrating partial responses, and three had stable disease throughout the cyclophosphamide treatment period. All six patients are alive and disease free after further therapy. One patient with recurrent disease demonstrated tumor progression on cyclophosphamide, and the other had stable disease throughout the cyclophosphamide treatment period. Both patients subsequently died of progressive disease. The major toxicity of high dose cyclophosphamide was hematopoietic, with one patient requiring a dose reduction after three courses due to prolonged thrombocytopenia. One patient was also withdrawn from treatment with cyclophosphamide due to impaired pulmonary function. This study demonstrates the activity of high dose cyclophosphamide in the treatment of pineoblastoma and may serve as basis for the design of future studies of this tumor.

[A case of pineoblastoma successfully treated with surgery, combined chemotherapy of cisplatin and etoposide, and radiotherapy]

A 5-year-old girl was admitted to another clinic because of vomiting and convulsions. She was brought to our clinic after a ventriculoperitoneal shunt was inserted. CT scan on admission in our clinic showed a tumor in the pineal region with tumoral hemorrhage. Tumor markers such as HCG, AFP, CEA, P-LAP were within normal range. A biopsy of the tumor was performed and the histological diagnosis was pineoblastoma. Her recovery was excellent and disseminated metastasis was not recognized. A subtotal removal of the tumor was performed through the occipital transtentorial approach. She had no neurological deficits after surgery. She then received two 5-day cycles of chemotherapy, consisting of intravenous administration of 20 mg/m2/day cisplatin and 60 mg/m2/day etoposide, and craniospinal radiotherapy. After these therapies, the tumor responded and disappeared completely. Follow-up radiographic investigations also demonstrated no abnormal evidence except for brain atrophy. She is attending a primary school without any problems. Pineoblastoma is quite rare and remarkably malignant. Hence, aggressive therapies including surgery, radiotherapy and chemotherapy is indicated for this tumor.

Nonresective treatment of pineoblastoma: a case report

BACKGROUND

Stereotactic biopsy followed by cytoreductive surgery and/or radiation are the standard treatment for pineoblastoma. We are reporting a patient with a relatively large pineoblastoma, who was treated with a combination of nonresective treatment modalities.

METHOD

The patient is a 20-year-old woman who presented with signs and symptoms of raised intracranial pressure. Magnetic resonance imaging (MRI) showed a large tumor in the pineal region and hydrocephalus. She was emergently treated by placement of a ventriculoperitoneal shunt. Three days later she underwent a stereotactic biopsy, which showed the tumor to be pineoblastoma. She was then further treated with the following treatment modalities: permanent implantation of high activity I125 seeds, external radiation, and chemotherapy.

RESULTS

At 10 months' follow-up, MRI showed complete disappearance of the tumor. At 18 months' follow-up, the patient is asymptomatic, neurologically intact, and her MRI scans show no evidence of intracranial or intraspinal tumor.

CONCLUSIONS

Though the follow-up is relatively short, the results of the nonresective approach in this patient have been excellent.

Lack of efficacy of postoperative chemotherapy and delayed radiation in very young children with pineoblastoma. Pediatric Oncology Group

Eleven infants with pineoblastomas were treated with prolonged postoperative chemotherapy in an attempt to delay radiation and reduce neurotoxicity. These infants were part of the Pediatric Oncology Group infant brain tumor study but the outcome of infants with pineoblastomas was not previously reported. Ages ranged from 1 month to 35 months, with eight of 11 < or = 12 months at diagnosis. Four had + cytology and three had + myelograms at diagnosis. The majority had partial surgical resection (25-75% reduction in tumor) and 10 had shunts. Chemotherapy consisted of two 28-day cycles of cyclophosphamide plus vincristine, followed by one 28-day cycle of cisplatin plus etoposide. Craniospinal radiation was planned following completion of either 2 years of chemotherapy (children less than 24 months at diagnosis) or following one year (children 24-36 months at diagnosis). Neuroimaging results following two cycles of cyclophosphamide and vincristine were one partial response, five stable disease, and five progressive disease. There were no responders in the leptomeninges. All children ultimately failed chemotherapy (2 months-11 months). Nine failed in the primary site. Of those eight children in whom a metastatic workup was performed at time of progression, all had evidence of leptomeningeal disease. Six received radiation following failure on chemotherapy. All failed either in the primary site, leptomeninges or extraneurally (peritoneal cavity). All children died. Survival following diagnosis ranged from 4 months to 13 months. This chemotherapy regimen was neither effective in controlling tumor in the primary site nor in treating or preventing leptomeningeal spread.

Survival and prognostic factors following radiation and/or chemotherapy for primitive neuroectodermal tumors of the pineal region in infants and children: a report of the Childrens Cancer Group

PURPOSE

To describe the biologic and clinical features of children with primitive neuroectodermal tumors (PNETs) arising in the pineal region (pineoblastomas) and evaluate prospectively the efficacy of radiation therapy (RT) and/or chemotherapy.

PATIENTS AND METHODS

Between 1986 and 1992, 25 children with PNETs of the pineal region were treated as part of a Childrens Cancer Group study. Eight infants less than 18 months of age were nonrandomly treated with eight-drugs-in-1-day chemotherapy without RT. The remaining 17 patients were treated with craniospinal RT and randomized to receive either vincristine, lomustine (CCNU), and prednisone or the eight-drugs-in-1-day regimen.

RESULTS

Of 24 completely staged patients, 20 (83%) had localized disease at diagnosis. All infants developed progressive disease a median of 4 months from the start of treatment. Of the 17 older patients treated with RT and chemotherapy, the Kaplan-Meier estimate of progression-free survival (PFS) at 3 years is 61% +/- 13%. This is superior to the PFS of children with other supratentorial PNETs (P = .026). Following RT, 12 of 17 patients (70.6%) had a residual pineal region mass, which persisted for as long as 5 years before resolving; only four subsequently developed progressive disease.

CONCLUSION

(1) Eight-in-1 chemotherapy without RT appears to be ineffective therapy for young children with PNETs of the pineal region. (2) For children more than 18 months of age at diagnosis treated with craniospinal RT and chemotherapy, the PFS is superior to that of children with other supratentorial PNETs. (3) A residual enhancing mass following RT is not predictive of treatment failure.

[Intensive and high-dose chemotherapy with peripheral blood stem cell transfusion for pediatric malignant brain tumor]

In this study, the newly developed marrow-rescue therapy during myelosuppression is utilized. In this therapy, peripheral blood stem cell transfusion (PBSCT) is administered following high-dose chemotherapy. Harvest of peripheral blood stem cells (PBSC) during myelosuppression following marrow-ablative chemotherapy is a safe, reliable procedure in children with leukemia. And administration of these cryopreserved PBSC is useful in reducing myelosuppression following intensive/ultra high-dose chemotherapy. In this study, several courses of intensive chemotherapy (1 course: VP-16 300mg/m2 x 5 days + carboplatin 400-500mg/m2 x 3 days) and one course of ultra-high dose chemotherapy (1 course: VP-16 400mg/m2 x 8 days + carboplatin 800mg/m2 x 5 days + MCNU 250, 200mg/m2 x each day) with PBSC transfusion were applied in four cases of pediatric malignant brain tumors (2 cases of medulloblastoma, one case of pineoblastoma and anaplastic ependymoma) after surgical reduction. With PBSC transfusion, myelosuppression following high-dose chemotherapy could be overcome without serious complication in all cases. Three cases showed complete remission and one showed partial remission after the operation and intensive chemotherapy. However, CSF dissemination appeared in two cases and they died 20 and 28 months after the onset respectively. Intensive/ultra high-dose chemotherapy with PBSC transfusion is a safe procedure in children with malignant brain tumors. This procedure may enable the postponement of radiation for pediatric malignant brain tumor cases under three years of age.

The role of cerebrospinal fluid cytology in radiotherapy planning for intracranial germinoma

PURPOSE

The association between the cerebrospinal fluid cytology findings and the clinical features of patients with intracranial germinoma was investigated to determine whether cerebrospinal fluid cytology could be helpful in determining the optimal radiation treatment volume.

METHODS AND MATERIALS

Between 1976 and 1992, cerebrospinal fluid cytology was performed in 42 germinoma patients using a cytocentrifugation method. Forty patients received irradiation and 2 received chemotherapy with cisplatin and etoposide.

RESULTS

Cerebrospinal fluid cytology was positive in 22 of the 42 patients (52%). Dissemination via cerebrospinal fluid (intraventricular or spinal) was present at the initial diagnosis in eight (36%) of the 22 cytology-positive patients and none of the 20 negative patients. After treatment, cerebrospinal fluid dissemination developed in four (18%) of the cytology-positive patients and one (5%) of the negative patients. Two of the former four patients had received chemotherapy alone as initial treatment. Five patients with positive cytology received irradiation to a smaller volume than the cerebrospinal axis (primary tumor site plus spinal axis in three and whole brain in two), but they have not developed recurrence in the 4 to 14 years since therapy. The 5-year survival rate was 93% for the cytology-positive patients and 94% for the negative patients.

CONCLUSION

Cerebrospinal fluid cytology-positive patients have a higher risk of cerebrospinal fluid dissemination and it seems reasonable to give them low-dose (20-24 Gy) prophylactic craniospinal irradiation. When properly irradiated, the prognosis of cytology-positive patients is as good as that of negative patients.

Treatment of nongerminomatous germ-cell tumors of the pineal region

Germ-cell tumors can be subdivided into germinoma, embryonal carcinoma, choriocarcinoma, endodermal sinus tumor (yolk-sac tumor), and teratoma. They are also distinguished by their production of secreted markers such as alpha-fetoprotein produced in endodermal sinus tumors and embryonal carcinoma or beta-human chorionic gonadotropin, produced by choriocarcinoma and embryonal carcinoma. Germinoma and teratoma produce none of the markers. Because it has been proposed that teratomas may differentiate from multipotent stem cells contained in embryonal carcinoma and are thus lineage related, the presence of markers indicates the presence of a nongerminomatous germ-cell tumor. Nongerminomatous germ-cell tumors are an invariably fatal subgroup within the pediatric pineal region germ-cell tumors. There is no effective, established therapeutic regimen. We report the treatment regimen for three children diagnosed with this highly aggressive tumor entity. The children were first given a course of chemotherapy with bleomycin, etoposide, and cisplatin. This resulted in the normalization of markers and the shrinkage of tumors. These were then removed by the infratentorial supracerebellar approach. Removal was followed by a second course of chemotherapy with vinblastine, ifosfamide, and cisplatin; after which the children underwent radiotherapy. All three children are well and without evidence of residual or recurrent disease 20, 30, and 32 months after surgery, respectively. We propose this therapy regimen for children in whom the markers are positive.

Successful treatment of recurrent malignant germ cell tumors: report of two cases

We report two patients with recurrent malignant germ cell tumors who were successfully treated with radiation therapy and cisplatin combination chemotherapy. Patient 1, who had a suprasellar mixed yolk sac tumor, had been free of tumor for 3.5 years after cisplatin/vinblastine/bleomycin combination chemotherapy alone but showed a recurrent tumor in the pineal region. In Patient 2, who had a pineal alpha-fetoprotein-producing tumor, recurrent tumors appeared in the lateral ventricle 3 years after the tumor was controlled by radiation and cisplatin/vinblastine/bleomycin therapy. They were treated successfully again by radiation therapy, followed by cisplatin and etoposide combination therapy, and they have been free of tumor for 5.5 and 7 years after recurrence, respectively. The total dose of cisplatin in both patients exceeded 1,000 mg/m2, which would have contributed to the control of the recurrent tumors. Anterior pituitary dysfunction observed in Patient 1 did not improve, even after tumor disappearance by chemotherapy, suggesting severe damage to the neurohypophysis by direct invasion of the tumor.

Response to neoadjuvant chemotherapy in children with pineoblastoma

BACKGROUND

The outlook of children with pineoblastoma treated with radiation therapy alone is extremely poor, but neoadjuvant chemotherapy has been tried only in a few cases of this rare childhood brain tumor with poor prognosis.

METHODS

Three consecutive children 3 to 7 years of age received neoadjuvant chemotherapy consisting of etoposide 100 mg/m2 days 1 to 3, cisplatin 100 mg/m2 day 1, and vincristine 1.5 mg/m2 day 1, repeated every 4 weeks. After four courses of chemotherapy, patients underwent craniospinal irradiation. The radiation doses to the primary site ranged from 5040 to 5440 cGy and craniospinal axis radiation dose was 2520 to 3060 cGy.

RESULTS

After chemotherapy, mild myelosuppression occurred in all three and mild to moderate bilateral high-frequency sensorineural hearing loss occurred in two of the three patients. One patient remains in near complete resolution of the tumor at 2 years after diagnosis and another remains in CR for 5 years. One patient achieved PR for 5 months but eventually died of progressive tumor.

CONCLUSIONS

This study suggests that the neoadjuvant chemotherapy as used here is effective and has acceptable toxicity.

Successful combination chemotherapy (cisplatin, vinblastine, and bleomycin) with small-dose irradiation in the treatment of pineoblastoma metastasized into spinal cord: case report

A case of successful combination chemotherapy using cisplatin, vinblastine, and bleomycin (PVB) therapy with small-dose irradiation (25 Gy) to treat a pineoblastoma that metastasized into the lumbar region through the cerebrospinal fluid is presented. Pain in the lower extremities and urinary incontinence with paraplegia improved during irradiation of the spinal cord after two courses of PVB therapy administered during a period of 6 weeks. The patient is presently attending school normally and has a score of 100% on the Karnofsky performance scale 4 years after therapy. These results suggest that combination chemotherapy with small-dose back-up radiotherapy may be one of the treatments of choice for recurrent or disseminated pineoblastoma.

Intracranial germ cell tumours: I. Experience with platinum based chemotherapy and implications for curative chemoradiotherapy

The results of treatment with platinum based combination chemotherapy in ten patients with intracranial germ cell tumours (GCT) are presented. Two patients, treated for relapse within the central nervous system (CNS), attained partial responses of short duration. One patient with systemic relapse was successfully salvaged with chemotherapy. Seven patients received primary chemotherapy, six of whom received a 'CNS friendly' regimen consisting of vincristine, etoposide, carboplatin (VEJ) prior to craniospinal axis (CSA) irradiation. Three complete and three partial responses, and one patient with stable disease, were seen prior to irradiation. All seven patients are alive and remain disease-free at a median time of 12 months after treatment. Current treatment policy for germinomas attaining complete response to two courses of VEJ is a lowered CSA dose prescription, while non-germinomatous germ cell tumours (NGGCT) receive standard total dose CSA irradiation.

Recurrent intracranial germinoma refractory to conventional irradiation: effective chemotherapy consisting of cisplatin and etoposide--case report

Recurrent intracranial germinoma with multiple spinal metastases occurred in a 16-year-old male presenting with persistent headache and visual disturbances. Computed tomography revealed enhanced lesions in the pineal region, anterior horn, and infundibulum. Conventional irradiation achieved remission, but local recurrences requiring further irradiation occurred after 23 months. Magnetic resonance imaging showed multiple spinal metastases 11 months later. Partial removal of the spinal lesions gave a histological diagnosis of typical germinoma. Postoperatively, intracranial recurrences were again detected. Chemotherapy consisting of intravenous cisplatin and etoposide achieved remission and no recurrence has occurred for 12 months.

Treatment of tumours of the pineal region and posterior part of the third ventricle

The evaluation of tumours located in the posterior part of the third ventricle or pineal region is achieved best by magnet resonance imaging (MRI). It shows the exact localization and extent, the involvement of neighbouring structures like thalamus or quadrigeminal plate and the displacement of the large veins, the internal cerebral veins, the vein of Galen and the veins of Rosenthal. If only CT is available, angiography should be performed prior to operation to identify the course of the veins. In children with a pineal region tumour the "tumour markers" AFP and beta-HCG should be determined before operation. We approach the rare tumours entirely located within the posterior part of the third ventricle by the posterior interhemispheric transcallosal route with the patient in prone position with the head elevated. The same approach is used for pineal region tumours extending above the internal cerebral veins. Tumours arising from the posterior thalamus extending into the thalamus and ventricle as well, are better approached by the posterior transcortical transventricular route since the lateral view is rather limited by the midline approach. The most frequent tumours in the pineal region are approached if they are located below the internal veins by the infratentorial, supracerebellar route in the sitting position. A total of 60 cases are evaluated. If AFP and/or beta-HCG are positive a highly malignant nongerminomatous germ-cell tumour must be suspected. We recommend initial chemotherapy with a combination of Vinblastine, Ifosfamide and Cis-platin without biopsy to avoid tumour seeding. After the "markers" are normalized operative removal of the residual tumour and radiotherapy should be carried out. In a series of 13 children operated on for pineal region tumours a rigid neuropsychological and endocrine evaluation was performed with encouraging results. During the last 10 years we have performed 49 open operations and 11 stereotactic biopsies. 40% of the patients were children under the age of 18. 40% of the tumours in childhood and 60% in adults were benign. In childhood 24% were germinomas and 20% non-germinomatous germ cell tumours.

Cisplatin, ara-C and etoposide (PAE) in the treatment of recurrent childhood brain tumors

Sixteen patients with recurrent childhood brain tumors were treated with intravenous cisplatin, cytosine arabinoside and etoposide (PAE), daily for three days every three to four weeks. Objective responses were observed in 6 of 15 evaluable patients and an additional six patients had stable disease for greater than 6 months. The tumor-specific response rate for astrocytoma/glioma was 3 of 7 and for medulloblastoma was 2 of 4. The mean progression-free interval was 11.0 months and the hazard rate for progression was 0.085 per patient-month of observation. The most common toxicities were neutropenia and thrombocytopenia. Clinically significant ototoxicity was identified in 7 patients. The activity of PAE chemotherapy for recurrent childhood brain tumors warrants further investigation.

Optimum management of pineal germ cell tumours

Non-seminomatous pineal region germ cell tumours have a poor prognosis when treated with radiation alone but little is known of the results of treatment with modern chemotherapy. Between 1983 and 1990 five pineal region germ cell tumours presented to the Charing Cross Hospital, London. All five patients received the EpPlt/OMB chemotherapy schedule with escalated dose systemic methotrexate and intra-CSF methotrexate. Two patients had had prior radiotherapy. Four patients (80%) remain well and disease-free 6 months--5 years after completing therapy. Chemotherapy is an effective modality for the treatment of pineal germ cell tumours and should be used when non-seminomatous elements are present or when the placement of ventriculo-peritoneal shunt in the presence of malignant cells in the CSF presents a risk of dissemination.

Intracranial germinoma: report of seven cases

Seven children with histologically verified intracranial germinomas, treated between 1983-1987, are reviewed. The four boys were 12, 14, 15, and 16 years old; two girls were 9, and one girl was 10 years old. Four tumors were suprasellar, and three were in the pineal region. Parinaud's sign was the first symptom in the pineal tumors and diabetes insipidus in the suprasellar ones. The latter four patients also had pituitary deficiencies. The tumors were totally removed in three patients, partially in three, and one patient had biopsy only. Two patients had disseminated tumor. All patients received radiation: four to the tumor bed, one to the whole brain, and two to the whole central nervous axis (CNA). The doses to the tumor were 30 Gy in three, 40 Gy in two (one whole brain), and 45 Gy in two. The dose to the CNA was 24 Gy. Five patients had chemotherapy as well: cyclophosphamid (cytoxan) 80 mg/kg in two doses, three times in 3-week intervals. All patients are alive and well. Total disappearance of tumor followed chemotherapy before radiation in three patients. Lower doses of radiation (30 Gy, 40 Gy) and irradiation of the tumor bed only were sufficient for tumor control in localized germinoma.

[Combined chemotherapy of CDDP and etoposide in intracranial germinomas]

Two cases with pineal germinomas were treated by the combined chemotherapy of CDDP and etoposide. The first case was a 15-year-old boy who had a pineal tumor of 2.2 x 1.8 cm in diameter. He was given intravenously 25 mg/body of CDDP and 30-60 mg/body of etoposide daily for five days. The tumor had already decreased at two days after starting chemotherapy and disappeared completely just after the first course of chemotherapy. The patient received another course of chemotherapy and focal radiation of 40 Gy to prevent tumor recurrence. The second case was 19-year-old man who had a pineal germinoma associated with CSF dissemination and hydrocephalus. He was also treated by 30 mg/body of CDDP and 80 mg/body of etoposide daily for five days. The tumor size decreased more than 50% just after the first course of chemotherapy, and complete remission was obtained by additional radiation of 6 Gy. From these results, this combined chemotherapy is useful for the treatment of intracranial germinoma, and this makes it possible to discontinue radiation therapy or at least reduce the radiation dose and radiation field.