Surgical management of primary central nervous system germ cell tumors

Proceedings from the Second International Symposium on Central Nervous System Germ Cell Tumors 

Restricted access

The successful treatment of children with a primary CNS germ cell tumor can be greatly influenced by the neurosurgeon involved in the diagnostic and therapeutic care of these children. Variability in surgical philosophies no doubt exists due to the relatively infrequent incidence of these tumors, a lack of consensus regarding diagnostic and therapeutic approaches, and the advent of recent surgical innovations. Many of these issues were discussed at the Second International Symposium on Central Nervous System Germ Cell Tumors through presented abstracts and invited presentations. The neurosurgical aspects of these proceedings are summarized here in an effort to present the agreed-upon and debated issues that may confront the pediatric neurosurgeon.

Abbreviations used in this paper: AFP = alpha-fetoprotein; β−HCG = beta subunit-human chorionic gonadotropin; COG = Children's Oncology Group; ETV = endoscopic third ventriculostomy; GCT = germ cell tumor; NGGCT = nongerminomatous GCT.

Article Information

Address correspondence to: Mark M. Souweidane, M.D., Department of Neurological Surgery, Weill Medical College of Cornell University, 525 East 69th Street, Box 99, New York, New York 10021. email: mmsouwei@med.cornell.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    A representative case of endoscopic tumor biopsy of a pineal region tumor. Left: Endoscopic view directed into the third ventricle from a left anterior approach. Choroid plexus is observed at the roof of the third ventricle. The tumor mass is observed situated posterior and inferior to the massa intermedia. Right: The tumor mass is undergoing sampling with cupped forceps.

  • View in gallery

    Example of germinoma dissemination noted at the time of endoscopic tumor biopsy. A and B: Sagittal (A) and coronal (B) postcontrast MR imaging scans obtained in an adolescent patient with a pineal region tumor. Endoscopic third ventriculostomy and tumor biopsy were planned for a presumed germinoma. C: Endoscopic view from a right anterior approach with a view into the third ventricle. Ependymal deposits (arrow) believed to be disseminated tumor are situated on the lateral margin of the foramen of Monro.

  • View in gallery

    Axial MR imaging scans obtained in a 15-year-old boy who presented with diabetes insipidus, confusion, and panhypopituitarism. Left: Image showing a heterogeneously enhancing suprasellar mass. The initial evaluation revealed serum β-HCG 1262 IU/L and AFP 56 ng/ml, and CSF β-HCG 5419 IU/L and AFP 43 ng/ml, with a normal spinal MR image and negative CSF cytology. Right: Image obtained after treatment with 5 cycles of chemotherapy (COG study ACNS 0122). Although the markers completely normalized, the MR imaging scan revealed a residual enhancing mass. Delayed second-look surgery resulted in a complete resection of a mature teratoma. The patient remains without evidence of disease following chemotherapy and craniospinal irradiation.

References

  • 1

    Abdullah JCaemaert J: Endoscopic management of craniopharyngiomas: a review of 3 cases. Minim Invasive Neurosurg 38:79841995

  • 2

    Allen JCDaRosso RCDonahue BNirenberg A: A phase II trial of preirradiation carboplatin in newly diagnosed germinoma of the central nervous system. Cancer 74:9409441994

  • 3

    Badie BBrooks NSouweidane MM: Endoscopic and minimally invasive microsurgical approaches for treating brain tumor patients. J Neurooncol 69:2092192004

  • 4

    Buckner JCPeethambaram PPSmithson WAGroover RVSchomberg PJKimmel DW: Phase II trial of primary chemotherapy followed by reduced-dose radiation for CNS germ cell tumors. J Clin Oncol 17:9339401999

  • 5

    Cavallo LMMessina ACappabianca PEsposito Fde Divitiis EGardner P: Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations. Neurosurg Focus 19:1E22005

  • 6

    Diez BBalmaceda CMatsutani MWeiner HL: Germ cell tumors of the CNS in children: recent advances in therapy. Childs Nerv Syst 15:5785851999

  • 7

    Ferrer ESantamarta DGarcia-Fructuoso GCaral LRumià J: Neuroendoscopic management of pineal region tumours. Acta Neurochir (Wien) 139:12211997

  • 8

    Finlay Jda Silva NSLavey RBouffet EKellie SJShaw E: The management of patients with primary central nervous system (CNS) germinoma: current controversies requiring resolution. Pediatr Blood Cancer 51:3133162008

  • 9

    Friedman JALynch JJBuckner JCScheithauer BWRaffel C: Management of malignant pineal germ cell tumors with residual mature teratoma. Neurosurgery 48:5185232001

  • 10

    Fujimaki TMatsutani M: Japanese Pediatric Brain Tumor Study Group: HCG-producing germinoma: analysis of the Japanese Brain Tumor Study Group. Neuro Oncol 7:5182005. (Abstract)

  • 11

    Hellwig DGrotenhuis JATirakotai WRiegel TSchulte DMBauer BL: Endoscopic third ventriculostomy for obstructive hydrocephalus. Neurosurg Rev 28:1382005

  • 12

    Hopf NJGrunert PFries GResch KDPerneczky A: Endoscopic third ventriculostomy: outcome analysis of 100 consecutive procedures. Neurosurgery 44:7958061999

  • 13

    Itoyama YKochi MYamamoto HKuratsu JUemura SUshio Y: Clinical study of intracranial nongerminomatous germ cell tumors producing alpha-fetoprotein. Neurosurgery 27:4544601990

  • 14

    Jenkin DBerry MChan HGreenberg MHendrick BHoffman H: Pineal region germinomas in childhood treatment considerations. Int J Radiat Oncol Biol Phys 18:5415451990

  • 15

    Jones RFStening WABrydon M: Endoscopic third ventriculostomy. Neurosurgery 26:86921990

  • 16

    Kassam AThomas AJSnyderman CCarrau RGardner PMintz A: Fully endoscopic expanded endonasal approach treating skull base lesions in pediatric patients. J Neurosurg 106:2 Suppl75862007

  • 17

    Kellie SJBoyce HDunkel IJDiez BRosenblum MBrualdi L: Intensive cisplatin and cyclophosphamide-based chemotherapy without radiotherapy for intracranial germinomas: failure of a primary chemotherapy approach. Pediatr Blood Cancer 43:1261332004

  • 18

    Kellie SJBoyce HDunkel IJDiez BRosenblum MBrualdi L: Primary chemotherapy for intracranial nongerminomatous germ cell tumors: results of the second international CNS germ cell study group protocol. J Clin Oncol 22:8468532004

  • 19

    Kumura EArita NHayakawa TUshio YNakata HMurasawa A: Successful combination chemotherapy (cisplatinum, vinblastine, and bleomycin) against peritoneal dissemination of intracranial germ cell tumor. Neurosurgery 18:8028041986

  • 20

    Lau C: Genomic profiling of intracranial germ cell tumors. Neuro Oncol 7:5145152005. (Abstract)

  • 21

    Luther NCohen ASouweidane MM: Hemorrhagic sequelae from intracranial neuroendoscopic procedures for intraventricular tumors. Neurosurg Focus 19:1E92005

  • 22

    Luther NDunkel IJSouweidane MM: Dissemination of intraventricular tumors following endoscopoic manipulation and third ventriculostomy. Neuro Oncol 7:5302005. (Abstract)

  • 23

    Luther NEdgar MADunkel IJSouweidane MM: Correlation of endoscopic biopsy with tumor marker status in primary intracranial germ cell tumors. J Neurooncol 79:45502006

  • 24

    Luther NSouweidane MM: Neuroendoscopic resection of posterior third ventricular ependymoma. Case report. Neurosurg Focus 18:6AE32005

  • 25

    Matsutani MSano KTakakura KFujimaki TNakamura OFunata N: Primary intracranial germ cell tumors: a clinical analysis of 153 histologically verified cases. J Neurosurg 86:4464551997

  • 26

    Modak SGardner SDunkel IJBalmaceda CRosenblum MKMiller DC: Thiotepa-based high-dose chemotherapy with autologous stem-cell rescue in patients with recurrent or progressive CNS germ cell tumors. J Clin Oncol 22:193419432004

  • 27

    Nicholson JCPunt JHale JSaran FCalaminus G: Germ Cell Tumour Working Groups of the United Kingdom Children's Cancer Study Group and International Society of Paediatric Oncology: Neurosurgical management of paediatric germ cell tumours of the central nervous system—a multi-disciplinary team approach for the new millennium. Br J Neurosurg 16:93952002

  • 28

    Ono NIsobe IUki JKurihara HShimizu TKohno K: Recurrence of primary intracranial germinomas after complete response with radiotherapy: recurrence patterns and therapy. Neurosurgery 35:6156211994

  • 29

    Pople IKAthanasiou TCSandeman DRCoakham HB: The role of endoscopic biopsy and third ventriculostomy in the management of pineal region tumours. Br J Neurosurg 15:3053112001

  • 30

    Reddy ATWellons JC IIIAllen JCFiveash JBAbdullatif HBraune KW: Refining the staging evaluation of pineal region germinoma using neuroendoscopy and the presence of preoperative diabetes insipidus. Neuro Oncol 6:1271332004

  • 31

    Robertson PLDaRosso RCAllen JC: Improved prognosis of intracranial non-germinoma germ cell tumors with multimodality therapy. J Neurooncol 32:71801997

  • 32

    Robinson SCohen AR: The role of neuroendoscopy in the treatment of pineal region tumors. Surg Neurol 48:3603671997

  • 33

    Sands SAKellie SJDavidow ALDiez BVillablanca JWeiner HL: Long-term quality of life and neuropsychologic functioning for patients with CNS germ-cell tumors: from the First International CNS Germ-Cell Tumor Study. Neuro Oncol 3:1741832001

  • 34

    Schwartz THFraser JFBrown STabaee AKacker AAnand VK: Endoscopic cranial base surgery: classification of operative approaches. Neurosurgery 62:99110052008

  • 35

    Shima HNishizaki TIshihara HMoroi JFujii MSuzuki M: Recurrent intracranial germinoma with dissemination along the ventricular catheter: a case report. J Clin Neurosci 9:7087102002

  • 36

    Smith AAWeng EHandler MForeman NK: Intracranial germ cell tumors: a single institution experience and review of the literature. J Neurooncol 68:1531592004

  • 37

    Souweidane MM: Endoscopic management of pediatric brain tumors. Neurosurg Focus 18:6AE12005

  • 38

    Souweidane MM: Endoscopic surgery for intraventricular brain tumors in patients without hydrocephalus. Neurosurgery 57:4 Suppl3123182005

  • 39

    Souweidane MMLuther N: Endoscopic resection of solid intraventricular brain tumors. J Neurosurg 105:2712782006

  • 40

    Souweidane MMSandberg DIBilsky MHGutin PH: Endoscopic biopsy for tumors of the third ventricle. Pediatr Neurosurg 33:1321372000

  • 41

    Wara WMJenkin RDEvans AErtel IHittle ROrtega J: Tumors of the pineal and suprasellar region: Childrens Cancer Study Group treatment results 1960–1975: a report from Childrens Cancer Study Group. Cancer 43:6987011979

  • 42

    Weiner HLFinlay JL: Surgery in the management of primary intracranial germ cell tumors. Childs Nerv Syst 15:7707731999

  • 43

    Weiner HLLichtenbaum RAWisoff JHSnow RBSouweidane MMBruce JN: Delayed surgical resection of central nervous system germ cell tumors. Neurosurgery 50:7277342002

  • 44

    Wellons JC IIIReddy ATTubbs RSAbdullatif HOakes WJBlount JP: Neuroendoscopic findings in patients with intracranial germinomas correlating with diabetes insipidus. J Neurosurg 100:5 Suppl Pediatrics4304362004

  • 45

    Wong KTKoh KBLee SHChee CP: Intracranial germinoma metastasizing via a ventriculo-peritoneal shunt. Singapore Med J 37:4414421996

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 216 216 31
Full Text Views 91 91 2
PDF Downloads 145 145 2
EPUB Downloads 0 0 0

PubMed

Google Scholar