Suprasellar germinoma

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✓ The clinical features of 18 cases of suprasellar germinoma were reviewed, and the following points stressed: 1) The incidence of intracranial germinoma and teratoma seems to be much higher in Japan than elsewhere. 2) Germinomas in the pineal region, the third ventricle, and the lateral ventricle were observed to be predominant in males. In suprasellar germinoma, however, males were not affected predominantly and the male:female ratio was 1:1. 3) Suprasellar germinomas caused three symptoms: diabetes insipidus, visual disturbances, and pituitary dysfunctions. 4) Pituitary functions were disturbed to various degrees. Some cases showed hypopituitarism but some showed an elevation of plasma concentrations of cortisol or luteinizing hormone and follicle stimulating hormone. 5) Some abnormalities showing a suprasellar mass were usually found on neuroradiological examination. 6) Suprasellar germinomas were very sensitive to radiotherapy and some of them rapidly disappeared on follow-up computerized tomography scanning after irradiation with as little as 1200 rads.

Abstract

✓ The clinical features of 18 cases of suprasellar germinoma were reviewed, and the following points stressed: 1) The incidence of intracranial germinoma and teratoma seems to be much higher in Japan than elsewhere. 2) Germinomas in the pineal region, the third ventricle, and the lateral ventricle were observed to be predominant in males. In suprasellar germinoma, however, males were not affected predominantly and the male:female ratio was 1:1. 3) Suprasellar germinomas caused three symptoms: diabetes insipidus, visual disturbances, and pituitary dysfunctions. 4) Pituitary functions were disturbed to various degrees. Some cases showed hypopituitarism but some showed an elevation of plasma concentrations of cortisol or luteinizing hormone and follicle stimulating hormone. 5) Some abnormalities showing a suprasellar mass were usually found on neuroradiological examination. 6) Suprasellar germinomas were very sensitive to radiotherapy and some of them rapidly disappeared on follow-up computerized tomography scanning after irradiation with as little as 1200 rads.

The incidence of intracranial teratoma and germinoma seems to be much higher in Japan than elsewhere. In 1963, Ueki,19 describing a series of surgical cases collected in Japan, reported that pineal germinomas accounted for 3.9% of 5714 brain tumors. In 1969, Araki and Matsumoto1 reported that the incidence of germinoma in the pineal region was about 4.5% in Japan, while outside of Japan it was 0.5% to 0.7%. Very recently, the report of the Brain Tumor Registry in Japan18 disclosed that the incidence of intracranial germinoma was 2.1% in 3802 primary brain tumors. Although this figure is lower than those of Ueki or Araki and Matsumoto, the incidence is much higher in the Japanese than in Caucasians. In this paper we present 18 cases of suprasellar germinoma.

Summary of Cases
Patient Population

From 1941 through 1976, 2609 intracranial tumors were treated in the Department of Neurosurgery, Kyoto University Hospital. There were 132 cases of germinoma and teratoma (5% of the total series), of which 87 cases (3.3%) were histologically verified and in the remaining 45 cases the diagnosis was likely because of their clinical course and radiological findings. Germinoma accounted for 55 (2.1%) of the 87 cases histologically verified. The germinomas originated in the pineal region in 27 cases, in the suprasellar area in 18 cases, in the third ventricle in five cases, and in the lateral ventricle in five cases. From their radiological findings, two pineal and six suprasellar germinomas were diagnosed as multiple midline tumors. In these cases the tumors were classified into pineal or suprasellar according to the site of their main mass. Among the 18 suprasellar germinomas, six have been reported previously,8,9 but are included in this series for analysis of clinical signs and symptoms (Table 1).

TABLE 1

Clinical course in 18 patients with suprasellar germinoma

Case No.Age, SexDiagnosisRadiation (rads)Duration of SurvivalOutcome
116, M biopsy 4 mos died
211, F biopsy 1 yr 6 mos died
314, M biopsy5500 16 yrs 8 mos working
421, M biopsy6000 14 yrs 2 mos working
522, M biopsy11,000 11 yrs 10 mos died of hypothalamic
    crisis and brain
    radiation necrosis
628, M biopsy6000 13 yrs 1 mo working
712, M biopsy5500 6 yrs 4 mos going to school
815, F biopsy6000 9 mos died of unknown cause
98, F CSF cytology6000 5 yrs going to school
1012, F biopsy6000 + 1 yr died of spinal
 2000 (spinal)*  metastasis
116, F biopsy6000 + 2 yrs 1 mo going to school
 2000 (spinal)  
1212, F biopsy6000 2 yrs 10 mos going to school
1311, M biopsy6000 + 1 yr 9 mos going to school
 3000 (spinal)  
1427, M biopsy6000 1 yr 6 mos manages himself but blind
1510, M biopsy6000 + 1 yr 5 mos going to school
 3000 (spinal)  
1615, F CSF cytology  died before treatment
179, F CSF cytology6000 1 yr going to school
1814, F CSF cytology5500 + 1 yr going to school
 3000 (spinal)  

Spinal irradiation was performed after spinal metastasis occurred. In other cases, spinal irradiation was performed protectively.

Age and Sex

Of the 92 patients with pineal tumor in our series, 80 were male and 12 were female (Table 2). Thus the male:female ratio was about 8:1. Such a male preponderance was also observed in germinomas and teratomas of the third and lateral ventricles. In suprasellar germinomas, however, there was no clear male predominance. Of the 18 patients with suprasellar germinoma, nine were male and nine were female. This was also true in suprasellar teratomas:17 of 26 patients with suprasellar germinoma and teratoma, 13 were male and 13 were female. This was confirmed by a review of the literature.3 In 70 cases of suprasellar germinoma collected from both the literature and our own cases, 34 were male and 36 were female. Accordingly, the male:female ratio for suprasellar germinoma is almost 1:1.

TABLE 2

The male to female ratios of germinoma and teratoma

LocationGerminoma (M : F)Teratoma (M : F)Mixed Germinoma & Teratoma (M : F)Histology Unknown (M : F)Total (M : F)
pineal26 : 2 15 : 32 : 038 : 780 : 12 
suprasellar9 : 9 3 : 41 : 013 : 13 
third ventricle5 : 0 5 : 0 
lateral ventricle5 : 0 3 : 01 : 09 : 0 
 total44 : 11 21 : 74 : 038 : 7107 : 25 

Age distribution was studied in 70 cases of suprasellar germinomas from the literature3 and our own series. It was found that females were more affected under the age of 10 years, while males were more affected over the age of 20 years (Fig. 1). Between the ages of 10 and 20 years, both sexes were affected equally. This may suggest that the growth of suprasellar germinomas might be influenced by a sex factor. Our 18 suprasellar germinoma cases ranged from 6 to 26 years old, and the mean age was 14.6 years.

Fig. 1.
Fig. 1.

Age distribution of suprasellar germinomas collected from the literature3 and our own cases.

Signs and Symptoms

The initial symptoms in these 18 patients were as follows: diabetes insipidus was found in nine cases (50%); visual disturbances in three (17%); retarded growth in three (17%); headache, nausea, or vomiting in two (11%); and obesity in one (5%). Thus, diabetes insipidus was the most common initial symptom of suprasellar germinoma (Fig. 2). It may precede other symptoms by many years in some cases.

Fig. 2.
Fig. 2.

Percentage of initial symptoms.

Throughout the course of the disease, diabetes insipidus occurred in 15 patients (83%), visual disturbances in 14 (78%), headache in nine (50%), retarded growth in seven (39%), hypogonadism in three (17%), hypothalamic fever of anorexia in five (28%), and nausea or vomiting in two (11%) (Fig. 3). Visual disturbances were composed of decreased visual acuity and visual field defects. Bitemporal hemianopsia was observed in eight cases (80%), homonymous hemianopsia in one (10%), and concentric construction in one (10%).

Fig. 3.
Fig. 3.

Percentage of signs and symptoms through the course of the disease.

These findings agree well with those described by Camins and Mount in a review of the literature.3

Hormonal Disturbances

In nine of the 18 patients, plasma human growth hormone (HGH), thyroid stimulating hormone (TSH), luteinizing hormone (LH), follicle stimulating hormone (FSH), and cortisol were assayed by radioimmunoassay methods. To stimulate these hormones, insulin (0.125 U/kg) was injected intravenously for HGH and cortisol, thyrotropin-releasing hormone (TRH) for TSH, and LH releasing hormone (LRH) for LH and FSH. To assess the pituitary-adrenal functions, lysine-vasopressin and rapid ACTH tests were combined with the insulin test, and plasma cortisol was assayed. Urinary 17-hydroxycorticosteroids (17-OHCS) was also assayed. Details of these hormonal examinations will be published elsewhere.

Among these five hormones examined, HGH was the most severely affected; eight of the nine patients tested (89%) were thought to be deficient in HGH. In eight of the nine cases (89%), LH and FSH were abnormally low or high, and in seven cases (78%), the pituitary-thyroid function was disturbed to various degrees. In two girls, LH was higher than normal (30 and 49 mIU/ml), and returned to normal after irradiation. In one of them, plasma human chorionic gonadotropin (HCG) was positive (68 mIU/ml). In recent years, there have been several reports that HCG was secreted by germinal neoplasms and it caused precocious puberty.2,4,6,14,16 However, no signs of precocious puberty were observed in these two cases. In another six cases, LH and/or FSH were abnormally low.

In four of eight cases, the plasma cortisol levels and urinary 17-OHCS titers were low. In the remaining four cases, three showed normal or slightly high cortisol levels, but all of them had disproportionately low urinary 17-OHCS titers (Fig. 4). Such a discrepancy between plasma cortisol and urinary 17-OHCS concentrations has been reported to occur in normal pregnancy,5 anorexia nervosa,10 and hypothyroidism.11

Fig. 4.
Fig. 4.

Hormonal disturbances of suprasellar germinoma. White block = normal; hatched block = abnormal. HGH = human growth hormone; LH = luteinizing hormone; FSH = follicle stimulating hormone; TSH = thyroid simulating hormone.

Radiological Findings

The plain skull films showed a normal sella turcica in 10 of the 18 cases. Among the remaining eight cases, a moderate degree of erosion of the sella turcica was found in seven, and a saucer-like deformity in one. Carotid angiography was performed in 16 cases. Three cases had normal findings. In the other 13 cases (81.3%), various types of abnormalities suggesting a suprasellar mass were seen. Symmetrical hydrocephalus was observed in five cases, the A1 segment of the anterior cerebral artery was moderately elevated in 11, the carotid syphon was open in three (Fig. 5), the anterior choroidal artery was stretched in three, the anterior thalamoperforators were stretched in three, and the venous angle was elevated in two. In one case, a tumor stain was observed in the arterial phase. In three cases, the top of the basilar artery was displaced backward on vertebral angiograms.

Fig. 5.
Fig. 5.

Carotid angiography demonstrates that the carotid siphon (large arrows) is opened, the anterior choroidal artery (small arrows) and the posterior communicating artery (arrowheads) are stretched, indicating a suprasellar mass.

Air or positive contrast medium ventriculography was performed in 10 cases, and in all of them a definite shadow defect in the anterior third ventricle was observed (Fig. 6).

Fig. 6.
Fig. 6.

Positive contrast medium ventriculography demonstrates a defect in the anterior part of the third ventricle.

In three patients, a computerized tomography (CT) scan showed a mass of slightly high density or isodensity in relation to the normal brain. This mass occupied the suprasellar cistern, and obliterated the anterior third ventricle. In each patient, the mass showed a marked contrast enhancement (Fig. 7). Interestingly, the tumors rapidly disappeared on CT scanning following the irradiation of as little as 1000 to 1200 rads, showing a high sensitivity to irradiation.15

Fig. 7.
Fig. 7.

The CT scanning demonstrates a suprasellar mass, before (left) and after (center) injection of contrast material. After irradiation (1200 rads), the mass completely disappeared (right).

Diagnosis

Diagnosis was made by craniotomy and biopsy in 14 cases, and by cerebrospinal fluid (CSF) cytology in four cases. Initially the tumor was removed as extensively as possible and diagnosis was made by histological examination. However, the accumulation of clinical, neuroradiological, and neuroendocrinological experiences with suprasellar germinoma has recently enabled us to suspect this disease without surgical intervention. Moreover, the technique of CSF cytology was introduced for diagnosis of this disease. Thus, it is our policy to first perform CSF cytology examination whenever this disease is suspected, and perform surgery only when CSF cytology is negative.

Histologically, the tumor was composed of uniform, large, usually polygonal but sometimes round cells with lightly stained cytoplasms and usually hyperchromatic but sometimes hypochromatic nuclei. Small lymphoid cells were observed abundantly infiltrating between the tumor cells and fibrous stroma, which often contained blood vessels (Fig. 8 left). In CSF cytology, the combination of large tumor cells and small lymphoid cells were also characteristic (Fig. 8 right).

Fig. 8.
Fig. 8.

Histology (left) and CSF cytology (right) of suprasellar germinoma. H & E, × 200.

Treatment and Survival

As this tumor was found to be radiosensitive, radiotherapy is preferred to extensive removal. Of our 18 cases, 15 were irradiated. The first 3000 rads were given to the whole brain and the remaining 2500 to 3000 rads were given to the suprasellar region through two ports, totaling 5500 to 6000 rads. When the patient's condition permitted, 2000 to 3000 rads were added to the spinal axis. From the findings on CT scanning, however, we now think that 2000 rads is probably enough for spinal axis irradiation. Of the 15 patients who underwent irradiation, 12 are living, with one patient surviving 16 years. Three patients, who are still alive 10 years after treatment, are working without medication. Eight children, under hormonal replacement therapy, are in good condition and go to school. All of them, however, have a tendency to tire easily. One 27-year-old patient cannot work due to blindness, which existed before treatment. Three patients who were irradiated have died; one died of spinal metastasis in which spinal irradiation was performed after metastasis occurred, one of an unknown cause, and one patient, who was given another 5000 rads in other hospital totaling 11,000 rads, died of hypothalamic crisis following radiation necrosis, which was confirmed on CT scan.

The first two patients, in whom radiotherapy was not performed, died 4 and 18 months, respectively, after surgery. One patient died before any treatment was started. Survival is thus not related to age at onset but to radiotherapy.

Discussion

Intracranial germinomas are very sensitive to radiotherapy. It is now well recognized that germinoma cells actually disappear completely after irradiation. Therefore, early diagnosis of the germinoma is essential for good results with the therapy. Several points are important for early diagnosis.

Clinically, it must be emphasized that suprasellar germinomas are frequently associated with diabetes insipidus. This may precede other signs or symptoms by several years, and it is possible that an incorrect diagnosis of idiopathic diabetes insipidus will be made. In fact, we experienced an additional patient, who had been treated for idiopathic diabetes insipidus for several years.

Neuroradiological findings are important. Our retrospective examinations of the angiograms revealed that some abnormalities indicating a suprasellar mass were found in over half of the cases, although these abnormalities were not as obvious as in craniopharyngioma or teratoma.17 Furthermore, air or positive contrast medium ventriculography always showed a mass in the suprasellar region. Angiography and ventriculography, however, cannot equal CT scanning as a diagnostic aid. The introduction of CT scanning was truly epoch-making, and we now think that CT scanning is the most appropriate examination method for the diagnosis of suprasellar germinoma. Germinomas should always be considered when a suprasellar mass has an equal or slightly higher density compared to the normal brain, no clearly defined margins, and is characteristically enhanced by contrast materials on CT scanning.7,12,13 On follow-up CT scanning, the tumors disappear rapidly after irradiation with only 1000 to 1500 rads. Other suprasellar tumors, such as pituitary adenoma, craniopharyngioma, meningioma, glioma, chordoma, epidermoid, dermoid, or teratoma, do not disappear so rapidly. One exception might be reticulum cell sarcomas, which are sometimes very sensitive to radiotherapy.

If the disease is diagnosed early, the results of therapy will be better. We believe that with the introduction of CT scanning it is possible to diagnose the disease at a much earlier stage.

Acknowledgment

We are greatly indebted to Dr. Junkoh Yamashita for CSF cytology.

References

  • 1.

    Araki CMatsumoto S: Statistical reevaluation of pinealoma and related tumors in Japan. J Neurosurg 30:1461491969J Neurosurg 30:

  • 2.

    Bruton OCMarts DCGerard ES: Precocious puberty due to secreting chorioepithelioma (teratoma) of the brain. J Pediatr 59:7197251961J Pediatr 59:

  • 3.

    Camins MBMount LA: Primary suprasellar atypical teratoma. Brain 97:4474561974Brain 97:

  • 4.

    Demura RDemura HShizume Ket al: A female case of the HCG-producing ectopic pinealoma associated with precocious puberty. Endocrinol Jpn (Tokyo) 23:2152191976Endocrinol Jpn (Tokyo) 23:

  • 5.

    Doe RPZinneman HHFlink EBet al: Significance of the concentration of nonprotein-bound plasma cortisol in normal subjects, Cushing's syndrome, pregnancy, and during estrogen therapy. J Clin Endocrinol Metab 20:148414921960J Clin Endocrinol Metab 20:

  • 6.

    Fukushima K: Tumors of the diencephalon and precocious puberty. Arch Jpn Chir (Kyoto) 27:5535781958Fukushima K: Tumors of the diencephalon and precocious puberty. Arch Jpn Chir (Kyoto) 27:

  • 7.

    Gonzalez CFGrossman CBPalacios E: Computed Brain and Orbital Tomography. Technique and Interpretation. New York: John Wiley and Sons197686Computed Brain and Orbital Tomography. Technique and Interpretation.

  • 8.

    Kageyama N: Ectopic pinealoma in the region of the optic chiasm. Report of five cases. J Neurosurg 35:7557591971Kageyama N: Ectopic pinealoma in the region of the optic chiasm. Report of five cases. J Neurosurg 35:

  • 9.

    Kageyama NBelsky R: Ectopic pinealoma in the chiasma region. Neurology 11:3183271961Neurology 11:

  • 10.

    Landon JGreenwood FCStamp TCBet al: The plasma sugar, free fatty acid, cortisol, and growth hormone response to insulin, and the comparison of this procedure with other tests of pituitary and adrenal function. II. In patients with hypothalamic or pituitary dysfunction or anorexia nervosa. J Clin Invest 45:4374491966J Clin Invest 45:

  • 11.

    Martin MMMintz DHTamagaki H: Effect of altered thyroid function upon steroid circadian rhythms in man. J Clin Endocrinol Metab 23:2422471963J Clin Endocrinol Metab 23:

  • 12.

    Naidich TPPinto RSKuschner MJet al: Evaluation of sellar and parasellar masses by computed tomography. Radiology 120:91991976Radiology 120:

  • 13.

    New PFJScott WR: Computed Tomography of the Brain and Orbit (EMI Scanner). Baltimore: Williams and Wilkins1975206207Computed Tomography of the Brain and Orbit (EMI Scanner).

  • 14.

    Romshe CASotos JF: Intracranial human chorionic gonadotropin-secreting tumor with precocious puberty. J Pediatr 86:2502521965J Pediatr 86:

  • 15.

    Rubin PKramer S: Ectopic pinealoma: radiocurable neuroendocrinologic entity. Radiology 85:5125231965Radiology 85:

  • 16.

    Stowell RESachs ERussell WO: Primary intracranial chorionepithelioma with metastases to the lungs. Am J Pathol 21:7878021945Am J Pathol 21:

  • 17.

    Takeuchi JMori KMoritake Ket al: Teratomas in the suprasellar region; report of five cases. Surg Neurol 3:2472551975Surg Neurol 3:

  • 18.

    The Committee of the Brain Tumor Registry in Japan: [Brain tumor registry in Japan]. Adv Neurol Sci (Tokyo) 22:5141978 (Jpn)The Committee of the Brain Tumor Registry in Japan: [Brain tumor registry in Japan]. Adv Neurol Sci (Tokyo) 22:

  • 19.

    Ueki K: [Diagnosis and treatment of brain tumors]Proceedings of the 16th General Assembly of the Japan Medical Congress3. Tokyo: Igaku-Shoin1963183188 (Jpn)

This paper was presented at the Annual Meeting of the American Association of Neurological Surgeons in Toronto, Canada, April, 1977.

Article Information

Address reprint requests to: Hajime Handa, M.D., Department of Neurosurgery, Kyoto University Medical School, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606 Japan.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Age distribution of suprasellar germinomas collected from the literature3 and our own cases.

  • View in gallery

    Percentage of initial symptoms.

  • View in gallery

    Percentage of signs and symptoms through the course of the disease.

  • View in gallery

    Hormonal disturbances of suprasellar germinoma. White block = normal; hatched block = abnormal. HGH = human growth hormone; LH = luteinizing hormone; FSH = follicle stimulating hormone; TSH = thyroid simulating hormone.

  • View in gallery

    Carotid angiography demonstrates that the carotid siphon (large arrows) is opened, the anterior choroidal artery (small arrows) and the posterior communicating artery (arrowheads) are stretched, indicating a suprasellar mass.

  • View in gallery

    Positive contrast medium ventriculography demonstrates a defect in the anterior part of the third ventricle.

  • View in gallery

    The CT scanning demonstrates a suprasellar mass, before (left) and after (center) injection of contrast material. After irradiation (1200 rads), the mass completely disappeared (right).

  • View in gallery

    Histology (left) and CSF cytology (right) of suprasellar germinoma. H & E, × 200.

References

1.

Araki CMatsumoto S: Statistical reevaluation of pinealoma and related tumors in Japan. J Neurosurg 30:1461491969J Neurosurg 30:

2.

Bruton OCMarts DCGerard ES: Precocious puberty due to secreting chorioepithelioma (teratoma) of the brain. J Pediatr 59:7197251961J Pediatr 59:

3.

Camins MBMount LA: Primary suprasellar atypical teratoma. Brain 97:4474561974Brain 97:

4.

Demura RDemura HShizume Ket al: A female case of the HCG-producing ectopic pinealoma associated with precocious puberty. Endocrinol Jpn (Tokyo) 23:2152191976Endocrinol Jpn (Tokyo) 23:

5.

Doe RPZinneman HHFlink EBet al: Significance of the concentration of nonprotein-bound plasma cortisol in normal subjects, Cushing's syndrome, pregnancy, and during estrogen therapy. J Clin Endocrinol Metab 20:148414921960J Clin Endocrinol Metab 20:

6.

Fukushima K: Tumors of the diencephalon and precocious puberty. Arch Jpn Chir (Kyoto) 27:5535781958Fukushima K: Tumors of the diencephalon and precocious puberty. Arch Jpn Chir (Kyoto) 27:

7.

Gonzalez CFGrossman CBPalacios E: Computed Brain and Orbital Tomography. Technique and Interpretation. New York: John Wiley and Sons197686Computed Brain and Orbital Tomography. Technique and Interpretation.

8.

Kageyama N: Ectopic pinealoma in the region of the optic chiasm. Report of five cases. J Neurosurg 35:7557591971Kageyama N: Ectopic pinealoma in the region of the optic chiasm. Report of five cases. J Neurosurg 35:

9.

Kageyama NBelsky R: Ectopic pinealoma in the chiasma region. Neurology 11:3183271961Neurology 11:

10.

Landon JGreenwood FCStamp TCBet al: The plasma sugar, free fatty acid, cortisol, and growth hormone response to insulin, and the comparison of this procedure with other tests of pituitary and adrenal function. II. In patients with hypothalamic or pituitary dysfunction or anorexia nervosa. J Clin Invest 45:4374491966J Clin Invest 45:

11.

Martin MMMintz DHTamagaki H: Effect of altered thyroid function upon steroid circadian rhythms in man. J Clin Endocrinol Metab 23:2422471963J Clin Endocrinol Metab 23:

12.

Naidich TPPinto RSKuschner MJet al: Evaluation of sellar and parasellar masses by computed tomography. Radiology 120:91991976Radiology 120:

13.

New PFJScott WR: Computed Tomography of the Brain and Orbit (EMI Scanner). Baltimore: Williams and Wilkins1975206207Computed Tomography of the Brain and Orbit (EMI Scanner).

14.

Romshe CASotos JF: Intracranial human chorionic gonadotropin-secreting tumor with precocious puberty. J Pediatr 86:2502521965J Pediatr 86:

15.

Rubin PKramer S: Ectopic pinealoma: radiocurable neuroendocrinologic entity. Radiology 85:5125231965Radiology 85:

16.

Stowell RESachs ERussell WO: Primary intracranial chorionepithelioma with metastases to the lungs. Am J Pathol 21:7878021945Am J Pathol 21:

17.

Takeuchi JMori KMoritake Ket al: Teratomas in the suprasellar region; report of five cases. Surg Neurol 3:2472551975Surg Neurol 3:

18.

The Committee of the Brain Tumor Registry in Japan: [Brain tumor registry in Japan]. Adv Neurol Sci (Tokyo) 22:5141978 (Jpn)The Committee of the Brain Tumor Registry in Japan: [Brain tumor registry in Japan]. Adv Neurol Sci (Tokyo) 22:

19.

Ueki K: [Diagnosis and treatment of brain tumors]Proceedings of the 16th General Assembly of the Japan Medical Congress3. Tokyo: Igaku-Shoin1963183188 (Jpn)

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