Aggressive spinal germinoma with ascending metastases

Abstract

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

Rapidly Progressing Germinoma Arising in the Lateral Ventricle and This Mimicked Choroid Plexitis

“…A patient with spinal germinoma underwent six surgical interventions and chemotherapy and/or radiotherapy due to repeated tumor recurrences, and the patient died with seeding around the brain stem (8). That report suggested the possibility of the positive relationship between the high proliferative index and the aggressive nature of this tumor because germinoma is by definition a primitive tumor, and it expected to have a high proliferative index (8). The cause of the rapid progression of our case is uncertain, but it may be explained that some of the germ cells showed mitotic figures on the histopathology.…”

Primary Intramedullary Spinal Cord Germinoma -Case Report-

“…Although dissemination is rare in low grade astrocytoma in the spinal cord, 1) high grade spinal gliomas or germinomas sometimes disseminate aggressively to other spinal or intracranial levels. 18,20,23,24) Therefore, search of the whole spine and cranium for disseminated tumors or lesions, and exclusion of the presence of cysts is useful in diagnosis. Furthermore, MR imaging of previous cases indicates that spinal germinomas may be characterized by swollen spinal cords in the anteroposterior direction on T 2 -weighted imaging.…”

“…3) Conversely, primary intramedullary spinal cord germinomas are rarely reported, but many of the reported cases occur in Asian patients. 2,3,5-11, [16][17][18][19][20][21][22][23][24][25][26] Spinal germinomas are difficult to identify based on the neuroimaging findings because of the similarity with spinal astrocytomas and ependymomas. However, correct diagnosis is important, because patients with germinomas can be treated with chemotherapy and radiotherapy, in contrast to patients with astrocytomas.…”

Primary Intramedullary Spinal Cord Germinoma: Diagnostic Challenge and Treatment Strategy -Two Case Reports-

“…The 24 previously reported cases of PISCG included 17 cases from East Asia, 16 from Japan and 1 from China (Table 1), 2,[4][5][6][7][8][9][10][11][13][14][15][17][18][19][20][21][25][26][27][28][29] a pattern similar to the distribution of primary intracranial GCT. The patients were two children and young adults, aged from 5 to 43 years.…”