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Management of malignant pineal germ cell tumors with residual mature teratoma
J A Friedman1, J J Lynch, J C Buckner
1Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA. friedman.jonathan@mayo.edu
Objective:
The treatment of intracranial mixed germ cell tumors presents a unique challenge, since eradication of malignant tumor by radiation and/or chemotherapy may spare the benign tumor component. We reviewed our surgical experience with residual malignant pineal germ cell tumors after neoadjuvant therapy.
Methods:
Between 1987 and 1997, 16 patients with malignant intracranial germ cell tumors were treated at the Mayo Clinic with a protocol of neoadjuvant chemotherapy and radiation therapy. After the diagnosis was confirmed by histopathological examination, all patients were treated with four cycles of etoposide and cisplatin as well as external beam radiation therapy (range, 3030-5940 cGy). Six patients had an incomplete response to therapy, as demonstrated by observation of residual tumor on magnetic resonance imaging scans. Initial pathology in these six patients was germinoma in four and combinations of yolk sac tumor, embryonal carcinoma, malignant teratoma, and germinoma in two. Two patients had synchronous pineal and suprasellar tumors, with leptomeningeal dissemination. Tumor markers were elevated in four of the six patients at presentation.
Results:
All patients with residual pineal tumors underwent surgical resection via an infratentorial, supracerebellar approach. Pathological examination revealed mature teratoma in five patients and amorphous debris in one patient. No patient had recurrent malignancy. Significant neurological morbidity occurred in one patient, with no mortality. At a mean follow-up of 23 months, no recurrence on magnetic resonance imaging has been documented.
Conclusion:
Residual pineal tumor occurring after treatment of malignant intracranial germ cell tumor with neoadjuvant therapy is likely to be mature teratoma. Operative resection of these benign recurrences is safe and effective.
Insights
Residual pineal tumors after neoadjuvant therapy for intracranial germ cell tumors are typically benign teratomas. Surgical resection of these residual tumors is safe and effective, with no reported recurrences.
Area of Science:
- Neurosurgery
- Oncology
- Pathology
Background:
- Intracranial germ cell tumors present complex treatment challenges.
- Neoadjuvant therapy (chemotherapy and radiation) can eradicate malignant components but may leave benign elements.
- Surgical management of residual tumors after neoadjuvant therapy is crucial.
Purpose of the Study:
- To review surgical outcomes for residual pineal germ cell tumors after neoadjuvant therapy.
- To determine the nature of residual tumors and the safety/efficacy of surgical resection.
Main Methods:
- Retrospective review of 16 patients treated between 1987-1997 with neoadjuvant chemotherapy (etoposide and cisplatin) and radiation therapy.
- Surgical resection via an infratentorial, supracerebellar approach for six patients with incomplete response.
- Histopathological examination of resected specimens.
Main Results:
- All six patients with residual tumors underwent successful surgical resection.
- Pathology revealed mature teratoma in five patients and amorphous debris in one.
- No patient experienced tumor recurrence at a mean follow-up of 23 months.
- One patient had significant neurological morbidity; no mortality occurred.
Conclusions:
- Residual pineal tumors after neoadjuvant therapy for intracranial germ cell tumors are predominantly mature teratomas.
- Surgical resection of these benign tumors is a safe and effective treatment option.
- This approach prevents malignant recurrence and improves patient outcomes.