Clinical investigation
Craniospinal radiation in the treatment of biopsy-proven intracranial germinomas: twenty-five years' experience in a single center

Presented at the 44th Annual Meeting of the American Society for Therapeutic Radiology and Oncology, October 6–10, 2002, New Orleans, LA.
https://doi.org/10.1016/j.ijrobp.2003.08.028Get rights and content

Abstract

Purpose

The optimal treatment for intracranial germinomas remains controversial. We report on our 25-year experience using craniospinal irradiation (CSI) for this disease.

Methods and materials

Between September 1976 and May 2001, 39 patients with biopsy-proven intracranial germinomas seen at the Children's Hospital of Philadelphia/Hospital of the University of Pennsylvania received CSI. Thirteen of 36 patients (36%) had evidence of spinal dissemination. Median doses to the whole brain, primary site, and spine were 36 Gy (range, 18–44.2 Gy), 50.4 Gy (range, 44–55.8 Gy), and 30.6 Gy (range, 18–40 Gy), respectively.

Results

With a median follow-up of 7.1 years (range: 1.5–20.2 years), there have been no documented relapses. This includes 5 patients without spinal dissemination who received 18–19.8 Gy to the craniospinal axis; for these patients, the median length of follow-up was 5.5 years (range, 1.3–6.8 years). One patient, who had no evidence of disease 12.9 years after CSI, died of unknown causes 4 months later.

Conclusions

Our treatment of intracranial germinomas with CSI has yielded outstanding results with no known relapses during a long follow-up period. These results must be considered when evaluating other approaches, such as chemotherapy only or local field irradiation.

Introduction

Primary germ cell tumors of the central nervous system (CNS) are extremely rare, accounting for only 1% of all brain tumors (1). Approximately 60% of CNS germ cell tumors are germinomas (2). Histologically, these tumors are indistinguishable from testicular seminomas and ovarian dysgerminomas (3). Germinomas typically arise from midline structures, including the pineal and suprasellar regions. They most commonly occur in boys in the second decade of life (4).

Historically, the treatment for intracranial germinomas has been craniospinal irradiation (CSI), which has led to a long-term survival of more than 90%. However, because of the potential late complications of CSI, there has been a trend in recent years toward using more limited radiation fields, either with or without chemotherapy. The assumption is that these alternative approaches will yield similar long-term survival results with fewer complications; however, this has never been rigorously tested. Therefore, evaluation of various treatment approaches will rest on comparison of results between different series, which, because of the rarity of the disease, include few patients, some of whom may not have had a histologic diagnosis. In addition, older reports include patients treated before the widespread availability of CT or MRI scans, making accurate treatment planning difficult 5, 6.

Our institutions have had a longstanding policy of obtaining tissue in patients who present with suprasellar or pineal tumors and of treating proven germinomas with CSI. The current report represents one of the largest series from a single institution of biopsy-proven intracranial germinomas treated in an era when CT scans and MRI scans were routinely done.

Section snippets

Patients

Between September 1976 and May 2001, 40 patients with biopsy-proven intracranial germinomas were treated by physicians in the Department of Radiation Oncology at the University of Pennsylvania School of Medicine. Thirty-nine of these patients received craniospinal radiation and form the subject of this study. During the earlier part of this period, members of our department also provided radiation oncology services at Fox Chase Cancer Center; therefore, 3 patients received radiation at that

Results

There was 1 death among the 39 patients after median and mean follow-up periods of 7.1 and 8.9 years, respectively (range, 1.5–20.2 years). The actuarial overall survival at 10 years is 100% with 1 patient death 13.2 years after radiation (Fig. 1). We were unable to ascertain the cause of death from chart review. The relapse-free survival Kaplan-Meier curve would appear identical to the overall survival curve shown in Fig. 1, because there were no documented relapses and this single death.

Discussion

There is considerable controversy regarding the optimal management of patients with intracranial germinomas. Our results show that it is possible to achieve close to 100% relapse-free survival using craniospinal irradiation. There have been no documented relapses with fairly long follow-up, despite the fact that over one-third of the patients who had cytologic and/or spinal imaging studies had evidence of dissemination. This incidence of dissemination (36%) is high compared to other reports in

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