Germinoma surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2]

Overview

The feasibility of surgery depends on the type of the intracranial germ cell tumor at diagnosis. Surgery is not the first-line treatment option for patients with germ cell tumors. Surgery is usually reserved for patients with either NGGCTs, or in patients who have had an incomplete response to initial chemotherapy, and in patients with "growing teratoma syndrome".[1][2][3][4][5][6][7][8][9][10][11][12]

Surgery

  • Surgical treatment of CNS GCTs varies according to the type of the tumor.
  • The recommended practice which is followed currently is to acquire a tissue biopsy sample, with the exception of patients who have a characteristic elevation in tumor markers and in whom surgical intervention may lead to significant complications.
  • Partial and gross total surgical resection of germinomas has no proven benefit and may lead to endocrinological and neurological deterioration. Therefore, in these patients surgical intervention is limited to biopsy and these patients are treated with radiation and chemotherapy.
  • Since patients with choriocarcinoma have an increased tendency to hemorrhage, these patients are treated with early and radical surgery.
  • Since patients with NGGCTs have poor long-term survival, therefore surgery for these patients is aimed at improving outcome. When removal of all tumor tissue is not possible in these patients reduction of tumor burden by partial resection is often an option available. Adjuvant chemotherapy and radiation therapy are often incorporated in the treatment plan. There are no definitive data that suggest that gross total resection of NGGCT at the time of diagnosis improves either an overall survival or a progression-free survival. However, resection of residual tumors after radiotherapy and/or chemotherapy may have a role, with a few small studies suggesting that gross total resection may improve survival.
  • In patients with small surgical samples that may not be representative, such as histological diagnosis of pure germinoma and raised alpha-fetoprotein should be treated more aggressively than those with pure germinoma with normal CSF/serum markers. Patients with a tissue diagnosis of nongerminomatous germ cell tumors NGGCT should be treated as such regardless of serum/CSF tumor markers.
  • Patients who presents with obstructive hydrocephalus may require a ventriculoperitoneal shunt.
  • Surgery may be performed to remove the residual tissue and permit its histological verification in patients who have had an incomplete response to initial chemotherapy. The residual tissue may contain malignant components; however, it may consist of necrosis, fibrosis, or a mature teratoma—the so-called growing teratoma syndrome. The growing teratoma syndrome is characterized by a solitary enlarging tumor mass during or after chemotherapy, with normal or declining AFP and/or beta-HCG. Surgical resection of the tumor is considered curative. The "growing teratoma syndrome" is defined as a solitary enlarging tumor, with normal or declining AFP and/or beta-HCG, which upon resection proves to be composed entirely of a mature teratoma.[1][2][3][4][5][6][7][8][9][10][11][12]


References

  1. 1.0 1.1 Echevarría ME, Fangusaro J, Goldman S (2008). "Pediatric central nervous system germ cell tumors: a review". Oncologist. 13 (6): 690–9. doi:10.1634/theoncologist.2008-0037. PMID 18586924.
  2. 2.0 2.1 Kaur H, Singh D, Peereboom DM (2003). "Primary central nervous system germ cell tumors". Curr Treat Options Oncol. 4 (6): 491–8. PMID 14585229.
  3. 3.0 3.1 Sethi RV, Marino R, Niemierko A, Tarbell NJ, Yock TI, MacDonald SM (2013). "Delayed diagnosis in children with intracranial germ cell tumors". J Pediatr. 163 (5): 1448–53. doi:10.1016/j.jpeds.2013.06.024. PMID 23896184.
  4. 4.0 4.1 Shibamoto Y (2009). "Management of central nervous system germinoma: proposal for a modern strategy". Prog Neurol Surg. 23: 119–29. doi:10.1159/000210058. PMID 19329866.
  5. 5.0 5.1 Sawamura Y (2009). "Strategy of combined treatment of germ cell tumors". Prog Neurol Surg. 23: 86–95. doi:10.1159/000210055. PMID 19329863.
  6. 6.0 6.1 Kretschmar C, Kleinberg L, Greenberg M, Burger P, Holmes E, Wharam M (2007). "Pre-radiation chemotherapy with response-based radiation therapy in children with central nervous system germ cell tumors: a report from the Children's Oncology Group". Pediatr Blood Cancer. 48 (3): 285–91. doi:10.1002/pbc.20815. PMC 4086720. PMID 16598761.
  7. 7.0 7.1 Finlay J, da Silva NS, Lavey R, Bouffet E, Kellie SJ, Shaw E; et al. (2008). "The management of patients with primary central nervous system (CNS) germinoma: current controversies requiring resolution". Pediatr Blood Cancer. 51 (2): 313–6. doi:10.1002/pbc.21555. PMID 18421722.
  8. 8.0 8.1 Janmohamed S, Grossman AB, Metcalfe K, Lowe DG, Wood DF, Chew SL; et al. (2002). "Suprasellar germ cell tumours: specific problems and the evolution of optimal management with a combined chemoradiotherapy regimen". Clin Endocrinol (Oxf). 57 (4): 487–500. PMID 12354131.
  9. 9.0 9.1 Kellie SJ, Boyce H, Dunkel IJ, Diez B, Rosenblum M, Brualdi L; et al. (2004). "Primary chemotherapy for intracranial nongerminomatous germ cell tumors: results of the second international CNS germ cell study group protocol". J Clin Oncol. 22 (5): 846–53. doi:10.1200/JCO.2004.07.006. PMID 14990640.
  10. 10.0 10.1 Saran, Frank; Peoples, Sharon (2008). "Pineal Tumors: Germinomas and Non-Germinomatous Germ Cell Tumors": 310–317. doi:10.1002/9781444300222.ch41.
  11. 11.0 11.1 Peltier J, Vinchon M, Baroncini M, Kerdraon O, Dhellemmes P (2008). "Bifocal mixed germ-cell tumor with growing teratoma syndrome and metachronous mature metastases: case report". J Neurooncol. 90 (1): 111–5. doi:10.1007/s11060-008-9640-3. PMID 18574668.
  12. 12.0 12.1 Friedman JA, Lynch JJ, Buckner JC, Scheithauer BW, Raffel C (2001). "Management of malignant pineal germ cell tumors with residual mature teratoma". Neurosurgery. 48 (3): 518–22, discussion 522-3. PMID 11270541.

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