[Experience of treatment for accumulation of extra-axil cerebrospinal fluid after skull surgery].

OBJECTIVE: To explore the treatment and pathophysiology of extra-axil cerebrospinal fluid accumulation aft er skull surgery. METHODS: The treatment of 46 cases of pineal regional tumor was retrospectively studied. RESULTS: The CT showed that all patients had postoperative extra-axil cerebrospinal fluid accumulation in 6 hours after operation. 5 cases displayed symptomatic accumulation of extra-axil cerebrospinal fluid. 1 died 30 days aft er discharge, 4 performed S-P shunt and 3 of them switched to V-P shunt after S-P shunt failed. CONCLUSION: Much more attention should be paid to postoperative accumulation of extra-axil cerebrospinal fluid. Both V-P and S-P are the effective strategies of therapy.

Late spinal metastases from an isolated pineal region germinoma mimicking a schwannoma.

A 20-year-old male with a prior history of germinoma presented 8 years after the initial diagnosis with progressive lower back pain. The preoperative diagnosis was schwannoma based on the appearances of a tumor in the lumbosacral region on MRI; however, histologically, a germinoma "drop" metastasis was seen. This report emphasizes the need for long-term follow-up in patients with germinoma. In addition, this patient is unusual in that the preoperative assessment favored schwannoma.

Re-evaluation of the significance of cerebrospinal fluid human chorionic gonadotropin in detecting intracranial ectopic germinomas.

This study was conducted to establish a reference value for cerebrospinal fluid (CSF) human chorionic gonadotropin (hCG) levels. We also evaluated the sensitivity of CSF hCG as a biomarker to detect intracranial ectopic germinomas that arise in rare sites other than the pineal and suprasellar regions. CSF hCG was measured in 201 male patients who had various types of neurological disease (not tumours of germ cell origin or other malignant tumours). A reference value of 1.009 U/L was established, and the CSF hCG level among different age groups was not significantly different. CSF and serum hCG were measured before and after radiotherapy in 14 consecutive patients with intracranial ectopic germinomas. The CSF hCG levels were all above 1.009 U/L before radiotherapy. In male patients, a CSF hCG value above 1.009 U/L suggests abnormal intrathecal hCG secretion. These results demonstrate that the CSF hCG assay is a sensitive method for diagnosing intracranial ectopic germinoma.

Metachronous mediastinal seminoma occurring after intracranial germinoma in an adolescent.

We report a case of a mediastinal seminoma occurring 19 months after the resolution of a pineal germinoma. A 15-year-old boy with headaches and visual changes was diagnosed with a pineal germinoma by biopsy and mildly elevated beta-human chorionic gonadatropin (beta-HCG) in serum and cerebral spinal fluid. Radiation therapy leads to the resolution of his pineal germinoma and normalization of the beta-HCG. A mediastinal seminoma (germinoma) was diagnosed nearly 2 years later because of rising serum beta-HCG. There was no evidence of recurrent central nervous system disease. The patient underwent systemic chemotherapy with the complete resolution of the mediastinal seminoma.

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.

BACKGROUND: This Phase II study was designed to determine response to chemotherapy and survival after response-based radiation (RT) in children with CNS germ cell tumors. PROCEDURE: Children with germinomas and normal markers received cisplatin 100 mg/m(2) + etoposide, alternating with vincristine + cyclophosphamide (CPM) 2 g/m(2)/d, for four cycles. Children with nongerminomatous tumors or with abnormal markers received doubled doses of cisplatin and CPM. For germinoma patients in complete response (CR), RT was decreased from 50.4 to 30.6 Gy. High-risk patients received neuraxis RT: 50.4 Gy local + 30.6 Gy neuraxis in CR; 54 Gy local + 36 Gy if less than CR. RESULTS: Of 12 germinoma patients, 4 had cerebrospinal fluid (CSF) human chorionic gonadotropin (HCG) 6.9-21 mIU/ml. Of 14 nongerminomatous patients, HCG in serum or CSF was >50 mIU/ml in 9, alpha-fetoprotein (AFP) abnormal in 9. Four germinoma patients attained CR, six PR, one SD, one not evaluable after resection. Two nongerminomatous patients had CR, three PR, three SD, one PD, four not evaluable after resection; one inadequately treated patient had progressive disease (PD). Both PD patients died; one SD patient died during a seizure. Eleven germinoma patients are PF at median 66 months; one patient in CR refused RT, had PD at 10 months, received RT, and was PF at 56 months. Eleven of 14 nongerminomatous patients were PF at median 58 months. CONCLUSION: Response (germinoma, 91%; nongerminomatous, 55%) and survival are encouraging after this regimen plus response-based RT.

Pineal region teratoma with high serum and CSF alpha-fetoprotein levels.

We report a patient with an immature teratoma of the pineal region with high levels of alpha-fetoprotein (AFP) in serum and cerebrospinal fluid. This is very rare and to the best our knowledge, the second case reported in the literature.

Central neurogenic hyperventilation in a conscious man with CSF dissemination from a pineal glioblastoma.

A 40-year old conscious man developed central neurogenic hyperventilation (CNH). He had tumor dissemination to the brainstem 10 months after undergoing partial removal of a pineal glioblastoma. To the best of our knowledge, this is the first report of CNH caused by the cerebrospinal fluid dissemination of a tumor. The authors suggest that multiple lesions from an infiltrative tumor in the brainstem may give rise to CNH and further our understanding of the pathogenesis of CNH.

[Pineal cyst in MRI: clinical symptoms and analysis]. / Analiza i symptomatologia torbieli szyszynki w badaniach rezonansu magnetycznego.

Application of magnetic resonance imaging (MRI) in radiology allows to estimate and analyse pineal gland and pineal region pathology more precisely. We report 47 MRI brain studies of patients in whom pineal cyst was recognized as the only pathologic finding. MRI of the brain was performed because of clinical symptoms as headaches (32%), vertigo (26%) and altered behaviour (13%). Because of the common occurrence of pineal cyst in MRI brain imaging it seems to be important to decide whether these patients need neurosurgical intervention, especially if together with morphologic abnormality definite clinical symptoms exist.

The role of cerebrospinal fluid cytology in radiotherapy planning for intracranial germinoma.

PURPOSE: The association between the cerebrospinal fluid cytology findings and the clinical features of patients with intracranial germinoma was investigated to determine whether cerebrospinal fluid cytology could be helpful in determining the optimal radiation treatment volume. METHODS AND MATERIALS: Between 1976 and 1992, cerebrospinal fluid cytology was performed in 42 germinoma patients using a cytocentrifugation method. Forty patients received irradiation and 2 received chemotherapy with cisplatin and etoposide. RESULTS: Cerebrospinal fluid cytology was positive in 22 of the 42 patients (52%). Dissemination via cerebrospinal fluid (intraventricular or spinal) was present at the initial diagnosis in eight (36%) of the 22 cytology-positive patients and none of the 20 negative patients. After treatment, cerebrospinal fluid dissemination developed in four (18%) of the cytology-positive patients and one (5%) of the negative patients. Two of the former four patients had received chemotherapy alone as initial treatment. Five patients with positive cytology received irradiation to a smaller volume than the cerebrospinal axis (primary tumor site plus spinal axis in three and whole brain in two), but they have not developed recurrence in the 4 to 14 years since therapy. The 5-year survival rate was 93% for the cytology-positive patients and 94% for the negative patients. CONCLUSION: Cerebrospinal fluid cytology-positive patients have a higher risk of cerebrospinal fluid dissemination and it seems reasonable to give them low-dose (20-24 Gy) prophylactic craniospinal irradiation. When properly irradiated, the prognosis of cytology-positive patients is as good as that of negative patients.

Tumor markers and cytologic features of cerebrospinal fluid.

Tumor markers are useful in establishing the diagnosis of certain central nervous system tumors, especially germinal tumors of the pineal region. They are not sufficiently specific to be able to replace biopsy for exact diagnosis. They may also be useful for monitoring of therapy, as an indicator of recurrence of the tumor. Cerebrospinal fluid cytology is not generally useful in establishing a specific histologic diagnosis, especially in children, but can help to monitor therapy and predict tumor recurrence. More extensive studies are needed in both areas to define more precisely the role of markers and cytologic studies.

Decreased cerebrospinal fluid glutamine levels in patients with benign brain tumors.

CSF glutamine concentrations were studied in 12 patients with benign brain tumors (meningioma, craniopharyngioma, or osteofibroma), 12 patients with malignant brain tumors (astrocytoma, medulloblastoma, pinealoblastoma, or chondrosarcoma), 9 patients with noncerebral tumors, and a reference group of 24 patients. The mean +/- SD levels in the benign tumor group (424 +/- 124 microM) were significantly lower (p less than 0.0004) than those in the reference group (642 +/- 195 microM). There was no significant difference between the CSF glutamine concentrations in the malignant cerebral tumor group (643 +/- 210 microM) or noncerebral tumor group (599 +/- 127 microM) and those in the reference group. In patients with benign brain tumors there was indication of an inverse linear relationship between the logarithm of CSF glutamine concentration and tumor diameter.

Concentrations of Ag, Al, Au, Bi, Cd, Cu, Pb, Sb, and Se in cerebrospinal fluid of patients with cerebral neoplasms.

We measured the concentrations of nine trace elements in cerebrospinal fluid of 11 patients with malignant brain tumors, 11 with benign brain tumors, and 10 control patients, using flameless atomic absorption spectrophotometry. The mean and standard deviation for these concentrations (microgram/L) in the control group were 5.1 +/- 2.9 (silver), 326.6 +/- 171.2 (aluminum), 38.5 +/- 32.2 (gold), 36.6 +/- 23.7 (bismuth), 1.5 +/- 1.3 (cadmium), 39.8 +/- 24.7 (copper), 15.7 +/- 11.5 (lead), 20.9 +/- 3.8 (antimony), and 19.1 +/- 13.3 (selenium). Concentrations of silver and lead were markedly increased in patients with malignant cerebral neoplasms. The malignant-tumor/control patient concentration ratios were 2.31 for silver and 2.11 for lead. We observed no significant differences between the results for the benign tumor patients and the control group.

Homovanillic acid and 5-hydroxyindoleacetic acid in the ventricular CSF of comatose patients with obstructive hydrocephalus.

Ventricular cerebrospinal fluid (CSF) levels of homovanillic acid (HVA) and 5-hydroxyindoleacetic acid (5-HIAA) were determined every 2 to 4 hours over a period of 1 to 4 days in 12 patients, consisting of seven cases of brain tumor, two cases of cerebrovascular disease, and three cases of head injury. The concentrations of HVA and 5-HIAA varied with time in all cases, and significant correlations were found between the two values in eight cases. However, the relationship between variations of HVA and 5-HIAA levels and rhythms of sleep and waking could not be clarified. Both HVA and 5-HIAA concentrations varied at high levels in two patients whose CSF flow was completely blocked by tumor at the site of the fourth ventricle and aqueduct, respectively. On the contrary, in a case with craniopharyngioma in the third ventricle which blocked the bilateral foramina of Monro, although the HVA values were high, the 5-HIAA values varied at low levels. Of five comatose patients, two had cerebrovascular lesions and three had sustained head injury, and, in four of the five, the values of either one or both of HVA and 5-HIAA were low, but in the fifth case the 5-HIAA value was high. Estimation of HVA and 5-HIAA concentrations in ventricular CSF may be a valuable tool in the investigation of brain monoamine metabolism. However, many factors must be considered in the interpretation of results of clinical studies.