Combine meetingCombine meeting

報告者 : NS R3 吳孟庭 醫師

Case Case

姓名 : 廖 xx 年齡 : 16 y/o Admission date:

2007-01-19

性別 : 男 ID: 001882314I

HistoryHistory

Chief Complaint:

Progressively unstable gait for two months

Present HistoryPresent History Present Illness:

According to the statement of patient himself and his parents, he was generally well before. However, he suffered from unstable gait for two months. He went to 澄清醫院 for help, where CT scan of brain showed huge brain tumor over left frontal horn, suprasella and cerebellum. Operation was suggested. He was brought to our OPD where Body weight loss 4 kg within two months was found. So, he was then admitted for removal of tumor.

Physical ExaminationPhysical Examination

Vital signs ： : BP ： 126 / 85 mmHg , RR ： 18 / min , PR ： 72 / min , BT ： 36 ℃

body weight 47 kg, height 171 cm Consciousness ： clear, Activity ： good HEENT: no pale conjunctivaExtremities : freely movable, no

weakness of limbs

Neurological examinationNeurological examination

GCS: E 4 V 5 M 6 , no disorientation , no cranial nerve palsy

Mild limited upper gaze muscle power over four limbs R/L : 5/

5 , DTR four limbs R/L : ++ / ++, Barbinski's sign R/L : - / -

Sensory impairment: no Brudzinski's sign , no Kernig sign

Tumor markerTumor marker

AFP CEA SCC 960122 3.61 2.07 < 0.3

Hospital CourseHospital Course

960119 admission960122 operation

ImpressionImpression

Germinoma, left frontal, suprasella and cerebellum s/p suboccpital craniotomy with removal of tumor

Intracranial germ cell tumors Intracranial germ cell tumors

Intracranial GCTs represent approximately 2.9 percent of all intracranial tumors in children under age 15.

GCTs (particularly germinomas) are more common in some Asian countries, where they account for 12 percent of all intracranial neoplasms.

Intracranial GCTs peak in incidence between 10 and 14 years of age.

There is a male predominance for pineal but not suprasellar GCTs.

Clinical presentationClinical presentation

Favor midline structures. The most common location is the pineal gland, but the tumor may be located in the suprasellar region, basal ganglia, posterior fossa, pituitary gland.

Leptomeningeal spread occurs-- 10 ~ 15 %

(may be delayed for as long as ten years after initial treatment )

Metastases outside of the CNS are rare

Clinical presentationClinical presentation

The presenting signs and symptoms are dependent upon tumor location.

Headache, nausea, vomiting, and lethargy (from increased intracranial pressure in patients with pineal lesions)

Diplopia, hypopituitarism or diabetes insipidus (with suprasellar tumors)

Paralysis of upward conjugate gaze (Parinaud's syndrome)

Radiographic imagingRadiographic imaging

Magnetic resonance imaging (MRI) of intracranial GCTs typically appear hypointense or isointense on T1-weighted images, and hyperintense on T2-weighted images; they enhance with intravenous contrast in a homogeneous or heterogeneous pattern. Cystic areas are common, and may be multiple.

HistologyHistology

Approximately 60 percent of intracranial GCTs are pure germinomas.

The remainder are teratomas and nongerminomatous GCTs. Mixed tumors (germinomas with nongerminomatous elements such as yolk sac tumor, choriocarcinoma, or embryonal carcinoma) are rare.

Tumor markersTumor markers

serum beta-hCG levels are elevated (usually <50 mIU/mL) in a minority of patients

serum AFP levels are generally within normal limits unless nongerminomatous elements are present.

Treatment of germinomasTreatment of germinomas

Most intracranial germinomas can be cured with external beam radiation therapy (RT) alone, and long-term survival rates are 90 percent or better