Images in neuro-oncology: brain metastases and leptomeningeal dissemination of nonseminomatous germ cell tumor

Abstract

A 39-year-old man with a right testicular mass and a 3month history of asthenia was admitted to hospital on June 6. Physical examination evidenced a large, hard right testicle and bilateral cervical nodes. Computerized tomography scanning revealed, in addition, retroperitoneal and lung metastases. Head CT scan was normal on admission. The patient’s a-fetoprotein level was 2414.7 lg/l b-human chorionic gonadotropin level was 2149.3 lg/l and LDH level was 1095 IU/l. On June 16, the right testicle was excised. Histological analysis revealed nonseminomatous germ cell tumor (NSGCT) with elements of embryonal cell carcinoma and endodermal sinus tumor (Figure 1). The patient underwent four courses of chemotherapy consisting of bleomycin, etoposide and cisplatin (BEP). By the end of this treatment, LDH, b-HCG and a-FP were normal, but residual retroperitoneal mass was still observed on CT scan. While waiting for surgery of this retroperitoneal mass, the patient developed partial motor seizures on the left arm. CT scan and cranial MRI were obtained showing bilateral parietal and left cerebellar metastases (Figure 2). Whole brain radiation therapy (10 · 300 cGy) was administered over 2 weeks, reducing the size of the lesions. We then decided to operate the largest metastases (>3 cm large in diameter) and treat with radiosurgery the other two lesions and the bed of the resected one. While waiting for radiosurgery, the patient complained of neck pain, gait difficulty and urinary incontinence. Cranial and spinal MRI were performed (Figure 3), showing massive regrowth of the right parietal metastases and cervical and thoracic leptomeningeal dissemination. Symptoms progressed very rapidly driving the patient lethargic, incontinent and bedridden. By that time, surgery was considered not indicated, and