Intracranial Germinoma: Atypical Presentation

Abstract

Fourteen year old female patient referred in June 2013 to the Emergency Department due to seizures of recent onset. The patient had a six-month history of behavioral changes and impaired academic performance; also, days before the seizure episodes she developed vomiting. The physical examination documented bradypsychia and papilledema. The results of hormone testing showed panhypopituitarism, a condition of the hypothalamic-hypophysis axis. An MRI was performed and it showed a heterogeneous tumor that compromises the frontal periventricular white matter extending through the rostrum of the corpus callosum, infiltrates the ependyma, it is heterogeneous with cystic areas; after contrast, it presents heterogeneous enhancement. In univoxel MR spectroscopy, it was observed an increase of choline, lipid and lactate, and a decrease in N-acetyl aspartate. It associates with the existence of edema in the bifrontal white matter, there is mass effect given by the compression of the frontal recesses of the lateral ventricles and effacement of the frontal anterior sulci. There is a second lesion that compromises the tuber cinereum, pituitary stalk and optic chiasm, it enhances after contrast administration and presents cystic areas. For the morphological characteristics and changes in spectroscopy, differential diagnosis as primitive neuroectodermal tumor (PNET) and glioblastoma were planted. The frozen biopsy reports a small celled tumor: PNET vs. Lymphoma. Due to the latter, a complete macroscopic resection is performed via a bifrontal craniotomy with an interhemispheric approach. Diabetes insipidus is developed immediately during the postoperative period. The full section biopsy reported a germinoma. Managed through sequential chemotherapy and radiation therapy.