Suprasellar Germinoma and Late Perioptic Seeding

Abstract

To report an unusual case of optic nerve seeding 12 years following treatment of a suprasellar germinoma. Observational case report. A 34-year-old woman presented with a 3-week history of subjective right eye visual loss. She had been diagnosed with a suprasellar germinoma at 22 years of age, which had been partially excised and radiated (5400 cGy). The tumor had shown complete radiographic regression without neurologic sequelae. Pertinent findings on current examination included right eye visual acuity of 20/150, right relative afferent papillary defect, and optic nerve pallor in the right eye. In addition, partial left facial paralysis was noted. Examination was otherwise unremarkable including 20/20 acuity in the left eye. Magnetic resonance imaging demonstrated abnormal enhancement and thickening of both optic nerves and along the course of the left V and VII cranial nerves. Serum levels of alpha-fetoprotein and beta-HCG were abnormal, consistent with metastatic germinoma. Following two cycles of chemotherapy (VIP-etoposide, ifosfamide, and cisplatin), visual acuity returned to 20/20 bilaterally, with corresponding radiographic improvement and normal cerebrospinal fluid cytology. Perioptic subarachnoid seeding may occur over a decade after presumed successful treatment of germinomas, suggesting the importance of lifelong observation.