Since 1989, CNS germinoma patients at the Mayo Clinic have been treated with chemotherapy (cisplatin/etoposide) followed by limited field and reduced-dose RT depending on response to chemotherapy. Here we present the long term results of patients treated in this manner. A retrospective chart review identified 28 patients diagnosed with CNS germinoma on the basis of biopsy or imaging with appropriate serum markers and treated with chemotherapy followed by RT between 1989-2007. Five patients were female. Median age was 16 years (range 9-42). Tumor locations were isolated suprasellar (n = 9) isolated pineal (n = 8) multiple intracranial (n = 6) and spinal leptomeningeal or positive CSF cytology (n = 5). Patients who had less than a complete response to chemotherapy (n = 7) underwent surgical resection and were included in analysis if pathologic examination of the specimen demonstrated residual germinoma (n = 2) scar tissue (n = 1) or teratoma without malignant features (n = 4). Serum hCG levels were <50 IU/dL in 23 patients (range 0-4.1) and unknown in 5. CSF hCG levels were <50 IU/dL in 20 patients (range 0-17) and unknown in 8. Serum AFP was <10 IU/L in 24 patients (range 0-6) and unknown in 4. CSF AFP was <2 IU/L in 20 patients (range 0-2.5) and unknown in 8. Median follow-up was 6.6 years (range 0.8-16.4). RT fields consisted of local tumor site only (n = 17), craniospinal axis (n = 10), and whole ventricle (n = 1). Total dose was 30.3-30.6 Gy (n = 23), 54 Gy (n = 3), 56 Gy (n = 1), and unknown in 1. Tumor recurrence occurred in 2 (of 28) patients. Both patients were male, young (11 and 19 y) and achieved a compete response (CR) to chemotherapy. One patient with an obstructing pineal germinoma received 30.6 Gy to local fields. He recurred at 1.1 y with in-field pineal failure and synchronous spinal leptomeningeal drop metastases. The second patient presented with a suprasellar germinoma with invasion into the optic tract and third ventricle. He received 30.6 Gy to local fields. He experienced an out-of-field recurrence in the right lateral ventricle and corpus callosum at 3.4 y. Review of initial diagnostic images revealed an unappreciated pineal cyst that resolved after chemotherapy. Both patients were successfully salvaged and are NED 16.4 y and 4 y after initial diagnosis, respectively. No patient experienced treatment- or tumor-related death. Treatment of CNS germinoma with chemotherapy and dose-reduced local RT resulted in 100% overall survival and 93% recurrence-free survival after a median follow-up of 7 y. Two of 17 patients (12%) treated with limited RT fields experienced local failure but were successfully salvaged. Patients with multiple midline tumors or brain parenchyma invasion may be at higher risk for recurrence.