Combine meeting 報告者 : NS R3 吳孟庭 醫師

Case 姓名 : 廖 xx 年齡 : 16 y/o Admission date: 性別 : 男 ID: I

History Chief Complaint: Progressively unstable gait for two months

Present History Present Illness: A ccording 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 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 conjunctiva Extremities : freely movable, no weakness of limbs

Neurological 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 marker AFP CEA SCC < 0.3

Hospital Course admission operation

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

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 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 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 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.

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