Intracranial Germinoma: Systemic Chemotherapy in Addition to Dose-Reduced Radiation Therapy

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The patient is a 31-year-old man who presented with blurry vision and progressive horizontal diplopia. He developed word finding and short-term memory impairment. His neurologic examination demonstrated minor bilateral cranial nerve VI palsies. Magnetic resonance imaging (MRI) of the brain revealed a left frontal mass which measured 4.5 cm, with enhancement of the left lateral ventricular wall and a 2-cm enhancing nodule at the medial aspect of both thalami. MRI of the spine was unremarkable. Cerebrospinal fluid analysis including cytology was negative for malignancy. Positron emission tomography with computed tomography showed no disease outside the central nervous system. Brain biopsy was consistent with a germinoma.
Serum tumor markers revealed an elevated lactate dehydrogenase (1359 U/L; normal range 313–618 U/L) and normal alpha-fetoprotein and beta-human chorionic gonadotropin levels. Alpha-fetoprotein and beta-human chorionic gonadotropin were also negative in the cerebrospinal fluid.
He received steroids with intermittent tapering doses. During the treatment, he received systemic chemotherapy with carboplatin-etoposide for 4 cycles with a complete response on MRI, followed by craniospinal irradiation (CSI) with 30 Gy with a boost to the primary tumor at a dose of 24 Gy.
The patient tolerated treatment well, with the exceptions of prolonged pancytopenia with 1 episode of febrile neutropenia, as well as mild facial swelling, grade 2 diarrhea, and grade 2 fatigue. His pancytopenia resolved after 2 months and repeat MRI of the brain showed a partial remission.
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