Necessity for craniospinal irradiation of germinoma with positive cytology without spinal lesion on MR imaging—A controversy

Abstract

Background Cerebrospinal fluid (CSF) cytology and spinal MR imaging are routinely performed for staging before treatment of intracranial germinoma. However, the interpretation of the results of CSF cytology poses two unresolved clinical questions: 1) Does positive CSF cytology correlate with the presence of spinal lesion before treatment?; and 2) Is craniospinal irradiation (CSI) necessary for patients with positive CSF cytology in the absence of spinal lesion? Methods Multicenter retrospective analyses were performed based on a questionnaire on clinical features, spinal MR imaging finding, results of CSF cytology, treatments, and outcomes which was sent to 86 neurosurgical and 35 pediatrics departments in Japan. Pretreatment frequencies of spinal lesion on MR imaging were compared between the patients with positive and negative cytology. Progression-free survival (PFS) rates were compared between patients with positive CSF cytology without spinal lesion on MR imaging treated with CSI and with whole brain or whole ventricular irradiation (non-CSI). Results A total of 92 germinoma patients from 45 institutes were evaluated by both CSF cytology and spinal MR images, but 26 patients were excluded because of tumor markers, the timing of CSF sampling or incomplete estimation of spinal lesion. Of the remaining 66 germinoma patients, spinal lesions were equally identified in patients with negative CSF cytology and positive cytology (4.9% and 8.0%, respectively). 11 patients treated with non-CSI had excellent PFS comparable to 11 patients treated with CSI. Conclusion CSI is unnecessary for germinoma patients with positive CSF cytology without spinal lesions on MR imaging.

Salvage craniospinal irradiation for recurrent intracranial germinoma: a single institution analysis

“…These dose-dependent structural changes might explain the mechanism behind the declines in intelligence and employment status observed in Group A patients. We have previously demonstrated that radiation volume and dose are positively associated with the number of microbleeds in germinoma patients [ 28 ]. Elucidation of the relationship between microbleeds and clinical symptoms and the significance of microbleeds for the prediction of neurological deterioration remains as a challenge for future research.…”

“…The radiation field was modified according to the distribution of the tumor. Patients with positive cerebrospinal fluid (CSF) cytology and/or spinal dissemination on magnetic resonance imaging (MRI) received 24 Gy of radiation therapy to the craniospinal axis [ 28 ], whereas patients with basal ganglia germinoma received 24 Gy to the whole brain.…”

Diagnosis and Management of Pineal Germinoma: From Eye to Brain

“…Unfortunately, tumor cells are present in the spinal fluid in only 38% of germinomas (25/66), so positive cytology is not a dependable diagnostic test. 71 Furthermore, positive CSF cytology was not correlated with presence of spinal lesions on MRI. 71 Even as a prognostic test, cytology has limitations as non-cranio-spinal irradiation achieved excellent progression-free survival (PFS) even in patients with positive CSF cytology without spinal lesion on MRI.…”

“… 71 Furthermore, positive CSF cytology was not correlated with presence of spinal lesions on MRI. 71 Even as a prognostic test, cytology has limitations as non-cranio-spinal irradiation achieved excellent progression-free survival (PFS) even in patients with positive CSF cytology without spinal lesion on MRI. Finally, CSF pleocytosis, presence of CSF oligoclonal bands, and abnormalities of CSF IgG can occur in germinoma, 40 , 55 so CSF suggestive of other disease processes, like multiple sclerosis, does not necessarily exclude germinoma.…”

“…Modified Cheng criteria can be used in which CSF cytology and spinal MR imaging are routinely examined for metastatic disease before treatment with positive cytology indicating metastatic disease. 71 Ilcus et al suggested staging as M0 if disease is localized on MRI with no evidence of metastasis and CSF cytology is negative. 27 If either intra-cranial or spinal metastasis is identified or positive cytology is present, then germinoma should be classified as disseminated disease M+.…”