GC-18: A CASE FOR RAPID COMMENCEMENT OF RADIOTHERAPY FOR GERMINOMAS WITH SECONDARY MASS EFFECT AND HYDROCEFALUS

A previously healthy seven years old girl presented with a two week history of headache and vomiting. Symptoms also included increased thirst, enuresis, diminished appetite and constipation. A CT-scan revealed a large centrally located intracranial mass and secondary hydrocephalus. Subsequent MRI gave the preliminary radiological diagnosis of a germinoma. S-prolactin was elevated, 1600mIE/L, S-AFP was normal but S-hCG was slightly elevated. No papillary oedema. Surgery was performed to reduce the tumor, to alleviate pressure on neural structures, histological diagnosis and treatment of hydrocephalus. Surgery was uneventful. Beta-hCG in CSF was elevated. Postoperatively the symptoms improved. Unfortunately the follow up MRI was delayed until 13 days postoperatively due to lack of radiological resources. The MRI revealed a marked tumor progress, beyond that of the preoperative imaging but no hydrocefalus. The histology showed a germinoma with KI67 of 80%. Acute radiotherapy was commenced two days later. The second day of radiotherapy she developed acute hydrocephalus, hemiparesis and reduced consciousness. Emergency surgery with bilateral external ventricular drains (EVD) was performed. A multidisciplinary discussion concluded to continue radiotherapy rather than reoperate to reduce tumor mass. The bilateral EVD was left in place for hydrocephalus. She recovered gradually. Repeat CT three days later showed marked tumor reduction and the EVD-treatment could subsequently be discontinued. She was discharged to her home without neurological sequelae 9 days after the initiation of radiotherapy. MRI after 5 weeks of radiotherapy showed near total reduction of tumor. This case demonstrates the importance of early radiotherapy of germinomas.