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Washington University Experience | NEOPLASMS (NON-GLIAL NON-NEURONAL) | Germ Cell Neoplasm - Choriocarcinoma | 2A0 Case 2 History
Case 2 History ---- The patient was a 14 year old male who was admitted to SLCH for the first time in July 1977 with a chief complaint of headache and diplopia. The patient was entirely in normal health until approximately 2 weeks previous to admission when he suffered a minor head injury followed by headache and occasional vomiting and diplopia with equivocal visual problems for 3 months before. First admission showed 6 mm sluggishly reactive pupils, spontaneous right nystagmus with diplopia and mild paresis of upgaze. The remainder of the neurologic and general physical examinations were entirely normal. A CT scan showed a right pulvinar contrast enhancing mass with extension across the midline, confirmed by right carotid and vertebral angiograms. Skull films had showed a left pineal shift. Radiation therapy and chemotherapy were begun. One month after diagnosis in the midst of his radiation therapy, he had no diplopia or headache and his neurologic exam seemed to be entirely within normal limits. He completed 3600 rads and a CT scan on October 4th showed complete resolution of the contrast enhancing mass. This response suggests a mixed germ cell tumor with a radiation-sensitive germinoma component but only choriocarcinoma was identified at biopsy or autopsy. The patient did well until approximately November 20th when he had back and anterior thigh pain which showed tightness of his posterior thighs on straight leg raising, but no motor or sensory loss in the lower extremities, bladder or bowel problems. Myelogram showed a lobulated, unresectable lesion at L1 attached to the roots and to the surface of the conus. A spinal root biopsy showed a germ cell tumor. Radiation (3600 rads) was given to the whole spine with a conus portal. Subsequent to this course of radiation the patient had problems with radiation sickness with nausea, vomiting, and anorexia. On January 6th an LP failed to show malignant cells. The patient was admitted for IV hydration on January 23rd because of continued radiation sickness with nausea, vomiting, and anorexia. During that hospitalization a CT scan showed interval increase in ventricular size treated successfully with a shunt. CT scan showed reappearance of a pineal tumor with a right parieto-occipital spread. He was begun on chemotherapy, both IV and intrathecal via the shunt. The patient was discharged and followed a progressive downhill course for a month with prominent eye signs with spontaneous nystagmus and limitation of upgaze. The patient lapsed into coma and was found apneic and pulseless in his bed on March 11th. ---- At autopsy a 2cm hemorrhagic mass involved the pulvinar is which appears to extend from the pineal region ventrally to involve the quadrigeminal plate and the midbrain tegmentum. The aqueduct is totally obliterated by this mass. A structure resembling the pineal is seen in the dorsal aspect of the mass and appears to merge imperceptibly with the mass. An 0.8 cm diameter yellow gray nodule lying within the ventral subarachnoid space represents the surgical biopsy site.
