Pattern of relapse and outcome of non-metastatic germinoma patients treated with chemotherapy and limited field radiation: the SFOP experience

Abstract

Over the last two decades, chemotherapy has been introduced in protocols for patients with intracranial germinoma with the objective of reducing the volume and the dose of irradiation without compromising survival rates. The aim of this work is to critically analyze the pattern of relapse in a cohort of patients with nonmetastatic germinoma prospectively treated with chemotherapy followed by focal field radiation. Data of all germinoma patients registered in the French protocol for intracranial germ cell tumors between 1990 and 1999 were reviewed. The pattern of relapse, management, and outcome were analyzed in 10 of 60 patients who developed a recurrence after initial treatment. In 9 patients, the site of recurrence was local or loco-regional, notably in the periventricular area for 8. One patient only had isolated distant leptomeningeal relapse. The review of the sites of relapse suggests that most recurrences could have been avoided with a larger ventricular field of radiation. Treatment at first relapse included chemotherapy (10 patients), high-dose chemotherapy and stem cell transplant (8 patients), and/or radiation therapy (4 patients). Five patients experienced a second relapse. At a median follow-up of 72 months since the first relapse, 8 patients are alive in second or third remission. This review identified an excess of periventricular relapses when the focal field of radiation is used in the combined management of germinoma. These relapses are predominantly marginal or outside radiation fields. Ventricular field radiation appears a logical alternative to decrease the incidence of such relapses. Future trials should aim at better identifying patients who may benefit from local and ventricular radiation, respectively.

Fig. 1.

Event-free and overall survival of patients with nonmetastatic germinoma treated with combined chemotherapy and focal radiation in the SFOP-TGM-TC-90 protocol.

Fig. 2.

Distribution of all sites of first relapse: several patients had more than 1 site of failure; 2 sites in patients 2, 4, and 5; 4 sites in patient 6; multiple sites in patients 8 and 9; and continuous spread along the wall of lateral ventricles in patient 10.

Fig. 3.

Periventricular relapse (arrows) with nodular heterogeneous and pseudocystic pattern in patient 9. Postcontrast T1-weighted left parasagittal MR view.

Fig. 4.

Nodular periventricular relapse in patient 5 (arrows). Postcontrast T1-weighted axial MR view.

Fig. 5.

Meningeal relapse located in the posterior part of the meningeal sheath of the right optic nerve (arrows) in patient 1. Postcontrast T1-weighted sagittal MR view.

Fig. 6.

Distant meningeal relapse located at the posterior face of the medulla oblongata (arrowhead) in patient 3. Postcontrast T1-weighted sagittal MR view.