Weiner Howard L, Lichtenbaum Roger A, Wisoff Jeffrey H, Snow Robert B, Souweidane Mark M, Bruce Jeffrey N, Finlay Jonathan L
Department of Neurosurgery, New York University Medical Center, New York Presbyterian Hospital, New York, New York 10016, USA.
Neurosurgery. 2002 Apr;50(4):727-33; discussion 733-4. doi: 10.1097/00006123-200204000-00008.
To determine the value of delayed surgical resection in patients with central nervous system germ cell tumors who exhibit less than complete radiographic response despite declining serum and cerebrospinal fluid (CSF) tumor markers after initial chemotherapy.
We retrospectively analyzed 126 patients enrolled on two international multicenter clinical trials (the First and Second International Central Nervous System Germ Cell Tumor Studies) for patients with newly diagnosed central nervous system germ cell tumors. After at least three cycles of chemotherapy, 10 of these patients underwent delayed surgical resection owing to evidence of residual radiographic abnormalities despite declining or completely normalized serum and CSF levels of alpha-fetoprotein and human chorionic gonadotropin.
Eight of these patients demonstrated nongerminomatous germ cell tumor elements at the time of initial diagnosis. In these patients, either serum or CSF tumor markers were elevated initially. Two patients demonstrated pure germinomas with normal levels of serum and CSF tumor markers. After chemotherapy, radiographic evaluation revealed a partial response in seven patients, a minor response in one patient, and stable disease in two patients. All 10 patients had either normal or decreasing levels of serum and CSF tumor markers before second-look surgery. At delayed surgical resection, 7 of the 10 patients underwent gross total resection, and 3 patients underwent subtotal resection of residual lesions. Pathological findings at second-look surgery demonstrated three patients to have mature teratomas, two with immature teratomas, and five with necrotic or scar tissue alone. To date, 7 of the 10 patients have had no recurrence during an average follow-up time of 36.9 months (range, 3-96 mo). Three of four patients with nongerminomatous germ cell tumors who had tumor markers that were decreased, but not normalized, before second-look surgery eventually developed tumor dissemination/progression, and they required subsequent radiation therapy despite having teratoma or necrosis/scar tissue at delayed surgery. In contrast, three of four patients with nongerminomatous germ cell tumors and completely normalized markers did not progress and did not require radiation therapy.
Delayed surgical resection should be considered in patients with central nervous system germ cell tumors who have residual radiographic abnormalities and normalized tumor markers, because these lesions are likely to be teratoma or necrosis/scar tissue. However, second-look surgery should be avoided in patients whose tumor markers have not normalized completely.
确定对于初始化疗后血清和脑脊液（CSF）肿瘤标志物下降但影像学反应不完全的中枢神经系统生殖细胞肿瘤患者，延迟手术切除的价值。
我们回顾性分析了126例纳入两项国际多中心临床试验（第一和第二次国际中枢神经系统生殖细胞肿瘤研究）的新诊断中枢神经系统生殖细胞肿瘤患者。在至少三个周期的化疗后，这些患者中有10例因尽管血清和脑脊液中甲胎蛋白和人绒毛膜促性腺激素水平下降或完全正常化，但仍有残留影像学异常证据而接受了延迟手术切除。
其中8例患者在初始诊断时表现为非生殖细胞性生殖细胞肿瘤成分。在这些患者中，血清或脑脊液肿瘤标志物最初升高。2例患者表现为血清和脑脊液肿瘤标志物水平正常的纯生殖细胞瘤。化疗后，影像学评估显示7例患者部分缓解，1例患者轻微缓解，2例患者病情稳定。所有10例患者在二次手术前血清和脑脊液肿瘤标志物水平均正常或下降。在延迟手术切除时，10例患者中有7例接受了全切除，3例患者接受了残留病变的次全切除。二次手术时的病理结果显示3例患者为成熟畸胎瘤，2例为未成熟畸胎瘤，5例仅为坏死或瘢痕组织。迄今为止，10例患者中有7例在平均36.9个月（范围3 - 96个月）的随访期间无复发。4例非生殖细胞性生殖细胞肿瘤患者中，有3例在二次手术前肿瘤标志物下降但未正常化，最终发生肿瘤播散/进展，尽管在延迟手术时有畸胎瘤或坏死/瘢痕组织，仍需要后续放疗。相比之下，4例非生殖细胞性生殖细胞肿瘤且标志物完全正常化的患者中，有3例未进展且不需要放疗。
对于有残留影像学异常且肿瘤标志物正常化的中枢神经系统生殖细胞肿瘤患者，应考虑延迟手术切除，因为这些病变可能是畸胎瘤或坏死/瘢痕组织。然而，对于肿瘤标志物未完全正常化的患者，应避免二次手术。
