Kuwabara, Michael

Malignant transformation of intracranial nongerminomatous germ cell tumors (NGGCTs) is a rare but clinically relevant phenomenon. We present the case of a 13-year-old boy with a localized, pineal NGGCT. After an initial favorable response, tumor growth was noted while still on chemotherapy. Histopathologic characterization revealed that 40% of the tumor was embryonal rhabdomyosarcoma (RMS), consistent with potential malignant transformation. Due to the rare nature of NGGCT malignant transformation, the best clinical approach to these cases remains unclear. We explore existing cases, treatments, and outcomes of malignant transformation in intracranial NGGCTs to help inform future clinical decision-making and the establishment of treatment guidelines.

Abstract BACKGROUND Non-germinomatous germ cell tumors (NGGCT) constitute 35%- 45% of intracranial germ cell tumors. Growing teratoma syndrome has been observed in patients with NGGCTs after starting chemotherapy. While growing teratomas are typically benign, this process can rarely involve malignant transformation and result in poor prognosis. We present the case of a patient with pineal NGGCT and growing teratoma syndrome with malignant transformation to embryonal rhabdomyosarcoma. CASE REPORT A 13-year-old male presented with headaches and vision changes. An MRI brain demonstrated a 26 x 25 x 19 mm (AP X TR X CC) mixed solid and cystic pineal mass with no evidence of metastatic disease. Due to elevated alpha fetoprotein levels in the serum and cerebrospinal fluid, he was diagnosed with intracranial NGGCT. Treatment was initiated with alternating cycles of Carboplatin/Etoposide and Ifosfamide/Etoposide. After 2 cycles of chemotherapy, a complete biochemical response was noted but MRI showed increased tumor size (presumed growing teratoma syndrome). The patient underwent complete tumor resection. Histology showed embryonal rhabdomyosarcoma as a somatic malignancy arising in a mature teratoma. Further molecular characterization revealed somatic NF1 and KRAS pathogenic mutations that are consistent with the primary diagnosis. Methylation profiling, however, did not exhibit a match with any known malignancies. Continued complete response was noted following two additional chemotherapy cycles. The patient is planned for six total chemotherapy cycles followed by high-dose craniospinal radiation with boost to the primary tumor. CONCLUSIONS Malignant transformation is a rare phenomenon in NGGCT. There is no standard of care for these patients. Further studies are needed to define ideal therapy for this patient population.

PurposeFluid‐attenuated inversion recovery (FLAIR) nulls the CSF signal and is widely used in neuro MRI exams. A 3D scan can provide high SNR, contiguous coverage, and reduced sensitivity to through‐plane CSF flow. In this work, a 3D spiral FLAIR technique is proposed to improve the image quality of conventional 3D Cartesian FLAIR.MethodsThe 3D spiral FLAIR sequence incorporated a spiral‐in/out readout to preserve higher scan efficiency and eliminate off resonance‐induced artifacts observed with a commonly implemented spiral‐out readout, a compensation approach to minimize phase errors due to the concomitant fields accompanying the spiral gradient, and an adapted variable flip angle scheme to preserve scan efficiency and maintain a long and stable echo train. 3D Cartesian and spiral FLAIR (~6 min each) were acquired on a 3 Tesla scanner from 6 subjects (age range: 31‐64 years; mean: 39.5). Two neuroradiologists rated the images in a blinded fashion on a 5‐point scale. The noise performance was assessed quantitatively.ResultsCompared to 3D Cartesian FLAIR, 3D spiral FLAIR exhibits greater reduction of artifacts from CSF, especially anterior to the brain stem (rated better in 4 cases), artifacts attributed to blood/flow in the deep brain (better or much better in all 6 cases), and superior overall image quality (much better in 5 cases) despite residual susceptibility artifacts near the nasal cavity. Quantitative assessment demonstrates ~1.5× higher average SNR than Cartesian data.Conclusion3D spiral FLAIR achieves higher SNR, reduced CSF, and blood/flow artifacts, providing an alternative to 3D Cartesian FLAIR for neurological exams.