Management of central nervous system germinoma: proposal for a modern strategy.

With the development of diagnostic, radiologic, and therapeutic modalities, strategies for management of central nervous system (CNS) germinoma are changing gradually. The author advocates that typical germinomas can be diagnosed based on their typical clinical and radiological findings, together with slight elevation of beta-human chorionic gonadotropin levels in the serum and/or cerebrospinal fluid (CSF) and quick response to radiation or chemotherapy. Radiation therapy has been the standard treatment for CNS germinoma until recently. Germinomas 4 cm or less in diameter can be cured with radiation doses of 40-45 Gy. Regarding the treatment volume, an individualized approach is recommended and a focal radiation field covering at least major parts of the ventricular system is recommended if no CSF dissemination is present and CSF cytology is negative. Such irradiation is best given by intensity-modulated radiation therapy. Systemic chemotherapy with reduced doses (24-30 Gy) of radiation has to some extent been successful, but longer follow-up periods are necessary to draw conclusions regarding the superiority of this treatment over standard-dose radiation therapy. CNS germinoma patients should be completely cured with minimum morbidity, probably by employing appropriate doses of chemotherapy and intensity-modulated radiation therapy in the future.