title: Bifocal intracranial germinoma: a retrospective analysis of treatment outcomes in 20 patients and review of the literature.
abstract: OBJECTIVE
  Bifocal germinoma (BFG) is a rare intracranial neoplasm for which the choice of radiation therapy (RT) field is controversial. Some believe that BFG represents disseminated disease requiring craniospinal irradiation (CSI), whereas others believe that BFG represents localized disease and advocate for more limited fields.
  
  
  METHODS
  We analyzed 20 BFG patients at our institutions with classic bifocal lesions (pineal gland and suprasellar region). In addition, we identified 60 BFG patients from the literature. The RT fields, use of chemotherapy and extent of disease were recorded and analyzed for each patient.
  
  
  RESULTS
  There were 55 patients with bifocal lesions only (Group I), and 25 with bifocal lesions plus ventricular and/or CSF positive disease (Group II). The 5-year progression-free survival was 95% for Group I and 80% for Group II. In Group I, there were no failures in patients receiving CSI (n = 11), two spinal failures in those treated with more limited RT fields without chemotherapy (n = 17), and one spinal failure with chemotherapy (n = 23). In Group II, there were no failures in patients receiving CSI (n = 11), but four spinal failures were observed in patients receiving more limited RT fields with chemotherapy (n = 13); 1 patient who received whole-brain RT without chemotherapy experienced failure in the spine and brain.
  
  
  CONCLUSIONS
  CSI is associated with excellent PFS in BFG. In Group I BFG patients, omission of spinal irradiation appears to be a reasonable approach, especially when chemotherapy is used. Patients with Group II BFG are best treated with CSI.
authors.affiliation: Department of Radiation Oncology, The Methodist Hospital, Houston, TX 77030, USA.
authors.forename: David C
authors.initials: DC
authors.lastname: Weksberg
authors.forename: Yuta
authors.initials: Y
authors.lastname: Shibamoto
authors.forename: Arnold C
authors.initials: AC
authors.lastname: Paulino
mesh_terms: D000293:Adolescent; D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D001932:Brain Neoplasms / Q000134:cerebrospinal fluid / Q000188:drug therapy / Q000473:pathology / Q000532:radiotherapy*; D002648:Child; D003131:Combined Modality Therapy / Q000379:methods; D016371:Cranial Irradiation / Q000379:methods; D018572:Disease-Free Survival; D005260:Female; D018237:Germinoma / Q000134:cerebrospinal fluid / Q000188:drug therapy / Q000473:pathology / Q000532:radiotherapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010871:Pinealoma / Q000188:drug therapy / Q000473:pathology / Q000532:radiotherapy*; D011879:Radiotherapy Dosage; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult