title: Delayed diagnosis in children with intracranial germ cell tumors.
abstract: OBJECTIVE
  To review symptoms and provider history in a large cohort of patients with germ cell tumors (GCTs) to highlight the variety of manifestations and assess the effect of delayed diagnosis on outcomes.
  
  
  METHODS
  Patients treated for intracranial pure germinoma and nongerminomatous GCTs at Massachusetts General Hospital between 1998 and 2012 were included (n = 70). The primary outcome was time from onset of symptoms to diagnostic imaging. Delay was defined as an interval of ≥ 6 months.
  
  
  RESULTS
  The median duration of symptoms before diagnostic magnetic resonance imaging was 6 months (range, 2 days to 72 months). Thirty-eight of the 70 patients (54%) had a delayed diagnosis. Patients with suprasellar tumors presented with symptoms related to endocrinopathies, and patients with pineal region tumors presented with symptoms related to hydrocephalus. Most of the patients were evaluated by a general pediatrician (49%) and/or pediatric subspecialists (66%) before diagnosis. Patients with delayed diagnosis saw a greater number of physicians before diagnosis (P = .006). The majority of patients (63%) with delayed diagnosis were seen by 2 or more physicians, and many (40%) were seen by 2 or more subspecialists. Progression-free survival was similar in the patients with delayed diagnosis and those without delayed diagnosis (P = .90), but the former were more likely to present with disseminated disease at diagnosis (34% vs 6%; P = .007).
  
  
  CONCLUSIONS
  A significant proportion of patients with GCT experience a delay in time to diagnosis, in some cases despite evaluation by general pediatricians and specialists. This delay increases the risk of disseminated disease.
authors.affiliation: Harvard Medical School, Massachusetts General Hospital, Boston, MA.
authors.forename: Roshan V
authors.initials: RV
authors.lastname: Sethi
authors.forename: Rose
authors.initials: R
authors.lastname: Marino
authors.forename: Andrzej
authors.initials: A
authors.lastname: Niemierko
authors.forename: Nancy J
authors.initials: NJ
authors.lastname: Tarbell
authors.forename: Torunn I
authors.initials: TI
authors.lastname: Yock
authors.forename: Shannon M
authors.initials: SM
authors.lastname: MacDonald
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D057210:Delayed Diagnosis; D018572:Disease-Free Survival; D005260:Female; D018237:Germinoma / Q000175:diagnosis*; D006801:Humans; D007223:Infant; D008279:Magnetic Resonance Imaging; D008297:Male; D009373:Neoplasms, Germ Cell and Embryonal / Q000175:diagnosis*; D010372:Pediatrics; D012306:Risk; D013997:Time Factors; D016896:Treatment Outcome
keywords: AFP; Alpha-fetoprotein; CNS; CSF; Central nervous system; Cerebrospinal fluid; DI; Diabetes insipidus; GCT; Germ cell tumor; HCG; Human chorionic gonadotropin; MGH; MRI; Magnetic resonance imaging; Massachusetts General Hospital; NGGCT; Nongerminomatous germ cell tumor; PFS; PG; Progression-free survival; Pure germinoma