Neuropathology 1996; 16,165-171

Original Article

Cerebral germinoma with marked granulomatous inflammation: Granulomatous germinoma

Hiroko Gotoda,' Miri Fujita,' Kazuaki Inoue,' Yutaka Sawamura,2 Mitsuhiro Tada,2 Hiroshi Abe; Koji Oka? Noritake Yanagida; Hiroshi Nanjo5 and

Kazuo Nagashima' Departments of IPathology and *Neurosurgery, Hokkaido University School of Medicine, Sapporo, 3Nakamura Memorial Hospital, Sapporo, 4Department of Neurosurgery, Okatsu Central Hospital,

Yuzawa-shi, Akita, SDepartment of Pathology, Akita University School of Medicine, Japan

Cerebral germinomas with granulomatous inflammation are rare lesions that can present diagnostic difficulties. Four cases (two male and two female) of germinomas with pro- nounced inflammatory reaction are presented. The age ranged. from 14 to 21 years (mean 18). Three patients with vision defects had masses around the sellar region, and a long duration of symptoms (2,4 and 5 years). The fourth patient had a mass in the temporal lobe; she had convulsions and the duration of her symptoms was short (3 weeks). All lesions consisted of inflammatory changes with scattered neoplastic germinoma cells that expressed placental alkaline phos- phatase. The inflammation area occupied more than two- thirds of the mass, and consisted of macrophages and their syncytial forms of multinucleated giant cells, T-cells, B-cells, plasma cells, fibroblasts, and histiocytes or glial cells. Sarcoid granulomata were frequently seen, and multinucleated giant cells with Schaumann's bodies were also visible. The term 'cerebral granulomatous genninoma' is proposed for these unusual tumors. Moreover, it is likely that the study of cere- bral granulomatous germinoma may provide some impor- tant clues towards the understanding of granulomatous inliammation in organs in general.

Key words: cerebral germinoma, granulomatous inflammation, immunohistochemistry, sarcoid nodules with Schaumann's body.

INTRODUCTION The incidence of cerebral germinoma is relatively frequent in Japan. According to a report of The Committee of Brain Tumor

Some of the cases were presented at the 34th Annual Meeting of the Japanese Society of Neuropathology in Tokyo, Japan, 1 1 May 1993.

Correspondence: Kazuo Nagashima, MD, Department of Pathology, Hokkaido University School of Medicine, North 15, West 7, Kita-ku, Sapporo 060, Japan.

Received and accepted 10 May 1996.

Registry of Japan,' between 1969 and 1987 cerebral gennino- mas accounted for 2.3% of all brain tumors, and 8.3% of child- hood (age < 15 years) brain tumors. Due to the characteristic two-cell pattern, which consisted of large neoplastic germ cells and small lymphoid cells, the histological diagnosis of intracra- nial germ cell tumors is usual.* In addition to lymphocytic infil- tration, there is occasionally granulomatous inflammation, which is also seen in gonadal germinomas. However, although 20% of seminomas and dysgenninomas have granulomatous inflammati~n,~.~ its frequency in cerebral germinomas is signifi- cantly 10wer.~ Thus, granulomatous inflammation was seen in only 1/23 cases (4.3%) in one series6 and in 2/70 (2.9%) in another? In contrast, the granulomatous reaction is not so exten- sive in gonadal germinomas that an erroneous diagnosis could be rendered. However, because of the rather pronounced and voluminous granulomatous reaction, some rare cerebral germi- nomas have been misdiagnosed as chronic inflammati~n.',~

Recently, we had the opportunity to study four cases of cere- bral germinoma in whom the inflammatory cells and granulo- matous reaction occupied more than two-thirds of the mass. We present the clinicopathologic findings and computed tomo- graphic (CT) and magnetic resonance image (MFU) features of these tentatively named cerebral granulomatous germinomas, and provide the results of immunohistochemical assays on the tumors as well as on the granulomas. In addition, we suggest certain diagnostically useful observations and tests, and address the relationship between germinomas and granulomas.

CASE PRESENTATION AND METHODOLOGY

Case 1

A 21-year-old male was referred to the Hokkaido University Hospital (HUH) because of his decreased visual acuity which had gradually worsened since the age of 16. Physical examina- tion showed diminished visual acuity of both eyes, and left

166 H. Gotoda et al.

lower quadrant homonymous hemianopsia was seen. The T1- weighted MRI showed an iso-intense mass with a cyst extend- ing from the suprasellar region to the third ventricle. The mass was markedly enhanced by gadolinium-DTPA (Gd) (Fig. 1). At surgery, the cyst was located behind the lamina terminalis hypo- thalami. The tumor was excised subtotally. After removal of the tumor, a swollen optic chiasm was found, indicating its involve- ment by the tumor. X-ray irradiation was given postoperatively. The patient has been free from disease for 5'12 years following surgery.

Case 2

A 21-year-old male with a 2% year history of diabetes insipidus and hypopituitarism was admitted to HUH because of distur- bances of his visual field and acuity which had been progressing over the past 12 months. Magnetic resonance imaging disclosed two apparently discontinuous Gd-enhanced masses at the suprasellar region and in the paraventricular white matter of the left lateral ventricle (Fig. 2). At surgery, the left optic nerve and chiasma appeared The suprasellar tumor was removed subtotally. The patient under-

Fig. 1 Case 1 . T1-weighted coronal MRI showing a Gd-enhanced suprasellar mass. Note a spherical cyst in the upper portion of the tumor.

due to

Fig.2 Case 2. (a) An enhanced irregu- larly shaped mass containing small non- enhanced parts seen in the suprasellar region. (b) A discrete enhanced mass observed in the paraventricular area of the left lateral ventricle.

Fig.3 Case 3 . (a) A discrete mass with a large cyst and Gd enhancement seen at the medial portion of the right temporal lobe, including the amygdaloid body. (b) An enhanced mass with hypodensity areas seen at the inner side of the temporal lobe.

Granulomatous germinoma 167

went radiotherapy and has been free of the disease for 3 years and 4 months following surgery.

Case 3 A 14-year-old girl was admitted to the hospital on 14 September 1994, due to a headache and generalized convulsion. The MRI disclosed a mass with ring enhancement in the medial surface of the left temporal lobe (Fig. 3). The mass was removed surgically on 6 October 1994, and the patient received postoperative chemotherapy consisting of CDDP and Vp16. She was well 1’/2 years after the operation.

Case 4

A 16-year-old female was admitted to the Nakamura Neuro- surgery Hospital on 18 July 1995 due to decreased visual acuity of her left eye following a mild head trauma. It was diagnosed in 1991 that she was a dwarf, but no therapy was instituted. On admission, her height was 134cm and she weighed 38 kg. Visual acuity of the right eye was 0.4, while her left was 0.01. A mass

(diameter 3 cm) was detected in the intrasellar region to the third ventricular region by image analyses. The mass was iso-intense, measured 32mm at its maximum diameter and was contrast- enhanced. The MRI showed an isodensity mass at the T1 level and a high signal at the T2 level with a cystic component (Fig. 4). The patient’s visual acuity worsened to 0.01 in the right eye, and the left eye could discern only light. The tumor was removed sur- gically on 5 September 1995. Following the operation her visual acuity improved to 0.7 right side, and she could see the move- ment of hands with her left eye.

Laboratory procedures

The resected tumor specimens were fixed in 10% neutral for- malin, embedded in paraffin and sectioned. Sections of all speci- mens were stained with hematoxylin and eosin (HE), Masson’s trichrome, and reticulin stains. Immunohistochemical assays were performed with antibodies to glial fibrillary acidic protein GFAP; monoclonal (mono); diluted 1 :200], placental alkaline phosphatase [PAI-P; polyclonal (poly); 1 :400], human chorionic gonadotropin (HCG; poly; working solution), alpha-fetoprotein

Table 1 Clinical and pathologic data of four patients with granulomatous germinoma

Case 1 Case 2 Case 3 Case 4 Agelsex Duration of symptoms Clinical features

21/M 5 years Visual defects

Image appearance Solid and cystic Outcome Well and alive;

Prominent pathologic features Lymphocytic aggregation 5 years 6 months

with multinucleated giant cell

21/M 2 years Visual defects, hypopituitarism, diabetes insipidus Two solid masses Well and alive; 3 years 4 months Lymphocytic infiltration and fibrosis

I 4/F 3 weeks Convulsion

Solid and cystic Well and alive; 1 year 6 months Sarcoid nodules, and multinucleated giant cell with Schaumann’s body

1 6/F 4 years Dwarf, visual defects

Solid and cystic Well and alive; 6 months Sarcoid nodules, multinucleated giant cell and germinal center

Fig. 4 Case 4. (a) On the sagittal section, a sellar mass extending to the hypothalamus and third ventricle is seen. The mass showed an iso-intensity signal with hypo- intensity areas. (b) The iso-intense areas on plain MRI were enhanced homogeneously by Gd. There is no enhancement of the hypointense areas.

168 H. Gotoda et al.

Fig. 5 (a) Lymphocytic aggregation with germinal center seen in the background of fibrous connective tissue of Case 1. Small clusters of germinoma cells are seen near the germinal center (+; HE X 200). (b) Immunostaining for placental alkaline phosphatase. The large neoplastic cells are positively stained (-+), and a few small non-neoplastic cells are stained non-specifically. (Counterstained with haematoxylin, X 200).

Fig. 6 Serial sections stained for (a) HE, (b) pla- cental alkaline phosphatase, and (c) CD68. (a) Epithelioid cells (*), forming granulomatous inflammation predominate in the mass, which has few neoplastic cells (+) in Case 3. (HE X 200). (b) Placental alkaline phosphatase-positive neo- plastic cells (-+; X 200). (c) The epithelioid cells are intensely labeled for CD68, but the tumor cells are not (+; X 200).

Fig.7 (a) Multinucleated giant cell with Schaumann’s body (+) of Case 3. Note the germinoma cells near the granuloma. (HE X 200). (b) The multinucleated giant cells are strongly CD68- positive, but the neoplastic cells are not stained. Note that the conchoidal Schaumann’s body is also not stained (4; X 200).

Fig. 8 (a) T-cells intermingled with tumor cells in Case 4 (UCHL-1 stain, X 400). (b) Lym- phoid cells forming germinal center are intensely stained for the B-cell marker L-26 (X 200). (c) Numerous plasma cells are seen near the neo- plastic cells (staining for plasma cell marker VS38c, X 400).

Granulomatous germinoma 169

(AFP; poly; 1: loo), S-100 protein (poly; 1: lOOO), human macro- phage CD68 (KP-1; mono; l:lOO), leukocyte common antigen (LCA; mono; 1:100), T-cell receptor subset CD3 (poly; 1:1OO), human T-cell subset UCHL-1 (CD45RO; mono; 1:100), human T-cell subset MT-1 (mono; l:lO), human B-cell subset L-26 (CD20; mono; 1:100), human B-cell subset MB-1 (mono; 1: loo), and human plasma cell marker VS38c (mono; 1:25, used after microwave pretreatment). All antibodies were purchased from Dako (Glostrup, Denmark) except for MT-1, which was obtained from Bioscience Product (Emmenbriicke, Switzerland).

RESULTS

A summary of clinicopathological findings is presented in Table 1. In each case the tumor was taken piece-by-piece, but overall approximately pea-sized specimens could be examined histo- logically. The surgical specimens consisted mostly of lympho- cytes, macrophages, epithelioid granulomas, multinucleated giant cells and a few large polygonal tumor cells in the back- ground of fibrous connective tissue or fibrous glial tissue. In addition, polymorphonuclear leukocytes and plasma cells were seen intermingled. The cell distribution differed between speci- mens. Thus, a small specimen consisted of only inflammatory cells without polygonal tumor cells. In other specimens, few tumor cells were scattered among the granulomatous tissues, or clusters of tumor cells were found adjacent to or between granu- lomas. The proportion of tumor cells to inflammatory tissue also varied between specimens, but the area of inflammation always occupied more than one-third of the mass. Lymphocytes were found not only near the epithelioid granulomas and tumor cells, but also in perivascular areas, forming cuffs. No teratoma ele- ment, syncytiotrophoblastic giant cell, or endodermal sinus tis- sue was identified in any specimen.

The germinoma cells were usually scattered in the inflamma- tion area, and in some places these were in sheets and lobules with lymphocytic infiltration, showing the typical two-cell pat- tern (Figs 5a,6a). The tumor cells had characteristically large, round vesicular nuclei and a pale, ill-defined cytoplasm that contained PAS-positive glycogen granules. The nucleoli were prominent, and mitotic figures were readily identified.

In Case 1, lymphocytic infiltration was most extensive and for- mation of germinal center was noted (Figs 5a,6a). The tumor cells were significantly larger than the large cells in the germinal center. In other areas, small clusters of neoplastic cells were found near the epithelioid or spindle-shaped cells (Fig. 6a). However, the tumor cells were so rare that the initial impression of Case 1 was that of a granulomatous inflammation. Lymphocytic infiltration was located not only close to the tumor cells, but also in perivas- cular areas and granulomatous areas distant from the neoplastic cells. Usually, the germinoma cells are scattered among the inflammatory cells.

The tumor mass of Case 2 consisted of diffuse infiltration of lymphocytes and plasma cells in which the large tumor cells were scattered. Sarcoid granulomata and multinucleated giant cells

were found scattered in Cases 1 and 2. In Case 3, the granuloma- tous reaction was most extensive, and numerous multinucleated giant cells were observed. Some of these cells contained con- choidal material known as Schaumann’s body (Fig. 7a). Frequently, the sarcoid granulomas and multinucleated giant cells were found some distance from the germinoma cells. No caseous necrosis was detected. Case 4 had massive lymphocytic infiltra- tion with germinal center, and sarcoid granulomata. In this patient the neoplastic cells were scattered among the inflammatory foci.

The immunohistochemical assays showed that the germinoma cells were usually positive for placental alkaline phosphatase (Figs 5b,6b). This helped to establish diagnoses, particularly in situations such as that of Case 1, in whom single individual tumor cells were present in the inflammatory foci. A positive immuno- reaction was seen in the contours of the tumor cells. However, some germinoma cells, recognizable by their large atypical nuclei, were not stained for placental alkaline phosphatase. Most epithelioid cells were labeled by the antibody to CD68 (Fig. 6c), which gave an indication of their macrophage origin. In addition, diffuse CD68-positive macrophages were frequently found in the inflammatory lesions. There were a few S-100 protein-positive spindle-shaped cells; these were considered to be either reactive glial cells also stained with GFAP or histiocytes without GFAP. The multinucleated giant cells were strongly CD68-positive (Fig. 7b). The lymphocytes consisted of both, B-cells (MB-1-, and L26-positive) and T-cells (CD3-, MT- 1-, and UCHL- l-positive) (Fig. 8a) with the latter predominating. Mainly T-lymphocytes were found near the tumor cells. However, mostly B-lymph@ cytes formed the germinal centers (Fig. 8b). Some perivascular lymphocytic cuffs consisted mostly of T-cells, but others, mostly of B-cells. There were scattered plasma cells which were strongly labeled by the specific monoclonal antibody (Fig. 8c). Overall, and in descending order of abundance, the inflammatory cells were macrophages, T-cells, B-cells, plasma cells, fibroblasts, glial cells or histiocytes. The number of germinoma cells in a given specimen ranged between those of plasma cells and fibro- blasts. The macrophages were predominant in areas of numerous sarcoid granulomas. We found no pronounced vascular reaction, and no HCG- or AFP-positive structure was identified.

DISCUSSION

It is well known that a germinoma exhibits a two-cell pattern consisting of large neoplastic cells and small lymphocytes. Most lymphocytes are T-cells and a small proportion, B- cells. ic12 The T-cells are both helpershnducers and suppres- sorkytotoxic, and are cytotoxic to allogeneic malignant tumor cells after activation by IL2.I3 However, because tumor cells do not express major histocompatibility antigens,”.” it remains unknown as to what attracts the lymphocytes or whether these cells attack tumor cells. Granulomatous inflammation, consist- ing of aggregates of classical epithelioid cells or macrophages and multinucleated giant cells, has been observed in germ cell tumors. There have been instances in which the granulomatous

170 H. Gotoda et al.

inflammation predominated in the lesions to such an extent that it has led to diagnostic failures such as the misinterpretation of a tumor as a non-neoplastic lesion with chronic granulomatous inflammati~n,~.~ particularly in patients who underwent stereo- tactic brain biopsy? Thus, it is important to bear in mind that in cases of germinoma with pronounced granulomatous inflam- mation, one should look for large germinoma cells. However, if their identification is difficult, immunohistochemical assay for placental alkaline phosphatase should be applied as the respec- tive antibody will specifically label germinoma cells. Therefore, to distinguish and recall cases such as those presented here, we tentatively used the term ‘cerebral granulomatous germinoma’ (CGG).

In an attempt to compare CGG with the common cerebral germinorna, we reviewed nine cases (our four plus five from the

The ages of these nine CGG patients ranged from 14 to 28 years (mean 19.8), indicating that they were slightly older than individuals with the common cerebral germinoma, in whom the mean age was reported as 16 years, 14 or 16.5 years.” The male/female ratio was 712, showing a male preponderance similar to that of the usual germinoma. In addition, tumor location, tumor size when initially detected, and favorable prog- nosis were similar.14J5 The duration of symptoms in three of our four cases was long; 5 years in Case 1, 2 years in Case 2, and 4 years in Case 4, but in Case 3 duration was only 3 weeks. Histologically, CD68-positive macrophages were the most pre- dominant cells in the inflammation. Moreover, in our four cases not only T-cells, but B-cells also were frequently present as aggregates in the germinal centers, and plasma cells labeled by the respective monoclonal antibody were also seen. By com- parison, a predominance of T-cells only has been documented in the usual germinoma. Thus, the presence of numerous macrophages and of relatively frequent B-cells and plasma cells appears to be characteristic of CGG. However, to determine whether granulomatous germinorna is a distinct clinical entity must await further cases and more detailed studies.

Some multinucleated giant cells of our Case 3 contained shell-like material characteristic of the so-called Schaumann’s body. This is not a novel observation as the presence of Schaumann’s bodies in a cerebral germinoma was described as early as 1931, when the tumor was called pinealoma.16 Schau- mann’s body in sarcoidosis was reported to contain calcium and phosphate, and smaller quantities of aluminum and i r ~ n . ’ ~ J ~ Although the precise origin of these substances in the brain remains unknown, it is particularly interesting that Schau- mann’s bodies are found in certain cerebral granulomatous ger- minomas.

Antigenic agents and the process of granuloma formation have been extensively studied in sarcoidosis, and the role of cytokines and cell interactions, as well as the expression of T- cell receptor molecules, were considered for the pathogenesis of g r a n u l ~ m a . ’ ~ ~ ~ ~ It is conceivable that germinoma cells, or some underlying germinoma-inducing factor(s) could be responsible for granuloma formation. Thus, studies on the interaction

between germinoma cells and granuloma cells may conversely provide clues towards an understanding of the genesis of the sarcoid reaction.

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