: 59 3 2000 1 = A bs trac t= A cas e of pineal g erminoma pre s e nting w ith diabe te s ins ipidus Sam Seok Park, M.D., Young Keun Choi, M.D., Woo Hyung Bae, M.D., Seok Man Son, M.D., In Ju Kim, M.D. and Yong Ki Kim, M.D. Department of Internal M edicine, College of M edicine, Pusan N ational University, Pusan, K orea Central diabetes insipidus caused by pineal gland neoplasm is rare. Here, we describe a case of central diabetes insipidus and pineal germinoma with seeding to pituitary stalk along CSF pathway. A 27 year- old male patient was admitted due to polyuria, polydipsia, headache, vomiting, diplopia, and decreased visual acuity for recent two months. Urine osmolality measured after water deprivation was below 100mOsm/ kg. However, urine osmolality increasd above 300 mosm/kg with pitressin administration. Brain MRI showed a 2cm sized mass with seeding into pituitary stalk along CSF in pineal region. Surgical biopsy revealed pineal germinoma. T wo cycles of chemotherapy with etoposide and cis- platin were done followed by brain irradiation(2,500cgy). Follow up brain MRI after second chemotherapy showed complete remission. T he patient had no neurologic and endocrinologic deficit after the treatment.(korean J Med 59:305-309, 2000) Key Words : Pinealoma; Germinoma; Diabetes insipidus, Neurogenic, (,, ), 1).,. (pinealomas) (ectopic pinealoma) 1% 2).,,, 3-8), 9). 1. : 1999513 : 19991015 :, 110, E- mail : psso911@hanmail.net - 305 -
Korean Journal of Medicine : Vol. 59, No. 3, 2000 :,, 27 :,, : 6 56 thiazide 2,,., : : 120/60 mmhg, 70 /, 20 /, 36.2.,,. : 6,970/mm3, 13.2 gm/dl, 40.7%, 259,000/ mm3, 140 meq/l, 3.4 meq/l, BUN 12 mg/dl, creatinine 0.9 mg/dl. - human chorionic gonadotropin( - hcg)197 IU/ ml( 5 IU/mL), - hcg4 IU/mL, alpha fetoprotein(afp)4.4ng/ml( 12 ng/ml), AFP0.60 ng/ml, antidiuretic hormone(adh)1.8 pg/ml( 7.6 pg/ml). : 2 kg 300 mosm/kg. 5 50% (T able 1). 48 ng/ml(20 ng/ml) (T able 2). : 222cm 3 4 810mm, (Figure 1). Figure 1. Gadolinium enhanced brain MRI(sagittal image) shows a well- enhancing round soft tissue mass(22 2cm) in pineal region. The mass extends into cerebral aqueduct and causes the dilatation of lateral and third ventricles. A 810mm sized mass is also noted at the pituitary stalk. Table 1. Water deprivation and pitressin test Hr(s) 0 1 2 3 4 5 6 7 Serum osmolality(mosm/ kg) Urine osmolality(mosm/ kg) 287 64 73 290 89 97 291 114 222 313 329 401 pitressin 5U SC T able 2. Basal hormone study GH(ng/mL) Prolactin(ng/ ml) LH(mIU/mL) FSH(mIU/mL) T estosterone(ng/dl) Cortisol(/dL) 07: 00 08: 00 09: 00 1.53 48.1 0.15 0.09 0.06 0.04 7.22 1.98-306 -
Sam Seok Park, et al : A case of pineal germinoma presenting with diabetes insipidus.. Figrue 2. Germinoma with a multinodular pattern produced by fibrous trabeculae containing a lymphoid infiltrate. Germinoma cells have clear to light eosinophilic cytoplasm and nuclei with prominent, central nucleoli. Lymphoid infiltration is intense in and around the fibrous trabeculae of neoplasm, but also seen intermingled with the neoplastic cells(h&e, 100). Figure 3. Follow- up brain MRI(sagittal image) shows no lesion of pineal area and hydrocephalus. : thiazide, DDAVP, (occipital transtentorial approach) (Figure 2). EP regimen(etoposidecis- platin) 2, 2 (Figure 3). 3 2,500 cgy. 6,,,, 10).,, (primary polydipsia),.,, 2).,,. 3,., 30. 2), 3. 80% 11).,,,. 9%, 9% 50%, 50% 1). 2 kg 300 mosm/kg. 5 50%. - 307 -
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