神経内視鏡的第三脳室底開窓術を契機に腫瘍内出血を生じた松果体部絨毛癌の1例

Intratumoral Hemorrhage in Choriocarcinoma during Neuroendoscopic Third Ventriculostomy : Case Report

Ⅰ．は じ め に

　頭蓋内原発胚細胞腫瘍の頻度は全脳腫瘍の3％程度で，小児期に多く20歳以下にほぼ70％が集中する．そのうち絨毛癌は3％以下で全脳腫瘍においては0.1％以下と稀である⁶⁾．頭蓋内原発胚細胞腫瘍の発生部位は主に松果体部，トルコ鞍上部や基底核で，松果体部胚細胞腫瘍においては，ほとんどの例に閉塞性水頭症による頭蓋内圧亢進症状が認められる⁵⁾．従来，閉塞性水頭症の治療は脳室ドレナージやV-Pシャントが行われてきたが，最近は神経内視鏡的第三脳室底開窓術（neuroendoscopic third ventriculostomy：NTV）が選択されることが多い．今回われわれは閉塞性水頭症で発症した松果体部絨毛癌に対してNTVを行い，術中に腫瘍内出血を来した1例を経験したので，若干の文献的考察を加え報告する．

The authors report a case of intratumoral hemorrhage in a pineal region choriocarcinoma during neuroendoscopic third ventriculostomy. A 12-year-old boy who presented with headache and vomiting had precocious puberty. Neuroimagings revealed a pineal region tumor with obstructive hydrocephalus and his serum HCG level was 4,280mIU/ml. He was diagnosed as having choriocarcinoma and underwent neuroendoscopic third ventriculostomy for obstructive hydrocephalus. There were many tumor vessels observed on the tumor surface,some of which bled subcapsularly. Postoperative CT scan showed the tumor increased in size with the intratumoral hemorrhage. After irradiation and chemotherapy,the tumor disappeared with normalization of serum HCG level. His symptoms improved and no additional neurological deficit was observed in his clinical course. We might infer from this case that the intratumoral hemorrhage was induced by the intracranial pressure change during neuroendoscopic surgery. Perioperative management is very important for avoiding fetal intratumoral hemorrhage.