tumors of the pineal gland are rare accounting for 0.4 - 1% of all primary tumors of the brain . different tumor types are found in the pineal region : tumors that derive from germ cells ( germinomas and " non - germinomatous " germ cell tumors like embryonic carcinomas and teratomas ) , from parenchymal cells ( pinealoblastomas and pineocytomas ) , and from glial cells are encountered as well as lesions that represent non neoplastic cysts . in all series germ cell tumors represent the most common histology ( 60% ) . in contrast to the other tumors mentioned which have no sex preference , germ cell tumors are more frequent in men than in women . first symptoms are often neurological signs and complaints caused by an obstructive hydrocephalus with headache , nausea , and vomiting and/or involvement of ocular pathways . determination of histology , tumor markers in serum and csf , and extent of disease are critical for optimal management of pineal region tumors . five year survival rates following radiation range from 44 - 78% and depend on extent of disease , age , radiation volume and dose to the primary site but primarily on histology . the five year survival of patients with germinoma is 76% as compared with 21% for those with a " non - germinomatous " germ cell tumor . there is no established therapy for relapsing or refractory intracranial germinoma . in analogy to germinomas of the testis a higher curability may be expected with high dose chemotherapy followed by autologous blood stem - cell retransfusion . for non germinomatous tumors no guidelines exist with respect to dosage , combination or sequence of chemotherapy and radiation . further examination revealed that these symptoms were caused by a primary afp producing germinoma of the pineal gland . the initial treatment in 1987 consisted of radiation of the tumor with 30 gy which resulted in a complete remission . seven years later he developed a first relapse in the anterior section of the first ventricle with infiltration of brain parenchyma , and extension to the intradural and extradural lumbosacral spinal canal . the spinal tumor was irradiated with 30 gy . immediately after radiation he was treated with   high dose methotrexate 12 g / m i.v . on day 1 three weeks later chemotherapy according to the peb - protocol was initiated : cisplatin 20 mg / m i.v . induced lung damage bleomycin was replaced by ifosfamide 1200 mg / m i.v . twice daily ( d1-d5 ) in two additional cycles . these six cycles resulted in a total dose of cisplatin 1070 mg , etoposide 4800 mg , bleomycin 395 mg , ifosfamide 24.5 g. staging three weeks after termination of the chemotherapy showed a complete remission of the brain lesion . another 10 months later the patient suffered from a second relapse localized again in the anterior section of the ventricle at the same location as the first relapse and additionally in the roof of the left ventricle . the patient was treated with a high dose chemotherapy followed by retransfusion of autologous stem cells . stem cell harvesting was successful after one cycle according to the pei - protocol with cisplatin 25 mg / m i.v . twice daily d2 - 4 ( total dose 170 mg ) , etoposide 100 mg / m i.v . once daily d1-d5 ( total dose 860 mg ) , and ifosfamide 1.5 g twice daily i.v . the harvest of three apheresis were enough for performing two cycles of high dose chemotherapy ( > 2 x 10 cd 34 pos . after hematologic reconstitution the patient underwent two cycles of high dose chemotherapy according to the cei - protocol ( cumulative dose of carboplatin 375 mg / m i.v . ) twice daily d1-d5 ( total dose of two cycles 5000 mg ) , etoposide 310 mg / m i.v . twice daily d1-d5 ( total dose of two cycles 4100 mg ) , and ifosfamide 2.5 g / m i. v. twice daily ( total dose of two cycles 33 g ) each followed by reinfusion of autologous peripheral blood stem cells . g / l ) for 7 and 9 days , respectively . after treatment afp decreased to 9.6 u / ml and the tumor manifestation in the brain disappeared . the therapy was complicated by a global insufficiency of the pineal gland . since first cranial radiation he received antidiuretic hormones ( adh ) applied as a nasal spray . during the high dose chemotherapy with fluid intakes up to 4 liter - to prevent cisplatin induced renal damage - his urine production increased up to 13 liter/24 hours after therapy . the patient remained in stable remission   for a period of 13 months until a third relapse . the tumor was then localized in the roof of the left ventricle and in the brain stem . this third relapse was complicated by seizures which resolved under high dose dexamethasone therapy . because of extensive pretreatment with chemotherapy the patients underwent cerebral radiation with another 30 gy , so the total dose to the brain was 60 gy . despite slow reconstitution of the performance status the patient died one month later at home most likely due to an electrolyte derailment . despite of considerable advances in the treatment of patients with germ cell tumors , certain patients , especially those who relapse after radiation and/or chemotherapy fare poorly   . guidelines have not yet been defined for therapy of relapsed and/or refractory germinoma of the pineal gland . considering that germ cell tumors of the pineal gland have   biological similarities to germ cell tumors of the testis , the patient was treated at second relapse with high dose chemotherapy and stem cell support in analogy to treatment protocols for systemic germ cell tumors . to date there are no reports on adult patients with relapse of a pineal germinoma treated with high dose chemotherapy and stem cell transplantation . kimura et al reported of a patient with a primary -hcg producing cerebral germinoma who gained a complete remission after high dose chemotherapy and autologous bone marrow transplantation . graham et al reported about a heterogeneous group of brain tumors in 49 children ( two children with germ cell tumors ) treated with different high dose chemotherapy regimens followed by autologous marrow rescue . both children were alive and had no evidence of disease 30 and 20 months respectively after treatment . in contrast to the here reported patient both children were treated with high dose chemotherapy and marrow rescue as first line treatment because of high risk of recurrence . our patient remained in stable complete remission for 13 months after high dose chemotherapy with autologous stem cell support . most likely due to the high curability rate of intracerebral germinoma with conventional therapy and/or radiation there are no published data of survival or disease free survival times after tumor recurrence for conventional therapy . however , in the most cases the duration of second or third remission is shorter than the first remission . the third remission gained after high - dose chemotherapy and stem cell transplantation high - dose chemotherapy with autologous stem cell support is a potentially curative treatment for patients with relapsed or high risk ( metastatic disease ) germinomas of the pineal gland . according to data from other tumor entities , the response to chemotherapy seems to be the best prognostic factor .
we report of a 34-year old man with second intracranial relapse of a suprasellar germinoma . despite of extensive pretreatment with radiation and conventional chemotherapy relapse occurred and was treated with sequential high - dose chemotherapy followed by transfusion of autologous peripheral stem cells . 
 the high - dose chemotherapy course was complicated by refractory derailment of pineal gland insufficiency . 
 the patient achieved a complete remission after high dose chemotherapy which lasted for 13 months . 
 subsequently , he developed a third relapse and died .