Clinical and neurophysiological changes in patients with pineal region expansions

In the last 20 years neurological and neurosurgical follow up of our patients with pineal region expansions (118 patients) pointed to certain clinical and neurophysiological regularities. We performed retrospective study which included 84 patients with pineal region expansions in the period from 1992 to 2009. The study included 55 women and 29 men, mean age 30.08 +/- 13.93 years, with positive brain magnetic resonance imaging (MRI)--70 patients (83.4%) had simple pineal gland cysts, and 14 patients (16.67%) had expansive process in pineal region with compressive effect. All patients had headache, while 32 patients (38%) had epileptic phenomena--primary generalized seizures. Patients had common electroencephalography (EEG) pattern with paroxysmal discharges of 3Hz (or more than 3 Hz) spike-and-wave complexes. Operation with supracerebellar infratentorial approach was performed in 70 patients. In most of our patients indication for the operation was established based on the size of the cyst (15 mm or more), with the signs of compression on the quadrigeminal plate and compression of the surrounding veins, which could result in seizures and EEG changes verified in our group of patients. Pathohistological analysis revealed pineocytomas in 11 cases (15.71%), pinealoblastomas in 2 cases (2.86%), one case of teratoma (1.43%), while 56 patients had pineal gland cysts (80%). Following surgery clinical condition improved in all patients--patients became seizure-free and headaches significantly decreased. Other symptoms including diplopiae, nausea, vomiting, vertigo as well as blurred vision also disappeared. There were no complications after surgical procedures. This study points to often appearance of seizures that clinically and neurophysiologically present as primary generalized epilepsy in patients with pineal region expansions. Our hypotheses are that mass effect on the surrounding veins that affects normal perfusion, compressive effect on the quadrigeminal plate and the aqueduct of the midbrain, hemosiderin deposists, as well as secretion disturbances of anticonvulsive agent melatonin can be involved in the pathogenesis of seizures. We suggest to perform high resolution brain MRI with special demonstration of pineal region in all young patients that have seizures and specific EEG changes.

[MRI with dynamic contrast enhancement in brain tumors]

Magnetic resonance imaging (MRI) is the leading method of radiation diagnosis of brain tumors. In conditions of the artificial contrast enhancement there are more clearly differentiated the boundaries of the tumor node on the back of peritumorous edema and identified structural features of the tumor. The purpose of this study was to examine indicators of the dynamics of accumulation and removal of contrast agents by brain tumors in MRI technique with dynamic contrast and identify opportunities of this method in the differential diagnosis of various types of tumors.

TEMPORARY REMOVAL: MRI and 1H-MRS on diagnosis of pineal region tumors

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Hemangiopericytoma of the pineal region

We report a unique case of a 37-year-old female suffering from hemangiopericytoma of the pineal region, successfully excised by surgery. Hemangiopericytomas are rare malignant vascular tumors arising from mesenchymal cells with pericytic differentiation. These tumors usually develop in the limbs, pelvis, head, neck, and mostly in the muscle tissue. They are aggressive lesions that tend to occur at an earlier age than other meningeal tumors, recur with high frequency, and metastasize extracranially. Hemangiopericytomas represent less than 1% of all CNS tumors. Surgery remains the mainstay treatment. Radiotherapy and/or chemotherapy are the other treatment options.

[Clinical study of pineal region tumors: experience with 132 patients]

OBJECTIVE

To review the clinical manifestations, imaging, tumor markers, treatment methods, pathology results and clinical curative effects of pineal region tumors and to evaluate the characteristics and intervention strategies for those tumors.

METHODS

The clinicopathological data of 132 patients with pineal region tumor treated in our department between January 2000 and May 2008 were retrospectively studied.

RESULTS

A moderate predominance in males was presented. The clinical manifestations of the disease included increased intracranial pressure and ocular movement impairment. There were some features but no regularity and specific appearance on imaging including CT and MRI. 88.6% of patients associated with hydrocephalus. A high serum level of alpha-fetoprotein (AFP) was presented in 14 cases and high HCG in 9 cases. Eighteen cases received direct radiation therapy and 7 had radiotherapy post biopsy. 107 cases were treated surgically and 63 cases received postoperative adjuvant treatment. 114 cases had pathology results including 56 germ cell tumors. The patients were followed up for 12 approximately 132 months. Recurrence developed in 23 cases and 12 cases died. The 5-year survival rate was 89.3%.

CONCLUSION

Pineal region tumors are often associated with hydrocephalus and this makes preoperative diagnosis difficult. Imaging examination may help diagnosis but less specific. Germ cell tumors may diagnosed by some tumor markers. Radiation therapy is the choice of treatment for pure germinomas. Other types of pineal region tumors should receive surgical treatment. Postoperative adjuvant treatment based on pathology can provide a good prognosis in pineal region tumor.

Metastatic bronchial neuroendocrine tumor to the pineal gland: a unique manifestation of a rare disease

Metastatic Neuroendocrine Tumor (NET) to the pineal gland is a unique manifestation previously unreported in the literature. We describe an unusual case of metastatic bronchial NET to the pineal gland in a 71-year-old male patient. His primary NET had been resected six years previously and there was no indication of the presence of disseminated metastatic disease at that time. Due to increased uptake by the pituitary gland on the post-operative 111Indium-pentetreotide scintigraphy (Octreoscan), an intra-sellar mass was diagnosed and excised using a transsphenoidal approach; histology revealed an unrelated non-functional pituitary macroadenoma. Four years later, a new mass appeared on MRI, involving the pineal gland, and was diagnosed on biopsy as a metastatic lesion from the original bronchial NET. Since this lesion was not accessible to surgery, it was treated successfully with radiosurgery. The case suggests that NETs should be considered in the differential diagnosis of pineal gland metastases and that radiosurgery may be an effective alternative in the treatment of these patients.

Pineal gland tumors: experience from the SEER database

Pineal gland tumors are rare and account for less than 1% of all primary brain tumor diagnoses. They are more commonly seen in pediatric patients than in adults. We analyzed the available SEER data on pineal gland tumors that were diagnosed during the period 1973-2005. The cohort was subdivided into groups on the basis of tumor histology: germ cell tumors, pineal parenchymal tumors, gliomas, and other pineal tumors. Analyses of incidence, survival, factors influencing survival, and treatment modalities are provided. Among the 633 patients with pineal tumors, male sex was predominant, i.e., sex ratio was 3:1 for the whole group and 11.8:1 for those with germ cell tumors. The 5-year overall survival (OS) for the cohort was 65% +/- 2.1%. Those with germ cell tumors experienced the best survival (OS = 78.9% +/- 2.3%), followed by those with gliomas (OS = 61% +/- 9.3%), and those with pineal parenchymal tumors (OS = 47.2% +/- 4.2%). Non-germ cell tumors, absence of radiotherapy from treatment regimen, and diagnosis before 1993 were the only factors associated with a negative impact on survival. The extent of surgical tumor resection did not affect survival in any histologic subgroup. We conclude that, although pineal tumors are histologically diverse, they share some similarities due to their unique location. An aggressive surgical approach should be considered with caution in this region. Further studies on different pineal tumors subtypes are needed.

Primary pineal melanoma with leptomeningeal spreading: case report and review of the literature

OBJECTIVE

Primary melanomas of the pineal region are exceedingly rare and may be difficult to diagnose. Clinical, radiological and pathological features as well as diagnostic procedures are discussed. CASE HISTORY We report herein on a 44-year-old man who presented with uncontrolled epileptic seizures. Magnetic resonance imaging revealed a pineal mass hyperintense on T1-weighted and isointense on T2-weighted sequences with diffuse leptomeningeal involvement and intense homogeneous contrast enhancement after gadolinium administration. A frontal leptomeningeal and cortical biopsy was performed. Histological examination showed a malignant melanocytic tumor cell proliferation expressing Melan-A, but not HMB-45 or S100 protein. Even if we have no proof that the tumor actually arose in the pineal gland, based on the radiological and histological findings, and on the unremarkable dermatologic and ophthalmologic examinations, a primary pineal melanoma with leptomeningeal dissemination was diagnosed. The patient received temozolomide-based chemotherapy followed by whole brain irradiation. The patient died 52 weeks after disease onset and 13 weeks after treatment initiation.

CONCLUSION

A diagnosis of pineal melanoma should be considered in the presence of a pineal mass that appears hyperintense on T1-weighted images and hypo- to isointense on T2-weighted images. The diagnosis is provided by pathological examination of tumor specimens obtained at surgical resection or at leptomeningeal biopsy. However, immunochemistry using anti-Melan-A, -S100 protein and/or -HMB45 antibodies on cerebrospinal fluid and leptomeningeal samples may be helpful in diagnosing such a disease. The prognosis of primary pineal melanoma is variable but meningeal spreading carries a dismal prognosis. The best therapeutic management is yet to be defined.

Management of central nervous system germinoma: proposal for a modern strategy

With the development of diagnostic, radiologic, and therapeutic modalities, strategies for management of central nervous system (CNS) germinoma are changing gradually. The author advocates that typical germinomas can be diagnosed based on their typical clinical and radiological findings, together with slight elevation of beta-human chorionic gonadotropin levels in the serum and/or cerebrospinal fluid (CSF) and quick response to radiation or chemotherapy. Radiation therapy has been the standard treatment for CNS germinoma until recently. Germinomas 4 cm or less in diameter can be cured with radiation doses of 40-45 Gy. Regarding the treatment volume, an individualized approach is recommended and a focal radiation field covering at least major parts of the ventricular system is recommended if no CSF dissemination is present and CSF cytology is negative. Such irradiation is best given by intensity-modulated radiation therapy. Systemic chemotherapy with reduced doses (24-30 Gy) of radiation has to some extent been successful, but longer follow-up periods are necessary to draw conclusions regarding the superiority of this treatment over standard-dose radiation therapy. CNS germinoma patients should be completely cured with minimum morbidity, probably by employing appropriate doses of chemotherapy and intensity-modulated radiation therapy in the future.

Pineal region tumors--neurosurgical review

The treatment for the pineal region tumors depends on tumor histology. Nowadays, germinomas can be cured by radiotherapy and chemotherapy without surgical resection but the other pineal region tumors should be primary treated by surgery. Two microsurgical approaches, the infratentorial supracerebellar and the occipital transtentorial, are accepted as the main standard accesses to the pineal region. For benign pineal tumors (pineocytoma, meningioma, mature teratomas, symptomatic pineal cysts, etc.) radical surgical resection can be curative. For malignant tumors radical surgical resection is not an objective. Serum and CSF markers contribute to the diagnosis of pineal parenchymal tumors. b-HCG is mainly positive in choriocarcinomas, embryonal carcinomas and mixed germ cell tumors and AFP is expressed by yolk sac tumors, embryonic carcinomas, immature teratomas and mixed germ cell tumors, b-HCG is usually low in germinomas which are often positive for PLAP on immunohistochemistry. Fifty-one pineal region tumors were surgically treated by senior author (NdT). Only 17 of them were the neoplasms originating from pineal body (pineal tumors). In conclusion it can be stressed that management of pineal tumors requires a multidisciplinary cooperation. With the exception of germinoma where only a biopsy is needed, the role of the surgeons still remains prominent as resection of pineal tumors requires high technical skill and experience as well as precise clinical judgment.

An unusual case of headache

Pinealgland tumors comprise 0.5%-1% of adult brain tumors. Pineoblastomas constitute less than half of these pineal gland tumors. Due to the key anatomic location, these tumors produce hydrocephalus by pressing on the aqueduct of Sylvius. Headache is a very common symptom. We describe the case of a 20-year-old female who presented with new onset persistent headache. Workup revealed a pineoblastoma. These tumors can be detected by MRI and diagnosed on cytology of cerebrospinal fluid (CSF) showing blue round tumor cells with specific tumormarkers. Combined chemo radiation therapy is the treatment for these tumors. New onset persistent headaches are present in 50%-60% of intracranial tumors. All new onset persistent headaches should be promptly evaluated.

[Case of pineocytoma causing repetitive subarachnoid hemorrhage for 43 years]

A 61-year-old woman had suffered from severe headache and nausea over 20 times during the last 43 years. An subarachnoid hemorrhage (SAH) was detected by spinal puncture in some other hospitals, but the source of hemorrhage remained unknown in spite of repeated angiography. At the age of 61, she was diagnosed as having normal pressure hydrocephalus, and received a ventriculo-peritoneal shunt. She suffered from sudden headache 12 days after surgery. A CT scan showed a SAH and enlargement of the pineal mass. The tumor was totally removed via the occipital interhemispheric transtentorial approach and was diagnosed histologically as a pineocytoma. She has been free from SAH for three years since removal of the tumor. Pineal apoplexy should be considered as a cause of SAH.

[A case of hypophyseal and pineal germinoma]

A case of 19-year-old male with idiopathic diabetes insipidus diagnosed 9 years ago. 1.5 years from the onset of the disease vision disturbances, neurologic deficiencies and symptoms of hypopituitarism showed up. MRI examination revealed an advanced hypophyseal and pineal gland tumor--germinoma. Total regression was achieved with radio- and chemotherapy. For 7 years from the end of treatment patient has not declared any complains except for vision disturbances and hypopituitarism has been substituted successfully. The case puts on the necessity of a strict endocrinologic and radiologic follow-up in patients with idiopathic diabetes insipidus due to the possibility of existing potentially curable disease ie. intracranial tumor.

[Combined modality therapy for primary choriocarcinoma in the pineal region: report of two cases]

OBJECTIVE

We report two rare cases of primary choriocarcinoma in the pineal region verified histologically. In both cases, the pre-operative serum level of human chorionic gonadotropin (HCG) was significantly elevated to 128-/+935.7 and 9 -/+088.9 mIU/ml, respectively, and serum alpha-fetoprotein (AFP) was negative. The tumors were microsurgically removed, and postoperative hydrocephalus were treated by endoscopic third ventriculostomy. Both patients underwent chemotherapy and radiotherapy. After adjunctive treatment, the serum HCG decreased within normal range. During the two-year-long follow-up, no radiological (MRI) evidence was found to suggest recurrence in MR imaging, and the serum HCG was normal in one patient, but mildly elevated in the other. HCG measurement can be crucial to the diagnosis and post-treatment monitoring of choriocarcinoma, and radical surgical tumor removal and combined modality therapy including chemotherapy and radiotherapy may ensure good results.

Recurrent intracranial germinoma along the endoscopic ventriculostomy tract. Case report

The authors report a case of a recurrent intracranial germinoma along the site of an endoscopic third ventriculostomy (ETV) after complete local tumor control using 3D conformal radiation therapy. A 13-year-old girl presented with sudden left upward gaze limitation for 4 days. A pineal region tumor and obstructive hydrocephalus were noted on magnetic resonance (MR) images. An ETV and tumor biopsy procedure were performed, which revealed the lesion to be a germinoma. The patient's visual symptoms and hydrocephalus disappeared postoperatively. Chemotherapy using cisplatin, etoposide, vincristine, and cyclophosphamide was initiated on postoperative Day 10. An MR image obtained 10 weeks after surgery and 2 weeks after chemotherapy revealed a significant (> 50%) reduction of the lesion. Radiation therapy was administered at 50.4 Gy to the target and 36 Gy to the periphery. Ten months after surgery, an MR image revealed further shrinkage of the tumor mass. One year after surgery, follow-up MR imaging demonstrated a small mass lesion at the entry site of the ETV, measuring 1.0 x 1.4 x 1.5 cm. An operation was performed to remove the small lesion, and pathological findings revealed it to be of the same histology as the primary tumor.

CNS germ cell tumor (CNSGCT) of childhood: presentation and delayed diagnosis

OBJECTIVE

To describe the relationship between symptomatology and time to diagnosis of an institutional series of patients with CNS germ cell tumor (CNSGCT) over a 16-year period.

METHODS

Thirty consecutive patients newly diagnosed with CNSGCT (mean age 10.9 years; range 6 to 17 years; 70% boys) were evaluated at our institution between 1990 and 2006.

RESULTS

Duration of symptoms prior to diagnosis ranged from 5 days to 3 years (mean 8.4 months). Tumor location included pineal (14), suprasellar (8), pineal/suprasellar (3), pineal/thalamic (4), and basal ganglionic/thalamic (3). Five patients had disseminated disease at the time of diagnosis. Features including headache, nausea, vomiting, and visual changes led to earlier diagnosis. Symptoms including movement disorders, enuresis, anorexia, and psychiatric complaints delayed diagnosis in 9 of 30 patients, diagnosed 7 months to 3 years (mean 22.3 months) from symptom onset. In 7 of 9 patients with delayed diagnosis, enuresis was present. Seventeen of 30 patients had signs of endocrine dysfunction at presentation that included diabetes insipidus (4), hypothyroidism (8), and growth hormone deficiency (4). Ophthalmologic findings of decreased visual acuity, visual field deficits, or ocular abnormalities were present in 13 patients. Duration of symptoms did not correlate with tumor subtype or event-free survival. In three patients with basal ganglionic/temporal lobe, thalamic, or pineal/suprasellar signal abnormalities on MRI, neuroradiographic diagnosis was difficult.

CONCLUSIONS

Diagnosis of CNS germ cell tumor is often delayed, and presentation may include movement disorders or mimic psychiatric disease. MRI interpretation can be challenging and may require serum/CSF markers and biopsy for diagnosis.

PAPILLARY PINEOCYTOMA IN CHILD: A CASE REPORT

BACKGROUND

Papillary pineocytoma is an extremely rare tumor usually with a poor outcome.

CASE REPORT

We report a case of a 10-year-old-girl with pineal gland tumor and obstructive hydrocephalus diagnosed using MRI. The child was successful treated by insertion of a ventriculoperitoneal shunt and consecutive tumor resection by supracerebellar-infratentorial approach. Histopathological examination showed a papillary structure of the pineocytoma. As such, tumors are considered to be aggressive the child was subjected to radio- and chemotherapy.

CONCLUSION

At six year follow-up after surgery, the patient is symptom-free and the MRI shows no tumor recurrence.

Papillary Tumors of the Pineal Region: Case Report

OBJECTIVE

The pineal region is a rare intracranial site for metastasis. We report three patients initially considered to have metastatic papillary adenocarcinoma to the pineal region. On review, these papillary, keratin-positive neoplasms meet the criteria for papillary tumor of the pineal region (PTPR).

CLINICAL PRESENTATION

These neoplasms occurred in three women (age range, 37–55 yr). Imaging studies demonstrated well-circumscribed lesions in the pineal region. All patients presented with obstructive hydrocephalus and symptoms attributable to hydrocephalus and tectal compression.

INTERVENTION

All three patients underwent near total microsurgical resection of the pineal region neoplasm, followed by adjuvant radiotherapy. The two patients with long-term follow-up (56–60 mo) have remained clinically stable without evidence of local or distant recurrence. The first two patients were initially diagnosed as having papillary metastatic carcinoma of unknown origin. The third patient was treated after the recent description of PTPR and met the histopathological diagnostic criteria. Retrospective pathological review of the previous two patients resulted in designation as PTPR.

CONCLUSION

The morphological features of the tumors in our series, along with the clinical presentations, are similar to those in the original description of the PTPR. Our findings agree with the original hypothesis that the cells composing the PTPR are similar to ependymal cells of the subcommissural organ, thus furthering the hypothesis that the PTPR derives from a specialized ependymocyte associated with the subcommissural organ. The two patients with long-term follow-up (56–60 mo) have remained clinically stable without evidence of local or distant recurrence.

Microfiberscope coaxial technique in neuroendoscopic surgery

Exploration in neuroendoscopic surgery is occasionally insufficient because of the structural limitations in endoscope. It is not easy to identify the precise position of the endoscope during an operation. We here show a coaxial technique for neuroendoscopic exploration with monitoring by means of a microfiberscope. The endoscopic coaxial technique consists of two scopes. The microfiberscope has a diameter of 0.75 mm, flexible body and high-quality image system. We tested its ability to visualize the subject at several distances and applied this coaxial technique in neuroendoscopic surgery. The microfiberscope not only visualizes the object but also magnifies it by a distance. The scope was easy to handle with monitoring of its movement in the endoscopic view. The technique allowed us to safely explore details which are difficult to approach with an ordinary fiberscope or rigid-rod scope. The microfiberscope also adjusts to the neuronal anatomy and many clinical situations. Taken together, the microfiber coaxial technique might offer new advantages to modern neuroendoscopic surgery.

Management of pineal region tumors

Tumors of the pineal region represent a diverse collection of tumors with a variety of natural histories. This diversity necessitates accurate histologic diagnosis to allow rational therapeutic planning. Evaluation of a pineal lesion should begin with craniospinal MRI and analysis of the cerebrospinal fluid (CSF). Whereas certainty of the histologic diagnosis is now a requirement for treatment in Western nations, some Asian centers continue to recommend a test dose of radiation therapy based on the high incidence of germinoma in those countries. If there is high clinical suspicion of a germinoma or tectal glioma, stereotactic or endoscopic biopsy may be pursued. All other lesions should be referred for open biopsy with microsurgical techniques. This approach provides adequate tissue for diagnosis, may be curative in low-grade tumors, and may substantially improve survival in patients with malignant tumors. If open surgery is not desired by the patient or practitioner, stereotactic or endoscopic biopsy may be followed by radiosurgery for localized, well-demarcated tumors. Radiation therapy is the first-line therapy for germinomas. Although the optimal radiation dosage and volume have not been decided, the current Children's Oncology Group trial may offer definitive evidence to address this dilemma in germ cell tumors. Evidence of CSF seeding requires craniospinal radiation and adjuvant chemotherapy regardless of tumor type. Diagnosis of any of the malignant tumors (non-germ cell tumors, pineoblastomas, and parenchymal tumors of intermediate determination) also requires craniospinal radiation (with local tumor doses of at least 50 Gy) and adjuvant chemotherapy (generally platinum based). Patients with tectal gliomas may undergo excision with or without postoperative radiation; however, they also may be observed with vigilant follow-up alone.