1
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Bora S, Santhoor HA, Kumar A, Das S, Sharma MC, Mishra S, Singh PK, Laythalling RK, Kale SS. Papillary Tumors of Pineal Region: A Single-Center Experience in Management of 11 Cases. World Neurosurg 2024; 184:e486-e493. [PMID: 38307196 DOI: 10.1016/j.wneu.2024.01.149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Papillary tumors of pineal region (PTPR) comprise a very rare subset of pineal region tumors that have been recently described. Literature on the management and outcome of PTPR is scarce owing to the rarity of these tumors. To address this lacuna, we analyzed our experience in management of PTPR. METHODS We retrospectively analyzed the outcome of 11 patients with histopathologically proven PTPR who underwent surgical excision at our center. RESULTS Mean patient age was 33.3 years (range, 12-45 years), and male-to-female ratio was 1.75:1. Headache was the most common presentation followed by visual disturbances, altered sensorium, Perinaud syndrome, and seizures. Cerebrospinal fluid diversion was required in 6 patients. Krause approach was the most common approach used for tumor excision (9/11 cases). There was no perioperative mortality. Two patients were lost to follow-up. In the remaining 9 patients, the average follow-up period was 45 months (range, 12-79 months). On first postoperative magnetic resonance imaging, 8 patients showed no evidence of residual tumor (gross total resection), while 1 patient had small residual tumor (near-total resection) that remained stable during follow-up. Four patients underwent adjuvant chemoradiotherapy. None of the patients developed recurrence during follow-up. CONCLUSIONS PTPR are a rare subgroup of pineal region tumors with distinct cells of origin but presentation similar to other pineal region tumors. Surgical resection constitutes the mainstay of management, and the extent of resection appears to be the most important determinant of prognosis. The role of adjuvant therapy still needs to be determined.
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Affiliation(s)
- Santanu Bora
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Hemanth A Santhoor
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Amandeep Kumar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
| | - Sumanta Das
- Department of Neuropathology, All India Institute of Medical Sciences, New Delhi, India
| | - Meher C Sharma
- Department of Neuropathology, All India Institute of Medical Sciences, New Delhi, India
| | - Shashwat Mishra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj K Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | | | - Shashank S Kale
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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2
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Vasiljevic A. Histopathology and molecular pathology of pediatric pineal parenchymal tumors. Childs Nerv Syst 2023; 39:2273-2284. [PMID: 35972537 DOI: 10.1007/s00381-022-05637-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/02/2022] [Indexed: 11/24/2022]
Abstract
Pineal parenchymal tumors in children are rare. They consist of two main types, pineoblastoma (PB) and pineal parenchymal tumor of intermediate differentiation (PPTID), which are World Health Organization (WHO) grade 4 and grade 2-3 respectively. PBs are divided into four distinct molecular groups: PB-miRNA1, PB-miRNA2, PB-RB1, and PB-MYC/FOXR2. PB-RB1 and PB-MYC/FOXR2 affect young children and are associated with a dismal prognosis. PB-miRNA1 and PB-miRNA2 groups affect older children and follow a more favorable course. They are characterized by mutually exclusive alterations in genes involved in miRNA biogenesis, including DICER1, DROSHA, and DGCR8. They may be sporadic or may represent one manifestation of DICER1 syndrome. PB-RB1 tumors show alterations in the RB1 gene and may develop in the setting of congenital retinoblastoma, a condition known as "trilateral retinoblastoma." In the pediatric population, PPTIDs typically affect adolescents. They are characterized by small in-frame insertions in the KBTBD4 gene which is involved in ubiquitination.
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Affiliation(s)
- Alexandre Vasiljevic
- Centre de Pathologie Et Neuropathologie Est, Groupement Hospitalier Est, Hospices Civils de Lyon, 59 Boulevard Pinel, 69677 BRON Cedex, Lyon, France.
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3
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Mesny E, Lesueur P. Radiotherapy for rare primary brain tumors. Cancer Radiother 2023; 27:599-607. [PMID: 37481341 DOI: 10.1016/j.canrad.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 07/24/2023]
Abstract
Rare central nervous system tumors are defined by an incidence rate of less than 6 cases per 100 000 individuals a year. It comprises a large panel of entities including medulloblastoma, glioneuronal tumors, solitary fibrous tumors, rare pituitary tumors, ependymal or embryonal tumors. The management of these tumors is not clearly defined and radiotherapy indications should be discussed at a multidisciplinary board. Image-guided and intensity-modulated radiation therapy should be proposed and MRI has a fundamental place in the treatment preparation. To avoid the occurrence of side effects, proton therapy is playing an increasingly role for the treatment of these tumors.
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Affiliation(s)
- E Mesny
- Radiation Oncology Department, centre hospitalier Lyon Sud, Pierre-Bénite, France.
| | - P Lesueur
- Centre de radiothérapie Guillaume-le-Conquérant, 76600 Le Havre, France; Département de radiothérapie, centre François-Baclesse, 14000 Caen, France; Équipe CERVOxy, ISTCT UMR6030-CNRS, CEA, université de Caen-Normandie, 14000 Caen, France
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4
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Upadhyayula PS, Neira JA, Miller ML, Bruce JN. Benign and Malignant Tumors of the Pineal Region. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1405:153-173. [PMID: 37452938 DOI: 10.1007/978-3-031-23705-8_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Pineal region tumors fall into five broad categories: benign pineal region tumors, glial tumors, papillary tumors, pineal parenchymal tumors, and germ cell tumors. Genetic and transcriptional studies have identified key chromosomal alterations in germinomas (RUNDC3A, ASAH1, LPL) and in pineocytomas/pineoblastomas (DROSHA/DICER1, RB1). Pineal region tumors generally present with symptoms of hydrocephalus including nausea, vomiting, papilledema, and the classical Parinaud's triad of upgaze paralysis, convergence-retraction nystagmus, and light-near pupillary dissociation. Workup requires neuroimaging and tissue diagnosis via biopsy. In germinoma cases, diagnosis may be made based on serum or CSF studies for alpha-fetoprotein or beta-HCG making the preferred treatment radiosurgery, thereby preventing the need for unnecessary surgeries. Treatment generally involves three steps: CSF diversion in cases of hydrocephalus, biopsy through endoscopic or stereotactic methods, and open surgical resection. Multiple surgical approaches are possible for approach to the pineal region. The original approach to the pineal region was the interhemispheric transcallosal first described by Dandy. The most common approach is the supracerebellar infratentorial approach as it utilizes a natural anatomic corridor for access to the pineal region. The paramedian or lateral supracerebellar infratentorial approach is another improvement that uses a similar anatomic corridor but allows for preservation of midline bridging veins; this minimizes the chance for brainstem or cerebellar venous infarction. Determination of the optimal approach relies on tumor characteristics, namely location of deep venous structures to the tumor along with the lateral eccentricity of the tumor. The immediate post-operative period is important as hemorrhage or swelling can cause obstructive hydrocephalus and lead to rapid deterioration. Adjuvant therapy, whether chemotherapy or radiation, is based on tumor pathology. Improvements within pineal surgery will require improved technology for access to the pineal region along with targeted therapies that can effectively treat and prevent recurrence of malignant pineal region tumors.
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Affiliation(s)
| | - Justin A Neira
- Department of Neurological Surgery, Columbia University, New York, USA
| | - Michael L Miller
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Jeffrey N Bruce
- Department of Neurological Surgery, Columbia University, New York, USA.
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5
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Nemir J, Maric LS, Trbojevic T, Zarkovic K, Jadrijević-Cvrlje F. Papillary tumor of the pineal region in pediatric patient – A case report. Surg Neurol Int 2022; 13:488. [DOI: 10.25259/sni_867_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 09/24/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Papillary tumor of the pineal region (PTPR) represents a rare and histologically distinct subgroup of tumors originating in the pineal region. Few pediatric cases have been reported so far in the literature; therefore, clinical data are scarce.
Case Description:
We describe a case of PTPR in a 9-year-old girl who presented with a 5-month history of excessive appetite and weight gain. The patient underwent neuroimaging procedures and total gross surgical resection with postoperative adjuvant local radiotherapy, which from our experience was the best treatment choice as an attempt to avoid local recurrence. During 78-month follow-up, the patient from our study manifested no disease recurrence.
Conclusion:
PTPR should be included in the differential diagnosis of pineal region masses.
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Affiliation(s)
- Jakob Nemir
- Department of Neurosurgery, University Hospital Center Zagreb, Zagreb, Croatia
| | - Lorna Stemberger Maric
- Department of Pediatric Infectious Diseases, University Hospital for Infectious Diseases, Dr. Fran Mihaljevic, Zagreb, Croatia
| | - Tena Trbojevic
- Department of Pediatrics, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Kamelija Zarkovic
- Department of Pathology, Clinical Medical Centre Zagreb, Zagreb, Croatia
| | - Filip Jadrijević-Cvrlje
- Department of Pediatrics, Division of Hematology and Oncology, Children’s Hospital Zagreb, Zagreb, Croatia
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6
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Mobark NA, Alharbi M, Alotabi F, Alshoumer A, Al Shakweer W, AlNaqib ZG, AlSaad AN, Balbaid AO, Alsolme E, Abedalthagafi MS. Papillary Tumor of the Pineal Region Rare Pediatric CNS Tumor Case Series Treated in King Fahad Medical City (KFMC). Curr Oncol 2022; 29:7558-7568. [PMID: 36290872 PMCID: PMC9600283 DOI: 10.3390/curroncol29100595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/26/2022] [Accepted: 10/09/2022] [Indexed: 11/05/2022] Open
Abstract
The clinical behaviors, prognosis, and appropriate treatments of papillary tumors of the pineal region (PTPR) are not fully defined due to the rarity of these tumors. At diagnosis, PTPR may present with clinical symptoms, including headache with obstructive hydrocephalus, diplopia, vomiting, and lethargy, as well as neurological signs, including Argyll Robertson pupils and Parinaud's syndrome due to compression of the dorsal midbrain, specifically the periaqueductal region with horizontal nystagmus. Radiological assessment of pineal region lesions is challenging, with a wide range of potential differential diagnoses. PTPR typically presents as a heterogeneous, well-circumscribed mass in the pineal region, which might contain cystic areas, calcifications, hemorrhages, or protein accumulations. Here, we report three female pediatric patients with PTPR treated in King Fahad Medical City (KFMC) in Saudi Arabia. Histological and immunohistochemical diagnosis was confirmed by analysis of genome-wide DNA methylation profiles. This case series expands on the available reports on the clinical presentations of PTPR and provides important information on the responses to different treatment modalities.
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Affiliation(s)
- Nahla A. Mobark
- Department of Pediatric Oncology Comprehensive Cancer Centre, King Fahad Medical City, Riyadh 12231, Saudi Arabia
| | - Musa Alharbi
- Department of Pediatric Oncology Comprehensive Cancer Centre, King Fahad Medical City, Riyadh 12231, Saudi Arabia
| | - Fahad Alotabi
- Pediatric Neurosurgical Department, King Fahad Medical City, Riyadh 12231, Saudi Arabia
| | - Azhar Alshoumer
- Department of Pathology & Laboratory Medicine, King Fahad Medical City, Riyadh 12231, Saudi Arabia
| | - Wafa Al Shakweer
- Department of Pathology & Laboratory Medicine, King Fahad Medical City, Riyadh 12231, Saudi Arabia
| | - Zaid G. AlNaqib
- Department of Pediatric Oncology Comprehensive Cancer Centre, King Fahad Medical City, Riyadh 12231, Saudi Arabia
| | | | - Ali O. Balbaid
- Radiation Oncology Department, Comprehensive Cancer Centre, King Fahad Medical City, Riyadh 12231, Saudi Arabia
| | - Ebtehal Alsolme
- Genomics Research Department, King Fahad Medical City, Riyadh 12231, Saudi Arabia
| | - Malak S. Abedalthagafi
- Genomics Research Department, King Fahad Medical City, Riyadh 12231, Saudi Arabia
- Department of Pathology & Laboratory Medicine, Emory University, Atlanta, GA 30322, USA
- Correspondence:
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7
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Ganz JC. Less common intraparenchymal tumors. PROGRESS IN BRAIN RESEARCH 2022; 268:303-314. [PMID: 35074087 DOI: 10.1016/bs.pbr.2021.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The chapter outlines the management of a great variety of rare intraparenchymal tumors. For some like medulloblastomas or ependymomas, GKNS has little to offer. For others like neurocytomas, primary central nervous system lymphomas, and papillary pineal tumors the current findings look most hopeful. For choroid plexus papillomas there is currently not enough information to define the role of GKNS in their treatment. Pineal region tumors are a complex and varied group of neoplasms. Their complexity, variety and ethnic variability means that defining the role of GKNS will require continuing research before a consensus about management can be reached.
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Affiliation(s)
- Jeremy C Ganz
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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8
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Bechri H, Oudrhiri MY, Louraoui SM, Melhaoui A, Sefiani S, Arkha Y, El Ouahabi A. Papillary tumor of the pineal region: Is stereotactic radiosurgery efficient for this rare entity? Surg Neurol Int 2021; 12:386. [PMID: 34513153 PMCID: PMC8422449 DOI: 10.25259/sni_613_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 06/30/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Papillary tumors of the pineal region are rare neuroepithelial lesions that were described for the 1st time in the WHO 2007 classification. Management of such lesions remains controversial. Case Description: We describe the case of a 26-year-old female who presented with intracranial hypertension syndrome secondary to a 1.9 cm3 lesion of the pineal region causing hydrocephalus. The patient benefited from an endoscopic third ventriculocisternostomy and a biopsy of her lesion in favor of a papillary tumor of the pineal region. After discussion of the surgical risks, the patient refused the surgical option and a stereotactic radiosurgery (SRS) was performed. She improved both clinically (allowing her to regain autonomy) and radiologically (reduction of 60% of tumor volume) at 1 year follow-up. Conclusion: Because of the rarity of the lesion, literature is yet not able to find consensus concerning management of such lesion, but SRS has proven efficiency for these Grades II or III lesions with high recurrence rates. Therefore, it should be considered as a primary therapeutic option allowing good outcome with low risks for the patient.
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Affiliation(s)
- Hajar Bechri
- Department of Neurosurgery, Hôpital des Spécialités, Rue Lamfadel Cherkaoui Rabat Institut, Rabat, Morocco
| | - Mohammed Yassaad Oudrhiri
- Department of Neurosurgery, Hôpital des Spécialités, Rue Lamfadel Cherkaoui Rabat Institut, Rabat, Morocco
| | - Sidi Mamoun Louraoui
- Department of Neurosurgery, Cheikh Khalifa Hospital, Ave Mohamed Taieb Naciri, Casablanca, Morocco
| | - Adyl Melhaoui
- Department of Neurosurgery, Hôpital des Spécialités, Rue Lamfadel Cherkaoui Rabat Institut, Rabat, Morocco
| | | | - Yasser Arkha
- Department of Neurosurgery, Hôpital des Spécialités, Rue Lamfadel Cherkaoui Rabat Institut, Rabat, Morocco
| | - Abdessamad El Ouahabi
- Department of Neurosurgery, Hôpital des Spécialités, Rue Lamfadel Cherkaoui Rabat Institut, Rabat, Morocco
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9
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Mehta N, Gupta G, Shaikh S. Recurrent Papillary Tumor of Pineal Region Misdiagnosed as Pineocytoma 9-Years Ago. Asian J Neurosurg 2021; 16:398-401. [PMID: 34268174 PMCID: PMC8244718 DOI: 10.4103/ajns.ajns_439_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 02/14/2021] [Accepted: 03/13/2021] [Indexed: 11/04/2022] Open
Abstract
Primary tumors of the pineal gland occur infrequently with a preponderance of either parenchymal tumors or germ cells tumors. Papillary tumor of the pineal region is a rare neuroepithelial lesion that arises exclusively in the pineal region. They have been designated as either Grade II or Grade III lesions as per the 2016 WHO classification of central nervous system tumors. Clinically, they usually present with obstructive hydrocephalus and visual disturbance. On imaging, these tumors are solid-cystic, heterogeneously enhancing, and show T2 hyperintensity. Pathologically, they can closely resemble a Grade I pineocytoma and immunohistochemistry is essential to differentiate the two. No definite guidelines exist to confirm the ideal protocol of treatment. Evidence regarding the role of radiation after surgery is limited to case reports and series. Adjuvant therapy is usually recommended for tumors with subtotal excision, high proliferative/mitotic index, or proven metastasis. We describe a case of a 29-year-old male with a recurrent papillary tumor of the pineal region, 9 years after primary surgery where it was misdiagnosed as a pineocytoma. The tumor was effectively controlled with surgical excision, cerebrospinal fluid diversion, and adjuvant radiation for 8 years before showing two recurrences within a span of 6 months with a rising proliferation index.
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Affiliation(s)
- Nirav Mehta
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Gaurav Gupta
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Salman Shaikh
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
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10
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Fiorentino A, Gregucci F, Desideri I, Fiore M, Marino L, Errico A, Di Rito A, Borghetti P, Franco P, Greto D, Donato V. Radiation treatment for adult rare cancers: Oldest and newest indication. Crit Rev Oncol Hematol 2021; 159:103228. [PMID: 33508447 DOI: 10.1016/j.critrevonc.2021.103228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 12/10/2020] [Accepted: 01/16/2021] [Indexed: 11/17/2022] Open
Abstract
AIM Aim of this analysis is to review the role of RT in the management of several rare tumors for adult patients. METHODS Collection data regarding RT and rare tumors was made by Pubmed. RESULTS For mucosal melanomas, RT is prescribed, being associated with lower local recurrence rate. For trachea tumors, RT was used as adjuvant or salvage treatment for unresectable disease. For pNET, RT can be a suitable option for post-surgical or unresectable/borderline. For bronchopulmonary neuroendocrine tumors the role of adjuvant treatments is uncertain. For hepatobiliary and ovarian malignancy, stereotactic body RT (SBRT) is a promising approach. For soft tissue sarcoma, perioperative treatments are indicated, and a growing role of SBRT in oligometastatic disease is recognized. For endocrine tumors, adjuvant RT has demonstrated benefits through reducing recurrence risk. CONCLUSION The radiotherapy is a frequent indication in adult rare cancers; thus the role of Radiation Oncologist must not be neglected.
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Affiliation(s)
- Alba Fiorentino
- Radiation Oncology Department, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Fabiana Gregucci
- Radiation Oncology Department, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti, Bari, Italy.
| | - Isacco Desideri
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", Section of Radiation Oncology, University of Florence, Italy
| | - Michele Fiore
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Lorenza Marino
- Radiation Oncology Department, Humanitas Istituto Clinico Catanese, Misterbianco, Catania, Italy
| | - Angelo Errico
- Radiotherapy Oncology Department, R. Dimiccoli Hospital, Barletta, Italy
| | - Alessia Di Rito
- Radiotherapy Oncology Department, IRCCS "Giovanni Paolo II", Bari, Italy
| | - Paolo Borghetti
- Radiation Oncology Department University and Spedali Civili, Brescia, Italy
| | | | - Daniela Greto
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", Section of Radiation Oncology, University of Florence, Italy
| | - Vittorio Donato
- Radiation Oncology Department, Azienda Ospedaliera San Camillo-Forlanini, Roma, Italy
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11
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Mathkour M, Hanna J, Ibrahim N, Scullen T, Kilgore MD, Werner C, Cormier I, Spencer P, Keen JR, Bui CJ. Papillary tumor of the pineal region in pediatric populations: An additional case and systematic review of a rare tumor entity. Clin Neurol Neurosurg 2020; 201:106404. [PMID: 33360024 DOI: 10.1016/j.clineuro.2020.106404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Abstract
Papillary tumors of the pineal region (PTPR) are a rare tumor entity first described in 2003, later codified in the 2007 WHO tumor classification system. PTPRs most commonly occur in the third and fourth decades, with exceedingly rare presentations in pediatric populations. Herein, we present an additional case of a 10-year-old female found to have PTPR in conjunction with Trisomy 21 managed successfully with cerebrospinal fluid diversion and gross total resection (GTR). Three years after resection she has returned to baseline without recurrence. We also performed a comprehensive review of the current literature discussing the diagnosis, treatment, and pathophysiologic correlations in children. Diagnosis and management of PTPRs is a topic that is increasingly garnering attention in the literature given the recent characterization of this tumor entity. However, relatively little is known about the presentation of PTPRs in pediatric populations. In adults, PTPRs have been linked with several chromosomal and genetic abnormalities; however this correlation is limited in pediatric literature. Although GTR is the mainstay for treatment, the application of adult treatment protocols may not be advisable due to age and the developmental changes of the CNS in children.
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Affiliation(s)
- Mansour Mathkour
- Ochsner Health System, Department of Neurosurgery, New Orleans, LA, USA; Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA; Neurosurgery Division, Surgery Department, Jazan University, Jazan, Saudi Arabia.
| | - Joshua Hanna
- Ochsner Health System, Department of Neurosurgery, New Orleans, LA, USA; Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Naser Ibrahim
- Ochsner Health System, Department of Neurosurgery, New Orleans, LA, USA; Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Tyler Scullen
- Ochsner Health System, Department of Neurosurgery, New Orleans, LA, USA; Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Mitchell D Kilgore
- Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Cassidy Werner
- Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Ian Cormier
- Ochsner Health System, Department of Neurosurgery, New Orleans, LA, USA; Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Pierce Spencer
- Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Joseph R Keen
- Ochsner Health System, Department of Neurosurgery, New Orleans, LA, USA; Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Cuong J Bui
- Ochsner Health System, Department of Neurosurgery, New Orleans, LA, USA; Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
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12
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Boßelmann CM, Gepfner-Tuma I, Schittenhelm J, Brendle C, Honegger J, Tabatabai G. Papillary tumor of the pineal region: a single-center experience. Neurooncol Pract 2020; 7:384-390. [PMID: 33133629 DOI: 10.1093/nop/npaa014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Papillary tumor of the pineal region (PTPR) is a rare entity. Its clinical presentation is diverse, and establishing an accurate and timely diagnosis may be challenging. Treatment recommendations are based on the evidence level of case series. Recently, several key advances have been made for immunohistochemical characterization, molecular diagnostics, and neurosurgical treatment of PTPR. Here, we describe our single-center experience.
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Affiliation(s)
- Christian Malte Boßelmann
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Eberhard Karls University Tübingen, Germany.,Department of Neurology and Epileptology, Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Eberhard Karls University Tübingen, Germany.,Department of Neurosurgery, University Hospital Tübingen, Eberhard Karls University Tübingen, Germany
| | - Irina Gepfner-Tuma
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Eberhard Karls University Tübingen, Germany.,Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Eberhard Karls University Tübingen, Germany
| | - Jens Schittenhelm
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Eberhard Karls University Tübingen, Germany.,Department of Neuropathology, University Hospital Tübingen, Eberhard Karls University Tübingen, Germany
| | - Cornelia Brendle
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Eberhard Karls University Tübingen, Germany.,Department of Diagnostic and Interventional Neuroradiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Germany
| | - Juergen Honegger
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Eberhard Karls University Tübingen, Germany.,Department of Neurosurgery, University Hospital Tübingen, Eberhard Karls University Tübingen, Germany
| | - Ghazaleh Tabatabai
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Eberhard Karls University Tübingen, Germany.,Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Eberhard Karls University Tübingen, Germany
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13
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Yamaki VN, Solla DJF, Ribeiro RR, da Silva SA, Teixeira MJ, Figueiredo EG. Papillary Tumor of the Pineal Region: Systematic Review and Analysis of Prognostic Factors. Neurosurgery 2020; 85:E420-E429. [PMID: 30989225 DOI: 10.1093/neuros/nyz062] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 02/08/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinical outcomes and biological behavior of papillary tumors of the pineal region (PTPR) are still under investigation. The best therapeutic strategy has not been defined. OBJECTIVE To perform a comprehensive patient-level analysis of all PTPR cases and identify their clinical features, treatment options, and prognostic factors. METHODS A search of the medical databases for case series and reports on PTPRs from January 2003 to June 2017 was performed. Data addressing PTPR's clinical presentation, imaging, treatment, and histological features were. Variables associated with the primary outcome of 36-mo survival were identified through Cox regression models. RESULTS The initial search yielded 1164 studies, of which 71 were included (60 case reports and 11 case series), containing 177 patients (mean age 33.0 ± 15.3 yr and 53.2% male). Intracranial hypertension and hydrocephalus prevailed as the clinical picture. Surgery was performed on 82.0% and gross total resection (GTR) was achieved on 71.4%. A total of 56.8% recurred after a median 29 mo (quartiles 10.5-45.5). The 36-mo survival rate was 83.5% (95% confidence interval [CI] 76.2-89.2%). Good functional outcomes (Glasgow Outcome Scale 4/5) were observed in 60.0%. The variables of interest were inconsistently reported and the multivariable analysis final sample was 133 patients. After adjustment for age, tumor size (each additional centimeter, hazard ratio [HR] 1.99, 95% CI 1.12-3.53, P = .019) and surgical treatment (HR 0.16, 95% CI 0.05-0.45, P = .001) were associated with 36-mo survival. CONCLUSION Tumor size and surgery are associated with improvement in 36-mo survival. We did not observe any significant benefits from GTR or adjuvant treatments.
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Affiliation(s)
- Vitor Nagai Yamaki
- Department of Neurosurgery, School of Medicine, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Renan Ribeiro Ribeiro
- Department of Pathology, School of Medicine, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Saul Almeida da Silva
- Department of Neurosurgery, School of Medicine, Universidade de Sao Paulo, Sao Paulo, Brazil
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14
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Lancia A, Becherini C, Detti B, Bottero M, Baki M, Cancelli A, Ferlosio A, Scoccianti S, Sun R, Livi L, Ingrosso G. Radiotherapy for papillary tumor of the pineal region: A systematic review of the literature. Clin Neurol Neurosurg 2019; 190:105646. [PMID: 31896492 DOI: 10.1016/j.clineuro.2019.105646] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/10/2019] [Accepted: 12/19/2019] [Indexed: 11/29/2022]
Abstract
Papillary tumor of the pineal region (PTPR) is a rare neuroepithelial brain tumor, characterized by a high risk of local recurrence (greater than 70 % at 6 years). The aim of our study was to review the available literature on radiotherapy for PTPR in order to evaluate timings, schedules, outcomes and toxicities of this treatment modality. In our review, 72.4 % (84) of the patients diagnosed with PTPR received radiation therapy. There is heterogeneity in the dose prescription, ranging from 45 Gy (25 × 1.8 Gy) to 60 Gy (30 × 2 Gy) for 3D Conformal Radiation Therapy and from 12 Gy to 36 Gy for Stereotactic Radiosurgery. Being considered as a grade II or III tumor, PTPR should receive higher total radiation dose in the adjuvant setting. Our analysis showed a very limited treatment-related toxicity with an expected 10-y OS of 72.5 %. At 5-years from the diagnosis, about 60 % of the patients experienced a local recurrence, whereas at 10 years the rate is higher than 80 %. In the literature, conflicting data about radiotherapy for PTPR are reported, in particular regarding disease progression. Although radiotherapy represents a fundamental treatment in the management of PTPR, prospective studies are required to better define its impact on overall survival and progression-free survival.
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Affiliation(s)
- Andrea Lancia
- Radiation Oncology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | | | - Beatrice Detti
- Radiotherapy Unit, Department of Oncology, AOU Careggi, Florence, Italy.
| | - Marta Bottero
- Department of Diagnostic Imaging, Molecular Imaging, Interventional Radiology and Radiotherapy, Tor Vergata General Hospital, Rome, Italy
| | - Muhammed Baki
- Radiotherapy Unit, Department of Oncology, AOU Careggi, Florence, Italy
| | - Alessandro Cancelli
- Department of Diagnostic Imaging, Molecular Imaging, Interventional Radiology and Radiotherapy, Tor Vergata General Hospital, Rome, Italy
| | - Amedeo Ferlosio
- Anatomic Pathology, Department of Biomedicine and Prevention, Tor Vergata University of Rome, Rome, Italy
| | - Silvia Scoccianti
- Radiotherapy Unit, Department of Oncology, AOU Careggi, Florence, Italy
| | - Roger Sun
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, 94800, Villejuif, France
| | - Lorenzo Livi
- Radiotherapy Unit, Department of Oncology, AOU Careggi, Florence, Italy
| | - Gianluca Ingrosso
- Radioterapia Oncologica, Dipartimento di Scienze Chirurgiche e Biomediche, Università degli Studi di Perugia, ospedale S. Maria della Misericordia, S. Andrea delle Fratte, 06156 Perugia, Italy
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15
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Cañizares Méndez MDLÁ, Amosa Delgado M, Álvarez Salgado JA, Villaseñor Ledezma JJ, Capilla Cabezuelo E, Díaz Crespo F. Papillary tumor of the pineal region: Case report and review of the literature. Neurocirugia (Astur) 2019; 30:38-43. [DOI: 10.1016/j.neucir.2018.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 03/14/2018] [Accepted: 03/15/2018] [Indexed: 11/16/2022]
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16
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Papillary Tumor of the Pineal Region in Children: Presentation of a Case and Comprehensive Literature Review. World Neurosurg 2018; 117:144-152. [DOI: 10.1016/j.wneu.2018.06.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 06/03/2018] [Accepted: 06/04/2018] [Indexed: 11/17/2022]
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17
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Braun M, Tomasik B, Bieńkowski M, Wiśniewski K, Kupnicka DJ, Jaskólski D, Papierz W, Fijuth J, Kordek R. Recurrent Pineocytomalike Papillary Tumor of The Pineal Region: A Case Report and Literature Review. World Neurosurg 2018; 120:1-14. [PMID: 30165231 DOI: 10.1016/j.wneu.2018.08.125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/17/2018] [Accepted: 08/18/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Papillary tumors of the pineal region (PTPRs) are malignant World Health Organization grade II/III tumors; however, they may perfectly mimic benign tumors (e.g., pineocytomas [World Health Organization grade I]). CASE DESCRIPTION We present a case of a 28-year-old man with a 35-mm tumor of the pineal region. Considering the typical radiological and pathologic presentation, the tumor was first diagnosed as pineocytoma. However, despite first total resection, the tumor recurred after 7 years. The recurrent neoplasm was composed mainly of papillary structures with low-grade atypical cells positive for CKAE1/AE3 and CK18. This categorization led to the final diagnosis of PTPR. The patient underwent adjuvant radiotherapy, which vastly improved his neurologic condition and resulted in significant tumor regression. CONCLUSIONS This case exemplifies that PTPRs can perfectly mimic pineocytomas and simple staining for cytokeratins may warrant correct diagnosis and better treatment.
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Affiliation(s)
- Marcin Braun
- Department of Pathology, Chair of Oncology, Medical University of Lodz, Lodz, Poland; Postgraduate School of Molecular Medicine, Medical University of Warsaw, Warsaw, Poland.
| | - Bartłomiej Tomasik
- Postgraduate School of Molecular Medicine, Medical University of Warsaw, Warsaw, Poland; Department of Biostatistics and Translational Medicine, Medical University of Lodz, Lodz, Poland; Department of Radiation Oncology, Medical University of Lodz, Lodz, Poland
| | - Michał Bieńkowski
- Department of Pathomorphology, Medical University of Gdansk, Gdansk, Poland
| | - Karol Wiśniewski
- Department of Neurosurgery and Neurooncology, Barlicki University Hospital, Medical University of Lodz, Lodz, Poland
| | | | - Dariusz Jaskólski
- Department of Neurosurgery and Neurooncology, Barlicki University Hospital, Medical University of Lodz, Lodz, Poland
| | - Wielisław Papierz
- Department of Pathomorphology, Medical University of Lodz, Lodz, Poland
| | - Jacek Fijuth
- Department of Radiation Oncology, Medical University of Lodz, Lodz, Poland
| | - Radzislaw Kordek
- Department of Pathology, Chair of Oncology, Medical University of Lodz, Lodz, Poland
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Ribeiro BNDF, Muniz BC, Ventura N, Gasparetto EL, Marchiori E. Papillary tumor of the pineal region accompanied by Parinaud's syndrome: magnetic resonance imaging findings. Radiol Bras 2018; 51:202-204. [PMID: 29991845 PMCID: PMC6034719 DOI: 10.1590/0100-3984.2016.0229] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
| | | | - Nina Ventura
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, RJ, Brazil
| | | | - Edson Marchiori
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
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19
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Long-Term Follow-Up After Radiosurgery of Papillary Tumor of Pineal Region: 2 Case Reports and Review of Literature. World Neurosurg 2018; 116:190-193. [PMID: 29787881 DOI: 10.1016/j.wneu.2018.05.080] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 05/10/2018] [Accepted: 05/11/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Tumors of the pineal region are rare in adulthood, accounting for approximately 1% of intracranial neoplasms in this age range. Because of their rarity, it has proven to be difficult to establish the optimal therapy. Furthermore, microsurgical total resection in this eloquent location is associated with not low rates of morbidity. CASE DESCRIPTION We describe 2 patients diagnosed with papillary tumors of the pineal region by stereotactic biopsy and referred for Gamma Knife radiosurgery after shunting for hydrocephalus. We report a long-term follow-up of 15 and 20 years, respectively, showing a good response to the treatment. CONCLUSIONS After a diagnosis of papillary tumors of the pineal region, radiosurgery is an alternative treatment, with high local control and low morbidity.
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20
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Iorio-Morin C, Kano H, Huang M, Lunsford LD, Simonová G, Liscak R, Cohen-Inbar O, Sheehan J, Lee CC, Wu HM, Mathieu D. Histology-Stratified Tumor Control and Patient Survival After Stereotactic Radiosurgery for Pineal Region Tumors: A Report From the International Gamma Knife Research Foundation. World Neurosurg 2017; 107:974-982. [PMID: 28751141 DOI: 10.1016/j.wneu.2017.07.097] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 07/16/2017] [Accepted: 07/17/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pineal region tumors represent a rare and histologically diverse group of lesions. Few studies are available to guide management and the outcomes after stereotactic radiosurgery (SRS). METHODS Patients who underwent SRS for a pineal region tumor and for whom at least 6 months of imaging follow-up was available were retrospectively assessed in 5 centers. Data were collected from the medical record and histology level analyses were performed, including actuarial tumor control and survival analyses. RESULTS A total of 70 patients were treated between 1989 and 2014 with a median follow-up of 47 months. Diagnoses were pineocytoma (37%), pineoblastoma (19%), pineal parenchymal tumor of intermediate differentiation (10%), papillary tumor of the pineal region (9%), germinoma (7%), teratoma (3%), embryonal carcinoma (1%), and unknown (14%). Median prescription dose was 15 Gy at the 50% isodose line. Actuarial local control and survival rates were 81% and 76% at 20 years for pineocytoma, 50% and 56% at 5 years for pineal parenchymal tumor of intermediate differentiation, 27% and 48% at 5 years for pineoblastoma, 33% and 100% at 5 years for papillary tumor of the pineal region, 80% and 80% at 20 years for germinoma, and 61% and 67% at 5 years for tumors of unknown histology. New focal neurological deficit, Parinaud syndrome, and hydrocephalus occurred in 9%, 7%, and 3% of cases, respectively. CONCLUSIONS SRS is a safe modality for the management of pineal region tumors. Its specific role is highly dependent on tumor histology. As such, all efforts should be made to obtain a reliable histologic diagnosis.
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Affiliation(s)
- Christian Iorio-Morin
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Hideyuki Kano
- Department of Neurological Surgery Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Marshall Huang
- Department of Neurological Surgery Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - L Dade Lunsford
- Department of Neurological Surgery Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | | - Or Cohen-Inbar
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Cheng-Chia Lee
- Taipei Veterans General Hospital Neurological Institute, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Taipei Veterans General Hospital Neurological Institute, Taipei, Taiwan
| | - David Mathieu
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada.
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21
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Nuclear CRX and FOXJ1 Expression Differentiates Non-Germ Cell Pineal Region Tumors and Supports the Ependymal Differentiation of Papillary Tumor of the Pineal Region. Am J Surg Pathol 2017; 41:1410-1421. [PMID: 28719464 DOI: 10.1097/pas.0000000000000903] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Papillary tumor of the pineal region (PTPR) is a neuroepithelial neoplasm first described in 2003. Despite the anatomic association of PTPR with the pineal gland, the features of these tumors resemble those of the ependymal circumventricular subcommissural organ (SCO) of the posterior third ventricle. Given the presumed distinct derivation of PTPR and pineal parenchymal tumors, we hypothesized that expression of lineage-specific transcription factors could distinguish these tumors and provide additional insight into the differentiation of PTPR. A broad series of pineal region samples was reviewed, including 7 benign pineal glands, 4 pineal cysts, 13 pineocytomas, 28 pineal parenchymal tumors of intermediate differentiation, 11 pineoblastomas, and 18 PTPR. All samples were evaluated by immunohistochemistry for expression of CRX, a master transcriptional regulator of photoreceptor differentiation expressed in pineal gland and retina and/or FOXJ1, a master transcriptional regulator of ciliogenesis expressed in normal ependymal cells and ependymal neoplasms. Diffuse nuclear CRX expression is present in 100% of pineal samples. FOXJ1 is negative in all pineal samples. CRX staining is present in 53% of PTPR, though expression is nearly always limited to rare cells. Diffuse nuclear FOXJ1 expression is present in 100% of PTPR. Fetal human SCO diffusely expressed FOXJ1 but was negative for CRX. Immunohistochemistry for FOXJ1 and CRX differentiates non-germ cell pineal region tumors with high sensitivity and specificity, including pineal parenchymal tumors and PTPR. Our findings support the hypothesis that PTPR have ependymal differentiation and are phenotypically more similar to SCO than pineal gland.
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22
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Kamamoto D, Sasaki H, Ohara K, Mizutani K, Yoshida K. A case of papillary tumor of the pineal region with a long clinical history: molecular characterization and therapeutic consideration with review of the literature. Brain Tumor Pathol 2016; 33:271-275. [PMID: 27472995 DOI: 10.1007/s10014-016-0270-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 07/25/2016] [Indexed: 11/24/2022]
Affiliation(s)
- Dai Kamamoto
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hikaru Sasaki
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Kentaro Ohara
- Department of Pathology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Katsuhiro Mizutani
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Raleigh DR, Solomon DA, Lloyd SA, Lazar A, Garcia MA, Sneed PK, Clarke JL, McDermott MW, Berger MS, Tihan T, Haas-Kogan DA. Histopathologic review of pineal parenchymal tumors identifies novel morphologic subtypes and prognostic factors for outcome. Neuro Oncol 2016; 19:78-88. [PMID: 27282397 DOI: 10.1093/neuonc/now105] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Pineal parenchymal tumors (PPTs) are rare neoplasms of the central nervous system, and data concerning clinical outcomes are limited. The purpose of this study was to define the clinical behavior of PPT according to current histopathologic criteria and identify prognostic factors to guide therapeutic decisions. METHODS Seventy-five patients treated for PPT at a single institution between 1992 and 2015 were retrospectively identified. Forty-five resection specimens were available and re-reviewed. Freedom from progression (FFP) and overall survival (OS) were estimated using the Kaplan-Meier method and compared using log-rank tests. RESULTS Median follow-up was 4.1 years. All patients initially underwent surgery; 78% of patients with PPT of intermediate differentiation (PPTID) and all patients with pineoblastoma received adjuvant therapy. Pathologic re-review refined classification in 27% of cases, with the majority of these being adult patients with pineal tumors originally classified as pineoblastomas that more accurately resembled PPTID based on the 2007 WHO classification. CLASSIFICATION Our histologic review also identified that PPTIDs can be classified into small-cell and large-cell morphologic subtypes, which have distinct clinical outcomes. Tumor grade, extent of resection, and neuraxis spread were prognostic for FFP. PPTID subtype, extent of resection, and neuraxis spread were prognostic for OS. Genetic analysis of a pineoblastoma case identified somatic mutations of DICER1, ARID1A, and KDM5C genes. CONCLUSIONS PPTIDs can be classified into 1 of 2 novel morphologic subtypes that are associated with distinct clinical outcomes. Tumor grade, neuraxis spread, and extent of resection also influence outcome for patients with PPT.
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Affiliation(s)
- David R Raleigh
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - David A Solomon
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - Shane A Lloyd
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - Ann Lazar
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - Michael A Garcia
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - Penny K Sneed
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - Jennifer L Clarke
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - Michael W McDermott
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - Mitchel S Berger
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - Tarik Tihan
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - Daphne A Haas-Kogan
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
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Shakir HJ, Qiu J, Prasad D, Mechtler LL, Fenstermaker RA. Papillary tumor of the pineal region with extended clinical and radiologic follow-up. Surg Neurol Int 2015; 6:S451-4. [PMID: 26539320 PMCID: PMC4604644 DOI: 10.4103/2152-7806.166782] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 08/03/2015] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Papillary tumor of the pineal region (PTPR) is a rare neoplasm with only anecdotal data to guide the treatment. Results of treatment with surgery, radiation therapy, and chemotherapy have been reported to have varying degrees of success. Here we report a patient with a PTPR, who underwent subtotal resection, gamma knife stereotactic radiosurgery, and adjuvant temozolomide chemotherapy. CASE DESCRIPTION During 9 years of clinical and radiographic follow-up, the patient has had regression of residual tumor and remains asymptomatic. CONCLUSION When gross total resection of a PTPR is not possible, treatment with gamma knife stereotactic radiosurgery and temozolomide chemotherapy may provide long-term tumor control.
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Affiliation(s)
- Hakeem J Shakir
- Department of Neurosurgery, Roswell Park Cancer Institute, University at Buffalo, State University of New York, Buffalo, NY, USA ; Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Jingxin Qiu
- Department of Pathology, Roswell Park Cancer Institute, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Dheerendra Prasad
- Department of Neurosurgery, Roswell Park Cancer Institute, University at Buffalo, State University of New York, Buffalo, NY, USA ; Department of Radiation Medicine, Roswell Park Cancer Institute, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Laszlo L Mechtler
- Department of Neuro oncology, Roswell Park Cancer Institute, University at Buffalo, State University of New York, Buffalo, NY ; Dent Neurologic Institute, Amherst, NY, USA
| | - Robert A Fenstermaker
- Department of Neurosurgery, Roswell Park Cancer Institute, University at Buffalo, State University of New York, Buffalo, NY, USA ; Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
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Cimino PJ, Gonzalez-Cuyar LF, Perry A, Dahiya S. Lack of BRAF-V600E Mutation in Papillary Tumor of the Pineal Region. Neurosurgery 2015; 77:621-8. [DOI: 10.1227/neu.0000000000000877] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Papillary tumor of the pineal region (PTPR) is a rare central nervous system tumor with a variably aggressive clinical behavior, corresponding to World Health Organization grade II/III. Very little is known about the genetic mutations comprising PTPR. Recent studies have shown that other papillary tumors harbor BRAF-V600E mutations, namely papillary thyroid carcinoma and papillary craniopharyngioma, the latter of which is a midline central nervous system papillary tumor like PTPR.
OBJECTIVE:
To determine whether PTPR may contain the BRAF-V600E mutation.
METHODS:
A search of our institutional files was conducted for PTPR cases. Chart review was performed to obtain demographics and pertinent clinical information when possible. Immunohistochemistry was performed with an anti–BRAF-V600E antibody for cases with additional material for testing.
RESULTS:
We identified 19 PTPR cases occurring in 16 patients. The patient age range was 1 to 73 years (average, 32.2 years). The male-to-female ratio was 1:1. Thirteen patients presented with symptoms of obstructive hydrocephalus, and the other 3 had unknown presenting symptoms. Initial magnetic resonance imaging characteristics tended to include partially cystic masses with heterogeneous postcontrast enhancement. The tumor size ranged from 1.1 to 4.4 cm (average, 2.5 cm).
CONCLUSION:
Of the 16 patients, 13 had additional material for BRAF-V600E immunohistochemistry, all of which demonstrated negativity for BRAF-V600E. This rate is unlike that of other midline papillary tumors and suggests that these tumors, despite their papillary phenotype, may have a distinctive molecular background.
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Affiliation(s)
- Patrick J. Cimino
- Division of Neuropathology, Department of Pathology and Immunology, Washington University, St. Louis, Missouri
| | - Luis F. Gonzalez-Cuyar
- Division of Neuropathology, Department of Pathology, University of Washington, Seattle, Washington
| | - Arie Perry
- Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California
| | - Sonika Dahiya
- Division of Neuropathology, Department of Pathology and Immunology, Washington University, St. Louis, Missouri
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Edson MA, Fuller GN, Allen PK, Levine NB, Ghia AJ, Mahajan A, Brown PD, DeMonte F, Li J. Outcomes After Surgery and Radiotherapy for Papillary Tumor of the Pineal Region. World Neurosurg 2015; 84:76-81. [PMID: 25749579 DOI: 10.1016/j.wneu.2015.02.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 02/23/2015] [Accepted: 02/24/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Papillary tumor of the pineal region (PTPR) is a rare neuroectodermal tumor that was first described in 2003 and formally codified by the World Health Organization in 2007. Limited reports suggest surgical resection is the mainstay of treatment; however, the role of multimodality therapy is not well defined. We evaluated our institutional experience in the treatment of PTPR. METHODS A retrospective review of 8 patients with pathologically confirmed PTPR diagnosed between 1999 and 2013 was performed. RESULTS The median age at diagnosis was 37 years (range, 25-56 years). After a median follow-up period of 60 months (range, 10-170 months), 7 of 8 patients were still living. All patients underwent maximum safe surgical resection; 5 received adjuvant radiation (63%). Overall and progression-free survival 5 years after diagnosis were 100% and 51%, respectively. Progression-free survival 5 years after completion of adjuvant radiotherapy was 64%. Crude recurrence rates for patients receiving adjuvant radiotherapy (n = 5) and patients not receiving adjuvant radiotherapy (n = 3) were 20% and 67%, respectively. Crude recurrence rate after gross total resection (GTR) and no adjuvant radiotherapy (n = 2) was 100% versus 0% when adjuvant radiotherapy was administered after GTR (n = 2). After subtotal resection, 3 patients received adjuvant radiotherapy; 1 of these patients had out-of-field recurrence at 46 months (crude recurrence rate 33%). In all cases, salvage with radiation at the time of recurrence was effective. CONCLUSIONS Our institutional experience confirms a recent multicenter retrospective series showing excellent survival but high risk of local recurrence for PTPR. Our findings suggest that radiotherapy provides durable local control, particularly when administered in the adjuvant setting after GTR.
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Affiliation(s)
- Mark A Edson
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gregory N Fuller
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pamela K Allen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas B Levine
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amol J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anita Mahajan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Paul D Brown
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Franco DeMonte
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
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No 5-ALA fluorescence seen in a recurrent papillary tumour of the pineal region (PTPR). Acta Neurochir (Wien) 2015; 157:215-6. [PMID: 25520052 DOI: 10.1007/s00701-014-2308-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 12/03/2014] [Indexed: 10/24/2022]
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Koziarski A, Grala B, Skrobowska E. Papillary tumor of the pineal region. Report of two cases and literature review. Neurol Neurochir Pol 2014; 48:356-62. [PMID: 25440015 DOI: 10.1016/j.pjnns.2014.09.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 08/12/2014] [Accepted: 09/29/2014] [Indexed: 11/28/2022]
Abstract
Papillary tumor of the pineal region (PTPR) was introduced to the WHO classification in 2007. This rare tumor of little known natural history and unpredictable behavior was described in fewer than 100 cases. Its optimal treatment is not established yet. We report another two cases of PTPR in whom tumors were totally removed via supracerebellar infratentorial approach and both were treated with radiotherapy. In a 37-year-old man the operation was delayed 6 years after the first tumor diagnosis and subsequent shunt placement. He has no complaints 10 years after the onset of the disease. A 45-year-old woman has no complaints 24 months after surgery. Our experience and the data from literature indicate that a total tumor removal is the major prognostic factor.
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Affiliation(s)
- Andrzej Koziarski
- Department of Neurosurgery, Military Institute of Medicine, Warszawa, Poland.
| | - Bartłomiej Grala
- Department of Pathology, Military Institute of Medicine, Warszawa, Poland
| | - Ewa Skrobowska
- Department of Radiology, Military Institute of Medicine, Warszawa, Poland
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PTEN mutations and activation of the PI3K/Akt/mTOR signaling pathway in papillary tumors of the pineal region. J Neuropathol Exp Neurol 2014; 73:747-51. [PMID: 25003235 DOI: 10.1097/nen.0000000000000093] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Papillary tumors of the pineal region (PTPR) are recognized as a distinct entity in the World Health Organization classification of CNS tumors. Papillary tumors of the pineal region frequently show loss of chromosome 10, but no studies have investigated possible target genes on this chromosome. Chromosome 10 harbors the PTEN (phosphatase and tensin homolog) gene, the inactivation of which, by mutation or epigenetic silencing, has been observed in different brain tumors, including high-grade gliomas. In this study, we investigated copy number changes by molecular inversion probe (MIP) analysis and the mutational status of PTEN in 13 PTPR by direct sequencing. MIP analysis of 5 PTPR showed chromosome 10 loss in all cases. In addition, there were losses of chromosomes 3, 14, 22, and X, and gains of whole chromosomes 8, 9, and 12 in more than 1 case. One case had a homozygous PTEN deletion; and 2 point mutations in exon 7 of PTEN (G251D and Q261stop) were found. Immunohistochemistry revealed decrease or loss of the PTEN protein and increased expression of p-Akt and p-S6. These results indicated that PTEN mutations and activation of the PI3K/Akt/mTOR signaling pathway may play a role in the biology of PTPR. This evidence may lead to the possible use of PI3K/Akt/mTOR inhibitors in therapy for patients with PTPR.
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Frappaz D, Conter CF, Szathmari A, Valsijevic A, Mottolese C. The management of pineal tumors as a model for a multidisciplinary approach in neuro-oncology. Neurochirurgie 2014; 61:208-11. [PMID: 24863688 DOI: 10.1016/j.neuchi.2014.03.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Revised: 03/03/2014] [Accepted: 03/05/2014] [Indexed: 12/11/2022]
Abstract
The management of pineal tumors is a model for multidisciplinarity. Apart from an emergency situation that requires immediate shunting of cerebrospinal fluid (CSF), the initial discussion should involve at least a radiologist, a surgeon, a neurologist and an oncologist. The initial decision is whether obtaining a histological proof is obligatory. It depends on age and ethnicity, site (mono- or bifocality), presence of markers in serum as well as CSF, and/or of malignant cells in the CSF. In cases of marker elevation indicating a germ cell tumor, front line chemotherapy can avoid dangerous immediate surgery. When histological proof is required, the extent of surgery should be discussed, aiming either only at obtaining tissue or removal. If a germ cell tumor is detected, treatment will include a cisplatin-containing chemotherapy followed by focal or ventricular irradiation. Tumors of the pineal parenchyma will be treated according to grade, either by surgery alone (pinealocytoma) or chemo-radiotherapy (pinealoblastomas). Similarly, gliomas will be treated depending on their grade with several different possible lines in low grade, and usually radio-chemotherapy in high grade. A careful balance between improved survival rates and decreased long-term side effects will guide the decisions of all these specialists.
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Affiliation(s)
- D Frappaz
- Neuro-oncologie, centre Léon-Bérard, 28, rue Laennec, 69673 Lyon, France.
| | - C Faure Conter
- Institut d'hématologie et d'oncologie pédiatriques, 69673 Lyon, France
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Meyronet D, Silva K, Figarella-Branger D, Godfraind C, Delisle MB, Maurage CA, Miquel C, Varlet P, Gentet JC, Salamon AIB, Vasiljevic A, Jouvet A. Réseau de relecture des tumeurs pédiatriques du système nerveux central par le Groupe d’étude de neuropathologie oncologique pédiatrique (GENOP). Ann Pathol 2014; 34:74-86. [DOI: 10.1016/j.annpat.2014.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 01/10/2014] [Indexed: 01/18/2023]
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Cohen AL, Salzman K, Palmer C, Jensen R, Colman H. Bevacizumab is Effective for Recurrent Papillary Tumor of the Pineal Region: First Report. Case Rep Oncol 2013; 6:434-40. [PMID: 24019784 PMCID: PMC3764969 DOI: 10.1159/000354753] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Papillary tumor of the pineal region (PTPR) is a rare brain tumor that probably arises from ependymal cells. There are no known systemic treatments for PTPR once it is refractory to surgery and radiation. We present the first case of a durable radiographic and clinical response of a PTPR to bevacizumab, an antibody against vascular endothelial growth factor, despite multiple prior treatments. Bevacizumab may be an effective treatment for PTPR.
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Affiliation(s)
- Adam L Cohen
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
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Heim S, Coras R, Ganslandt O, Kufeld M, Blümcke I, Paulus W, Hasselblatt M. Papillary tumor of the pineal region with anaplastic small cell component. J Neurooncol 2013; 115:127-30. [PMID: 23817812 DOI: 10.1007/s11060-013-1202-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 06/26/2013] [Indexed: 10/26/2022]
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