Diagnosis and management of pineal tumors

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✓ The management of pineal region tumors remains controversial. Advocates of a conservative approach emphasize the excellent results of radiotherapy, particularly with germinomas, while a number of recent reports have demonstrated the safety of direct surgery. In order to improve treatment planning, attempts have been made to distinguish the various tumor types by computerized tomography (CT) and by the use of markers for germ-cell tumors. This paper reports a study of 35 patients with pineal tumors including two ectopic germinomas. Pretreatment CT was performed in all 35 patients, and human chorionic gonadotropin and alpha-fetoprotein levels were assayed in 11. Histological verification was available for 33 tumors; the other two were characterized by clinical and CT features plus tumor markers. Of the 27 tumor operations, 21 were for a pineal mass and six for ectopic germinoma or metastasis. There was no operative mortality. Morbidity was minimal, and surgery did not increase the incidence of subarachnoid seeding.

Each histological type of tumor has a typical appearance on CT scanning, although, in the individual case, a firm diagnosis is not always possible. However, consideration of CT scans together with the clinical features, cerebrospinal fluid cytology, tumor markers, and (if there is still doubt) response to a small dose of irradiation will generally allow a specific diagnosis with a high degree of probability. In this way, germinomas may be selected for radiotherapy and the tumors less likely to respond may be subjected to primary surgery.

Article Information

Address reprint requests to: Rashid Jooma, M.B.B.S., F.R.C.S., Department of Neurosurgery, Frenchay Hospital, Bristol BS16 1LE, England.

© AANS, except where prohibited by US copyright law.

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Figures

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    Contrast-enhanced computerized tomography scans showing a germinoma. There are discrete masses homogeneously enhancing in the suprasellar, pineal, and anterior interhemispheric regions.

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    Computerized tomography scans showing a malignant teratoma: plain scan (left) and scan after administration of medium (right). There is an ill-defined mass within the quadrigeminal cistern protruding into the posterior half of the third ventricle and encroaching on both thalami. The tumor contains fat and flecks of calcification as well as enhancing tissue isodense with brain.

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    Computerized tomography scans showing a germinoma: plain scan (left) and after administration of contrast medium (right). A high-density homogeneously enhancing mass is seen, with well defined edges and no surrounding edema. The calcified pineal body is adjacent to the anterior margin of the mass. The tumor is protruding into and occluding the posterior part of the third ventricle and almost filling the quadrigeminal cistern.

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    Computerized tomography scans of a germinoma: plain scan (left) and after intravenous administration of contrast medium (right). There is symmetrical hydrocephalus with dilatation of the third ventricle. A highdensity area around the margins of the lateral ventricles is considerably enhanced with intravenous contrast medium.

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    Computerized tomography scans of an ectopic germinoma: plain scan (left) and after intravenous administration of contrast medium (right). There is a high-density, markedly enhancing mass filling the suprasellar cisterns and extending into the parasellar regions. A normal calcified pineal gland is also seen.

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    Computerized tomography scans of a malignant teratoma; plain scan (left) and after administration of contrast medium (right). There is a well defined, mainly idosense mass within the posterior half of the third ventricle and quadrigeminal cistern. It contains a small fleck of calcification and a small central nonenhancing cystic component. There is mild hydrocephalus.

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    Vertebral angiograms, lateral projection, showing a choriocarcinoma. Arterial phase (left) and venous phase (right). The pineal tumor obtains a rich pathological circulation mainly from posteromedial choroidal arteries. The tumor elevates the vein of Galen and displaces the superior vermian vessels posteriorly and inferiorly.

  • View in gallery

    Computerized tomography scans of a benign teratoma: plain scan (left) and after contrast medium administration (right). The large, well defined, mixed-density mass contains fat and calcification as well as isodense tissue. The tumor involves the pineal and third ventricular regions as well as most of the inferior half of the right parietal lobe.

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    Computerized tomography scans of a pineoblastoma: plain scan (left) and after intravenous administration of contrast medium (right). A well defined, homogeneously enhancing mass of a density greater than brain, surrounded by a thin rim of low density, lies in the quadrigeminal cisterns and occludes the posterior half of the third ventricle. There is moderate hydrocephalus.

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    Computerized tomography scans of a pineoblastoma, enhanced with contrast material. A large homogeneously enhancing mass expands from the third ventricle into the quadrigeminal cistern and encroaches on both thalami. There is a smaller mass consistent with seeded metastasis in the left trigone.

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    Computerized tomography scans showing an astrocytoma: plain scan (left) and after intravenous administration of contrast medium (right). There is a mass with the density of brain projecting into the posterior half of the dilated third ventricle. The left side of the mass blends with and apparently arises from the medial wall of the left thalamus. There is hydrocephalus with periventricular lucency.

  • View in gallery

    Computerized tomography scans of a germinoma. Left: Plain scan made at the time of the patient's presentation with diabetes insipidus in January, 1981. The normal-sized pineal gland is visible within the quadrigeminal cistern. Right: Plain scan made in September, 1981. There is a large, well demarcated, high-density mass in the pineal region, obliterating the quadrigeminal cistern.

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