Skip to main content

Advertisement

SpringerLink
Log in

Radical resection of nongerminomatous pineal region tumors via the occipital transtentorial approach based on arachnoidal consideration: experience on a series of 143 patients

  • Clinical Article - Brain Tumors
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

An Erratum to this article was published on 10 December 2014

Abstract

Backgroud

The role of radical resection for nongerminomatous pineal region tumors is still controversial. The purpose of this study was to present the surgical results in a large series and evaluate the feasibility of radical surgical strategy.

Methods

We retrospectively reviewed the records of 143 patients with nongerminomatous pineal region tumors surgically treated via an occipital transtentorial approach between 2000 and 2011. The tumor was small (<2 cm) in 14.7 % of patients, medium (2–4 cm) in 52.4 %, and large (>4 cm) in 32.9 %.

Results

Gross total tumor removal was achieved in 91.6 % of patients, subtotal in 7.0 %, and partial in 1.4 %. Histological diagnosis was nongerminomatous germ cell tumor in 41.3 %, pineal parenchymal tumor in 14.7 %, glial tumors in 28.7 %, and miscellaneous in 15.4 %. The overall complication and mortality rate was 18.2 % and 0.7 %, respectively. Permanent morbidity occurred in 5.6 % of patients, including hemianopsia in 3.5 % and Parinaud syndrome in 2.1 %. Hydrocephalus was resolved in 82.1 % without surgery for the CSF diversion. Sixty-eight patients with malignant tumors underwent radiotherapy; 35 also received adjuvant chemotherapy. One hundred thirty patients were successfully followed up with a mean duration of 43 months. Finally, 86.9 % of the patients achieved a favorable functional outcome (mRS ≤ 2), 3.1 % had an mRS score of 3, 1.5 % had an mRS score of 4, and 8.5 % had died (mRS = 6).

Conclusions

Radical surgery was recommended as the optimal treatment for nongerminomatous pineal region tumors. Favorable results could be achieved by experienced neurosurgeons. Hydrocephalus could be cured by radical tumor removal in the majority of cases. The occipital transtentorial approach was indicated for most pineal region tumors, but surgeon’s preference and experience should also be considered. New understanding of the arachnoid membranes of this region may be helpful for tumor resection.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Cho BK, Wang KC, Nam DH, Kim DG, Jung HW, Kim HJ, Han DH, Choi KS (1998) Pineal tumors: experience with 48 cases over 10 years. Childs Nerv Syst 14:53–58

  2. Jia W, Ma Z, Liu IY, Zhang Y, Jia G, Wan W (2011) Transcallosal interforniceal approach to pineal region tumors in 150 children. J Neurosurg Pediatr 7:98–103

    Article  PubMed  Google Scholar 

  3. Nomura K (2001) Epidemiology of germ cell tumors in Asia of pineal region tumor. J Neurooncol 54:211–217

    Article  CAS  PubMed  Google Scholar 

  4. Tomita T (1999) Pineal region tumors. In: Albright AL, Pollack IF, Adelson PD (eds) Priciples and practice of pediatric neurosurgery. Thieme New York, pp 571–589

  5. Bruce JN, Ogden AT (2004) Surgical strategies for treating patients with pineal region tumors. J Neurooncol 69:221–236

    Article  PubMed  Google Scholar 

  6. Hernesniemi J, Romani R, Albayrak BS, Lehto H, Dashti R, Ramsey C 3rd, Karatas A, Cardia A, Navratil O, Piippo A, Fujiki M, Toninelli S, Niemela M (2008) Microsurgical management of pineal region lesions: personal experience with 119 patients. Surg Neurol 70:576–583

    Article  PubMed  Google Scholar 

  7. Pendl G (2002) Management of pineal region tumors. Neurosurg Quart:279–298

  8. Bruce JN, Stein BM (1995) Surgical management of pineal region tumors. Acta Neurochir (Wien) 134:130–135

    Article  CAS  Google Scholar 

  9. Konovalov AN, Pitskhelauri DI (2003) Principles of treatment of the pineal region tumors. Surg Neurol 59:250–268

    Article  PubMed  Google Scholar 

  10. Pettorini BL, Al-Mahfoud R, Jenkinson MD, Avula S, Pizer B, Mallucci C (2013) Surgical pathway and management of pineal region tumours in children. Childs Nerv Syst 29:433–439

    Article  PubMed  Google Scholar 

  11. Davidson L, McComb JG (2013) The safety of the intraoperative sacrifice of the deep cerebral veins. Childs Nerv Syst 29:199–207

    Article  PubMed  Google Scholar 

  12. Giordano M, Ludemann WO, Stieglitz L, Gerganov VM, Columbano L, Samii A, Samii M (2011) Identification of venous variants in the pineal region with three-dimensional preoperative magnetic resonance imaging navigation in patients harbouring tumors in this area: significance for surgical approach to the lesion. Clin Neurol Neurosurg 113:387–392

    Article  PubMed  Google Scholar 

  13. Hart MG, Santarius T, Kirollos RW (2013) How I do it—pineal surgery: supracerebellar infratentorial versus occipital transtentorial. Acta Neurochir (Wien) 155:463–467

    Article  Google Scholar 

  14. Hasegawa M, Yamashita J, Yamashima T (1991) Anatomical variations of the straight sinus on magnetic resonance imaging in the infratentorial supracerebellar approach to pineal region tumors. Surg Neurol 36:354–359

    Article  CAS  PubMed  Google Scholar 

  15. Kodera T, Bozinov O, Surucu O, Ulrich NH, Burkhardt JK, Bertalanffy H (2011) Neurosurgical venous considerations for tumors of the pineal region resected using the infratentorial supracerebellar approach. J Clin Neurosci 18:1481–1485

    Article  PubMed  Google Scholar 

  16. Luo SQ, Li DZ, Zhang MZ, Wang ZC (1989) Occipital transtentorial approach for removal of pineal region tumors: report of 64 consecutive cases. Surg Neurol 32:36–39

    Article  CAS  PubMed  Google Scholar 

  17. Tanaka R, Washiyama K (2003) Occipital transtentorial approach to pineal region tumors. Oper Tech Neurosurg 6:215–221

    Article  Google Scholar 

  18. Yamamoto I (2001) Pineal region tumor: surgical anatomy and approach. J Neurooncol 54:263–275

    Article  CAS  PubMed  Google Scholar 

  19. Qi ST, Fan J, Zhang XA, Pan J (2011) Reinvestigation of the ambient cistern and its related arachnoid membranes: an anatomical study. J Neurosurg 115:171–178

    Article  PubMed  Google Scholar 

  20. Qi ST, Zhang XA, Fan J, Huang GL, Pan J, Qiu BH (2011) Anatomical study of the arachnoid envelope over the pineal region. Neurosurgery 68:7–14, discussion 14–15

    PubMed  Google Scholar 

  21. Zhang XA, Qi S, Fan J, Huang G, Peng J, Xu J (2012) The distribution of arachnoid membrane within the velum interpositum. Acta Neurochir (Wien) 154:1711–1715

    Article  Google Scholar 

  22. Habrand JL, De Crevoisier R (2001) Radiation therapy in the management of childhood brain tumors. Childs Nerv Syst 17:121–133

    Article  CAS  PubMed  Google Scholar 

  23. Matsutani M, Sano K, Takakura K, Fujimaki T, Nakamura O (1998) Combined treatment with chemotherapy and radiation therapy for intracranial germ cell tumors. Childs Nerv Syst 14:59–62

    Article  CAS  PubMed  Google Scholar 

  24. Oi S (1998) Recent advances and racial differences in therapeutic strategy to the pineal region tumor. Childs Nerv Syst 14:33–35

    Article  CAS  PubMed  Google Scholar 

  25. Morgenstern PF, Osbun N, Schwartz TH, Greenfield JP, Tsiouris AJ, Souweidane MM (2011) Pineal region tumors: an optimal approach for simultaneous endoscopic third ventriculostomy and biopsy. Neurosurg Focus 30:E3

    Article  PubMed  Google Scholar 

  26. Morgenstern PF, Souweidane MM (2013) Pineal region tumors: simultaneous endoscopic third ventriculostomy and tumor biopsy. World Neurosurg 79(S18):e19–13

    Google Scholar 

  27. Pople IK, Athanasiou TC, Sandeman DR, Coakham HB (2001) The role of endoscopic biopsy and third ventriculostomy in the management of pineal region tumours. Br J Neurosurg 15:305–311

    Article  CAS  PubMed  Google Scholar 

  28. Regis J, Bouillot P, Rouby-Volot F, Figarella-Branger D, Dufour H, Peragut JC (1996) Pineal region tumors and the role of stereotactic biopsy: review of the mortality, morbidity, and diagnostic rates in 370 cases. Neurosurgery 39:907–912, discussion 912–904

    CAS  PubMed  Google Scholar 

  29. Teo C, Young R 2nd (1999) Endoscopic management of hydrocephalus secondary to tumors of the posterior third ventricle. Neurosurg Focus 7:e2

    Article  CAS  PubMed  Google Scholar 

  30. Zacharia BE, Bruce JN (2011) Stereotactic biopsy considerations for pineal tumors. Neurosurg Clin N Am 22:359–366, viii

    Article  PubMed  Google Scholar 

  31. Kanamori M, Kumabe T, Tominaga T (2008) Is histological diagnosis necessary to start treatment for germ cell tumours in the pineal region? J Clin Neurosci 15:978–987

    Article  PubMed  Google Scholar 

  32. Barnett DW, Olson JJ, Thomas WG, Hunter SB (1995) Low-grade astrocytomas arising from the pineal gland. Surg Neurol 43:70–75, discussion 75–76

    Article  CAS  PubMed  Google Scholar 

  33. MacKay CI, Baeesa SS, Ventureyra EC (1999) Epidermoid cysts of the pineal region. Childs Nerv Syst 15:170–178

    Article  CAS  PubMed  Google Scholar 

  34. Vaquero J, Ramiro J, Martinez R, Coca S, Bravo G (1990) Clinicopathological experience with pineocytomas: report of five surgically treated cases. Neurosurgery 27:612–618, discussion 618–619

    Article  CAS  PubMed  Google Scholar 

  35. Lutterbach J, Fauchon F, Schild SE, Chang SM, Pagenstecher A, Volk B, Ostertag C, Momm F, Jouvet A (2002) Malignant pineal parenchymal tumors in adult patients: patterns of care and prognostic factors. Neurosurgery 51:44–55, discussion 55–46

    Article  PubMed  Google Scholar 

  36. Matsutani M, Sano K, Takakura K, Fujimaki T, Nakamura O, Funata N, Seto T (1997) Primary intracranial germ cell tumors: a clinical analysis of 153 histologically verified cases. J Neurosurg 86:446–455

    Article  CAS  PubMed  Google Scholar 

  37. Reddy AT, Janss AJ, Phillips PC, Weiss HL, Packer RJ (2000) Outcome for children with supratentorial primitive neuroectodermal tumors treated with surgery, radiation, and chemotherapy. Cancer 88:2189–2193

    Article  CAS  PubMed  Google Scholar 

  38. Weiner HL, Finlay JL (1999) Surgery in the management of primary intracranial germ cell tumors. Childs Nerv Syst 15:770–773

    Article  CAS  PubMed  Google Scholar 

  39. Little KM, Friedman AH, Fukushima T (2001) Surgical approaches to pineal region tumors. J Neurooncol 54:287–299

    Article  CAS  PubMed  Google Scholar 

  40. Reid WS, Clark WK (1978) Comparison of the infratentorial and transtentorial approaches to the pineal region. Neurosurgery 3:1–8

    Article  CAS  PubMed  Google Scholar 

  41. Mottolese C, Szathmari A, Ricci-Franchi AC, Beuriat PA, Grassiot B (2014) The sub-occipital transtentorial approach revisited base on our own experience. Neurochirurgie. doi:10.1016/j.neuchi.2013.12.005

    Google Scholar 

  42. Oliveira J, Cerejo A, Silva PS, Polonia P, Pereira J, Vaz R (2013) The infratentorial supracerebellar approach in surgery of lesions of the pineal region. Surg Neurol Int 4:154

    Article  PubMed Central  PubMed  Google Scholar 

  43. Pluchino F, Broggi G, Fornari M, Franzini A, Solero CL, Allegranza A (1989) Surgical approach to pineal tumours. Acta Neurochir (Wien) 96:26–31

    Article  CAS  Google Scholar 

  44. Sajko T, Kudelic N, Lupret V, Lupret V Jr, Nola IA (2009) Treatment of pineal region lesions: our experience in 39 patients. Coll Anthropol 33:1259–1263

    Google Scholar 

  45. Vaquero J, Ramiro J, Martinez R, Bravo G (1992) Neurosurgical experience with tumours of the pineal region at Clinica Puerta de Hierro. Acta Neurochir (Wien) 116:23–32

    Article  CAS  Google Scholar 

  46. Deshmukh VR, Smith KA, Rekate HL, Coons S, Spetzler RF (2004) Diagnosis and management of pineocytomas. Neurosurgery 55:349–355, discussion 355–347

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We are grateful to Xiaoyu Qiu and Yiping Mo (Medical Secretary, Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China) for their help with the data collection.

Disclosure

The authors have no personal financial or institutional interest in any of the drugs, materials, or devices described in this article.

Conflicts of interest

None.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Dadao Bei Street, Guangzhou, 510515, People’s Republic of China

    Songtao Qi, Jun Fan, Xi-an Zhang, Hui Zhang, Binghui Qiu & Luxiong Fang

Authors
  1. Songtao Qi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jun Fan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Xi-an Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hui Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Binghui Qiu
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Luxiong Fang
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Songtao Qi.

Additional information

Drs. Songtao Qi, Jun Fan, and Xi-an Zhang contributed equally to this work.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Surgical case illustration. An occipital transtentorial approach was performed in a patient with a mixed germ cell tumor in pineal region. As shown by the preoperative MRI, the tumor arose within the arachnoid envelope wrapping the vein of Galen and its tributaries. Therefore, the envelope was dissected carefully prior to the tumor resection. After the deep veins had been totally released, a satisfactory exposure of the tumor could be achieved, and the retraction of veins could be reduced to minimize the risk of injury. During the procedure, the pineal vein was identified, coagulated, and separated from the tumor. Once all tumor-brain interfaces had been dissected, the tumor was removed en bloc. The adjacent neurovascular structures remained intact after tumor resection. Early postoperative MRI showed total removal of the tumor. Histology-specific adjuvant therapy was then performed as planned. A 5-year follow-up postoperative MRI presented no tumor recurrence. (WMV 16,185 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Qi, S., Fan, J., Zhang, Xa. et al. Radical resection of nongerminomatous pineal region tumors via the occipital transtentorial approach based on arachnoidal consideration: experience on a series of 143 patients. Acta Neurochir 156, 2253–2262 (2014). https://doi.org/10.1007/s00701-014-2224-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00701-014-2224-4

Keywords

Search

Navigation