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20 Pineal Region Tumors

  • Jeffrey N. BruceEmail author
  • Charles Teo
Chapter

Abstract

Aggressive surgical resection remains vital to the management of tumors of the pineal region. Surgical resection facilitates accurate diagnosis, the reduction of mass effect, and the management of associated symptoms such as hydrocephalus. Management strategies based on aggressive resection have produced excellent long-term outcomes for patients with benign tumors, as well as improved outcomes in patients with malignant tumors. Modern neurosurgery employs several adaptable surgical approaches to lesions located within the pineal region. Choice of surgical strategy must consider the relevant associated anatomy, the natural history of the various pathologies, and the goals of surgical intervention. As always, operative strategies should be tailored to the individual clinical presentation, with special attention to associated hydrocephalus, elevated tumor markers, metastatic disease, and the general medical condition of the patient. In 20.2, a variety of open transcranial approaches to the pineal region are presented and clinical strategies, potential pitfalls, and outcomes are discussed. The pineal region harbors many critical structures of the brain. Given the high risk nature of surgery in this region (as a spectrum of pathologies can exist in the pineal region, many of which require a gross total resection for a better chance of survival), critics would argue that a minimally invasive, keyhole approach is inappropriate. On the contrary, a keyhole mini-craniotomy approach is ideal for these tumors, as the targets are deep and the options for endoscopic exploration of CSF spaces are numerous. The trajectories to this region, similar to standard approaches, are from below or above the tentorium cerebelli. These approaches, discussed in 20.3, include the occipital supratentorial interhemispheric, infratentorial supracerebellar, and anterior transcallosal approaches. Preoperative radiographic characteristics of the various pineal region tumors and anatomic configurations will determine the best approach, and this also is covered. We will also discuss the use of the endoscope to ensure a thorough and safe resection of pineal region tumors.

Keywords

Supracerebellar infratentorial Occipital transtentorial Pineal Pineal tumor Lateral supracerebellar Interhemispheric transcallosal Brain tumor Germinoma Pineocytoma Pineoblastoma Pineal parenchymal tumor of intermediate differentiation Keyhole craniotomy Minimally invasive neurosurgery Neuroendoscopy Pineal region tumors Skull base neurosurgery Neuro-oncology 

Abbreviations

AFP

α-Fetoprotein

CSF

Cerebrospinal fluid

CT

Computed tomography

ETV

Endoscopic third ventriculostomy

EVD

External ventricular drain

ICP

Intracranial pressure

MRI

Magnetic resonance imaging

OTT

Occipital transtentorial

PPTID

Pineal parenchymal tumor of intermediate differentiation

SCIT

Supracerebellar infratentorial

VPS

Ventriculoperitoneal shunt

βHCG

β-human chorionic gonadoptrin

References (Key References Bolded)

  1. 1.
    Ostrom QT, Gittleman H, Fulop J, et al. CBTRUS statistical report: primary brain and central nervous system tumors diagnosed in the United States in 2008–2012. Neuro-Oncology. 2015;17 Suppl 4:iv1–iv62.CrossRefGoogle Scholar
  2. 2.
    Hasegawa A, Ohtsubo K, Mori W. Pineal gland in old age; quantitative and qualitative morphological study of 168 human autopsy cases. Brain Res. 1987;409:343–9.CrossRefGoogle Scholar
  3. 3.
    Nolte I, Brockmann MA, Gerigk L, Groden C, Scharf J. TrueFISP imaging of the pineal gland: more cysts and more abnormalities. Clin Neurol Neurosurg. 2010;112:204–8.CrossRefGoogle Scholar
  4. 4.
    Pu Y, Mahankali S, Hou J, et al. High prevalence of pineal cysts in healthy adults demonstrated by high-resolution, noncontrast brain MR imaging. AJNR Am J Neuroradiol. 2007;28:1706–9.CrossRefGoogle Scholar
  5. 5.
    Han SJ, Clark AJ, Ivan ME, Parsa AT, Perry A. Pathology of pineal parenchymal tumors. Neurosurg Clin N Am. 2011;22:335–40, viiCrossRefGoogle Scholar
  6. 6.
    Hirato J, Nakazato Y. Pathology of pineal region tumors. J Neuro-Oncol. 2001;54:239–49.CrossRefGoogle Scholar
  7. 7.
    Louis DN, Perry A, Reifenberger G, et al. The 2016 World Health Organization classification of tumors of the central nervous system: a summary. Acta Neuropathol. 2016;131:803–20.CrossRefGoogle Scholar
  8. 8.
    Chandy MJ, Damaraju SC. Benign tumours of the pineal region: a prospective study from 1983 to 1997. Br J Neurosurg. 1998;12(3):228–33.CrossRefGoogle Scholar
  9. 9.
    Radovanovic I, Dizdarevic K, de Tribolet N, Masic T, Muminagic S. Pineal region tumors – neurosurgical review. Med Arh. 2009;63(3):171–3.PubMedGoogle Scholar
  10. 10.
    Bruce JN, Ogden AT. Surgical strategies for treating patients with pineal region tumors. J Neuro-Oncol. 2004;69(1–3):221–36. Google Scholar
  11. 11.
    Kennedy BC, Bruce JN. Surgical approaches to the pineal region. Neurosurg Clin N Am. 2011;22(3):367–80, viiiCrossRefGoogle Scholar
  12. 12.
    Sonabend AM, Bowden S, Bruce JN. Microsurgical resection of pineal region tumors. J Neuro-Oncol. 2016;130(2):351–66.CrossRefGoogle Scholar
  13. 13.
    Tien RD, Barkovich AJ, Edwards MS. MR imaging of pineal tumors. AJR Am J Roentgenol. 1990;155(1):143–51.CrossRefGoogle Scholar
  14. 14.
    Edwards MS, Davis RL, Laurent JP. Tumor markers and cytologic features of cerebrospinal fluid. Cancer. 1985;56(7 Suppl):1773–7.CrossRefGoogle Scholar
  15. 15.
    Blakeley JO, Grossman SA. Management of pineal region tumors. Curr Treat Options in Oncol. 2006;7(6):505–16.CrossRefGoogle Scholar
  16. 16.
    Bruce JN. In: Winn HR, editor. Pineal tumors. 6th ed. Philadelphia: Elsevier Saunders; 2011.Google Scholar
  17. 17.
    Choi JU, Kim DS, Chung SS, Kim TS. Treatment of germ cell tumors in the pineal region. Childs Nerv Syst. 1998;14(1-2):41–8.CrossRefGoogle Scholar
  18. 18.
    Quick-Weller J, Lescher S, Baumgarten P, Dinc N, Bruder M, Weise L, et al. Stereotactic biopsy of pineal lesions. World Neurosurg. 2016;96:124–8.CrossRefGoogle Scholar
  19. 19.
    Balossier A, Blond S, Reyns N. Endoscopic versus stereotactic procedure for pineal tumor biopsies: focus on overall efficacy rate. World Neurosurg. 2016;92:223–8.CrossRefGoogle Scholar
  20. 20.
    Ahmed AI, Zaben MJ, Mathad NV, Sparrow OC. Endoscopic biopsy and third ventriculostomy for the management of pineal region tumors. World Neurosurg. 2015;83(4):543–7.CrossRefGoogle Scholar
  21. 21.
    Ito T, Kanno H, Sato K, Oikawa M, Ozaki Y, Nakamura H, et al. Clinicopathologic study of pineal parenchymal tumors of intermediate differentiation. World Neurosurg. 2014;81(5-6):783–9.CrossRefGoogle Scholar
  22. 22.
    Bruce JN, Stein BM. Surgical management of pineal region tumors. Acta Neurochir. 1995;134(3–4):130–5. Google Scholar
  23. 23.
    Kulwin C, Matsushima K, Malekpour M, Cohen-Gadol AA. Lateral supracerebellar infratentorial approach for microsurgical resection of large midline pineal region tumors: techniques to expand the operative corridor. J Neurosurg. 2016;124(1):269–76.CrossRefGoogle Scholar
  24. 24.
    Matsuo S, Baydin S, Gungor A, Miki K, Komune N, Kurogi R, et al. Midline and off-midline infratentorial supracerebellar approaches to the pineal gland. J Neurosurg. 2016:1–11.Google Scholar
  25. 25.
    Konovalov AN, Pitskhelauri DI. Principles of treatment of the pineal region tumors. Surg Neurol. 2003;59(4):250–68. Google Scholar
  26. 26.
    Lozier AP, Bruce JN. Surgical approaches to posterior third ventricular tumors. Neurosurg Clin N Am. 2003;14(4):527–45.CrossRefGoogle Scholar
  27. 27.
    Hernesniemi J, Romani R, Albayrak BS, Lehto H, Dashti R, Ramsey C, 3rd, et al. Microsurgical management of pineal region lesions: personal experience with 119 patients. Surg Neurol. 2008;70(6):576–83. Google Scholar
  28. 28.
    Qi S, Fan J, Zhang XA, Zhang H, Qiu B, Fang L. 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. 2014;156(12):2253–62. Google Scholar
  29. 29.
    Lapras C, Patet JD, Mottolese C, Lapras C Jr. Direct surgery for pineal tumors: occipital-transtentorial approach. Prog Exp Tumor Res. 1987;30:268–80.CrossRefGoogle Scholar
  30. 30.
    Matsutani M, Sano K, Takakura K, Fujimaki T, Nakamura O, Funata N, et al. Primary intracranial germ cell tumors: a clinical analysis of 153 histologically verified cases. J Neurosurg. 1997;86(3):446–55.CrossRefGoogle Scholar
  31. 31.
    Wolden SL, Wara WM, Larson DA, Prados MD, Edwards MS, Sneed PK. Radiation therapy for primary intracranial germ-cell tumors. Int J Radiat Oncol Biol Phys. 1995;32(4):943–9.CrossRefGoogle Scholar
  32. 32.
    Sawamura Y, de Tribolet N, Ishii N, Abe H. Management of primary intracranial germinomas: diagnostic surgery or radical resection? J Neurosurg. 1997;87(2):262–6.CrossRefGoogle Scholar
  33. 33.
    Weiner HL, Finlay JL. Surgery in the management of primary intracranial germ cell tumors. Childs Nerv Syst. 1999;15(11–12):770–3.CrossRefGoogle Scholar
  34. 34.
    Kersh CR, Constable WC, Eisert DR, Spaulding CA, Hahn SS, Jenrette JM 3rd, et al. Primary central nervous system germ cell tumors. Effect of histologic confirmation on radiotherapy. Cancer. 1988;61(11):2148–52.CrossRefGoogle Scholar
  35. 35.
    Kochi M, Itoyama Y, Shiraishi S, Kitamura I, Marubayashi T, Ushio Y. Successful treatment of intracranial nongerminomatous malignant germ cell tumors by administering neoadjuvant chemotherapy and radiotherapy before excision of residual tumors. J Neurosurg. 2003;99(1):106–14.CrossRefGoogle Scholar
  36. 36.
    Reddy AT, Janss AJ, Phillips PC, Weiss HL, Packer RJ. Outcome for children with supratentorial primitive neuroectodermal tumors treated with surgery, radiation, and chemotherapy. Cancer. 2000;88(9):2189–93.CrossRefGoogle Scholar
  37. 37.
    Jakacki RI, Zeltzer PM, Boyett JM, Albright AL, Allen JC, Geyer JR, et al. Survival and prognostic factors following radiation and/or chemotherapy for primitive neuroectodermal tumors of the pineal region in infants and children: a report of the Children’s Cancer Group. J Clin Oncol. 1995;13(6):1377–83.CrossRefGoogle Scholar
  38. 38.
    Gururangan S, McLaughlin C, Quinn J, Rich J, Reardon D, Halperin EC, et al. High-dose chemotherapy with autologous stem-cell rescue in children and adults with newly diagnosed pineoblastomas. J Clin Oncol. 2003;21(11):2187–91.CrossRefGoogle Scholar
  39. 39.
    Lutterbach J, Fauchon F, Schild SE, Chang SM, Pagenstecher A, Volk B, et al. Malignant pineal parenchymal tumors in adult patients: patterns of care and prognostic factors. Neurosurgery. 2002;51(1):44–55; discussion -6CrossRefGoogle Scholar
  40. 40.
    Fauchon F, Hasselblatt M, Jouvet A, Champier J, Popovic M, Kirollos R, et al. Role of surgery, radiotherapy and chemotherapy in papillary tumors of the pineal region: a multicenter study. J Neuro-Oncol. 2013;112(2):223–31.CrossRefGoogle Scholar
  41. 41.
    Barnett DW, Olson JJ, Thomas WG, Hunter SB. Low-grade astrocytomas arising from the pineal gland. Surg Neurol. 1995;43(1):70–5; discussion 5–6CrossRefGoogle Scholar
  42. 42.
    Yamamoto I, Kageyama N. Microsurgical anatomy of the pineal region. J Neurosurg. 1980;53(2):205–21. Google Scholar
  43. 43.
    Gale T, Leslie K. Anaesthesia for neurosurgery in the sitting position. J Clin Neurosci: Off J Neurosurg Soc Aust. 2004;11(7):693–6.CrossRefGoogle Scholar
  44. 44.
    Teo C, Greenlee JD. Application of endoscopy to third ventricular tumors. Clin Neurosurg. 2005;52:24–8. Google Scholar
  45. 45.
    Yamini B, Refai D, Rubin CM, Frim DM. Initial endoscopic management of pineal region tumors and associated hydrocephalus: clinical series and literature review. J Neurosurg. 2004;100(5 Suppl Pediatrics):437–41.PubMedGoogle Scholar
  46. 46.
    Teo C, Young R 2nd. Endoscopic management of hydrocephalus secondary to tumors of the posterior third ventricle. Neurosurg Focus. 1999;7(4):e2.CrossRefGoogle Scholar
  47. 47.
    Broggi M, Darbar A, Teo C. The value of endoscopy in the total resection of pineocytomas. Neurosurgery. 2010;67(3 Suppl Operative):ons159–65.PubMedGoogle Scholar
  48. 48.
    Wisoff JH, Epstein F. Surgical management of symptomatic pineal cysts. J Neurosurg. 1992;77(6):896–900. Google Scholar
  49. 49.
    Kalani MY, Wilson DA, Koechlin NO, Abuhusain HJ, Dlouhy BJ, Gunawardena MP, et al. Pineal cyst resection in the absence of ventriculomegaly or Parinaud’s syndrome: clinical outcomes and implications for patient selection. J Neurosurg. 2015;123(2):352–6. Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of NeurosurgeryNew York-Presbyterian—Columbia University Medical CenterNew YorkUSA
  2. 2.Prince of Wales Private HospitalSydneyAustralia

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