Pineal Region Lesions

Mohamed Wael Samir, MDProf. of NeurosurgeryAin Shams University

Pathology

V Vascular : Vein of Galen MalformationI Infectious : Cysticercous cystsT Trauma: A Autoimmune/inflammatory M Metabolic/toxic I Iatrogenic N Neoplastic: C NextC Congenital/familial: Pineal cystsD Degenerative :E Epileptic :F Functional :

Neoplasms of Pineal Region Metastatic tumors (very rare) Primary tumors: from pineal tissue

Primary Pineal parenchymal tumors [PPTs] (15%) Pineocytoma (GI) Pineal parenchymal tumour of intermediate differentiation (GII/III) Pineoblastoma (GIV) Papillary tumor of the pineal (GII/III)

Germ Cell Tumors [GCTs) (70%) Pure germinoma (52%) Teratoma (192%) Mixed germ cell tumor (16%) Endodermal sinus tumor (Yolk sac tumour) (5%) Embryonal cell carcinoma (4%) Choriocarcinoma (4%)

Secondary tumors: from adjacent tissueAstrocytoma ► Hemangiopericytoma Meningioma ► Ependymoma

Neoplasms of Pineal Region

Adult # Pediatric Population

60% Benign

60% Malignant

Non Neoplastic Pineal Body Cyst

Pathogenesis

Developmental:

Degenerative:

Epidemiology

Incidence: Up to 23% in MRI Up to 40% in autopsy

Gender: More in female

Race: Age:

Any age but mainly in adults in the fourth decade of life Risk factors:

Macroscopic Features

Site : Size:

2mm - > 2 cm Character:

Uni-locular or multi-locular

Microscopic Features

Radiological Features

Natural History

Stationary: ~ 75% (*)

Regressive: ~ 16% (*)

Progressive: ~ 8% (*)

(*) Barboriak DP et al: AJR Am J Roentgenol 2001;176:737–43

Clinical Presentation

Asymptomatic: Compression:

Acute: Apoplexy Gradual:

Management

Asymptomatic: Sure of diagnosis:

No intervention or follow up radiologically Not sure of diagnosis:

Follow up clinically and radiological

Symptomatic: Stable minor symptoms and signs:

Follow up clinically and radiological Progressive or major symptoms and signs

Intervention

Reference

HERRMANN HD, WINKLER D, WESTPHAL M. Treatment oftumours of the pineal region and posterior part of the third ventricle. Acta Neurochir (Wien) 1992;116:13746

LAURE-KAMIONOWSKA M, MASLINSKA D, DEREGOWSKI K, CZICHOS E, RACZKOWSKA B. Morphology of pineal glands in human foetuses and infants with brain lesions. Folia NeuropathoI2003;41:209-15.

Jelena Bosnjak, Mislav Budisic, Draien Azman, Maja Strineka, Miljenko Crnjakovic and Vida Demarin: PINEAL GLAND CYSTS - AN OVERVIEW. Acta Clin Croat 2009; 48:355-358

KATZMAN GL, DAGHER AP, PATRONAS NJ. Incidental findings on brain magnetic resonance imaging from 1000 asymptomatic volunteers. JAMA 1999;282:36-9.

Reference

JINKINS JR, XIONG L, REITER R]. The midline pineal "eye": MR and CT characteristics of the pineal gland with and without benign cyst formation. J Pineal Res 1995;19:64-71.

PETITCOLIN V, GARCIER JM, MOHAMMEDI R, RAVEL A, MOFID R, VIALLET JF, VANNEUVILLE G, BOYER L. Prevalence and morphology of pineal cysts discovered at pituitary MRI: review of 1844 examinations. J Radio12002;8H41-5.

MAMOURIAN AC, TOWFIGHI]. Pineal cysts: MR imaging. AJNR AmJ NeuroradioI1986;7:1081-6.

TAPP E. The histology and pathology of the human pineal gland. In: KAPPERS ]A, PEVET P, editors. The pineal gland of vertebrates including man. Amsterdam: Elsevier! North-Holland,1979:481-500.

PU Y,MAHANKALI S, HOUJ, LIJ, LANCASTERJL, GAO J-H, APPELBAUM DE, FOX PT. High prevalence of pineal cysts in healthy adults demonstrated by high-resolution, noncontrast brain MR imaging. AJNR AmJ Neuroradio12007; 28;1706-9.

Reference

Jelena Bosnjak, Mislav Budisic, Draien Azman, Maja Strineka, Miljenko Crnjakovic and Vida Demarin: PINEAL GLAND CYSTS - AN OVERVIEW. Acta Clin Croat 2009; 48:355-358 Michael A. Fleege, Gary M. Miller, Geoffrey P. Fletcher, Jonathan S. Fain , and Bernd W. Scheithauer: Benign Glial Cysts of the Pineal Gland: Unusual Imaging Characteristics with Histologic Correlation. AJNR Am J Neuroradiol 15:16 1-166, Jan 1994 Hirato J, Nakazato Y. Pathology of pineal region tumors. J Neurooncol 2001;54:239–49 Burger PC, Scheithauer BW (eds.). Atlas of Tumor Pathology. Tumors

of the Central Nervous System. AFIP, Washington 1994; pp. 233-236 Hirato J, Nakazato Y. Pathology of pineal region tumors. J

Neurooncol 2001;54:239–49

Reference

5. Engel U, Gottschalk S, Niehaus L, Lehmann R, May C, Vogel S, Janisch W. Cystic lesions of the pineal region – MRI and pathology. Neuroradiology 2000; 42: 399-402.

6. Fain JS, Tomlinson FH, Scheithauer BW, Parisi JE, Fletcher GP, Kelly PJ, Miller GM. Symptomatic glial cysts of the pineal gland. J Neurosurg 1994; 80: 454-460.

15. Klein P, Rubinstein LJ. Benign symptomatic glial cysts of the pineal gland: a report of seven cases and a review of the literature. J Neurol Neurosurg Psychiatry 1989; 52: 991-995.

18. Louis DN, Reifenberger G, Brat DJ, Ellison DW. Tumours: introduction and neuroepithelial tumours. In: Love S, Louis DN, Ellison DW (eds.). Greenfi eld’s Neuropathology. Edward Arnold 2008; pp. 1942-1943

19. MENA H, ARMONDA RA, RIBAS JL, ONDRA SL, RUSHING EJ. Nonneoplastic pineal cyst: a clinicopathologic study of twenty-one cases. Ann Diagn Pathol 1997;1:11-18.

Reference

LOUIS DN, OHGAKI H, WIESTLER OD, CAVENEE WK, BURGER PC, ]OUVET A, SCHEITHAUER BW, KLEIHUES P. The 2007 WHO classification of tumours of the central nervous system. Acta Neuropathol 2007;114:97109Barboriak DP, Lee L, and Provenzale JM. Serial MRI imaging of pineal cysts: implications for natural history and follow-up. AJR Am J Roentgenol 2001;176:737–43Milroy CM, Smith CL. Sudden death due to a glial cyst of the pineal gland. J Clin Pathol 1996;49:267–69Richardson JK, Hirsch CS. Sudden, unexpected death due to pineal apoplexy. Am J Forensic Med Pathol 1986;7:64–68Y. Pu, S. Mahankali, J. Hou, J. Li, J.L. Lancaster, J.-H. Gao, D.E. Appelbaum, P.T. Fox: High Prevalence of Pineal Cysts in Healthy Adults Demonstrated by High-Resolution, Noncontrast Brain MR Imaging. AJNR Am J Neuroradiol 28:1706–09 Oct 2007

Ain Shams University