Pineal Gland Tumors

Introduction Pineal Gland is midline structure located in the

epithalamus, near the centre of the brain, between the two hemispheres, in a groove where the two halves of the thalamus join.

Pineal region neoplasm's constitute only 0.3-2.7% of intracranial tumors.

They are considered an important clinical entity because of their strategic location.

Clinical features• hydrocephalus and increased intracranial pressure• headaches• nausea • vomiting • lethargy• altered mental function.

• Visual Problems • Parinaud's syndrome, which includes inability to look

upward, double vision and nystagmus

Differential diagnosis of pineal region mass• Pineal parenchymal tumours• Pineocytoma• Pineal parenchymal tumour with intermediate differentiation• Papillary tumour of the pineal region• Pineoblastoma

• Germ cell tumours• Pineal germinoma (most common; ~ 50% of all tumours)• Pineal embryonal carcinoma• Pineal choriocarcinoma• Pineal yolk sac carcinoma - endodermal sinus tumour• Pineal teratoma

• astrocytoma of pineal gland• pineal metastasis• pineal cyst• meningioma near pineal region• cavernoma in pineal region• aneurysm in pineal region

Pineal calcification: seen in approximately 40% of normal people by the age of 20 years and usually less than 1 cm in diameter. Larger calcifications should raise concerns for underlying tumor.

MRI

•MRI is the preferred imaging modality•enables the accurate delineation of pineal masses before surgery. •allows true pineal masses to be distinguished from parapineal masses that impinge on the pineal gland

Limitations • Computed tomography (CT) scanning may be needed to

evaluate a calcified pineal gland that is associated with a pineal germinoma or tumor calcification associated with other neoplasms in the pineal region.

Radiography

• Germinomas are associated with a high incidence of

pineal gland calcification.

• The tumor does not calcify, but it may engulf a calcified

pineal gland.

• A calcified pineal gland on plain radiographs in a boy

younger than 10 years suggests pineal germinoma.

Computed Tomography

• Nonenhanced CT scans

• Typically demonstrate a slightly hyperattenuating

mass that engulfs a prominent calcified pineal gland.

• Contrast-enhanced CT scanning

• demonstrates homogeneous and intense

enhancement.

• More sensitive than plain radiography in depicting pineal calcification.• Small speckles of calcification can be seen in children 6

years and are considered normal • Pineal calcification in children younger than 6 years is

suggestive of pineal neoplasm. • Pineal calcifications should be less than 1 cm in diameter

in size.

Germinoma …..MRI findings •T1/T2: • Usually isointense relative to cerebral gray matter

•Occasionally• T1:hypointense• T2:hyperintense

• I/V injection of gadolinium-based contrast material, • homogeneous and intense enhancement is seen.

• contrast-enhanced MRI (subarachnoid seeding of germinomas.)

Pineal germinoma in a 30-year-old man. Axial T2-weighted MRI shows a mildly hyperintense lesion involving the pineal region.

Pineal germinoma in a 30-year-old man. Sagittal T1-weighted contrast-enhanced image demonstrates an enhancing mass in the pineal region.

Pineal germinoma in a 30-year-old man. Sagittal T1-weighted contrast-enhanced image demonstrates an enhancing mass in the pineal region.

Pineal germinoma in a 30-year-old man. After radiation therapy, sagittal T1-weighted contrast-enhanced MRI demonstrates no abnormal enhancing tumor.

Pineal germinoma in a 19-year-old man. Axial T1-weighted MRI shows an isointense lesion in the pineal region.

Pineal germinoma in a 19-year-old man. Axial T2-weighted MRI shows an isointense mass in the pineal region.

Pineal germinoma in a 30-year-old man. Sagittal T1-weighted contrast-enhanced image demonstrates an enhancing mass in the pineal region.

Pineal germinoma in a 19-year-old man. Sagittal T1-weighted contrast-enhanced MRI image demonstrates an enhancing mass in the pineal region. Compression of the aqueduct is shown.

Axial, post-contrast CT demonstrates an enhancing mass in the pineal region, which engulfs a calcified pineal gland

Pineoblastoma

CT IMAGING

•The solid component tends to be slightly hyperdense compared to adjacent brain due to high cellularity.

• Peripherally disperse or "exploded" calcification (Mnemonic: blasted calcification), similar to pineocytomas. In contrast pineal germinomas tend to engulf pineal calcification.

MRI IMAGING

•T1 - isointense to hypointense to adjacent brain•T2 isointense to adjacent brain•Areas of cyst formation or necrosis my be present•T1 C+ (Gd) - vivid heterogeneous enhancement

T1 weighted post contrast axial views showing an enhancing mass in pineal region and areas of necrosis within it after treatment

Axial T1 weighted MRI with contrast showing pineoblastoma

Papillary tumor of the pineal region (PTPR)

•T1 hyperintense

•The presence of such a mass in the posterior commissure

or pineal region, in the imaging absence of fat,

hemorrhage, melanin, or calcification, suggests the

diagnosis of PTPR.

Pineal cysts• Benign cysts in the pineal gland, which have been found

in almost a quarter of healthy young adults, • Are sharply delineated and ovoid shaped, with signal

intensity similar to ventricular CSF on both T1- and T2-weighted images. • Diameter (range, 2–14 mm).• Incidental finding , rarely become symptomatic.

A T2-weighted axial MR scan shows an ovoid mass in the pineal region with smooth edges and isointense to CSF.

T1 sagittal and axial views :Ruptured dermoid

Pineocytoma on precontrast Sagittal T1-weighted MR shows an ovoid lesion that is hypointense to white matter and close to CSF in signal intensity

Pineocytoma on Axial T2-weighted MR image shows a homogeneous ovoid lesion (arrow), which is isointense to CSF in signal intensity with a thin intermediate-intensity rim centered on the pineal region.

Pineocytoma on postcontrast Axial postcontrast T1-weighted MR image shows a homogeneously enhancing mass (arrow) centered on the pineal recess

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