• Journal of Korean Neurosurgical Society
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• v.40 no.5
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• pp.342-345
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• 2006

Objective : Gamma Knife Surgery[GKS] for the management of pineal region tumors is challengeable strategy as direct access to this area is not easy. The experiences of pineal region tumor patients treated with GKS were analyzed to evaluate the effectiveness. Methods : Seven patients with tumors in the pineal region were treated with GKS between September 1998 and May 2005. The histological diagnosis were pineal parenchymal tumor [2 patients], low-grade astrocytoma [2 patients], immature teratoma [1 patient], and choriocarninoma [1 patient]. One patient was diagnosed as metastatic brain tumor based on histological diagnosis for primary site and brain imaging study. The median marginal dose was 15Gy [range; $11{\sim}20$] at the 50% isodose line. The median target volume was $2.5cm^3$ [range; $0.8{\sim}12.5$]. The median clinical follow up period was 29 months [range; $13{\sim}93$] and the median radiological follow up period was 18 months [range; $6{\sim}73$]. Results : Tumor volume measured in follow-up images showed reduction in six patients, disappearance in one. No adverse effect due to GKS was found during the follow-up period. The performance status was preserved in all patients except one who died due to progression of primary cancer in spite of controlled metastatic brain lesion. Conclusion : Gamma Knife Surgery can be applied to pineal region tumors irrespective of their histology whenever surgery is not indicated.

• Journal of Korean Neurosurgical Society
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• v.58 no.5
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• pp.479-482
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• 2015

We report a case of a 31-year-old woman with glioblastoma multiforme (GBM) in the pineal region with associated leptomeningeal dissemination and lumbar metastasis. The patient presented with severe headache and vomiting. Magnetic resonance imaging (MRI) of the brain showed a heterogeneously enhanced tumor in the pineal region with obstructive hydrocephalus. After an urgent ventricular-peritoneal shunt, she was treated by subtotal resection and chemotherapy concomitant with radiotherapy. Two months after surgery, MRI showed no changes in the residual tumor but leptomeningeal dissemination surrounding the brainstem. One month later, she exhibited severe lumbago and bilateral leg pain. Thoracico-lumbar MRI showed drop like metastasis in the lumbar region. Finally she died five months after the initial diagnosis. Neurosurgeons should pay attention to GBM in the pineal region, not only as an important differential diagnosis among the pineal tumors, but due to the aggressive features of leptomeningeal dissemination and spinal metastasis.

• Journal of Korean Neurosurgical Society
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• v.56 no.6
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• pp.504-508
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• 2014

A 59-year-old male patient had 5-month history of gait disturbance and memory impairment. His initial brain computed tomography scan showed $3.5{\times}2.8cm$ sized mass with high density in the pineal region. The tumor was hypointense on T2 weighted magnetic resonance images and hyperintense on T1 weighted magnetic resonance images with heterogenous enhancement of central portion. The tumor was totally removed via the occipital transtentorial approach. Black mass was observed in the operation field, and after surgery, histopathological examination confirmed the diagnosis of malignant melanoma. Whole spine magnetic resonance images and whole body 18-fluoro-deoxyglucose positron emission tomography could not demonstrate the primary site of this melanoma. Scrupulous physical examination of his skin and mucosa was done and dark pigmented lesion on his left leg was found, but additional studies including magnetic resonance images and skin biopsy showed negative finding. As a result, final diagnosis of primary pineal malignant melanoma was made. He underwent treatment with the whole brain radiotherapy and extended local boost irradiation without chemotherapy. His preoperative symptoms were disappeared, and no other specific neurological deficits were founded. His follow-up image studies showed no recurrence or distant metastasis until 26 weeks after surgery. Primary pineal malignant melanomas are extremely rare intracranial tumors, and only 17 cases have been reported since 1899. The most recent case report showed favorable outcome by subtotal tumor resection followed by whole brain and extended local irradiation without chemotherapy. Our case is another result to prove that total tumor resection with radiotherapy can be the current optimal treatment for primary malignant melanoma in the pineal region.

• Brain Tumor Research and Treatment
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• v.6 no.2
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• pp.73-77
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• 2018

Germinoma is the most common type of intracranial germ cell tumors (GCTs). Pineal gland and suprasellar region are the most frequent sites of central nervous system (CNS) involvement. Intracranial masses caused by Langerhans cell histiocytosis (LCH) mimics features of CNS GCTs. LCH frequently involve spine and is the most common cause of vertebra plana in children. A 15-year-old boy presented with progressing symptoms of polydipsia, polyuria, general headache, nausea and severe back pain. Brain MRI showed brain tumor with simultaneous involvement of suprasellar region and pineal gland. An excisional biopsy of suprasellar mass was done. The pathologic assessment confirmed the diagnosis of germinoma. Patient's treatment continued accordingly. A spine MRI, done due to persistent backache, showed a vertebra plana. We reevaluated the primary diagnosis suspecting LCH. Germinoma of CNS was confirmed and a biopsy of vertebral lesion resulted in hemangioma. Thus we report a case of CNS germinoma with co-occurrence of vertebra plana. We emphasized the importance of histopathologic diagnosis of pineal/suprasellar masses and primary investigation of other CNS regions including spine for possible metastasis or comorbidities.

• Journal of Korean Neurosurgical Society
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• v.30 no.5
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• pp.575-580
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• 2001

Purpose : In general, pineal region tumors are managed by using microsurgical approach or stereoctactic biopsy. However, in selected cases endoscopic approach to pineal lesions might prove to be as effective as microsurgery and less invasive. We report an alternative surgical strategy for managing certain patients with pineal neoplasms that allows treatment of the symptomatic hydrocephalus as well as tumor biopsy under direct vision in the same sitting. Materials and Methods : Twenty-two patients with pineal region tumors with associated hydrocephalus were treated in one session by endoscopic third ventriculostomy and endoscopic tumor biopsy at our institution from October 1996 to January 2000. All patients were retrospectively evaluated. Results : There was no operative mortality. There was one cause of significant bleeding during biopsy, but was controlled endoscopically, and the patient recovered completely without neurologic deficit resulting from intra-operative bleeding. The symptoms related to increased intracranial pressure(ICP) have resolved in all patients, and the need for a shunt is completely eliminated. Histological diagnosis was achieved in 21 of the 22 patients by this procedure. A biopsy was not obtained in one patient. Although this pineal region tumor was seen endoscopically, this could not be biopsied because of technical difficulties in working around an enlarged massa intermedia. The lesions included fourteen germinomas, three mixed germ cell tumors, and one each of the followings: pineocytoma, pineoblastoma, pineocytoma/pineoblastoma(intermediate type), meningioma, and low grade glioma. Five of the 22 patients subsequently underwent formal microsurgical tumor removal. Additional chemotherapy or radiotherapy could then be initiated according to the histological diagnosis. Conclusion : We consider that endoscopy affords a minimally invasive way of reaching three objectives by one-step surgery in the management of pineal region tumors with associated hydrocephalus : 1) cerebrospinal fluid(CSF) sample for analysis of tumour markers and cytology, 2) treatment of hydrocephalus by third ventriculostomy, and 3) several biopsy specimens can be obtained identifying tumors which will require further open surgery or adjuvant radiation and/or chemotherapy. However, complications and morbidities should be emphasized so as to be avoided with further technical experience.

• Journal of Korean Neurosurgical Society
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• v.58 no.4
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• pp.334-340
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• 2015

Objective : Pineal parenchymal tumors (PPTs) in adults are rare, and knowledge regarding their optimal management and treatment outcome is limited. Herein, we present the clinical results of our series of PPTs other than pineoblastomas managed by stereotactic radiosurgery (SRS) at upfront setting. Methods : Between 1997 and 2014, nine consecutive adult patients with the diagnosis of PPTs, either pineocytoma or pineal parenchymal tumor of intermediate differentiation, were treated with SRS. There were 6 men and 3 women. The median age was 39 years (range, 31-53 years). All of the patients presented with symptoms of hydrocephalus. Endoscopic third ventriculostomy and biopsy was done for initial management. After histologic diagnosis, patients were treated with Gamma Knife with the mean dose of 13.3 Gy (n=3) or fractionated Cyberknife with 32 Gy (n=6). Results : After a mean follow-up of 78.6 months (range, 14-223 months), all patients were alive and all of their tumors were locally controlled except for one instance of cerebrospinal fluid seeding metastasis. On magnetic resonance images, tumor size decreased in all patients, resulting in complete response in 3 patients and partial response in 6. One patient had experienced temporary memory impairment after SRS, which improved spontaneously. Conclusion : SRS is effective and safe for PPTs in adults and can be considered as a useful alternative to surgical resection at upfront setting.

• Journal of Korean Neurosurgical Society
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• v.29 no.1
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• pp.113-117
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• 2000

Objective : Asymptomatic cyst of the pineal gland is a common incidental finding in adults on computerized tomography or magnetic resonance image(MRI) or at postmortem examination. This study was conducted to identify MRI findings of the benign pineal cysts and to determine the proper management of asymptomatic pineal cysts. Methods : From January 1995 to March 1999, 13 cases of asymptomatic pineal cysts were diagnosed incidentally on MRI. The mean age of the patients at diagnosis was 43 years(ranged 8 to 69 years). Five patients were females and eight patients were males. We analyzed the clinical presentations and MRI findings. Results : Clincal features were not related to pineal cysts in all 13 cases included posttraumatic headache in seven cases, headache related to brain tumor in two cases, one of facial palsy, one of diabetic neuropathy, and two of other diseases. MRI demonstrated a well-demarcated mass lesion(mean 1.3cm in diameter) of low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. Gadolinium-enhanced MRI, performed in 10 cases, demonstrated a rim enhancement. Hydrocephalus was not present in all cases. Follow-up MRI(ranged 12 to 36 months) obtained in 3 of the 13 patients showed stability of cyst size. After symptomatic treatment, presenting symptoms were resolved in all patients and symptom related to pineal cysts have not been developed during follow up period(mean 27 months). Conclusion : The long-term behavior of asymptomatic pineal cysts is still unknown. But we advocate conservative management of these benign pineal cysts that may be developmental variants of normal pineal gland.

• Radiation Oncology Journal
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• v.9 no.2
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• pp.177-184
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• 1991

From December 1984 to February 1990, 16 patients with tumors of pineal and suprasellar location were treated with radiation therapy. Tissue diagnoses were obtained before radiation therapy in 5 patients and 11 were irradiated without histologic confirmation. Initial treatments for these patients were craniospinal plus boost primary irradiation(six), whole brain plus boost primary irradiation(nine), primary tumor site irradiation(one). The 5 year actuarial survival rate is $71\%$. Three cases with elevated beta-human chorionic gonadotropin(HCG) responded favorably to radiation, but pineal tumors with elevated alpha-fetoprotein(AFP) did not respond well. Spinal metastasis developed in 2 cases(2/15) with elevated AFP : one received prophylactic spinal irradiation, another did not. Our studies suggest that more aggressive treatment would be necessary in patient with elevated AFP and in this patient, radiation therapy may be initiated without pathologic confirmation. From the result of our study, routine use of prophylactic spinal irrdiation for all patients with pineal region tumor is not indicated and use of prophylactic spinal irradiation is considered for the patients with positive craniospinal fluid cytology, meningeal seeding, disease extension along the ventricular wall and biopsy proven germinoma.

• Journal of Korean Neurosurgical Society
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• v.42 no.1
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• pp.56-58
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• 2007

A 64-year-old man was admitted to our hospital in semicomatous consciousness. Brain computed tomography scans demonstrated $2.6{\times}2.5\;cm$ sized hyperdense mass in the pineal region with multiple punctate calcifications and hydrocephalus. Brain magnetic resonance imaging demonstrated a pineal mass which was heterogeneously enhanced with gadolinium. After external ventricular drainage, the patient regained consciousness. The mass was totally removed via occipital transtentorial approach. No consequent ventricular shunt was needed and the patient recovered without any neurological deficit. Final pathologic report of the tumor was ependymoma.

• Journal of Korean Neurosurgical Society
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• v.30 no.3
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• pp.366-370
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• 2001

Objective : The authors present three cases of brain tumors in which epidural hematomas(EDHs) were developed postoperatively in the remote areas from craniotomy sites. The preventive tactics as well as possible mechanisms of development of remote EDH are discussed. Material and Methods : The magnetic resonance imagings of three patients revealed a left lateral ventricular mass located just aside of foramen Monro in a 27-year-old male, a large cystic mass in the temporal lobe in a 35-year-old male, and a partially calcified pineal mass in a 27-year-old male patient. The surgical removals of these tumors were performed without any noticeable events during surgery via left frontal transcortical transventricular approach for lateral ventricular tumor, left temporal craniotomy for cystic temporal tumor, and right occipital transtentorial approach for pineal tumor. Results : Postoperative EDHs remote from the sites of craniotomy were detected by the immediate postoperative computerized tomographic scans. We obtained good outcomes without any morbidity in all three patients with emergent evacuation of the hematoma. The pathologic diagnoses were lateral ventricular ependymoastrocytoma, temporal craniopharyngioma and mixed germinoma of the pineal region. Conclusion : It is postulated that a sudden reduction of intracranial pressure(ICP) at the time of tumor removal may strip the dura from the inner table of the skull to cause EDH from the remote site of craniotomy. Gradual reduction of ICP with slow drainage of cerebrospinal fluid before tumor removal as well as lowering the head position of patient during surgery might be helpful for preventing this unusual complication.