Pineal region tumours in childhood. A 30-year experience

Pineal/germ cell tumors and pineal parenchymal tumors

INTRODUCTION

Pineal region tumors (PRTs) are tumors arising from the pineal gland and the paraspinal structures. These tumors are rare and heterogeneous that account for 2.8-10.1% and 0.6-3.2% of tumors in children and in all ages, respectively. Almost all types and subtypes of CNS tumors may be diagnosed in this region. These tumors come from cells of the pineal gland (pinealocytes and neuroglial cells), ectopic primordial germ cells (PGC), and cells from adjacent structures. Hence, PRTs are consisted of pineal parenchyma tumors (PPTs), germ cell tumors (GCTs), neuroepithelial tumors (NETs), other miscellaneous types of tumors, cystic tumors (epidermoid, dermoid), and pineal cyst in addition. The symptoms of PRTs correlate to the increased intracranial cranial pressure due to obstructive hydrocephalus and dorsal midbrain compression. The diagnostic imaging studies are mainly MRI of brain (with and without gadolinium) along with a sagittal view of whole spine. Serum and/or CSF AFP/β-HCG helps to identify GCTs. The treatment of PRTs is consisted of the selection of surgical biopsy/resection, handling of hydrocephalus, neoadjuvant and/or adjuvant therapy according to age, tumor location, histopathological/molecular classification, grading of tumors, staging, and threshold value of markers (for GCTs) in addition.

METHODS

In this article, we review the following focus points: 1. Background of pineal region tumors. 2. Pineal GCTs and evolution of management. 3. Molecular study for GCTs and pineal parenchymal tumors. 4. Review of surgical approaches to the pineal region. 5. Contribution of endoscopy. 6. Adjuvant therapy (chemotherapy, radiotherapy, and combination). 7.

FUTURE DIRECTION

RESULTS

In all ages, the leading three types of PRTs in western countries were PPTs (22.7-34.8%), GCTs (27.3-34.4%), and NETs (17.2-28%). In children and young adults, the leading PRTs were invariably in the order of GCTs (40-80.5%), PPTs (7.6-21.6%), NETs (2.4-37.5%). Surgical biopsy/resection of PRTs is important for precision diagnosis and therapy. Safe resection with acceptable low mortality and morbidity was achieved after 1970s because of the advancement of surgical approaches, CSF shunt and valve system, microscopic and endoscopic surgery. Following histopathological diagnosis and classification of types and subtypes of PRTs, in PPTs, through molecular profiling, four molecular groups of pineoblastoma (PB) and their oncogenic driver were identified. Hence, molecular stratified precision therapy can be achieved.

CONCLUSION

Modern endoscopic and microsurgical approaches help to achieve precise histopathological diagnosis and molecular classification of different types and subtypes of pineal region tumors for risk-stratified optimal, effective, and protective therapy. In the future, molecular analysis of biospecimen (CSF and blood) along with AI radiomics on tumor imaging integrating clinical and bioinformation may help for personalized and risk-stratified management of patients with pineal region tumors.

Papillary tumor of the pineal region in pediatric patient – A case report

Background:

Papillary tumor of the pineal region (PTPR) represents a rare and histologically distinct subgroup of tumors originating in the pineal region. Few pediatric cases have been reported so far in the literature; therefore, clinical data are scarce.

Case Description:

We describe a case of PTPR in a 9-year-old girl who presented with a 5-month history of excessive appetite and weight gain. The patient underwent neuroimaging procedures and total gross surgical resection with postoperative adjuvant local radiotherapy, which from our experience was the best treatment choice as an attempt to avoid local recurrence. During 78-month follow-up, the patient from our study manifested no disease recurrence.

Conclusion:

PTPR should be included in the differential diagnosis of pineal region masses.

Reduced-volume radiotherapy for patients with localized intracranial nongerminoma germ cell tumors

Craniospinal irradiation is standard radiotherapy (RT) for localized intracranial nongerminoma germ cell tumors (NGGCT). Given its toxicity, there is interest in using smaller fields. We examined outcomes of NGGCT patients receiving reduced-volume RT at a single institution. Records of 16 patients who received reduced-volume RT as part of definitive treatment between 1996 and 2016 were reviewed. Median age at presentation was 10.8 years (range 4.6-41.0 years). Ten patients had pineal tumors and 6 had suprasellar tumors. All received chemotherapy and 9 patients received second-look surgery thereafter. RT volume was tumor-only to a median of 54 Gy (range 50.4-54 Gy) in 3 patients and whole-ventricle irradiation to a median of 30.6 Gy (range 30.6-36 Gy) with a boost to 54 Gy in 13 patients. Median follow-up was 4.1 years (range 1.9-19.3 years). Three patients recurred locally at a median 9.9 months (range 9.6-10.6 months) after diagnosis, and one of these developed leptomeningeal relapse after 30 months. One patient expired from disease 2.6 years post-diagnosis and another due to stroke 19.3 years post-diagnosis. Fourteen patients are alive with no evidence of disease. Kaplan-Meier estimates of the 4-year overall survival and failure-free survival are 92% (95% confidence interval [CI], 57-99%) and 81% (95% CI 53-94%), respectively. Excellent disease control was observed in these patients with no initial relapses outside of these RT fields. The results of ACNS1123 may better delineate patterns of failure and identify subgroups likely to benefit from this approach.

Time to diagnosis of brain tumors in children: a single-centre experience

BACKGROUND

The aim of the study was to analyze the pre-diagnostic symptomatic interval (PSI) of children with brain tumors with regard to the parental and doctor's delay and the clinical symptoms.

METHODS

A retrospective review of all children with brain tumors diagnosed in a single centre over a period of 11 years was carried out.

RESULTS

Seventy-nine patients (35 boys, 44 girls), with a mean age of 9.2 years (0.2-23.5 years), were analyzed. PSI was 28 weeks with a parental delay of 11.1 weeks and a doctor's delay of 16.9 weeks. Main clinical symptoms were headache (66.7%), vomiting (57.7%), vision (46.2%) and gait (41.6) disorders and fatigue (41.0%) followed by other neurological signs.

CONCLUSIONS

Diagnosis of pediatric brain tumors is often delayed in relation to the presenting symptoms. If parents report a combination of headache with other neurological abnormalities, a brain tumor should always be considered.

Magnetic resonance imaging of pineal region tumours

Objectives

Pineal lesions can present as a heterogeneous collection of benign and malignant disease conditions. Pineal lesions include germ cell tumours, neoplasms arising from the pineal parenchyma, as well as other pineal region masses.

Methods

A variety of cases of pineal lesions are presented. The important clinical features and typical imaging findings of each pineal lesion are described with emphasis on their morphological appearance and signal intensity characteristics on magnetic resonance imaging (MRI).

Conclusion

Knowledge of the imaging characteristics and clinical features of varying pineal lesions can assist in narrowing the differential diagnosis for more accurate and rational therapeutic planning.

Teaching Points

• Pineal parenchymal tumours show an “explosion” of normal pineal calcifications towards the periphery.

• Pineoblastomas often have restricted diffusion, with apparent diffusion coefficient (ADC) values lower than germinomas.

• Pineal teratomas and pineal lipomas display fat signal characteristics and fat saturation on MRI.

• Pineal lesions in patients with known malignancy should raise suspicion of metastatic involvement.

• Pineal cysts and arachnoid cysts show MRI signal characteristics similar to cerebrospinal fluid (CSF).

Pediatric papillary tumors of the pineal region: to observe or to treat following gross total resection?

INTRODUCTION

Papillary tumors of the pineal region (PTPR) are rare brain tumors characterized by frequent local recurrences. Standardized treatment strategies are not yet defined.

CASE REPORT

We present the case of a 3-year-old girl diagnosed with PTPR. Due to her young age, adjuvant radiotherapy was omitted after gross total tumor resection. Thirty-six months later, local tumor recurrence occurred. Considering the possible risks of secondary surgery, the recurrent tumor was irradiated with proton radiotherapy. Three months later, the tumor showed near-complete remission.

DISCUSSION

Based on this experience and other pediatric case reports from the literature, local radiotherapy might be suggested also after complete tumor resection.

Hydrocephalus with brain tumors in children

BACKGROUND

Tumor-associated hydrocephalus is common in primary pediatric brain tumors. The managements involve radical tumor resection, temporary external ventricular drainage, and different definite shunting procedures. The purpose of this study is to sum up our experience of definite shunting procedures for tumoral hydrocephalus in children and correlate with reported literatures.

METHODS

This is a retrospective review of a series of 1,250 cases of primary pediatric brain tumors in patients <18 years of age collected in Taipei Veterans General Hospital from 1971 to 2008. Cases with questionable records about hydrocephalus were excluded.

RESULTS

A total of 56.7% of cases presented hydrocephalus, including hydrocephalus that occurred at tumor diagnosis (51.5%), and hydrocephalus developed after tumor diagnosis (5.1%). At tumor diagnosis, the hydrocephalus was mainly obstructive type (98%) and rarely communicating type (1.9%). Definite shunting procedures in this series comprised of ventriculoperitoneal (VP) shunt in 54.4%, endoscopic third ventriculostomy (ETV) in 10.9%, subduroperitoneal (SP) shunt in 4.8%, septostomy in 0.7%, lumboperitoneal shunt in 0.6%, and ventriculoatrial shunt in 0.1% of patients with hydrocephalus. There was a tendency of decreasing requirement and changing timing for VP shunt implantation. There was a gradual increase in usage of ETV for hydrocephalus in specific types and locations of tumors.

CONCLUSION

In the past two decades, we tended to use the VP shunt more cautiously for obstructive tumoral hydrocephalus. We try to perform initial radical resection of tumors as indicated and the more frequent use of ETV in selective cases that help to decrease the requirement of VP shunt implantation.

Single burr hole endoscopic biopsy with third ventriculostomy-measurements and computer-assisted planning

OBJECTIVE

In cases of non-communicating hydrocephalus, a combined endoscopic third ventriculostomy (ETV) and tumor biopsy might be necessary. We suggest a computer-assisted planning procedure to perform ETV and biopsy via a single burr hole.

METHODS

In 15 patients with non-communicating hydrocephalus with a mass obstructing the Sylvian aqueduct, an ETV in parallel to targeting the lesion was planned to be performed via a single burr hole. Prior to surgery, a 3D MRI data set was planned to be acquired for computer-assisted planning. The lesion target points were located in the third ventricle or in the lateral ventricle. By defining the optimal entry point as single burr hole, the trajectory was calculated to cause the least amount of tissue shift at the foramen of Monro (FM) or within the hemispheric tissue. The burr hole localization was measured relative to nasion and to midline. The diagnostic yield and the success rate of ETV were evaluated.

RESULTS

The optimal entry point for third ventricular lesions was 111 ± 17 mm to the nasion and 16 ± 11 mm to the midline. Tissue shift at the level of FM was 2.4 ± 4 mm. For targeting the floor of the third ventricle in parallel to lesions of the lateral ventricle, the entry point was at 122 ± 11 mm to the nasion and 17 ± 9 mm to the midline. Rate of diagnostic yield was 86.7%. Success rate of ETV at follow-up of 34 ± 19 months was 86.7%.

CONCLUSIONS

Performing ETV in parallel to target paraventricular lesions causing a hydrocephalus is feasible via a single burr hole by using computer-assisted planning and performing a navigated endoscopic procedure.

Neuroendoscopy in the management of pineal tumors

INTRODUCTION

Endoscopy has been applied for the management of pineal tumors and the associated obstructive hydrocephalus. The techniques include endoscopic third ventriculostomy (ETV), endoscopic biopsy, and endoscopic-assisted open surgery of tumor in selected cases. The purpose of this study is to report our experience and techniques of endoscopic surgeries for pineal tumors in children.

METHODS

This is a retrospective review of 36 ETVs, 25 endoscopic transventricular biopsies (ETB), 2 endoscopic transnasal transsphenoid biopsies, and 5 endoscopic-assisted open resections of pineal tumors.

RESULTS

One patient died of delay tumor hemorrhage after ETV and ETB were excluded. With a mean follow-up period of 5.4 years, ETV failure occurred in 7 of 35 patients with long-term success rate of 80.0%. Histological diagnosis was established in 21 of 25 (84.0%) patients through ETBs. Tissue diagnosis was obtained in two selected patients with bifocal germ cell tumors by endoscopic transnasal transsphenoid approach to the intrasellar lesion. Direct radical resections were achieved in four of five selected patients of pineal tumors with hydrocephalus by endoscopic-assisted open surgery.

Papillary tumor of the pineal region in a 15-month-old boy

The papillary tumor of the pineal region (PTPR) is a distinct entity that is particularly rare in the pediatric population. The authors document the youngest reported patient with this clinicopathological entity to date. A case of PTPR in a 15-month-old boy is described. Initially thought to be a tectal glioma, the tumor was later identified as a pineal region tumor after demonstrating growth on routine imaging. Diagnosis of PTPR was established by histopathological evaluation of biopsy samples, which revealed papillary, cystic, and solid tumor components. The patient's postoperative course was complicated by tumor growth despite several debulking procedures and chemotherapy, as well as persistent hydrocephalus requiring 2 endoscopic third ventriculostomies and eventual ventriculoperitoneal shunt placement. After a 15-month follow-up period, the patient has received proton-beam therapy and has a stable tumor size. The PTPR is a recently described tumor of the CNS that must be included in the differential diagnosis of pineal region masses. The biological behavior, prognosis, and appropriate treatment of PTPR have yet to be fully defined.

Pineal region tumors: an optimal approach for simultaneous endoscopic third ventriculostomy and biopsy

Object

Simultaneous endoscopic third ventriculostomy (ETV) and tumor biopsy is a widely accepted therapeutic and diagnostic procedure for patients with noncommunicating hydrocephalus secondary to a pineal region tumor. Multiple approaches have been advocated, including the use of a steerable fiberoptic or rigid lens endoscope via 1 or 2 trajectories. However, the optimal approach has not been established based on the individual anatomical characteristics of the patient.

Methods

A retrospective review of patients undergoing simultaneous ETV and tumor biopsy was undertaken. Preoperative MR images were examined to measure the width of the anterior third ventricle and maximal diameters of the tumor, Monro foramen (right), and massa intermedia. The distances between the tumor and massa intermedia, tumor and anterior commissure, midbrain and massa intermedia, and the dorsum sella and anterior commissure were also recorded. Single and dual trajectory approaches were compared using paired t-tests for each parameter.

Results

Over an 8-year interval, 15 patients underwent simultaneous ETV and tumor management. These patients ranged from 6 to 71 years of age (mean 36.7 years); 5 were younger than 18 years of age. Seven were treated using a dual trajectory approach, and 8 were treated using a single trajectory approach. All cases were completed without complications or the need for an additional CSF diversionary procedure within 6 months. The diagnostic yield at biopsy was 86.7%. There were no statistically significant differences between the single and dual trajectory groups for the measured parameters. However, the dual trajectory group demonstrated a larger anterior third ventricular diameter (1.43 vs 1.21 cm, p = 0.29). The single trajectory group trended toward a smaller tumor–anterior commissure interval (2.23 vs 2.51 cm, p = 0.24) and a larger dorsum sella–anterior commissure distance (1.67 vs 1.49 cm, p = 0.28).

Conclusions

These data confirm the safety and diagnostic efficacy of simultaneous ETV and biopsy for tumors of the pineal region. Although no statistically significant differences were seen in the authors' recorded measurements, several trends suggest a role for a tailored approach to selecting a single or dual trajectory approach when using a rigid endoscope.

From the archives of the AFIP: lesions of the pineal region: radiologic-pathologic correlation

Lesions of the pineal region include a diverse group of entities. The most common neoplastic lesions are the germ cell tumors. Germ cell tumors may be hormonally active, and evaluation of serum or cerebrospinal fluid levels of oncoproteins assists in making the diagnosis. Neoplasms arising from the pineal parenchyma include the low-grade pineocytoma, pineal parenchymal tumor of intermediate differentiation, and the highly malignant pineoblastoma. Germ cell tumors and pineal parenchymal neoplasms do not have pathognomonic imaging findings, but imaging in combination with laboratory evaluation helps narrow the differential diagnosis. Neoplasms may also arise from the variety of cell types residing in the proximity of the pineal gland. These include lipomas, meningiomas, and astrocytomas. Congenital lesions such as epidermoid and dermoid cysts and lipomas can also occur. Knowledge of the variety of lesions that occur in the pineal region, their imaging appearances, and their clinical features assists in narrowing the radiologic differential diagnosis and optimizing patient treatment.

Descriptive epidemiology of central nervous system germ cell tumors: nonpineal analysis

Central nervous system (CNS) germ cell tumors (GCT) have not been epidemiologically well described. Our study describes 2 population-based series of nonpineal CNS GCT. Data on all primary (malignant and nonmalignant) CNS (ICD-O-3 sites: C70.0-C72.9, C75.1-C75.3) GCT diagnosed between 2000 and 2004 from the Central Brain Tumor Registry of the United States (CBTRUS) and on all malignant GCT diagnosed between 1992 and 2005 from the Surveillance, Epidemiology, and End Results (SEER) were analyzed. Of 234 nonpineal GCT in CBTRUS, the most common site was brain, NOS (31.6%). Males had a greater frequency (59.7%) than females (40.3%). However, by age group, the male-to-female incidence rate ratio (IRR) differed: children (0-14 years) had an IRR of 1.1, young adults (15-29 years) an IRR of 2.3, and adults (aged 30+) an IRR of 1.0. For children and young adults, most tumors were malignant (86.8% and 89.0%, respectively), whereas for adults, more than half were nonmalignant (56.8%). Germinoma was the most frequent diagnosis (61.5%). In SEER, the frequency of malignant GCT in the CNS (2.5%) was greater than that in the mediastinum (2.1%). Of 408 malignant CNS GCT, 216 (52.9%) were nonpineal. The male-to-female IRR was 1.5. Overall relative survival for nonpineal CNS malignant GCT was 85.3% at 2 years, 77.3% at 5 years, and 67.6% at 10 years. Previous studies of GCT that have not stratified by site have suggested greater gender disparity. Nonpineal CNS GCT show no significant gender preference, yet have outcomes similar to pineal GCT.

Endoscopic biopsy during third ventriculostomy in paediatric pineal region tumours

OBJECTS

The goal of the study was to establish if endoscopic biopsy during third ventriculostomy contributes to morbidity in the management of paediatric pineal region tumours presenting with hydrocephalus.

MATERIALS AND METHODS

This study was a retrospective descriptive study in patients less than 18 years of age who have presented with a pineal region tumour between 2000 and 2006. Data were obtained from case notes. Twelve patients had presented with a pineal region mass with symptomatic hydrocephalus. Of these, eight had endoscopic biopsy during third ventriculostomy.

CONCLUSIONS

No mortality or permanent morbidity was seen following endoscopic biopsy. Two cases of transient worsening of pre-operative diplopia were noted. Diagnostic sensitivity for endoscopic biopsy is 75%. Tumour markers were not significantly raised in any plasma and cerebrospinal fluid samples. Endoscopic biopsy during third ventriculostomy in paediatric pineal region tumours is safe and results in good diagnostic yields. It should play an integral role in the initial management of patients in this setting.

Papillary tumor of the pineal region in a child: case report and review of the literature

CASE REPORT

A 13-year-old boy presented with a history of intracranial hypertension. Radiologic studies revealed triventricular hydrocephalus secondary to a space-occupying lesion in the pineal region. Endoscopic third ventriculostomy was performed to treat hydrocephalus, and the lesion was biopsied. Complete resection of the tumor was subsequently performed. After a period of uncertainty, the diagnosis of papillary tumor of the pineal region was established. Tumor bed radiotherapy at a dose of 50 Gy was associated. With a follow-up of 15 months, the postoperative course was satisfactory with return to school and no residual tumor on magnetic resonance imaging.

CONCLUSION

Papillary tumors of the pineal region constitute a rare entity, with a difficult diagnosis, an uncertain prognosis, and a high risk of local recurrence; they must be treated by a combination of surgery and radiotherapy. The only identified prognostic factor is the complete or incomplete nature of surgical resection.

Malignant pineal germ-cell tumors: an analysis of cases from three tumor registries

The exact incidence of pineal germ-cell tumors is largely unknown. The tumors are rare, and the number of patients with these tumors, as reported in clinical series, has been limited. The goal of this study was to describe pineal germ-cell tumors in a large number of patients, using data from available brain tumor databases. Three different databases were used: Surveillance, Epidemiology, and End Results (SEER) database (1973-2001); Central Brain Tumor Registry of the United States (CBTRUS; 1997-2001); and National Cancer Data Base (NCDB; 1985-2003). Tumors were identified using the International Classification of Diseases for Oncology, third edition (ICD-O-3), site code C75.3, and categorized according to histology codes 9060-9085. Data were analyzed using SAS/STAT release 8.2, SEER*Stat version 5.2, and SPSS version 13.0 software. A total of 1,467 cases of malignant pineal germ-cell tumors were identified: 1,159 from NCDB, 196 from SEER, and 112 from CBTRUS. All three databases showed a male predominance for pineal germ-cell tumors (>90%), and >72% of patients were Caucasian. The peak number of cases occurred in the 10- to 14-year age group in the CBTRUS data and in the 15- to 19-year age group in the SEER and NCDB data, and declined significantly thereafter. The majority of tumors (73%-86%) were germinomas, and patients with germinomas had the highest survival rate (>79% at 5 years). Most patients were treated with surgical resection and radiation therapy or with radiation therapy alone. The number of patients included in this study exceeds that of any study published to date. The proportions of malignant pineal germ-cell tumors and intracranial germ-cell tumors are in range with previous studies. Survival rates for malignant pineal germ-cell tumors are lower than results from recent treatment trials for intracranial germ-cell tumors, and patients that received radiation therapy in the treatment plan either with surgery or alone survived the longest.

Presentation of childhood CNS tumours: a systematic review and meta-analysis

BACKGROUND

Suspicion of a CNS tumour is classically raised by symptoms of raised intracranial pressure, focal deficits (including seizures), or papilloedema. Development of guidelines is needed for the identification and referral of children who might have a CNS tumour. We did a systematic literature review and meta-analysis to identify the clinical presentation of childhood CNS tumours to provide evidence to support the development of guidelines to assist with the identification and referral for imaging of children who might have a central nervous system tumour.

METHODS

Medline, Embase, and PubMed were searched for cohort studies and case series in children, published between January, 1991, and August, 2005, detailing the symptoms and signs at diagnosis of a CNS tumour.

FINDINGS

74 papers (n=4171) met the inclusion criteria. 56 symptoms and signs at diagnosis were identified, ranked by frequency, and clustered according to age, anatomical criteria, and genetic criteria. The most frequent symptoms and signs at diagnosis were: headache (33%), nausea and vomiting (32%), abnormalities of gait and coordination (27%), and papilloedema (13%) for intracranial tumours; macrocephaly (41%), nausea and vomiting (30%), irritability (24%), and lethargy (21%) for children aged under 4 years with intracranial tumours; reduced visual acuity (41%), exophthalmia (16%), and optic atrophy (15%) for children with an intracranial tumour and neurofibromatosis; nausea and vomiting (75%), headache (67%), abnormal gait and coordination (60%), and papilloedema (34%) for posterior fossa tumours; unspecified symptoms and signs of raised intracranial pressure (47%), seizures (38%), and papilloedema (21%) for supratentorial tumours; headache (49%), abnormal eye movements (21%), squint (21%), and nausea and vomiting (19%) for central brain tumours; abnormal gait and coordination (78%), cranial nerve palsies (52%), pyramidal signs (33%), headache (23%), and squint (19%) for brainstem tumours; and back pain (67%), abnormalities of gait and coordination (42%), spinal deformity (39%), focal weakness (21%), and sphincter disturbance (20%) for spinal-cord tumours. Other features noted were weight loss, growth failure, and precocious puberty. Symptoms of raised intracranial pressure were absent in more than half of children with brain tumours. Other neurological features were heterogeneous and related to tumour location.

INTERPRETATION

Apart from raised intracranial pressure, motor and visual system abnormalities, weight loss, macrocephaly, growth failure, and precocious puberty also suggest presence of an intracranial tumour. Children with signs and symptoms that could result from a CNS tumour need a thorough visual and motor system examination and an assessment of growth and pubertal status. Occurrence of multiple symptoms and signs should alert clinicians to possible CNS tumours.

The presenting features of brain tumours: a review of 200 cases

OBJECTIVE

To determine the presenting features of brain tumours in children.

DESIGN

Retrospective case note review.

SETTING

Paediatric and neurosurgical services at the Wessex Neurology Centre and Southampton General Hospital, UK.

PATIENTS

200 patients presenting with a CNS tumour between 1988 and 2001.

RESULTS

The commonest first presenting symptoms were headache (41%), vomiting (12%), unsteadiness (11%), visual difficulties (10%), educational or behavioural problems (10%), and seizures (9%). The commonest symptoms occurring at any time were headache (56%), vomiting (51%), educational or behavioural problems (44%), unsteadiness (40%), and visual difficulties (38%). Neurological signs were present at diagnosis in 88%: 38% had papilloedema, 49% cranial nerve abnormalities, 48% cerebellar signs, 27% long tract signs, 11% somatosensory abnormalities, and 12% a reduced level of consciousness. The median symptom interval was 2.5 months (range 1 day to 120 months). A short symptom interval was significantly associated with high grade tumours and patient age of 3 years or younger.

CONCLUSIONS

The well known predominance of headache in children with CNS tumours is confirmed. Visual, behavioural, and educational symptoms were also prominent. With the exception of seizures, every initial symptom was accompanied by other symptoms or signs by the time of diagnosis. Questions about visual symptoms and educational or behavioural difficulties, as well as the more widely recognised symptoms of raised intracranial pressure and motor dysfunction, are important in the diagnosis of brain tumours, as are vision assessment and the appropriate plotting of growth and head size.

Pineal tumors: analysis of treatment results in 20 patients

OBJECT

The authors evaluate their results when using gamma knife surgery (GKS) in the management of patients with tumors in the pineal region.

METHODS

This is a retrospective clinical evaluation of 20 patients with primary tumors of the pineal region treated with GKS from November 1994 through August 2003. There were 13 germ cell tumors, two pineoblastomas, two low-grade gliomas, one primitive neuroectodermal tumor, one teratoma, and one pineocytoma. There were 10 male and 10 female patients. Their median age was 15.5 years (range 5-71 years). The median margin dose was 11 Gy (range 8-20 Gy). The median target volume was 3.1 cm3 (range 0.1-49.9 cm3). Five patients received sequential systemic chemotherapy and four underwent adjuvant conventional radiation therapy. Seventeen (85%) of 20 patients are alive with a median survival of 30.4 months (range 0-85.7 months). Two patients required retreatment. Three patients died: one of unrelated causes, one who presented with extensive local disease, and the other of meningeal carcinomatosis with local control of the primary tumor. No complications from GKS were noted.

CONCLUSIONS

This initial experience suggests that GKS is a valuable treatment modality for the management of pineal region tumors. This technique offers excellent local tumor control and minimal patient morbidity, allowing for immediate use of systemic chemotherapy and/or conventional radiation if indicated.

Pineal tumors: analysis of treatment results in 20 patients

Object. The authors evaluate their results when using gamma knife surgery (GKS) in the management of patients with tumors in the pineal region.

Methods. This is a retrospective clinical evaluation of 20 patients with primary tumors of the pineal region treated with GKS from November 1994 through August 2003. There were 13 germ cell tumors, two pineoblastomas, two low-grade gliomas, one primitive neuroectodermal tumor, one teratoma, and one pineocytoma. There were 10 male and 10 female patients. Their median age was 15.5 years (range 5–71 years). The median margin dose was 11 Gy (range 8–20 Gy). The median target volume was 3.1 cm3 (range 0.1–49.9 cm3). Five patients received sequential systemic chemotherapy and four underwent adjuvant conventional radiation therapy. Seventeen (85%) of 20 patients are alive with a median survival of 30.4 months (range 0–-85.7 months). Two patients required retreatment. Three patients died: one of unrelated causes, one who presented with extensive local disease, and the other of meningeal carcinomatosis with local control of the primary tumor. No complications from GKS were noted.

Conclusions. This initial experience suggests that GKS is a valuable treatment modality for the management of pineal region tumors. This technique offers excellent local tumor control and minimal patient morbidity, allowing for immediate use of systemic chemotherapy and/or conventional radiation if indicated.

Pallister-Killian syndrome: case report with pineal tumor

Pallister-Killian syndrome, an aneuploidy syndrome, comprises a characteristic facial appearance, mental retardation, and multiple other anomalies. It is caused by mosaicism with a supernumerary isochromosome 12p. This chromosomal abnormality has been reported also in human germ cell tumors. We report on a 15-year-old girl with Pallister-Killian syndrome and pineal tumor.