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Case 3: 82 y female

Pineal region mass, DDx:

Germ Cell Tumors (60%)

Germinoma

Teratoma

Embryonal carcinoma

Endodermal Sinus Tumor

Choriocarcinoma

Pineal parenchymal tumors (14%)

Pineocytoma

Pineoblastoma (PNET)

Others

Metastasis, Pineal cyst, glioma, meningioma, vein of Galen aneurysm, arachnoid cyst, lipoma

Diagnosis

Germ Cell Tumors (60%)

Germinoma

Teratoma

Embryonal carcinoma

Endodermal Sinus Tumor

Choriocarcinoma

Pineal parenchymal tumors (14%)

Pineocytoma

Pineoblastoma (PNET)

Others

Metastasis, Pineal cyst, glioma, meningioma, vein of Galen aneurysm, arachnoid cyst, lipoma

Pineocytoma

Age: any

Peak: 10-20 y.o.

Mean age: 35 y.o.

Sex: Male = Female

Pineocytoma

Clinical Presentation

Parinaud syndrome: paralysis of upward gaze

Due to compression of superior colliculi

Hydrocephalus

Headache

Mental Status changes

Prognosis

Slow-growing

5 year survival: 86 %

Pineocytoma

CT

Iso- to hypodense

Peripheral Ca++…“Explodes” pineal calcification.

May see:

cystic change

hydrocephalus

Pineocytoma

MRI

T1: Iso- to hypointense

T2: Hyperintense

T2* GRE: susceptibility effects of the Ca++

Intense, homogeneous enhancement

May compress the tectum.

Top DDx:

Germinoma

Other Germ Cell Tumors

Pineoblastoma

Pineal cyst

Metastasis

Astrocytoma

Meningioma

Germinoma

Peak age: puberty (adolescence)

PINEAL: MALES 10: 1 females

Suprasellar (35%): NO sex predilection

Prognosis:

Germinoma: 93% 10-year survival

Malignant teratoma: 71% 10-year survival

Embryonal, Yolk sac, Choriocarcinoma

27% 3-year survival

Germinoma

CT

Iso-, HYPERdense

“Engulf” physiologic calcification

(Pineal tumors: “exploded” calcification)

MR

T1: hypointense

T2:

Hyperintense (most common)

Hypointense: favors GERMINOMA (over Pineal tumor)

Intense Enhancement

CSF dissemination common

Post-Gd MR to screen spine (& suprasellar)

Teratoma

Location: Pineal (most common), 3rd ventricle, posterior fossa

Midline, heterogeneous mass, Child

Heterogeneous: fat, Ca++, cysts

Prognosis: 71% 10-year survival

“Other” Germ Cell Tumors

Highly malignant

Embryonal carcinoma

Choriocarcinoma

Endodermal sinus tumor

Hemorrhage: frequent

AFP elevated: teratoma, embryonal, choriocarcinoma

hCG elevated: teratoma, choriocarcinoma

Germinoma: neither AFP or hCG elevated

Pineal Cyst

Pineoblastoma

Tectal Glioma

Meningioma