Pineal Tumors Research Articles

Transcranial extraventricular endoscopic surgeries: Expanding the role of endoscope in neurosurgery.

Background and Aim: Transcranial endoscopic surgeries are mainly limited to intraventricular lesions. This study aims to elaborate on the various benefits of transcranial endoscopic surgeries in extraventricular regions of the brain. Methods and Materials/Patients: It is a retrospective study of transcranial extraventricular endoscopic surgeries (TEESs) operated between June 2022 to May 2023. The authors described the surgeries done for brain lesions other than intraventricular lesions as extraventricular surgeries. Access to the intracranial region was obtained through the transcranial approach. The transnasal rigid endoscope was used for the surgeries. The surgery was performed as either pure endoscopic surgery or endoscopic-assisted microscopic surgery. Results: The authors have performed 6 microvascular decompressions using an endoscope. Three pineal tumors, 3 craniopharyngiomas, 1 cerebellopontine angle epidermoid cyst, and 1 petrous neurenteric cyst were excised using an endoscope by transcranial approach. One internal carotid artery bifurcation aneurysm was clipped using an endoscope. All patients improved in the postoperative period. Surgeries were done using the 0-degree and 30-degree endoscopes. The endoscopic eye was able to reach the deep-seated area of surgical interest and authors were able to visualize the structures in a wide panoramic view with good illumination and magnification. There was no misinterpretation of structures. Conclusion: Endoscope can reach the deep-seated extraventricular areas of the brain with a narrow corridor, giving good illumination and magnification at the site of surgery. An endoscope can reach beyond the obstructing anatomical structure and visualize the area behind it. It is used as a complimentary to microscope to access the microscopic invisible areas. It has increased the ease of doing surgery, decreased tissue dissection, decreased complications, and improved surgical results. TEES improves the hand-eye coordination of surgeons in transcranial surgeries and it will help in adapting to exoscope easily

Use of Suture-mediated closure device system after inadvertent medport placement in Subclavian artery leading to multifocal ischemic infarct: a case report

Abstract Background Totally implantable venous access devices or chemoports are progressively being used in oncologic patients for long-term chemotherapy administration. We present the case of an iatrogenic arterial catheter placement in the aortic arch complicated with multi-focal ischemic stroke. Case summary Case of a 73-year-old woman with a history of hypertension, diabetes mellitus, pineal gland tumor s/p VP shunt, and breast and bladder cancer who presented with a 2-week history of impaired balance, dysarthria, and right-sided facial drop. The chemoport was placed less than a month prior to the onset of symptoms at another institution. A brain MRI revealed a left hemispheric supra and infratentorial subacute ischemic infarcts. The head and neck CTA notably showed a misplaced venous port at the left subclavian artery with a distal tip projecting towards the ascending aortic arch, revealing the most likely etiology of multifocal ischemic stroke. The patient underwent successful subclavian artery catheter extraction and endovascular repair with a suture-mediated closure device system without complications. Discussion Subclavian artery iatrogenic cannulation may lead to catastrophic outcomes, including stroke. A high level of suspicion for venous port misplacement must be entertained when ipsilateral multifocal ischemic infarct occurs in time relation to catheter placement. Conducting an endovascular catheter retrieval and using a suture-mediated closure device is an alternative approach to manual compression in locations where achieving hemostasis is challenging. A suture-mediated closure device system might be useful for anatomy not amenable to manual compression, such as the subclavian artery.

Blindness due to the third eye: Sudden visual loss in pineal gland tumor

We report a rare case of sudden visual loss in a 9-year-old child with a pineal gland tumor. At presentation, examination revealed nil light perception in both eyes, features suggestive of Parinaud’s syndrome and one-and-a-half syndrome, and a normal fundus. Neuroimaging revealed a pineal region mass compressing the midbrain, aqueduct of Sylvius, and third ventricle, with the latter being displaced anteriorly. The patient underwent ventriculoperitoneal shunting, after which the visual perception recovered and was followed by mass excision. Although the mechanism of brainstem symptoms is typical, pineal gland tumors are not a known cause of sudden vision loss.

Purines and purinergic receptors in primary tumors of the central nervous system.

Purine nucleotides and nucleosides play critical roles in various pathological conditions, including tumor cell growth. Adenosine triphosphate (ATP) activates pro-tumor receptors, while adenosine (ADO) is a potent immunosuppressant and modulator of cell growth. This study aims to analyze the purinergic actions of ATP and its metabolites, associated enzymes, and P1 or P2 class receptors in primary central nervous system tumors. Additionally, we sought to correlate the levels of nucleosides and the density of P1, P2X, and P2Y receptors in cells with tumor progression. The results indicate that purinergic signaling depends on the receptor concentration and signaling molecules specific to each cell type, tissue, and tumor histology. The purinergic system may function as either a tumor-promoting agent or an antitumor factor, depending on the microenvironmental conditions and the concentrations of receptors and their respective activators. Notably, ATP emerges as the most significant extracellular signal, capable of being converted into other cellular stimulators pertinent to neoplasms, such as adenosine diphosphate, adenosine monophosphate, adenosine, and inosine. Consequently, a cascade of responses to these stimuli promotes tumor development, cell division, and metastasis. Purine nucleotides in central nervous system tumors are pivotal in cellular responses in glioblastoma multiforme, vestibular schwannoma, medulloblastoma, adenomas, gliomas, meningiomas, and pineal tumors. These findings hold the potential for developing novel therapeutic strategies and aiding in therapeutic management.

Moyamoya syndrome after proton beam therapy in a pediatric patient with a pineal germ cell tumor and a germline polymorphism in RNF213.

The effects of RNF213, which leads to moyamoya disease susceptibility, on radiation-induced moyamoya syndrome (MMS) remain unknown. We report a case of MMS after proton beam therapy (PBT) was deployed to treat a brain tumor in a patient with an RNF213 polymorphism. An 8-year-old boy underwent whole ventricular and local PBT for a pineal germ cell tumor and was diagnosed with radiation-induced MMS 9months later. He underwent right and left revascularization surgeries for cerebral hemodynamic compromise at 17- and 18-years of age, respectively. Genetic analysis revealed a heterozygous germline polymorphism RNF213 p.R4810K. This is the first report to suggest an association between RNF213 polymorphism and radiation-induced MMS.

AB085. Trans-cortical trans-ventricular approach to pineal tumors: a case series.

Attributing to its deep-seated location, surrounded by significant vessels, surgical management of pineal gland lesions is still considered a challenge. Various surgical approaches are employed to access these lesions, based on patient-specific risks and benefits. Each approach has its merits and demerits. In this study, we aim to narrate our experience with trans-cortical trans-ventricular (TT) approach for pineal tumor resection. We aim to outline the procedure details, safety, efficacy, and treatment outcome of TT. This is a single-center, consecutive case series. All patients with pineal gland tumors who underwent surgical intervention, namely biopsy or resection using TT approach from 2000 to 2023 were included. Data for the patient characteristics, intraoperative details and complications were collected from the hospital's database. Mean [standard deviation (SD)] and frequency (proportions) were calculated for continuous and discrete variables, respectively. We identified 13 patients, mean age 24 (SD: 13) years in our case series. Of them, 8 (61.5%) were male. Most common presenting complains were headaches (69%), nausea/vomiting (38.5%), seizure (23%), and visual deficit (23%). Most patients, 60%, had high grade tumor and average size of tumors were 43.5 mm (SD: 18.45 mm). Pilocytic astrocyotma (23%) and pineal parenchymal tumor of intermediate differentiation (23%) were the most common diagnoses. In total, nine patients had pineal gland lesion biopsy done using TT approach along with the cerebrospinal fluid (CSF) diversion. Of them, four had tumor resection done using the same approach. Whereas four patients had primary excision done using TT approach. There were no intra-operative complications. Two patients had post-operative seizures which were treated with anti-epileptics. We did not identify any long-term sequalae attributed to this approach. We presented our data regarding the safety, efficacy, and outcomes of trans-cortical trans-ventricular approach for pineal tumor surgical management. Utilizing this novel approach for pineal lesion resection can be a great addition to surgeons' armamentarium. This unique approach allows to access the tumor for biopsy/resection and perform CSF diversion procedure, simultaneously. Moreover, the same incision can be used for the second/redo surgery.

SNO-EANO-EURACAN consensus on management of pineal parenchymal tumors.

Pineal parenchymal tumors are rare neoplasms for which evidence-based treatment recommendations are lacking. These tumors vary in biology, clinical characteristics, and prognosis, requiring treatment that ranges from surgical resection alone to intensive multimodal antineoplastic therapy. Recently, international collaborative studies have shed light on the genomic landscape of these tumors, leading to refinement in molecular-based disease classification in the 5th edition of the World Health Organization (WHO) classification of tumors of the central nervous system. In this review, we summarize the literature on diagnostic and therapeutic approaches, and suggest pragmatic recommendations for the clinical management of patients presenting with intrinsic pineal region masses including parenchymal tumors (pineocytoma, pineal parenchymal tumor of intermediate differentiation, and pineoblastoma), pineal cyst, and papillary tumors of the pineal region.

Microsurgical Management of Pineal Region Tumors

BackgroundPineal tumours are rare and the pineal region is a challenging surgical location for neurosurgeons. The present study aimed to investigate the effects of microsurgical management in patients with pineal region tumours and explore probable factors associated with preoperative hydrocephalus, postoperative hydrocephalus remission, and prolonged length of hospital stay (LoS). MethodsA retrospective study of patients with pineal region tumours, who underwent microsurgical management at the First Affiliated Hospital of Soochow University(Jiangsu, China) between 1 January 2010 and 31 October, 2022, was conducted. ResultsData from 36 patients were included in this study. The top five common symptoms included headache (58%), dizziness (44%), double vision (22%), vomiting (19%), and nausea (14%). Patients with a lower Karnofsky Performance Score (KPS), younger age, and larger maximum tumour diameters were more vulnerable to preoperative hydrocephalus. Preoperative hydrocephalus also led to a prolonged postoperative LoS (P=0.021). Patients with a lower KPS score (P=0.020) or larger maximum tumour diameters (P=0.045) were more likely to achieve postoperative remission of hydrocephalus. Most postoperative complications led to increased hospital LoS. ConclusionMicrosurgical resection of pineal tumours yielded favourable long-term outcomes. Patients with a lower KPS score, younger age, and larger maximum tumour diameters were more vulnerable to preoperative hydrocephalus and prolonged LoS. Patients with a lower KPS score or larger tumour diameter were likely to achieve significant remission of hydrocephalus after tumour resection.

Endoscopic Third Ventriculostomy and Pineal Biopsy from a Single Entry Point.

Pineal neoplasms have a significant impact on children although they are relatively uncommon. They account for approximately 3-11% of all childhood brain tumors, which is considerably higher than the <1% seen in adult brain tumors. These tumors can be divided into three main categories: germ cell tumors, parenchymal pineal tumors, and tumors arising from related anatomical structures. Obtaining an accurate and minimally invasive tissue diagnosis is crucial for selecting the most appropriate treatment regimen for patients with pineal gland tumors. This is due to the diverse treatment options available and the potential risks associated with complete resection. In cases where patients present with acute obstructive hydrocephalus caused by a pineal gland tumor, immediate treatment of the hydrocephalus is necessary. The urgency stems from the potential complications of hydrocephalus, including increased intracranial pressure and neurological deficits. To address these challenges, a minimally invasive endoscopic approach provides a valuable opportunity. This technique allows clinicians to promptly relieve hydrocephalus and obtain a histological diagnosis simultaneously. This dual benefit enables a more comprehensive understanding of the tumor and assists in determining the most effective treatment strategy for the patient.

Clinical effects of neuroendoscopic infratentorial supracerebellar approach surgical technique for resecting pineal tumors: a retrospective study

ObjectivePineal tumors are relatively rare central nervous system lesions with a predilection for the pediatric population. This article aims to explore the clinical effects of neuroendoscopic infratentorial supracerebellar approach for resecting tumors in the pineal area. MethodsThis is a retrospective study that included patients who underwent neuroendoscopic infratentorial supracerebellar approach to resect nine tumors in the pineal area at the Department of Neurosurgery of the Second Hospital of Lanzhou University from December 2017 to October 2023. ResultsThe results of postoperative MRI revealed that all tumors were resected. Five patients received postoperative radiotherapy, three patients received radiotherapy along with chemotherapy, and one patient received neither radiotherapy nor chemotherapy. The pathological results showed that four patients were diagnosed with germinoma, two patients with teratoma, two patients with mixed germ cell tumors, and one patient with central neurocytoma. After surgery, one patient developed psychiatric symptoms, two patients developed binocular upward vision and diplopia, and one patient developed unstable walking and diplopia. With a follow-up of 1.7–4.8 years, all nine patients lived normally. Furthermore, none of them had tumor recurrence or death. ConclusionThe simple neuroendoscopic infratentorial supracerebellar approach has some safety and efficacy. It is suitable for tumors in the pineal region where the disease is mainly located below the Galen vein complex.

GCT-20. PRESENTATION AND OUTCOME OF BIFOCAL GERMINOMA TREATED ACCORDING TO SIOP CNS GCT II

Abstract BACKGROUND Between 2/2012 and 7/2018, 261 patients with germinoma were registered as intent-to-treat patients within the SIOP CNS GCT II trial. 209 patients were male/ 52 female. The median age was 14.1 years (range 5,0-41,0 years). 194 patients had localised and 67 had metastatic disease. 64 patients had bifocal germinoma, defined as synchronous suprasellar and pineal tumours at diagnosis. PATIENTS/METHODS The main symptoms were diabetes insipidus (DI) (n=47), visual impairment (33), raised intracranial pressure (21), headache (20), neurological symptoms (14), non-DI endocrine disturbances (14), and somnolence (12). Diagnosis was confirmed by biopsy in 38/64 patients and by resection in 4/64. 22/64 were diagnosed by imaging only. Patients with localised disease received 24 Gy whole-ventricular irradiation (WVI) alone if they achieved complete response (CR) after induction chemotherapy, or WVI with boost to both tumour sites (16 Gy) if partial response (PR) or stable disease (SD) was documented. Patients with metastases (dissemination on MRI or positive CSF cytology) received cranio-spinal irradiation (CSI) 24 Gy with boost to primary sites/ to visible metastases (16 Gy). RESULTS After induction chemotherapy, 17/40 with localised disease achieved CR, 21/40 PR, and 2/40 SD. After completion of treatment, 16/17 patients who achieved CR after chemotherapy remained in CR and one patient died after a relapse. 13/21 patients with PR post-chemotherapy achieved CR post-treatment, 3/21 remained in PR and 5/21 relapsed, one of which achieved a second CR. Both patients with SD remained in CR after radiotherapy and additional surgical intervention. Among patients with dissemination 21/24 achieved CR and 3/24 PR after completion of treatment (CSI). No relapses occurred. CONCLUSION Localised bifocal germinoma can be treated with WVI ± tumour boost depending on the response to chemotherapy. Bifocal germinoma with or without dissemination have an excellent prognosis. For the SIOP CNS GCT group, supported in part by German Childhood Cancer Aid

Pineal gland: Sleep, malignancy and statistics.

e14042 Background: The pineal gland is a neuroendocrine gland located deep in the middle brain that regulates the circadian rhythm through Melatonin. Pineal parenchymal tumors arise from pineocytes, have no sexual predominance, occur most frequently in the pediatric population and result in melatonin level disruptions.Pineal region tumors can spread via CSF to other areas in the CNS. The first treatment for pineal region tumors is surgery. Treatments after surgery may include radiation, chemotherapy or clinical trials. Methods: Data was collected from Surveillance, Epidemiology and End Result database Research Plus Data, 17 Registries, Nov 2022 Sub (2000-2020). Pineal gland tumor cases that were labeled as the primary site were extracted from the data base. Further selection was made using the ICD Code D75.3 for neoplasm of pineal gland-primary site labelled. The data was stratified based on age, sex, race and survival curves were compared using the Log-Rank test (GraphPad Prism). Results: A total of 416 pineal gland tumor cases were found, of which ~ 50.48% were males. These tumors were most commonly seen in White (51.68%) patients followed by Hispanic (23.32%), Black (16.10%), Asians/Pacific Islander (6.97%) and Alaskans/Native American (0.96%) patients. The median age of diagnosis was 24.5 years. The incidence rate (per 1,000,000 population) for the general population has increased from 0.69 in 2000 to 0.73 in 2020. As of 2020, the incidence was noted to be higher in males, although overall the incidence among females has been ion the rise. Incidence rate was highest among the Native Americans/Alaskans population followed by Hispanics, Asians/Pacific Islanders, Blacks and Whites. Within the races, incidence was noted to be increasing in the Native Americans/Alaskans &amp; Hispanic populations, stable in the Asians/Pacific Islanders &amp; Black populations and decreasing amongst the White population over the period of 20 years. When the survival curves were compared on the basis of gender and race, the data was clinically significant only for gender. The median of survival (mOS) for males was 146 months but was undefined for females (CI:5.344-12.55, HR: 8.191, p &lt;0.0001) mostly likely due to zero death events being recorded for females. Conclusions: Pineal gland tumors are rarely encountered malignancy with only 416 case reported in the last two decades. It has an almost equal predilection for males and females, more common in the younger population. The incidence is higher among males, although being relatively constant since 2000, and is trending up in females. Overall survival was superior in females with no reported death events. Native Americans/Alaskans are more affected overall survival is independent of the race.

Pineal Tumor Surgery—The Choice of the Approach Related to Tumor Characteristics and Posterior Fossa Anatomy

This research aimed to determine whether an adequate surgical approach can be chosen based on clearly defined values of anatomical landmarks (tentorial angle) and tumor size and extension. We conducted a retrospective analysis of patients operated on because of pineal tumors. The cohort was divided depending on the surgical approach. On preoperative magnetic resonance imaging, we measured maximal diameters, tumor volume, and tumor propagation. In the group of patients operated with the supracerebellar infratentorial approach, we also tested the correlation of tentorial angle with residual tumor. Differences among groups in resection, complications rate, and outcome were tested by the χ2 test. Finally, in both groups, the correlation of residual tumor with tumor volume, propagation, and diameters was tested using the receiver operating characteristic curve. In the group operated with a supracerebellar approach, total resection was achieved in 78% of the patients. The critical value of cranio-caudal diameter correlated with tumor residue was 31mm, for lateral-lateral diameter 25mm, for the lateral extension 14mm, and tumor volume 12cm3. Tentorial angle did not influence the extent of the resection. In the group operated with an occipital transtentorial approach, the critical tumor volume related to tumor residue was 9mm3, anterior-posterior diameter 29mm, and cranio-caudal diameter 28mm. The extent of the resection was significantly higher in the supracerebellar group. In both approaches, tumors larger than 3cm show an increased risk of subtotal resection. Except when most tumor volume is localized above the venous system, we advocate a supracerebellar corridor as an effective approach that is not limited by tentorial angle.

Evolution of Surgical Management of Pineal Region Tumors in the Pediatric Population: A 17-Year Experience at a Single Institution

Introduction: Pineal region tumors have historically been challenging to treat. Advances in surgical techniques have led to significant changes in care and outcomes for these patients, and this is well demonstrated by our single institution’s experience over a 17-year-period in which the evolution of diagnosis, treatment, and outcomes of pineal tumors in pediatric patients will be outlined. Methods: We retrospectively collected data on all pediatric patients with pineal region lesions treated with surgery at Children’s National Hospital (CNH) from 2005 to 2021. Variables analyzed included presenting symptoms, presence of hydrocephalus, diagnostic and surgical approach, pathology, and adverse events, among others. IRB approval was obtained (IRB: STUDY00000009), and consent was waived due to minimal risk to patients included. Results: A total of 43 pediatric patients with pineal region tumors were treated during a 17-year period. Most tumors in our series were germinomas (n = 13, 29.5%) followed by pineoblastomas (n = 10, 22.7%). Twenty seven of the 43 patients (62.8%) in our series received a biopsy to establish diagnosis, and 44.4% went on to have surgery for resection. The most common open approach was posterior interhemispheric (PIH, transcallosal) – used for 59.3% of the patients. Gross total resection was achieved in 50%; recurrence occurred in 20.9% and mortality in 11% over a median follow-up of 47 months. Endoscopic third ventriculostomy (ETV) was employed to treat hydrocephalus in 26 of the 38 patients (68.4%) and was significantly more likely to be performed from 2011 to 2021. Most (73%) of the patients who received an ETV also underwent a concurrent endoscopic biopsy. No difference was found in recurrence rate or mortality in patients who underwent resection compared to those who did not, but complications were more frequent with resection. There was disagreement between frozen and final pathology in 18.4% of biopsies. Conclusion: This series describes the evolution of surgical approaches and outcomes over a 17-year-period at a single institution. Complication rates were higher with open resection, reinforcing the safety of pursuing endoscopic biopsy as an initial approach. The most significant changes occurred in the preferential use of ETVs over ventriculoperitoneal shunts. Though there has been a significant evolution in our understanding of and treatment for these tumors, in our series, the outcomes for these patients have not significantly changed over that time.

Plasma miRNA expression profile in pediatric pineal pure germinomas.

Pure germinomas account for 40% of pineal tumors and are characterized by the lack of appreciable tumor markers, thus requiring a tumor biopsy for diagnosis. MicroRNAs (miRNA) have emerged as potential non-invasive biomarkers for germ cell tumors and may facilitate the non-invasive diagnosis of pure pineal germinomas. A retrospective chart review was performed on all patients treated at the Children's Cancer Hospital Egypt diagnosed with a pineal region tumor between June 2013 and March 2021 for whom a research blood sample was available. Plasma samples were profiled for miRNA expression, and DESeq2 was used to compare between pure germinoma and other tumor types. Differentially expressed miRNAs were identified. The area under the curve of the receive;r operating characteristic curve was constructed to evaluate diagnostic performance. Samples from 39 pediatric patients were available consisting of 12 pure germinomas and 27 pineal region tumors of other pathologies, including pineal origin tumors [n = 17; pineoblastoma (n = 13) and pineal parenchymal tumors of intermediate differentiation (n = 4)] and others [n = 10; low-grade glioma (n = 6) and atypical teratoid rhabdoid tumor (n = 4)]. Using an adjusted p-value <0.05, three miRNAs showed differential expression (miR-143-3p, miR-320c, miR-320d; adjusted p = 0.0058, p = 0.0478, and p = 0.0366, respectively) and good discriminatory power between the two groups (AUC 90.7%, p < 0.001) with a sensitivity of 25% and a specificity of 100%. Our results suggest that a three-plasma miRNA signature has the potential to non-invasively identify pineal body pure germinomas which may allow selected patients to avoid the potential surgical complications.

Case series: pediatric pineoblastoma (PNETs) – radiological, and clinicopathological studies

A rare type of brain tumor, pineoblastoma (PNET) is found in young adults and children. PNETs are rarest representing under 1% of all cerebrum cancers. The most common type of this type of tumor starts at the pineal glands, a small gland located at the base of the brain. Pineoblastomas make up approximately 50% of all pineal gland tumors. These tumors can be challenging to treat because of their location in the brain. The five-year endurance of patients of PNETs or pineoblastoma is around 50-60%. Infants and children who have had partial surgical removal and a poor response to radiation therapy have less favorable outcomes.

Tumors of the third ventricle in children (literature review).

Tumors of the third ventricle are rare and account for 0.6–0.9 % of all pediatric brain tumors. Tumors of the third ventricle are divided into primary tumors, such as choroid plexus papillomas and ependymomas, and secondary tumors, such as craniopharyngiomas, optic nerve gliomas, pineal tumors, and meningiomas. Choroid papilloma is a common tumor, the treatment of which is mainly based on microsurgical resection. Apart from the many treatment options for craniopharyngiomas, microsurgery is the preferred treatment option. Ependymomas also have several treatment options, with microsurgical removal considered the first line of treatment.

Bifocal germ cell tumor of pineal germinoma and neurohypophyseal embryonal carcinoma: illustrative case.

Bifocal germ cell tumors, with primarily identical tissue composition, occur concurrently in the neurohypophyseal and pineal regions. A 16-year-old male patient exhibited increased intracranial pressure symptoms, with concurrent tumors in the pineal and neurohypophyseal regions, causing obstructive hydrocephalus. His serum human chorionic gonadotropin level was elevated, measuring 506.6 mIU/mL. Upon gross endoscopic examination, the pineal tumor appeared white, whereas the neurohypophyseal tumor appeared red and hemorrhagic. Because of the limited sample size of the latter, a frozen section biopsy was feasible only for the pineal lesion, which indicated the presence of a germinoma. Subsequently, carboplatin and etoposide were administered, resulting in the reduction of the pineal tumor, but no effect was observed in the neurohypophyseal tumor. Histopathological analysis confirmed the pineal lesion as a germinoma, whereas the neurohypophyseal lesion was an embryonal carcinoma. Thus, the treatment was altered to ifosfamide, carboplatin, and etoposide (ICE), leading to a response in both tumors. The patient underwent three additional cycles of ICE therapy and high-dose chemotherapy, followed by whole craniospinal irradiation, achieving complete remission. Although most bifocal germ cell tumors share the same histological tissue, occasional differences may arise, necessitating separate biopsies for accurate assessment.

Consensus guidelines for the management of pineal region tumours for low- and middle-income countries.

Pineal region tumours are rare and mainly arise at a younger age. They can be categorized into various types: germ cell tumours (GCT), pineal parenchymal tumours (PPT), meningiomas, gliomas, pineoblastoma, pineal parenchymal tumours of intermediate differentiation, papillary tumours of the pineal region, and SMARCB1- mutant desmoplastic myxoid tumour. Within GCT, germinomas are the most prevalent, comprising the majority of tumours in this region, while nongerminomatous GCTs are also present. In rare instances, metastases from other sites may manifest. These tumours often lead to obstructive hydrocephalus and commonly exhibit symptoms related to mass effect, including headache, nausea, vomiting, and impaired gait stability. Different subtypes of pineal region tumours exhibit distinct radiological characteristics, thus imaging remains the primary diagnostic tool. Histologic diagnosis necessitates biopsy, unless in cases of germ cell tumours, particularly germinomas, which can be identified through elevated levels of tumour markers like alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG) in both cerebrospinal fluid (CSF) and serum. While benign tumours might be effectively treated with radical resection alone, malignant tumours demand additional chemotherapy and radiotherapy following surgical removal.

Krause approach to pineal tumour with intraoperative oculomotor nerve monitoring

BackgroundThe supra-cerebellar infratentorial approach to pineal region tumours is versatile and safe corridor to lesions located below the deep veins. Monitoring of the extra-ocular muscle pathways using the evoked compound muscle action potential can lead to safer resections. Technical noteTo describe the use of electrooculography and a three handed retractor less method for pineal region tumour surgeries. Material and methodsIntraoperative electrooculography uses recording done from two channels (horizontal and vertical)by inserting disposable subdermal needle electrodes along the periorbital area. The oculomotor nerve is being monitored as it exits the midbrain. Retractor-less three-handed-technique allows for minimal handling of the cerebellum while maximizing the operative corridor. ResultThe oculomotor nerve was stimulated post resection and correspondingly led to improved symptoms post-operatively. Discussion and conclusionWe demonstrate a method for the intraoperative monitoring of the continuity of the oculomotor tracts and a three handed retractor-less method of resection of pineal region tumours. The placement of electrodes and area of stimulation need sound knowledge of anatomy of the region. Haemostasis at every step is absolutely essential to be able to visualize in the narrow corridor.