Surgical Strategies for Treating Patients with Pineal Region Tumors

Abstract

Optimal management of pineal region tumors depends on securing an accurate histologic diagnosis to facilitate management customized to the nuances of specific pathologies. As an initial step, surgical intervention by either stereotactic biopsy or open surgery is necessary to obtain tissue for pathologic examination. Stereotactic biopsy has the benefit of relative ease and minimal morbidity but is associated with greater likelihood of diagnostic inaccuracy compared to open surgery where more extensive tissue sampling is possible. The role of surgical debulking in the management of pineal tumors is clearly defined for some tumors but is less evident for others. Among the one third of pineal tumors that are benign or low grade, complete surgical resection is achievable and constitutes optimal management with excellent long-term recurrence-free survival. The benefits of aggressive surgical resection among malignant tumors are less clear but several studies have correlated degree of tumor removal with improved outcome. Advances in technology, surgical technique, and post-operative care have minimized surgical complications, however all surgical procedures in the pineal region, including both stereotactic biopsy and open surgery, are potentially hazardous. Advanced judgment, experience, and expertise are necessary to achieve rates of success sufficient to justify aggressive management. Management strategies using stereotactic biopsy, endoscopy, and radiosurgery can also provide favorable outcomes in some cases. Selective incorporation of these innovations can be expected to improve the already highly favorable outcome for all pineal region tumors.

Neurosurgical venous considerations for tumors of the pineal region resected using the infratentorial supracerebellar approach

“…In the case of the intraoperative diagnosis of germinomas during instantaneous section, further resection is unnecessary due to its high sensitivity to radiation and/or chemotherapy (7,8). If a malignant germ-cell tumor is strongly suspected preoperatively, due to elevated concentrations of α-fetoprotein (AFP) and/or β-human chorionic gonadotropin (β-4 HCG) measured by preoperative examination of serum or cerebrospinal fluid (CSF) (1,9), chemotherapy combined with radiation therapy may precede the surgery, and neurosurgical resection should only be planned for residual tumors (7). If the patient's symptoms are caused by obstructive hydrocephalus, its treatment should precede the tumor resection.…”

“…If the patient's symptoms are caused by obstructive hydrocephalus, its treatment should precede the tumor resection. Temporary ventricular drainage, a permanent ventriculo-peritoneal (VP) shunt, or an endoscopic third ventriculostomy are possible treatments for obstructive hydrocephalus (9). Surgical resection of the tumor should then be performed.…”

Pineal Region Tumors

“…Generally used for pediatric patients and for supratentorial approaches (Bruce et al, 1996). The head is neutrally fixed and slight flexed but the anatomical landmarks are inverted.…”

“…Under microscope magnification, severing the bridging veins between cerebellum and tentorium is a crucial point to gain the corridor carrying out the approach through. As some authors reported (Ueyama et al, 1998;Bruce & Stein, 1993;Fain et al, 1994;Page 1977), bridging veins in the midline can be sacrificed but this could lead to cerebellar venous infarction and consequent swelling. The arachnoidal adhesions should be released on the surface of cerebellum and all along the tentorial incisura as well, where they are particularly thickened.…”

Gamma Knife Radiosurgery in the Management of Unusual Grade I/II Primitive Neuroepithelial Tumours of the Brain

“…The surgical major morbidity rate associated with pineocytomas is comprised between 3% and 6.8%, and permanent minor morbidity rate was 3-28%. The risk of surgical mortality associated with pineocytoma removal has been reduced in these last 20 years, but it remains less than 2% (Friedman et al, 2001, Bruce & Ogden, 2004. The role of adjuvant RT has not been clearly delineated.…”