- A 9-year-old female patient presented with headache and numbness in the upper and lower limbs. Imaging showed a relatively well-defined heterogeneous enhancing mass lesion in the pineal region with a concurrent suprasellar mass and leptomeningeal spread. - The differential considerations included germinoma, pineoblastoma and choroid carcinoma. However, the likely diagnosis is germinoma given the age of the patient, pineal mass with concurrent suprasellar mass, and pattern of calcifications. Histopathological examination is awaited for confirmation.

1. CASE PRESENTATION
• MODERATOR
• Dr. Anil Rawat
• M.D.
PRESENTER
• RAHUL KM. TIWARI
• JR III
1

2. HISTORY
• 9 year old female patient present with
Headache and
Numbness & pain in both upper and lower limbs.
No H/O fever and seizures.
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3. 3

4. 4

5. 5

6. 6

7. DIFFERENTIALS
Concurrent pineal and suprasellar region mass
• Germinoma
• Other germ cell tumours
Choriocarcinoma
• Pineoblastomas
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8. 8

9. Approach to pineal region masses:
1) Determine if the mass is pineal or extra-pineal in origin
• This can be done by evaluating the direction of mass effect
on the internal cerebral veins and Vein of Galen.
• This relationship will also affect surgical planning as
follows:
1. If the tumor is below these veins, a suboccipital
infratentorial approach.
2. If the tumor is above these veins, an interhemispheric or
Sub temporal approach is used.
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10. 10

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12. 2) Age of the patient
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13. 3) Pattern of calcifications (if present)
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14. GERMINOMA
• Involve midline structures (80-90%)
• Pineal (50-65%)> > suprasellar (25-35%) > basal ganglia
• Multiple (20%, usually pineal + suprasellar)
• > 90% of patients under age 20. Peak presentation is 10-12
years
• Pineal germinoma has male predominance, M:F = 3-10:1;
suprasellar, M = F
• Dissemination by CSF and invasion of the adjacent brain
commonly occur, but the prognosis is good (5-year survival
at least 90%).
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15. IMAGING FINDINGS
CT FINDINGS
• NECT-
Hyper dense compared to brain .
Appear to be “draped” around the posterior third ventricle.
Obstructive hydrocephalus is variable.
Pineal calcifications are “engulfed” and surrounded by tumor .
Look for a second lesion in the suprasellar region!
• CECT- Strong uniform enhancement is typical.
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16. MR FINDINGS
• Iso- to slightly hyperintense to cortex on T1- and T2WI.
• T2* (GRE, SWI) may show “blooming” due to intratumoral
calcification.
• Enhancement is strong and usually homogeneous .
• Because of their high cellularity, germinomas may show
restricted diffusion.
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17. CHORIOCARCINOMA
• CNS choriocarcinoma can be primary or metastatic, arising
from an extracranial site such as the retroperitoneum or
mediastinum.
• Typically present in patients 3-20 years of age.
• 4:1 male predominance
• MC sites are the pineal and suprasellar regions.
• Intratumoral hemorrhage with stripe-like or patchy
hypointensities on T2WI are common.
• Heterogeneous rim and nodular enhancement is seen in most
cases.
• Extraneural/CSF metastases are common
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18. Imaging
18
• Appearance on CT is non-specific;
like germinomas they often show
areas of high attenuation on plain
CT and show prominent contrast
enhancement.
• Ectatic vascular channels within
make them prone to hemorrhage.
• Heterogeneous signal intensity seen
on MR images reflects the various
components contained within the
lesion, such as intratumoral
hemorrhage, fibrosis, cysts,
necrosis, or vascular proliferation.

19. Pineoblastoma
• Highly malignant PNET (Primitive
Neuroectodermal tumor)
• Malignant lesions, typically > 3 cm.
Nearly 100% present with hydrocephalus.
• Age: children > young adults. Sex: M:F ~ 1:2
• CSF seeding common
• In patients with trilateral retinoblastoma, Pineoblastoma may
develop in patients with familial and or bilateral retinoblastoma
• (Exploded calcifications) along outside of mass
(peripherally), unlike germinoma which engulfs and induces
calcification of the pineal gland
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20. GERMINOMA
• Points in Favour
 Age of the patient
 Pineal mass with
concurrent suprasellar
mass
Calcification pattern
CSF seeding
• Point against
Female patient
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21. PINELOBLASTOMA
• Point in favour
Age of the patient
CSF seeding
Features of obstructive
hydrocephalus
• Point Against
Pattern of Calcification
Pineal mass with
concurrent suprasellar
mass
21

22. CASE SUMMARY
• 9yr old female patient present with headache and
numbness of limbs
• On imaging shows Relatively well define
hetrogenous enhancing mass lesion in pineal region
and concurrent suprasellar mass with
leptomeningeal spread
• Likely Diagnosis is GERMINOMA
• HPE is awaited
22

23. QUESTIONS
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24. Q 1. Which of the following is false statetment
A. Pineal gland is a small ( ~ 7mm) structure located at the level of
the midbrain, between the thalami at the posterior aspect of the third
ventricle
B. Internal cerebral veins and vein of Galen are located superior
and posterior to the pineal gland, respectively.
C. Principal neuronal cell of the pineal gland is the pinealocyte; a
Modified retinal neuronal cell that is innervated by the sympathetic
plexus originating in the retina.
D. Main product of the pineal gland; Serotonin, modulates the
sleep/wake cycle.
• Ref: European society of radiology, Systematic Approach to
Pineal Region Lesions S. Moawad, S. Hasan, H. Semaan, S. pinsky.
24

25. Ans1. D
Q 2. Which of the following is wrong statement
A. The pineal gland does not have a blood-brain barrier.
B. Mass lesion in the pineal region with Compression of the
cerebral aqueduct of Sylvius producing obstructive
hydrocephalus.
C. Compression of the tectal plate producing Parinaud
syndrome (vertical gaze palsy), pupillary light dissociation,
and nystagmus.
D. Physiologic calcification is usually seen before the age of
10 years.
25
Ref: European society of radiology, Systematic Approach to Pineal Region Lesions
S. Moawad, S. Hasan, H. Semaan, S. pinsky.

26. Ans2: D
Q 3. Exploded pattern of calcification seen in
which pineal tumour
A. Pinelocytoma
B. Pineloblastoma
C. Pineal germinoma
D. Both A & B
26
Ref: European society of radiology, Systematic Approach to Pineal Region
Lesions S. Moawad, S. Hasan, H. Semaan, S. pinsky.

27. Ans3: D
Q 4. Identify the structure labelled as 2 in this
T1 weighted axial image of pineal region
A.Pineal gland
B.Habenula
C.3rdventricle
D. Pulvinar
27
Ref: European society of radiology,
Systematic Approach to Pineal Region
Lesions S. Moawad, S. Hasan, H. Semaan,
S. pinsky.

28. Ans4: B
Q 5. Identify the structure labelled 1 in T1
weighted sagittal image of Pineal region
A. Posterior commissure
B. Cerebral aqueduct (of Sylvius)
C. Tectum
D. Pineal gland
28
Ref: European society of radiology, Systematic
Approach to Pineal Region Lesions S. Moawad,
S. Hasan, H. Semaan, S. pinsky.

29. Ans5: A
Q 6. Axial NECT showing a lobulated homogenously
hyperdense midline mass with"engulfed" central
pineal calcifications.Likely
diagnosis is
A. Pinelocytoma
B. Pineloblastoma
C. Pineal germinoma
D. Meningioma
29
Ref: European society of radiology, Systematic Approach to Pineal Region
Lesions S. Moawad, S. Hasan, H. Semaan, S. pinsky.

30. Ans6: C
Q 7. Drop metastasis is commonly seen in all
except
A. Pineloblastoma
B. Germinoma
C. Pinelocytoma
D. Ependymoma
30
Ref: European society of radiology, Systematic Approach to Pineal
Region Lesions S. Moawad, S. Hasan, H. Semaan, S. pinsky.

31. Ans7: C
Q 8. 11 yr old female patient
present with Large heterogeneous
mass with "exploded", peripheral
calcification with obstructive
hydrocephalus,likely diagnosis is
A. Pineloblastoma
B. Germinoma
C. Craniopharyngioma
D. Meningioma
31
Ref: European society of radiology, Systematic
Approach to Pineal Region Lesions S. Moawad,
S. Hasan, H. Semaan, S. pinsky.

32. Ans8: A
Q 9. Quadrilateral retinoblastoma includes all
except
A. Bilateral Retinoblastoma
B. Pineal tumor
C. Suprasellar mass
D. Medulloblastoma
32
Ref: European society of radiology, Systematic Approach to Pineal Region Lesions
S. Moawad, S. Hasan, H. Semaan, S. pinsky.

33. Ans9: D
Q 10. 5 year old female patient presented
with headache since 1 month
A. Pinelocytoma
B. Pineloblastoma
C. Germinoma
D. Craniopharyngioma
33

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