dr amit is doing his residency from medical college trivandum. very much intrested in day to day case discussion and academic activities

1. APROACHES TO PINEAL
TUMORS
Dr amit medical college
trivandrum

2. Anteriorly
-Posterior 3rd V
Posteriorly
-Cerebellar vermis
Inferiorly
-Quadrigeminal plate /
Midbrain tectum
Superiorly
-Splenium
-Tela choroidea

5. • Grouped into four main categories
1. Germ cell tumors
2. Pineal parenchymal cell tumors
3. Glial cell tumors
4. Miscellaneous tumors and cysts

6. Generally manifested in
THREE WAYS
1. Symptoms of
increased
ICP(obstructive
HCP)
2. Direct brainstem and
cerebellar
compression
3. Endocrine
dysfunction

7. DIAGNOSIS
• MRI with GADOLINIUM ENHANCEMENT
• MR VENOGRAPHY
• Tumor histology cannot be reliably predicted on the
basis of imaging features alone
• COMPUTED TOMOGRAPHY - complement MRI
• Angiography is not necessary unless a vascular anomaly
is suspected
• AFP or Β HCG (serum or CSF) =
Pathognomonic for malignant germ cell
elements
• BIOPSY
MRI with gadolinium enhancement
Tumor markers
Biopsy

8. • CSF levels tend to be
more sensitive than
serum levels
 AFP - Fetal yolk sac
elements
Markedly elevated -
Endodermal sinus
tumors
 β-HCG - Trophoblastic
elements
High levels –
Choriocarcinomas
 LDH & PLAP
 Melatonin and S-antigen
- Specimens / Not in
USES
Monitoring response to
adjuvant therapy
Early sign of recurrence
Reliable indicators of
malignant germ cell
elements – Presence
make surgery and
biopsy unnecessary
(RT + CT)

9. CSF ANALYSIS
Cytology for cells
Tumor markers
• Non secreting tumors
- CSF levels increased
- Not detectable in blood
• Germinoma
- Beta HCG and PLAP only in CSF

10. TREATMENT
Management
• Hydrocephalus = EVD / Shunt / ETV (+/- biopsy)
• Tissue diagnosis = ETV + biopsy / Stereotactic biopsy / Open surgery
• Tumor control = Radiotherapy / Surgery / Combined / SRS / Chemotherapy

12. BIOPSY
• Histology strongly influences
- Choice of postoperative adjuvant therapy
- Metastatic work-up
- Estimation of prognosis, and
- Planning of long-term follow-up
Tissue diagnosis unnecessary in the
presence of malignant germ cell markers

13. TISSUE DIAGNOSIS :
STEREOTACTIC BIOPSY V/S OPEN
RESECTION
• Clinical features
• Radiographic features
• Experience
Stereotactic biopsy
- Known primary systemic tumors, multiple
lesions, or medical reasons
• Radiographic evidence of brainstem
invasion???

14. TISSUE DIAGNOSIS : STEREOTACTIC BIOPSY
V/S OPEN RESECTION
OPEN RESECTION
- Larger amounts of tissue &
Extensive tissue sampling
- Heterogenecity / Mixed cell
populations
- Clinical advantage = Tumor burden
is reduced
- Benign - Complete resection is
curative
- Malignant tumors – Improve
response to adjuvant therapy
- Shunting avoided

15. SURGICAL
CONSIDERATIONS

16. SURGICAL ANATOMY
• Undersurface of velum interpositum
• BS - Posterior medial and lateral choroidal arteries
• Most Veins surround or cap periphery of tumors
• Some trs - Foramen of Monro
• Most - Pineal gland
• IMP : Relationship of tumor to 3RD V &
quadrigeminal cistern; Lateral & superior extent of
tumor
• Determine - Route of operation & Degree of
difficulty

17. MANAGEMENT OF
HYDROCEPHALUS
EVD = Symptomatic HCP, but GTR
expected
Best = Stereotactic guided ETV
VP Shunt = Infection, Over shunting,
Peritoneal seeding

18. Surgical Approaches
OPERATIVE CONSIDERATIONS

19. SURGICAL APPROACHES
• STEREOTACTIC BIOPSY
• ENDOSCOPIC BIOPSY
• SUPRATENTORIAL APPROACHES
- OCCIPITAL TRANSTENTORIAL
- POSTERIOR INTERHEMISPHERIC TRANSCALLOSAL
APPROACH
- TRANS CORTICAL TRANSVENTRICULAR
• INFRATENTORIAL APPROACHES
- INFRATENTORIAL SUPRACEREBELLAR
- LATERAL PARAMEDIAN INFRATENTORIAL
• COMBINED APPROACHES
- COMBINED SUPRATENTORIAL – INFRATENTORIAL
TRANSSINUS

20. Most common surgical approaches are as
follows:
1. Infratentorial-supracerebellar approach =
Krause (popularized by Stein)
2. Occipital transtentorial approach = Foerster
and Poppen
3. Posterior transcallosal approach = Dandy
4. Transventricular approach = Van Wagenen

24. PATIENT POSITIONING
• The three basic positions -
Sitting position,
lateral position, and
prone
• Sitting position -
Infratentorial
supracerebellar approach
• Occipital transtentorial
approach - Three-quarter
prone / Lateral decubitus
• Concorde position -
Combine aspects of both the
prone and semi sitting

25. INFRATENTORIAL
SUPRACEREBELLAR APPROACH IS
PREFERRED
1. Approach is to the center of the tumor
2. Approach is ventral to the velum interpositum
and the deep venous system
3. Exposure is comparable
4. No normal tissue is violated

26. COMPLICATIONS AND CONSIDERATIONS
INFRATENTORIAL APPROACHES
ADVANTAGES
- MC Location
- Natural corridor
- Gravity helps
- Midline trajectory
- DVS more
avoidable
DISADVANTAGES
• Air embolism
• Ventricular collapse
 SDH,
pneumocephalus
• Not suitable -
supratentorial or
lateral extension

27. M I D L I N E I N F R A T E N T O R I A L S U P R A C E R E B E L L A R
A P P R O A C H

28. M I D L I N E
I N F R A T E N T O R I A L
S U P R A C E R E B E L L A R
A P P R O A C H

29. M I D L I N E
I N F R A T E N T O R I A L
S U P R A C E R E B E L L A R
A P P R O A C H

30. M I D L I N E
I N F R A T E N T O R I A L
S U P R A C E R E B E L L A R
A P P R O A C H

31. M I D L I N E
I N F R A T E N T O R I A L
S U P R A C E R E B E L L A R
A P P R O A C H

32. M I D L I N E
I N F R A T E N T O R I A L
S U P R A C E R E B E L L A R

33. M I D L I N E
I N F R A T E N T O R I A L
S U P R A C E R E B E L L A R
A P P R O A C H

34. M I D L I N E
I N F R A T E N T O R I A L

35. M I D L I N E
I N F R A T E N T O R I A L

36. M I D L I N E
I N F R A T E N T O R I A L
S U P R A C E R E B E L L A R
A P P R O A C H

37. M I D L I N E
I N F R A T E N T O R I A L
S U P R A C E R E B E L L A R
A P P R O A C H

38. M I D L I N E
I N F R A T E N T O R I A L
S U P R A C E R E B E L L A R
A P P R O A C H

39. M I D L I N E
I N F R A T E N T O R I A L
S U P R A C E R E B E L L A R
A P P R O A C H

40. M I D L I N E
I N F R A T E N T O R I A L

41. M I D L I N E
I N F R A T E N T O R I A L
S U P R A C E R E B E L L A R
A P P R O A C H

42. M I D L I N E
I N F R A T E N T O R I A L
S U P R A C E R E B E L L A R
A P P R O A C H

43. M I D L I N E
I N F R A T E N T O R I A L
S U P R A C E R E B E L L A R

44. M I D L I N E
I N F R A T E N T O R I A L
S U P R A C E R E B E L L A R
A P P R O A C H

45. M I D L I N E
I N F R A T E N T O R I A L
S U P R A C E R E B E L L A R
A P P R O A C H

46. M I D L I N E
I N F R A T E N T O R I A L
S U P R A C E R E B E L L A R
A P P R O A C H

49. PARAMEDIAN INFRATENTORIAL
SUPRACEREBELLAR
APPROACH

50. PARAMEDIAN INFRATENTORIAL
SUPRACEREBELLAR
APPROACH

51. PARAMEDIAN INFRATENTORIAL
SUPRACEREBELLAR
APPROACH

52. PARAMEDIAN INFRATENTORIAL
SUPRACEREBELLAR
APPROACH

53. TRANSCALLOSAL INTERHEMISPHERIC OR
OCCIPITAL TRANSTENTORIAL APPROACH
1. Superior extension , involving posterior CC &
deflecting DVS in dorsolateral direction
2. Lateral extension (trigone)
3. Inferior extension (quadrigeminal plate)

55. COMPLICATIONS AND CONSIDERATIONS
TRANSCALLOSAL INTERHEMISPHERIC APPROACH
• ADVANTAGES
- Extensive exposure
• DISADVANTAGES
- Subtentorial portion on C/L side not easily
visualized
- Retraction of parietal lobe & Disruption of bridging
veins b/w PL & SS

56. ANTERIOR INTERHEMISPHERIC
TRANSCALLOSAL APPROACH

58. ANTERIOR INTERHEMISPHERIC
TRANSCALLOSAL APPROACH

59. ANTERIOR INTERHEMISPHERIC
TRANSCALLOSAL APPROACH

60. ANTERIOR INTERHEMISPHERIC
TRANSCALLOSAL APPROACH

61. ANTERIOR INTERHEMISPHERIC
TRANSCALLOSAL APPROACH

62. ANTERIOR INTERHEMISPHERIC
TRANSCALLOSAL APPROACH

63. ANTERIOR INTERHEMISPHERIC
TRANSCALLOSAL APPROACH

64. ANTERIOR INTERHEMISPHERIC
TRANSCALLOSAL APPROACH

65. ANTERIOR INTERHEMISPHERIC
TRANSCALLOSAL APPROACH

66. ANTERIOR INTERHEMISPHERIC
TRANSCALLOSAL APPROACH

67. ANTERIOR INTERHEMISPHERIC
TRANSCALLOSAL APPROACH

68. ANTERIOR INTERHEMISPHERIC
TRANSCALLOSAL APPROACH

69. ANTERIOR INTERHEMISPHERIC
TRANSCALLOSAL APPROACH

70. ANTERIOR INTERHEMISPHERIC
TRANSCALLOSAL APPROACH

71. ANTERIOR INTERHEMISPHERIC
TRANSCALLOSAL APPROACH

72. ANTERIOR INTERHEMISPHERIC
TRANSCALLOSAL APPROACH

74. ANTERIOR INTERHEMISPHERIC
TRANSCALLOSAL APPROACH

75. ANTERIOR INTERHEMISPHERIC
TRANSCALLOSAL APPROACH

78. OCCIPITAL TRANSTENTORIAL
APPROACH

80. • A lateral or three-quarter prone position
• Occipital craniotomy
• Division of tentorium - Exposure of
quadrigeminal plate and tumors with inferior
extension
• U-shaped right occipital scalp flap
• Craniotomy - Across SS & begin just above
the torcula
• 1st Burr hole over SS just above torcula & 2nd
over SS 6-10 cm above

81. Dura - ‘U’& reflected towards SS
Interhemispheric fissure accessed & Occipital
lobe retracted
SS identified, Tentorium divided adjacent and
parallel to SS
Falx - Retracted / Divided
Arachnoid opened
Tumor removed

86. COMPLICATIONS AND CONSIDERATIONS
OCCIPITAL TRANSTENTORIAL
ADVANTAGES
- Greater exposure
- Nondominant occipital
lobe will retract easily
- Rarity of bridging veins
near the occipital pole
DISADVANTAGES
- DVS
- Oblique angle
- Visual field deficits
- Disconnection syndrome
- Limited exposure of
contralateral side

87. COMBINED SUPRATENTORIAL
INFRATENTORIAL TRANSSINUS

89. COMBINED SUPRATENTORIAL INFRATENTORIAL TRANSSINUS
• Large tumors
• Very wide view & excellent view of venous
anatomy
• Can reach large pineal region tumors extending
anteriorly into the third ventricle and above the
deep venous complex
• Higher projection, obtained by splitting the
transverse sinus and the tentorium
• Pitfall - Injury to DVS , Should not be cauterized
& if possible repaired (8-0 nylon / 7-0 prolene )

90. Combined Supratentorial –
Infratentorial Transsinus
• Retraction of C/L occipital lobe with falx provides =
Quadrigeminal region.
• Falx = Natural barrier
• Tumor reached along midline / Line angled to opposite
side
• Minimizes retraction of ipsilateral occipital lobe
• Sectioning the hypoplastic transverse sinus after
uneventful test occlusion seems to be a safe procedure.
• OTHGER DISADVANTAGES
- Brain edema
- Venous infarcts

91. • Position & type of anesthesia influence the venous
pressure
• Absence of brain edema increases safety
• Reconstruction of TS = Not necessary
• No significant complications were reported in association
with the permanent obliteration of the unilateral
transverse sinus
• Reconstruction of the cerebellar tentorium with a
duramater substitute is advisable

92. Combined Supratentorial –
Infratentorial Transsinus
• Semiprone position
• Operative side in
dependent position
• Inverted J
• Craniotomy made in
three pieces

93. Combined Supratentorial –
Infratentorial Transsinus

94. Edoscopic view
Endoscopic view

96. Post operative care
• Steroids first few days
• CT = Suspicion of any complications
• Mobilize and ambulate
• Drain – removed/ converted to shunt within
72 hrs
• Post OP MRI – 72 hrs
• Tumour markers
• Spinal MRI = malignant Pineal cell trs,
malignant GCT, ependymomas

97. Complications of surgery
• Sitting position-air embolism, subdural hygromas,
pneumocephalus
• Hemorrhage – Incomplete resection
• Cognitive impairment
• HCP – air, debris , blood
• Hemiparesis from brain retraction/ sacrifice of bridging vein
• Impairment of extraocular movements (up gaze,
convergence), pupillary abnormalities
• Interhemispheric – sensory or stereognostic deficits
• Occipital transtentorial- visual field defects
• Disconnection syndrome is rare

98. outcomes
• Mortality = 0-8%
• Permanent morbidity = 0 – 12%
• Depends on histology and response to
adjuvant therapy

99. OTHER THERAPEUTIC MODALITIES

100. Adjuvant therapy
• All patients with malignant pineal region tumors
 5500cGy to pineal region (4000 to
ventricular system, 1500 to tumour bed)
• Spinal Radiation is not given unless there is
documented evidence of spinal seeding.
Overall, the incidence of spinal seeding is
relatively small
• Germinomas are the most radiosensitive
malignant tumors in CNS

101. • Germinomas associated with elevated β
HCG levels may have less favourable
prognosis
• CHEMOTHERAPY is most useful for patients
with Nongerminomatous malignant germ cell
tumors
• Chemotherapy is mostly used for recurrent or
disseminated pineal cell tumors
• Cisplatin, vincristine, bleomycin
• Cyclophosphamide, etoposide,
• cisplatin/carboplatin+etoposide

102. • Delayed surgery after RT = residual trs whose
germ cell markers are normalised

103. Role of radiosurgery
• Limited to tumors < 3cm in diameter
• Useful for tumors that recur locally
• Can provide a local boost to tumor bed so
that radiation exposure to ventricles &
surrounding brain ↓