Print version ISSN 1130-1473
Neurocirugía vol.22 n.6 Dec. 2011
Metástasis del carcinoma de pulmón que se presenta como tumor de la región pineal
Y. Samanci; C. Iplikcioglu; E. Ozek; D. Ozcan* and B. Marangozoglu**
Neurosurgery and Pathology* Departments. Ministry of Health Okmeydani Education and Research Hospital. Istanbul Turkey. Department of Neurology**. Istanbul University. Istanbul Faculty of Medicine. Istanbul. Turkey.
The pineal region is an unusual site for brain metastasis and most metastatic pineal lesions are asymptomatic. A 53 year-old man presented with severe headache, limitation of upward gaze and diplopia. The patient's neurological examination was unremarkable. Magnetic resonance imaging (MRI) scans of the brain demonstrated a 1,5 x 2 cm well demarcated solitary mass in the pineal region with hydrocephalus. Surgery was performed and adenocarcinoma was diagnosed. A systemic investigation revealed adenocarcinoma of the lung as primary lesion. Although rare, metastatic tumor should be considered in the differential diagnosis of pineal region tumors.
Key words: Pineal region. Metastasis. Lung carcinoma. MRI. Pineal tumor.
La región pineal es un sitio inusual para el depósito de metástasis y la mayoría de las metástasis pineales son asintomáticas. Un hombre de 53 años debutó con una cefalea intensa, limitación en la supraversión y diplopia. La exploración neurológica fue irrelevante. La resonancia magnética (RM) cerebral demostró una lesión solitaria de 1,5 x 2 cm bien delimitada, en la región pineal con hidrocefalia. Fue intervenido quirúrgicamente siendo el diagnóstico anatomopatológico de adenocarcinoma. Un estudio sistémico descubrió un adenocarcinoma de pulmón como tumor primario. Aunque muy raramente, las metástasis deben considerarse en el diagnóstico diferencial de tumores de la región pineal.
Pineal region neoplasms are rare and compose only %1 of all intracranial tumors27,30,32. Pineal region metastasis is even rarer and accounted for only 1.8% to 4% in literature3,8,22,29. In approximately half of reported cases, the pineal gland was the only site of intracranial metastasis with variable sizes1,2,16,17,25,28,33,35. The most common site of primary origin is lung carcinoma, followed by breast carcinoma and malignant melanoma33. The mechanism of pineal metastasis seems most probable via the bloodstream.
Here we report a patient with a pineal region metastasis proven to be from adenocarcinoma of the lung mimicking a primary pineal region tumor.
A 53-year-old man suffered sudden onset severe headache and diplopia. He had developed progressively worsening visual and consciousness disturbance. He had no history of any systemic disease. The patient's neurological examination was unremarkable, except limitation of upward gaze and bilateral Babinski sign. Standard blood work-up was normal. A computed tomography (CT) scan showed hydrocephalus and a hyperdense space-occupying lesion located in the pineal region with perifocal edema. MRI revealed a 1,5 x 2 cm well demarcated solitary mass in the pineal region. MRI demonstrated the tumor to be hyperintense on both T1 and T2-weighted images and to enhance heterogeneously after administration of contrast. (Figure 1a,1b). The patient underwent a supracerebellar infratentorial approach with total microsurgical resection of the pineal region mass following a ventriculoperitoneal shunt operation. Histological examination of the tumor specimen taken from the central part of the tumor revealed atypical epithelial cells arranged in papillary patterns with coagulation necrosis. (Figure 2a, 2b) Based on the histological characteristics of the tumor cells, the mass was diagnosed as lung carcinoma metastatic to the pineal body. The patient suffered pulmonary complications and died.
Metastasis to the pineal region is a rare manifestation of malignancy and was first reported in a patient with carcinoma of the lung7. Pineal metastasis used to be found at autopsy3,10,14,16,22 in older cases but more recently due to better diagnostic imaging, CT and/or MRI has detected such lesions1,14-17,19,25,28,33,35 which would previously have been subclinical. A literature review suggested that lung carcinoma was the most frequent primary lesion responsible1,2,10,16,17,22,23,33,35. In these cases, histologically small cell carcinoma1,16,17,23,35 and undifferentiated carcinoma10,22,33 are frequently seen, although other histological types including squamous cell carcinoma10 and adenocarcinoma14,22 have also been reported. Carcinomas in other organs, such as breast22, stomach13-15,36, esophagus19,22, rectum19,25 and kidney19,23 have been reported as primaries. Occasionally plasma cell leukemia12,31, lymphoma, multiple myeloma, melanoma6,22,33, melanocytoma4 and frontal sinus malignancy constituted a solitary tumor mass in the pineal region. Although Ortega et. al suggested hematogeneous spread to the pineal body through the posterior choroidal arteries22, the mechanism of metastasis is still unclear.
The differential diagnosis of a pineal region mass in elderly patients would include the various histological types of primary pineal tumors11, however, metastasis should also be considered, especially in patients with a history of malignancy. In these patients approximately 90% of all supratentorial lesions represent metastasis34.
There are more than 17 different pathological tumor types in the pineal region5 and therapeutic approach differs for each21. The correct histopathological diagnosis of a neoplasm arising in the pineal region often cannot be determined on the basis of imaging characteristics or cerebrospinal fluid sampling30. So the primary objective of surgical management of pineal region tumors is the establishment of an accurate histological diagnosis by examination of the tissue obtained by surgical intervention. Stereotactic biopsy rather than open surgery may be adequate investigation of a pineal region mass18,24,26 in patients with poor medical condition.
The present tumor represented adenocarcinoma, and that seems to be a rare histological type observed in cases with lung cancer metastatic to the pineal body. It is well known that germ cell tumors of the pineal gland can undergo malignant transformation into enteric type adenocarcinoma9,20. In such cases, glandular epithelium of enteric character may retain αFP expression9. In the present case no germ cell tumor elements or no α-FP-positive cells were found in mass.
Although rare, solitary metastasis to the pineal gland is one of the possible diagnosis when dealing with a mass in this region. Careful examination for systemic malignant disease will be needed. For an accurate histological diagnosis, sample tissue should be obtained by surgical intervention from the mass. Stereotactic biopsy rather than open surgery may be adequate only for establishing the histological diagnosis of pineal tumors18,26,33. Therapeutic approach can be determined based on histopathological diagnosis. Selection of open surgery, stereotactic biopsy, or radiotherapy for the treatment of pineal tumors should give full consideration to the patient's medical history and the imaging diagnosis.
1. Brasseur, P., Sukkarieh, F., Dupont, H., Brohee, D.: Pineal body metastasis. J Belge Radiol 1994; 77: 162-163. [ Links ]
2. Bruner, J.M., Tien, R.D.: Secondary tumors. In: Bigner DD, McLendon RE, Bruner JM (eds). Russell and Rubinstein's Pathology of Tumors of the Nervous System, 6th edn, Vol. 2. London: Arnold, 1998; 419-450. [ Links ]
3. Chason, J.L., Walker, F.B., Landers, J.W.: Metastatic carcinoma in the central nervous system and dorsal root ganglia. Cancer 1963; 16: 781-787. [ Links ]
4. Czirjak, S., Vitanovic, D., Slowik, F., Magyar, A.: Primary meningeal melanocytoma of the pineal region. Case report. J Neurosurg 2000; 92: 461-465. [ Links ]
5. Edwards, M.S.B., Hudgins, R.J., Wilson, C.B. et al.: Pineal region tumors in children. J Neurosurg 1988; 68: 689-697. [ Links ]
6. Enriquez, R., Egbert, B., Bullock, J.: Primary malignant melonoma of central nervous system. Pineal involvement in a patient with nevus of ota and multiple pigmented skin nevi. Arch Pathol 1973; 95: 392-395 [ Links ]
7. Förster. Ein fall von markschwamm mit ungewohnlich vielfacher metastatischer verbreitung. Arch Path Anat 1858; 13: 271-274. [ Links ]
8. France,, L.H.: Contribution to the study of 150 cases of cerebral metastases. J Neurosurg Sci 1975; 4: 189-210. [ Links ]
9. Freilich, R.J., Thompson, S.J., Walker, R.W., Rosenblum, M.K.: Adenocarcinomatous transformation of intracranial germ cell tumors. Am J Surg Pathol 1995; 19: 537-544. [ Links ]
10. Halpert, B.,Erickson, E.E.,Fields, W.S.: Intracranial involvement from carcinoma of the lung. AMA Arch Pathol 1960; 69: 93-103. [ Links ]
11. Hirato, J., Nakazato, Y.: Pathology of pineal region tumors. J Neurooncol 2001; 54: 239-249. [ Links ]
12. Holness, R.O., Sangalang, V.E.: Myelomatous metastases to the pineal body. Surg Neurol 1976; 5: 97-100. [ Links ]
13. Joyner, J.E.: Metastatic gastric adenocarcinoma to the pineal body. A case report. Acta Neuropathol 1962; 1: 416-419. [ Links ]
14. Kakita, A., Kobayashi, K., Aoki, N., Eguchi, I., Morita, T., Takahashi, H.: Lung carcinoma metastasis presenting as a pineal region tumor. Neuropathology 2003; 23: 57-60. [ Links ]
15. Kanai, H., Yamada, K., Aihara, N., Watanabe, K.: Pineal region metastasis appearing as hypointensity on T2-weighted magnetic resonance imaging. Neurol Med Chir (Tokyo) 2000; 40: 283-286. [ Links ]
16. Kashiwagi, S., Hatano, M., Yokoyama, T.: Metastatic small cell carcinoma to the pineal body: Case report. Neurosurgery 1989; 25: 810-813. [ Links ]
17. Keyaki, A., Makita, Y., Nabeshima, S. et al.: Pineal metastatic tumor from lung cancer initially caused by neurological abnormalities of pineal body tumor. No Shinkei Geka 1989; 17: 495-499 (in Japanese with English abstract). [ Links ]
18. Kreth, F.W., Schatz, C.H., Pagenstecher, A., Faist, M., Volk, B., Ostertag, C.B.: Stereotactic management of lesions of the pineal region. Neurosurgery 1996;39: 280-291. [ Links ]
19. Lauro, S., Trasatti, L., Capalbo, C., Mingazzini, P.L., Vecchione, A., Bosman, C.: Unique pineal gland metastasis of clear cell renal carcinoma: case report and review of the literature. Anticancer Res 2003; 22: 3077-3080. [ Links ]
20. Matsutani, M., Sano, K., Takakura, K. et al.: Primary intracranial germ cell tumors: A clinical analysis of 153 histologically verified cases. J Neurosurg 1997; 86:446-455. [ Links ]
21. Oi, S., Matsuzawa, K., Choi, J.U. et al.: Identical characteristics of the patient populations with pineal region tumors in Japan and in Korea and therapeutic modalities. Childs Nerv Syst 1998; 14:36-40 [ Links ]
22. Ortega P, Malamud N, Shimkin M. Metastasis to the pineal body. Arch Pathol 1951; 52: 518-528. [ Links ]
23. Ouyang, R., Rozdilsky, B.: Metastases of carcinoma to the pineal body. Arch Neurol 1966; 15: 399-403. [ Links ]
24. Pecker, J., Scarabin, J.M., Vallee, B., Brucher, J.M.: Treatment in tumours of the pineal region. Value of stereotaxic biopsy. Surg Neurol 1979; 12: 341-348. [ Links ]
25. Ramina, R., Coelho Neto, M., Mariushi, W.M., Arruda, W.O.: Pineal metastasis as first clinical manifestation of colorectal adenocarcinoma. Case report. Arq Neuropsiquiatr 1999; 57: 92-95. [ Links ]
26. Regis, J., Bouillot, P., Rouby-Volot, F., Figarella-Branger, D., Dufour, H., Peragut, J.C.: Pineal region tumors and the role of stereotactic biopsy. Review of the mortality, morbidity, and diagnostic rates in 370 cases. Neurosurgery 1996; 39: 907-914. [ Links ]
27. Russell, D.S., Rubinstein, L.J.: Pathology of Tumors of the Nervous System. Baltimore, Williams & Wilkins, 1977, pp 283-298 [ Links ]
28. Schuster, J.M., Rostomily, R.C., Hahn, C., Winn, H.R.: Two cases of esophageal carcinoma metastatic to the pineal region with a review of the literature. Surg Neurol 1998; 49: 100-103. [ Links ]
29. Screiber, D., Bernstein, K., Schneider, J.: Tumor metastasen im Zentralnervensystem. Eine prospektive Studie. 3. Mitteilung: Metastasen in Hypophyse, Epiphyse und Plexus chorioidei. Zentralbl Allg Pathol 126: 64-73, 1982 (with Eng abstract) [ Links ]
30. Trojanowski, J.Q., Tascos, N.A., Rorke, L.B.: Malignant pineocytoma with prominent papillary features. Cancer 1982; 50: 1789-1793. [ Links ]
31. Umahara, T., Kikawada, M., Arai, H., Iwamoto, T., Takasaki, M., Hirabayashi, Y., Kudo, M., Tsuchiya, K., Shimada, H.: An autopsy case of multiple myeloma with pineal body and spinal cord dura mater infiltration. No To Shinkei 1997; 49: 655-658. [ Links ]
32. Vaquero, J., Coca, S., Martinez, R., Escandon, J.: Papillary pineocytoma. Case report. J Neurosurg 1990; 73: 135-137. [ Links ]
33. Vaquero, J., Martinez, R., Magallon, R., Ramiro, J.: Intracranial metastases to the pineal region. Report of three cases. J Neurosurg Sci 1991; 35: 55-57. [ Links ]
34. Voorhies, R., Sunaresan, N., Thaler, H.: The single supratentorial lesion. An evaluation of preoperative diagnostic tests. J Neurosurg 1980; 53: 364-368. [ Links ]
35. Weber, P., Shepard, K.V., Vijayakumar, S.: Metastases to pineal gland. Cancer 1989; 63: 164-165. [ Links ]
36. Yanamoto, H., Kakita, K., Fukuma, S.: Pineal metastasis. A case report and a review of literature. No Shinkei Geka 1987; 15: 1329-1334 (in Japanese with English abstract). [ Links ]
Yavuz Samanci, M.D.
Ministry of Health Okmeydani Education and Research Hospital.