Radiotherapy After Endoscopic Biopsy in an Adult with Pineocytoma, the Rare Brain Tumor in an Adult: A Case Report and Literature Review

Abstract

Tumors in the pineal region usually present with acute hydrocephalus. Histologic diagnosis is most important, as it greatly influences treatment, because over 17 tumor types occur in this area. Biopsies of these lesions play an important role in further management. Pineocytomas are benign and rare tumors that typically exhibit a slow progression. However, the appropriate treatment for pineocytoma varies. Surgical excision was considered for good long-term outcomes; however, this may not always be possible. Radiotherapy also appears to be effective in patients with residual pineocytomas. We report a case of pineocytoma with hemorrhagic transformation and complicated hydrocephalus. The patient refused to undergo aggressive tumor excision. Thus, the patient only underwent endoscopic biopsy and external ventricular drain (EVD) implantation, but the outcome was acceptable. In addition, we reviewed the current management strategies for pineocytomas in the literature.

Keywords: biopsy; hydrocephalus; pineal tumor; pineocytoma; subtotal resection.

Figure 1

(A) Computed tomography with contrast-enhancement axial view. (B) Computed tomography with contrast-enhancement sagittal view. A heterogeneous enhanced tumor mass over the pineal region is shown, approximately 3.8 cm, with ventricular dilatation, suspected pineal tumor with hemorrhagic transformation, and complicated hydrocephalus.

Figure 2

(A) T1 weighted with contrast-enhancement axial view. (B) T1 weighted with contrast-enhancement sagittal view. A lobulated heterogeneous enhancing tumor of the pineal region with foci of hemorrhage and calcifications is shown, suggesting pineal parenchymal tumor or metastasis. Moreover, mass effect with obstructive hydrocephalus and tectal plate compression were noted.

Figure 3

(A) Hematoxylin and eosin stain; original magnification × 100. (B) Hematoxylin and eosin stain; original magnification × 200. A hypervascular tumor composed of lobules of tumor cells with uniform round nuclei is shown. Also, a hypercellular tumor but similar to the normal pineal gland was noted. No necrosis or mitotic figure is seen. No definite papillary structure is noted. (C) GFAP immunostaining; original magnification × 100. Immunohistochemical staining showed negative for glial fibrillary acidic protein (GFAP). (D) Synaptophysin immunostaining; original magnification × 100. Positive for synaptophysin. (E) Ki-67 proliferation index; original magnification × 200. The Ki-67 proliferation index is very low.

Figure 4

(A) T1 weighted with contrast-enhancement axial view. (B) T1 weighted with contrast-enhancement sagittal view. After 6 months of operation, a mild decrease of tumor volume was noted.

Figure 5

(A) T1 weighted with contrast-enhancement axial view. (B) T1 weighted with contrast-enhancement sagittal view. After 3 years of follow-up, the image showed no obvious change in the tumor volume.