Outcomes and Surgical Approaches for Pineal Region Tumors in Adults: A Retrospective Study of a Single-Center Over 12 Years

Abstract

Background Pineal region tumors are considered rare, deeply located, and very difficult to resect. They can cause various symptoms by compressing and obstructing different structures. Contradictory data have been reported regarding various aspects of surgical outcomes in different patient positioning. Objectives This retrospective study aimed to describe the variety of pineal region tumors and patient positioning in pineal region surgeries and compare the neurological outcomes during different approaches. Materials and Methods From January 1, 2010, to December 31, 2022, 61 patients with pineal area tumors were hospitalized at the National Center for Neurosurgery. Thirty-five patients' histology examinations were available. Twenty-nine patients had open surgical excision. Regarding approaches, supracerebellar infratentorial, posterior transfalcine interhemispheric, and occipital transtentorial approaches were employed. Results Among 35 patients, 17 had hydrocephalus and required ventricular drainage to address third ventricle obstruction. Complete tumor resection was achieved in 55% of patients. The mortality rate was 13.7% in the open surgical group and 15.625% in the endoscopic third ventriculostomy (ETV) group. Conclusion Proper patient positioning and selecting the optimal approach are crucial for a successful outcome.

Keywords: germ cell tumor; occipital transtentorial approach; oncology; pineal biopsy; pineal region tumor; supracerebellar approach.

Fig. 1

Selection of surgical approaches to pineal region tumors. ( A ) Posterior transcallosal interhemispheric approach for meningiomas with a falcotentorial matrix, ( B ) transoccipital approach for a big mass in the supratentorial area, and ( C ) supracerebellar infratentorial approach if the veins are from above, for a mass compromising the cerebellum, extending to the tectum, or extending to the rear side of the third ventricle.

Fig. 2

Modified lateral decubitus position (park bench). ( A ) After induction of anesthesia, the patient was turned to the left side, and pillows were placed under the armpit and iliac crest. A soft pillow was also placed between the knees. Then, we performed hand positioning with the help of a multi-axis surgical arm positioner. The skull clamp was positioned on this stage. The bed was elevated to 30 degrees to increase brain relaxation. ( B ) The bandage on the upper shoulder was used to retract the shoulder to the back. After shoulder retraction, we performed pelvic fixation with the belt. ( C ) The top view. ( D ) The view from the front.

Fig. 3

( A–C ) Postcontrast T1-weighted images demonstrating falcotentorial meningioma with sinus invasion and brainstem compression. ( D–F ) Postoperative images demonstrating complete tumor removal.

Fig. 4

Intraoperative photograph demonstrating pineal region meningioma resection. ( A ) Suturing sinus bleeding ( big white arrow )—hemostatic agent (Surgicel) applied on the bleeding site. ( B ) Meningioma resection after identifying anatomical orientation and a basal vein of Rosenthal ( small white arrow ). ( C ) Cutting the tentorium.

Fig. 5

( A–C ) Computed tomography images demonstrating supratentorial meningioma with sinus invasion and brainstem compression. ( D–F ) Postoperative magnetic resonance imaging T1-weighted images demonstrating complete removal of the meningioma.

Fig. 6

Preoperative magnetic resonance imaging demonstrating pineal region tumor with ( A ) aqueductal compression and ( B, C ) ventriculomegaly with the internal cerebral veins being pushed aside. (D–F) Postoperative computed tomography images demonstrating complete tumor removal.

Fig. 7

Kaplan–Meier curves show survival dependent on ( A ) histological examination and ( B ) the extent of resection.