Pineoblastomas are tumours that are best thought of as primitive neuroectodermal tumours (PNET) located in the pineal region and thus they closely resemble (both on imaging and on histology) medulloblastomas, retinoblastomas and supratentorial PNETs. They are the most agressive and highest grade tumour among pineal parenchymal tumours.
Pineoblastomas are the most agressive pineal parenchymal tumour and account for a substantial proportion of such tumours (24-50%) 7. They are typically found in young children, with both sexes being equally affected (in contrast to the male predominance seen in pineal germinomas).
There is a well established association with hereditary retinoblastomas. Patients with hereditary (bliateral) retinoblastoma 5-15% develop midline (suprasellar or pineal) neuroblastic tumours 6. Such cases are sometimes referred to as trilateral retinoblastoma.
Pineoblastomas are typically large and almost always associated with obstructive hydrocephalus, due to compression on the aqueduct. Compression of the tectal plate may also result in the Parinaud syndrome.
They are highly malignant tumours prone to CSF seeding, which is present in 15% of patients at the time of diagnosis.
The tumour originates from neuroectodermal cells. It is the least differentiated pineal cell tumours, with pineocytomas and pineal parenchymal tumour with intermediate differentiation representing better differentiated tumours along the same spectrum.
Pineoblastomas are considered WHO grade IV tumours.
The tumours are composed of tightly packed small round blue cells (high nuclear to cytoplasmic ratio) which in turn determines their imaging appearances (see below) 7.
Pineoblastomas tend to be large poorly defined masses, with frequent CSF seeding at presentation. They have a tendency to directly involve adjacent brain structures, which helps distinguish them from other pineal tumours which tend to be better circumscribed.
The solid component tends to be slightly hyperdense compared to adjacent brain due to high cellularity. This is a characteristic shared by other small round blue cell tumours such as PNET and medulloblastoma.
Classically, they are described as having peripherally disperse or "exploded" calcification (Mnemonic: blasted calcification), similar to pineocytomas. In contrast pineal germinomas tend to engulf pineal calcification.
Pineoblastomas tend to appear as sizable (>4cm) irregular masses often with evidence of invasion into adjacent brain 6,9. Typical signal characteristics include 9:
- T1 - isointense to hypointense to adjacent brain
- isointense to adjacent brain
- areas of cyst formation or necrosis may be present
- T1 C+ (Gd) - vivid heterogenous enhancement
- DWI/ADC - restricted diffusion due to dense cellular packing
Central necrosis is sometimes present which can make the mass appear centrally cystic and thus can roughly mimic a pineal cyst, although the latter should have a smooth thin wall 6.
Screening of the whole neural axis is necessary as CSF seeding is seen in 45% of cases 7.
Treatment and prognosis
Treatment is usually a combination of surgery, chemotherapy and radiation 7. Despite this prognosis is poor, with a 5 year survival of only 58% 8.
General imaging diefferential considerations include
- other pineal parenchymal tumours
- pineocytoma - mature well-differentiated tumor : smaller and better circumscribed
- pineal parenchymal tumour with intermediate differentiation
- papillary tumour of the pineal region
- germ cell tumours
- thin (<2mm) wall
- astrocytoma of pineal gland
- imaging is very similar
- located in the vermis rather than pineal region but can be difficult to distinguish if very high in the vermis and very large
Pineal region masses
The pineal region is anatomically complex and plays host to a number of unique masses and tumours as well as potentially affected by many entities seen more frequently elsewhere in the brain.
- cystic non-neoplastic lesions
- pineal parenchymal tumours
- germ cell tumours
- tumours also encountered in the pineal region
- vascular lesions
- 1. Smirniotopoulos JG, Rushing EJ, Mena H. Pineal region masses: differential diagnosis. Radiographics. 1992;12 (3): 577-96. Radiographics (abstract) - Pubmed citation
- 2. Chang T, Teng MM, Guo WY et-al. CT of pineal tumors and intracranial germ-cell tumors. AJR Am J Roentgenol. 1989;153 (6): 1269-74. AJR Am J Roentgenol (abstract) - Pubmed citation
- 3. Ganti SR, Hilal SK, Stein BM et-al. CT of pineal region tumors. AJR Am J Roentgenol. 1.86;146 (3): 451-8. AJR Am J Roentgenol (abstract) - Pubmed citation
- 4. Tien RD, Barkovich AJ, Edwards MS. MR imaging of pineal tumors. AJR Am J Roentgenol. 1990;155 (1): 143-51. AJR Am J Roentgenol (abstract) - Pubmed citation
- 5. Banks KP, Brown SJ. AJR teaching file: solid masses of the pineal region. AJR Am J Roentgenol. 2006;186 (3): S233-5. doi:10.2214/AJR.05.0519 - Pubmed citation
- 6. Rodjan F, De Graaf P, Moll AC et-al. Brain abnormalities on MR imaging in patients with retinoblastoma. AJNR Am J Neuroradiol. 2010;31 (8): 1385-9. AJNR Am J Neuroradiol (full text) - doi:10.3174/ajnr.A2102 - Pubmed citation
- 7. Dumrongpisutikul N, Intrapiromkul J, Yousem DM. Distinguishing between germinomas and pineal cell tumors on MR imaging. AJNR Am J Neuroradiol. 2012;33 (3): 550-5. AJNR Am J Neuroradiol (full text) - doi:10.3174/ajnr.A2806 - Pubmed citation
- 8. Zimmerman RD, Grossman RI. Neuroradiology. Mosby. (2010) ISBN:0323045219. Read it at Google Books - Find it at Amazon
- 9. Griscom NT. Practical Pediatric Imaging. Lippincott Williams & Wilkins. (1998) ISBN:0316494739. Read it at Google Books - Find it at Amazon
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