The Diagnosis and Treatment of Pineal Tumors

Pineal tumors are among the rarer forms of intracranial new growths, but during recent years we have come to realize that certain of them respond extremely favorably to either operative or roentgen therapy, or at times to a combination of the two. It is for this reason that it appears worth while to review the symptomatology and to summarize the treatment which we have found useful. From its anatomical relationships in the brain (Fig. 1), it is evident that the pineal body lies in such a position that a tumor arising from it will ordinarily involve important structures as soon as it attains even moderate size. The most important of these structures from the clinical aspect are the corpora quadrigemina and the aqueduct of Sylvius. Pressure upon the former causes certain changes in the oculomotor apparatus, while complete or intermittent occlusion of the aqueduct results in internal hydrocephalus. The signs and symptoms referable to such pressure will be discussed under clinical symptomatology. Pathology So far as the pathology of pineal tumors is concerned, the so-called pinealoma is by far the most frequent type. This tumor is composed mainly of large undifferentiated cells simulating the pineal parenchyma cell, as well as small, darkly staining “lymphoid” cells, and also varying numbers of neuroglial cells, all of which are contained sometimes in a loose stroma of connective tissue, while at other times there may be heavy connective-tissue septa (Fig. 2). The other type of pineal tumor is the teratoma. This tumor may have all the characteristics of teratomas found elsewhere in the body, or there may be obviously teratomatous elements in what appears to be largely an ordinary pinealoma, as shown by Dorothy Russell (1). Clinical Symptomatology There is nothing particularly characteristic about the history given by patients harboring pineal tumors so far as any localizing significance is concerned. Headache is the chief and almost universal complaint, and its duration may have been for as brief a period as a few days or as long as a year and a half, presumably varying with the degree of compression of the aqueduct of Sylvius and the ensuing hydrocephalus. In many instances the headache is referred to the frontal area. Vomiting due to increased intracranial pressure accompanies the headaches in many patients. In past years, before patients with intracranial tumors were referred promptly to neurologists or to neurosurgeons, failing vision and blindness were likewise distressing symptoms, but fortunately these sequelae are not seen nearly so frequently nowadays. Other less usual symptoms are those referable to secondary pressure upon the cerebellum, chiefly unsteadiness or staggering. Another occasional complaint of patients with pineal tumors is excessive thirst and an unusually large urinary output, i.e., diabetes insipidus.