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Symptomatic glial cysts of the pineal gland
468
Surg Neurol 1988;30:468-70
Symptomatic Glial Cysts of the Pineal Gland Jes•s
Vaquero, M.D., Roberto Martfnez, M.D., Jorge Escand6n, M.D.,
and Gonzalo Bravo, M.D. Department of Neurosurgery, Puerta de Hierro Clinic, Autonomous University, Madrid, Spain
Vaquero J, Martinez R, Escandon J, Bravo G. Symptomatic glial cysts of the pineal gland. Surg Neurol 1988;30:468-70.
Two cases of symptomatic glial cysts of the pineal gland are reported. An origin similar to that proposed for paraventricular glial cysts of the brain is accepted. These unusual lesions could be considered in the differential diagnosis of cystic pineal masses. KEY WORDS: Pineal tumors; Glial cysts; Pineal gland
Benign intraparenchymal brain cysts with a glial lining have been described occasionally in the literature, and the cerebellum is the most frequent location [7-9]. In the pineal gland, little cysts lined by nontumoral glial tissue may be seen as casual findings in necropsy, and especially in patients with systemic cancer [2]. Nevertheless, significant enlargement of these cysts, enough to produce obstruction of cerebrospinal fluid (CSF) pathways, has been rarely described [1,5,6]. In this report wedescribe two new cases of symptomatic glial cysts of the pineal gland.
1985, a supracerebellar approach was performed, and a cystic lesion, with xanthochromic fluid, was removed. Pathologic diagnosis resulted in the discovery of pineal tissue and a large cyst lined by reactive gliosis (Figure 3). In March 1986, the V - P shunt was withdrawn and, 3 years after surgery, she is symptom-free.
Case 2 A 34-year-old man first came to our clinic in July 1986, with a 1-month history of diplopia and headache. A C T scan showed hydrocephalus and an irregular hypodense lesion within the quadrigeminal cistern that enhanced with polycystic appearance after contrast medium administration (Figure 4). A V - P shunt was performed, and markers for germ-cell tumors were assayed; they were negative. Two-thousand rads were administered over the lesion; it did not respond. In November 1986, the mass was resected by a supracerebellar route. Surgery showed a lesion with multiple cysts filled by xanthochromic fluid that suggested an astrocytoma arising Figure 1. Case 1. A C T
scan showing hydrocephalus and a hypodense rounded mass in the pineal region.
R e p o r t o f Cases Case 1 A 22-year-old woman was studied in August 1985, because she complained of a persistent headache. Neurologic examination revealed incipient papilledema, and a computed tomography (CT) scan showed hydrocephalus and a hypodense, rounded mass, without contrast enhancement, in the pineal region (Figure 1). A V - P shunt was performed and, after it, magnetic resonance imaging (MRI) confirmed the lesion, which was 2.4 × 1.5 cm (Figure 2). Determinations of alpha-fetoprotein and human chorionic gonadotropin were done in CSF and blood, with negative results in both. In November Address reprint requests to: J. Vaquero, M.D., Servicio de Neurocirugfa. Clfnica Puerta de Hierro, San Martfn de Porres, 4, 28035Madrid, Spain. Received May 2, 1988; accepted July 19, 1988.
© 1988 by Elsevier Science PublishingCo., Inc.
0090-3019/88/$3.50
Glial Cysts of the Pineal Gland
Surg Neurol 1988;30:468-70
469
Figure 4. Case 2. A CT scan, after contrast administration, showing a Figure 2. Case 1. Magnetic resonance imaging showing the mass at the
lesion with polycystic appearance on the quadrigeminal plate.
pineal level.
from the quadrigeminal plate. Nevertheless, pathologic study revealed pineal tissue within the lesion, and a diagnosis of simple glial cysts was established (Figure 5). The patient is symptom-free, with normal CT scan, 2 years after surgery.
Our two cases are examples of symptomatic glial cysts of the pineal gland. They represent nearly 4% of our
present series of 53 pineal region tumors. Although recent literature does not show specific reports about these rare lesions, in our opinion it is difficult to establish the actual incidence of symptomatic glial cysts of the pineal gland because several surgical series included cysts without a precise histologic diagnosis [3]. When glial cysts of the brain are near the ventricular system, they have been considered the result ofventricular wall rupture at some point in development, causing
Figure 3. Case I. Histologic picture showing the wall of the resected cyst.
Figure 5. Case 2. Histologic picture of the resected lesion showing glial
Only glial tissue lined the cyst. (Hematoxylin and eosin technique; original magnification ×90).
tissue lining the lumen of the cyst. Pineal tissue can be identified below. (Hematoxylin and eosin technique; original magnification × 90).
Discussion
~ i~ ~ i~ ~i
i
470
Surg Neurol 1988;30:468-70
CSF dissection into the adjacent parenchyma [10]. The possibility of regressive changes in a previous astrocytoma has been speculated when they are into the cerebellum [8]. Large glial cysts of the pineal body have been related to degenerative process in the central core of fibrillary astroglia [4], but it is difficult to explain why these degenerative cysts grow. For this reason, we think that some kind of partial communication between the pineal gland parenchyma and the third ventricle, perhaps due to anomalous persistence of pineal diverticulum, is a better explanation. This theory is in accord with the pathogenic explanation for paraventricular glial cysts [ 10], and it is supported by the finding of the cystic fluid. With respect to the clinical management of these lesions, our reported cases show that a simple glial cyst should be considered when a pineal cystic lesion is diagnosed. In this event, surgical approach to the mass may be the best treatment.
Vaquero et al
References 1. Cooper ERA. Human pineal gland and pineal cysts. J Anat 1932; 67:28-46. 2. Hadju SI, Porro RS, Lieberman PH, Foote FW. Degeneration of the pineal gland of patients with cancer. Cancer 1972;29:706-9. 3. Obrador S, Soto M, Gutierrez-Diaz JA. Surgical management of tumours of the pineal region. Acta Neurochir (Wien) 1976; 34:159-71. 4. Russell DS, Rubinstein LJ. Pathology of tumours of the nervous system. London: Edward Arnold, 1977:295. 5. Schmidek HH. Pineal tumors. New York: Masson, 1977:6. 6. Sevitt S, Schorstein J. A case of pineal cyst. Br J Med 1947; 2:490-1. 7. Silverberg GD. Simple cysts of the cerebellum. J Neurosurg 1971;35:320-7. 8. Vaquero J, Cabezudo JM, Areitio E. Glial cysts of the cerebellum. Surg Neurol 1981;16:288-9. 9. Weisberg LA. Non-neoplastic gliotic cerebellar cysts: clinical and computed tomographic correlations. Neuroradiology 1982; 24:53-7. 10. Wilkins RH, Burger PC. Benign intraparenchymal brain cysts without an epithelial lining. J Neurosurg 1988;68:378-82.
Surg Neurol 1988;30:468-70
Symptomatic Glial Cysts of the Pineal Gland Jes•s
Vaquero, M.D., Roberto Martfnez, M.D., Jorge Escand6n, M.D.,
and Gonzalo Bravo, M.D. Department of Neurosurgery, Puerta de Hierro Clinic, Autonomous University, Madrid, Spain
Vaquero J, Martinez R, Escandon J, Bravo G. Symptomatic glial cysts of the pineal gland. Surg Neurol 1988;30:468-70.
Two cases of symptomatic glial cysts of the pineal gland are reported. An origin similar to that proposed for paraventricular glial cysts of the brain is accepted. These unusual lesions could be considered in the differential diagnosis of cystic pineal masses. KEY WORDS: Pineal tumors; Glial cysts; Pineal gland
Benign intraparenchymal brain cysts with a glial lining have been described occasionally in the literature, and the cerebellum is the most frequent location [7-9]. In the pineal gland, little cysts lined by nontumoral glial tissue may be seen as casual findings in necropsy, and especially in patients with systemic cancer [2]. Nevertheless, significant enlargement of these cysts, enough to produce obstruction of cerebrospinal fluid (CSF) pathways, has been rarely described [1,5,6]. In this report wedescribe two new cases of symptomatic glial cysts of the pineal gland.
1985, a supracerebellar approach was performed, and a cystic lesion, with xanthochromic fluid, was removed. Pathologic diagnosis resulted in the discovery of pineal tissue and a large cyst lined by reactive gliosis (Figure 3). In March 1986, the V - P shunt was withdrawn and, 3 years after surgery, she is symptom-free.
Case 2 A 34-year-old man first came to our clinic in July 1986, with a 1-month history of diplopia and headache. A C T scan showed hydrocephalus and an irregular hypodense lesion within the quadrigeminal cistern that enhanced with polycystic appearance after contrast medium administration (Figure 4). A V - P shunt was performed, and markers for germ-cell tumors were assayed; they were negative. Two-thousand rads were administered over the lesion; it did not respond. In November 1986, the mass was resected by a supracerebellar route. Surgery showed a lesion with multiple cysts filled by xanthochromic fluid that suggested an astrocytoma arising Figure 1. Case 1. A C T
scan showing hydrocephalus and a hypodense rounded mass in the pineal region.
R e p o r t o f Cases Case 1 A 22-year-old woman was studied in August 1985, because she complained of a persistent headache. Neurologic examination revealed incipient papilledema, and a computed tomography (CT) scan showed hydrocephalus and a hypodense, rounded mass, without contrast enhancement, in the pineal region (Figure 1). A V - P shunt was performed and, after it, magnetic resonance imaging (MRI) confirmed the lesion, which was 2.4 × 1.5 cm (Figure 2). Determinations of alpha-fetoprotein and human chorionic gonadotropin were done in CSF and blood, with negative results in both. In November Address reprint requests to: J. Vaquero, M.D., Servicio de Neurocirugfa. Clfnica Puerta de Hierro, San Martfn de Porres, 4, 28035Madrid, Spain. Received May 2, 1988; accepted July 19, 1988.
© 1988 by Elsevier Science PublishingCo., Inc.
0090-3019/88/$3.50
Glial Cysts of the Pineal Gland
Surg Neurol 1988;30:468-70
469
Figure 4. Case 2. A CT scan, after contrast administration, showing a Figure 2. Case 1. Magnetic resonance imaging showing the mass at the
lesion with polycystic appearance on the quadrigeminal plate.
pineal level.
from the quadrigeminal plate. Nevertheless, pathologic study revealed pineal tissue within the lesion, and a diagnosis of simple glial cysts was established (Figure 5). The patient is symptom-free, with normal CT scan, 2 years after surgery.
Our two cases are examples of symptomatic glial cysts of the pineal gland. They represent nearly 4% of our
present series of 53 pineal region tumors. Although recent literature does not show specific reports about these rare lesions, in our opinion it is difficult to establish the actual incidence of symptomatic glial cysts of the pineal gland because several surgical series included cysts without a precise histologic diagnosis [3]. When glial cysts of the brain are near the ventricular system, they have been considered the result ofventricular wall rupture at some point in development, causing
Figure 3. Case I. Histologic picture showing the wall of the resected cyst.
Figure 5. Case 2. Histologic picture of the resected lesion showing glial
Only glial tissue lined the cyst. (Hematoxylin and eosin technique; original magnification ×90).
tissue lining the lumen of the cyst. Pineal tissue can be identified below. (Hematoxylin and eosin technique; original magnification × 90).
Discussion
~ i~ ~ i~ ~i
i
470
Surg Neurol 1988;30:468-70
CSF dissection into the adjacent parenchyma [10]. The possibility of regressive changes in a previous astrocytoma has been speculated when they are into the cerebellum [8]. Large glial cysts of the pineal body have been related to degenerative process in the central core of fibrillary astroglia [4], but it is difficult to explain why these degenerative cysts grow. For this reason, we think that some kind of partial communication between the pineal gland parenchyma and the third ventricle, perhaps due to anomalous persistence of pineal diverticulum, is a better explanation. This theory is in accord with the pathogenic explanation for paraventricular glial cysts [ 10], and it is supported by the finding of the cystic fluid. With respect to the clinical management of these lesions, our reported cases show that a simple glial cyst should be considered when a pineal cystic lesion is diagnosed. In this event, surgical approach to the mass may be the best treatment.
Vaquero et al
References 1. Cooper ERA. Human pineal gland and pineal cysts. J Anat 1932; 67:28-46. 2. Hadju SI, Porro RS, Lieberman PH, Foote FW. Degeneration of the pineal gland of patients with cancer. Cancer 1972;29:706-9. 3. Obrador S, Soto M, Gutierrez-Diaz JA. Surgical management of tumours of the pineal region. Acta Neurochir (Wien) 1976; 34:159-71. 4. Russell DS, Rubinstein LJ. Pathology of tumours of the nervous system. London: Edward Arnold, 1977:295. 5. Schmidek HH. Pineal tumors. New York: Masson, 1977:6. 6. Sevitt S, Schorstein J. A case of pineal cyst. Br J Med 1947; 2:490-1. 7. Silverberg GD. Simple cysts of the cerebellum. J Neurosurg 1971;35:320-7. 8. Vaquero J, Cabezudo JM, Areitio E. Glial cysts of the cerebellum. Surg Neurol 1981;16:288-9. 9. Weisberg LA. Non-neoplastic gliotic cerebellar cysts: clinical and computed tomographic correlations. Neuroradiology 1982; 24:53-7. 10. Wilkins RH, Burger PC. Benign intraparenchymal brain cysts without an epithelial lining. J Neurosurg 1988;68:378-82.