eMedicine Specialties > Radiology > Brain/Spine

Pineal Germinoma: Imaging

Author: Chi-Shing Zee, MD, Chief of Neuroradiology, Professor, Departments of Radiology and Neurosurgery, University of Southern California School of Medicine
Coauthor(s): Paul Kim, MD, Assistant Professor of Radiology, USC School of Medicine; Vi Vu, MD, Clinical Instructor, USC School of Medicine
Contributor Information and Disclosures

Updated: Apr 18, 2007

Radiography

Findings

Germinomas are associated with a high incidence of pineal gland calcification. The tumor does not calcify, but it may engulf a calcified pineal gland. A calcified pineal gland is rarely seen on radiographs in a child younger than 10 years. If a calcified pineal gland is seen on plain radiographs in a boy younger than 10 years, pineal germinoma is suggested.

Degree of Confidence

The degree of confidence with radiographs is low. A calcified pineal gland in young male patients is suggestive of germinoma, but a normal pineal gland can also become calcified. In patients younger than 10 years, physiologic calcification of a healthy pineal gland is usually not detectable on plain radiographs. Furthermore, pineal calcification can be seen in patients with pineal cell tumors.

Computed Tomography

Findings

Nonenhanced CT scans typically demonstrate a slightly hyperattenuating mass that engulfs a prominent calcified pineal gland. Contrast-enhanced CT demonstrates homogeneous and intense enhancement.

CT is more sensitive than plain radiography in depicting pineal calcification. Small speckles of calcification can be seen in children as young as 6 years. In general, pineal calcification in children younger than 6 years is suggestive of pineal neoplasm. Other authors believe that pineal calcification is uncommon in children younger than 10 years and that areas of pineal calcification should be smaller than 1 cm in diameter.

Degree of Confidence

The degree of confidence is moderate with CT.

Magnetic Resonance Imaging

Findings

Germinomas are usually relative to cerebral gray matter on both T1-weighted images and T2-weighted images. Occasionally, tumors may be hypointense on T1-weighted images and hyperintense on T2-weighted images. After the intravenous injection of gadolinium-based contrast material, homogeneous and intense enhancement is seen. For this reason, contrast-enhanced MRI is particularly useful for evaluating the subarachnoid seeding of germinomas.

Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have recently been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. As of late December 2006, the FDA had received reports of 90 such cases. Worldwide, over 200 cases have been reported, according to the FDA. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble movingor straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.

Pineal germinomas predominantly involve the pineal gland, but involvement of the medial aspect of the pulvinar of the thalamus frequently is seen. Occasionally, small cystic changes may be seen in the germinoma.

A recent study demonstrated that the tumoral response to radiation therapy is negatively correlated with the presence of cystic changes in the germinoma.

Degree of Confidence

The degree of confidence is high within MRI. MRI enables the accurate anatomic delineation of the tumoral mass and the determination of its relationship with the surrounding structures. Thus, MRI can provide adequate information with which the neurosurgeon can plan a biopsy.

Angiography

Findings

No abnormality is seen on arterial-phase cerebral angiograms. In the venous phase, superior and posterior displacement of the internal cerebral veins and the vein of Galen may be seen on lateral projections. A larger pineal region mass can cause posterior bowing of the precentral cerebellar vein. On anteroposterior projections, the posterior portion of the 2 internal cerebral veins may be slightly separated.

Degree of Confidence

Venous-phase cerebral angiograms can help in identifying a pineal region mass, but a more specific diagnosis is not possible.

More on Pineal Germinoma

Overview: Pineal Germinoma
Imaging: Pineal Germinoma
Multimedia: Pineal Germinoma
References
[ CLOSE WINDOW ]

References

  1. Allen JC, Nisselbaum J, Epstein F, et al. Alphafetoprotein and human chorionic gonadotropin determination in cerebrospinal fluid. An aid to the diagnosis and management of intracranial germ-cell tumors. J Neurosurg. Sep 1979;51(3):368-74. [Medline].

  2. Chang CG, Kageyama N, Kobayashi T, et al. Pineal Tumors: clinical diagnosis, with special emphasis on the significance of pineal calcification. Neurosurgery. Jun 1981;8(6):656-68. [Medline].

  3. Edwards MS, Hudgins RJ, Wilson CB, et al. Pineal region tumors in children. J Neurosurg. May 1988;68(5):689-97. [Medline].

  4. Farng KT, Chang KP, Wong TT. Pediatric intracranial germinoma treated with chemotherapy alone. Chung Hua I Hsueh Tsa Chih (Taipei). Dec 1999;62(12):859-66. [Medline].

  5. Ganti SR, Hilal SK, Stein BM, et al. CT of pineal region tumors. AJR Am J Roentgenol. Mar 1986;146(3):451-8. [Medline].

  6. Hoffman HJ, Otsubo H, Hendrick EB, et al. Intracranial germ-cell tumors in children. J Neurosurg. Apr 1991;74(4):545-51. [Medline].

  7. Jenkin D, Berry M, Chan H, et al. Pineal region germinomas in childhood treatment considerations. Int J Radiat Oncol Biol Phys. Mar 1990;18(3):541-5. [Medline].

  8. Jenkin RD, Simpson WJ, Keen CW. Pineal and suprasellar germinomas. Results of radiation treatment. J Neurosurg. Jan 1978;48(1):99-107. [Medline].

  9. Kilgore DP, Strother CM, Starshak RJ, Haughton VM. Pineal germinoma: MR imaging. Radiology. Feb 1986;158(2):435-8. [Medline].

  10. Kluczewska E, Staniek-Sadowska J, Malecka-Tendera E. [Radiological evaluation of pineal pathology and its regions]. Neurol Neurochir Pol. Sep-Oct 1999;33(5):1129-38. [Medline].

  11. Koide O, Watanabe Y, Sato K. Pathological survey of intracranial germinoma and pinealoma in Japan. Cancer. Apr 15 1980;45(8):2119-30. [Medline].

  12. Lin SR, Crane MD, Lin ZS, et al. Characteristics of calcification in tumors of the pineal gland. Radiology. Mar 1978;126(3):721-6. [Medline].

  13. Moon WK, Chang KH, Han MH, Kim IO. Intracranial germinomas: correlation of imaging findings with tumor response to radiation therapy. AJR Am J Roentgenol. Mar 1999;172(3):713-6. [Medline].

  14. Rivarola, Belgorosky A, Mendilaharzu H. Precocious puberty in children with tumours of the suprasellar and pineal areas: organic central precocious puberty. Acta Paediatr. Jul 2001;90(7):751-6. [Medline].

  15. Smirniotopoulos JG, Rushing EJ, Mena H. Pineal region masses: differential diagnosis. Radiographics. May 1992;12(3):577-96. [Medline].

  16. Tamaki N, Yin D. Therapeutic strategies and surgical results for pineal region tumours. J Clin Neurosci. Mar 2000;7(2):125-8. [Medline].

  17. Teo HE, Tan AM. Clinics in diagnostic imaging (37). Germinoma of the pineal gland. Singapore Med J. May 1999;40(5):375-8. [Medline].

  18. Zee CS, Segall H, Apuzzo M, et al. MR imaging of pineal region neoplasms. J Comput Assist Tomogr. Jan-Feb 1991;15(1):56-63. [Medline].

  19. Zimmerman RA, Bilaniuk LT, Wood JH, et al. Computed tomography of pineal, parapineal, and histologically related tumors. Radiology. Dec 1980;137(3):669-77. [Medline].

  20. Zimmerman RA, Bilaniuk LT. Age-related incidence of pineal calcification detected by computed tomography. Radiology. Mar 1982;142(3):659-62. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

pineal gland, pineal region neoplasms, germ cell tumors, pineal cell tumors, germinoma, mature teratoma, malignant teratoma, embryonal cell carcinoma, endodermal sinus tumor, choriocarcinoma, mixed germ cell tumor, parapineal masses, thalamic quadrigeminal plate and tectum, glioma, ependyma, ependymoma, velum interpositum and tentorium, meningioma, Parinaud syndrome

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Chi-Shing Zee, MD, Chief of Neuroradiology, Professor, Departments of Radiology and Neurosurgery, University of Southern California School of Medicine
Chi-Shing Zee, MD is a member of the following medical societies: American Society of Neuroradiology
Disclosure: Nothing to disclose.

Coauthor(s)

Paul Kim, MD, Assistant Professor of Radiology, USC School of Medicine
Disclosure: Nothing to disclose.

Vi Vu, MD, Clinical Instructor, USC School of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Pamela W Schaefer, MD, Assistant Professor of Radiology, Harvard Medical School; Associate Director of Neuroradiology, Clinical Director of Magnetic Resonance Imaging, Department of Radiology, Massachusetts General Hospital
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

James G Smirniotopoulos, MD, Professor of Radiology, Neurology, and Biomedical Informatics, Chairman, Department of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences
James G Smirniotopoulos, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, American Society of Head and Neck Radiology, American Society of Neuroradiology, American Society of Pediatric Neuroradiology, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.