Treatment of tumor of the pineal area of the brain with surgery, radiotherapy and radio surgery

Dr. Moradi, a neurologist

Pineoblastoma is a rare, aggressive type of cancer that begins in the cells of the brain's pineal gland. Your pineal gland, located in the center of your brain, produces a hormone (melatonin) that plays a role in your natural sleep-wake cycle. Pineoblastoma can occur at any age, but it tends to occur most often in young children. Pineoblastoma may cause headaches, sleepiness and subtle changes in the way the eyes move. Pineoblastoma can be very difficult to treat. It can spread within the brain and the fluid (cerebrospinal fluid) around the brain, but it rarely spreads beyond the central nervous system. Treatment usually involves surgery to remove as much of the cancer as possible. Additional treatments may also be recommended.

What causes pineoblastoma?

Because pineoblastomas are quite rare, the exact cause of these tumors is not yet known. Most are thought to occur by chance. However, there is some evidence that a small proportion of pineoblastomas may be caused by an inherited predisposition, meaning that changes (mutations) in a geneinherited from a parent may increase the chance that a pineoblastoma could develop.

Signs of the tumor of the pineal area

Because this type of tumor blocks the flow of CSF, many of its symptoms are related to CSF buildup. These symptoms include the following:

  • A brain tumour can affect your vision. You might experience blurred vision, making it difficult to read and watch TV. You may experience fleeting loss of vision, often occurring when you suddenly stand up or change posture. Or you may find you have lost part of your field of vision. This could lead to you bumping into objects, or you could feel as if objects or people are suddenly appearing on one side of you.
  • Headache changes: This may result in new headaches, or a change in your old pattern of headaches, such as the following:
    • You have persistent pain, but it’s not like a migraine.
    • It hurts more when you first get up in the morning.
    • It’s accompanied by vomiting or new neurological symptoms.
    • It gets worse when you exercise, cough, or change position.
    • over-the-counter pain medicines don’t help at all.
  • Nausea and vomiting: You might have nausea and vomiting in the early stages because a tumor is causing a hormone imbalance. During treatment for a cancerous brain tumor, nausea and vomiting could be side effects from chemotherapy or other treatments.

Diagnosis of pineal gland tumor

Tests and procedures used to diagnose pineoblastoma include:

  • Imaging tests:Imaging tests can help your doctor determine the location and size of your child's brain tumor. Magnetic resonance imaging (MRI) is often used to diagnose brain tumors, and advanced techniques, such as perfusion MRI and magnetic resonance spectroscopy, may also be used. Additional tests might include computerized tomography (CT) and positron emission tomography (PET).
  • Removing a sample of tissue for testing (biopsy): A biopsy can be done with a needle before surgery or during surgery to remove the pineoblastoma. The sample of suspicious tissue is analyzed in a laboratory to determine the types of cells and their level of aggressiveness.
  • Removing cerebrospinal fluid for testing (lumbar puncture):Also called a spinal tap, this procedure involves inserting a needle between two bones in the lower spine to draw out cerebrospinal fluid from around the spinal cord. The fluid is tested to look for tumor cells or other abnormalities. In certain situations, cerebrospinal fluid may instead be collected during a biopsy procedure to remove suspicious tissue from the brain.

Treatment for pineal tumor

Pineoblastoma treatment options include:

brain Surgery

prepare for brain surgery

  • Your neurosurgeon may ask you to see your internist (or a specialist such as a cardiologist) in order to get "medically cleared" for surgery. The intent is to reduce the risk of anesthesia by identifying and optimally treating medical conditions. For patients with a history of heart problems or who may be at increased risk of a heart attack, this may involve specific tests to assess the blood flow to the heart.
  • In order to reduce the risk of bleeding during or immediately following brain surgery, it is important to tell your neurosurgeon if you are taking any medications that thin the blood (anticoagulants) or if you have a natural tendency for bleeding (hemophilia). Always tell your neurosurgeon if you take aspirin (even baby aspirin) because in most cases aspirin should be stopped at least eight days prior to surgery. Other medications, including herbs, vitamins, or nonsteroidal anti-inflammatories such as Motrin, may also have to be stopped prior to surgery.

Types of Surgery of Pineal Tumor

  • Surgery to relieve fluid buildup in the brain: A pineoblastoma may grow to block the flow of cerebrospinal fluid, which can cause a buildup of fluid that puts pressure on the brain (hydrocephalus). An operation to create a way for the fluid to flow out of the brain may be recommended. Sometimes this procedure can be combined with a biopsy or surgery to remove the tumor.
  • Surgery to remove the pineoblastoma:The brain surgeon (neurosurgeon) will work to remove the pineoblastoma with the goal of removing as much of the tumor as possible. But it's often impossible to remove the tumor entirely because pineoblastoma forms near critical structures deep within the brain. Most children with pineoblastoma receive additional treatments after surgery to target the remaining cells.

after brain surgery

  • Most patients recover quickly after brain tumor surgery and are able to leave the hospital after only a few days. Depending upon your functional abilities after surgery, our physical therapists and occupational therapists will evaluate you. In some instances, a short stay at a rehabilitation hospital near your home may be recommended.
  • In addition to the discharge instructions you are given, it may be helpful to gather key information prior to discharge. It is important to determine which doctor(s) you need to see after discharge for the treatment of your brain tumor. An appointment with a radiation oncologist may be necessary so radiation therapy can begin soon after surgery. It may be beneficial to make an appointment to discuss chemotherapy with a neuro-oncologist. In most circumstances, the neuro-oncologist will be the main doctor coordinating your care related to the brain tumor after surgery. Lastly, a follow-up appointment with your neurosurgeon will be necessary to make certain your wound is healing properly.

The risks and complications of brain surgery

You should call your neurosurgeon in the following situations: seizure, severe headache, worsening neurological problems, fever or chills, swelling of the ankles, bleeding or bruising, severe nausea or vomiting, and skin rash.

Radiation therapy

Radiation therapy uses high-energy beams, such as X-rays or protons, to kill cancer cells. During radiation therapy, your child lies on a table while a machine moves around him or her, directing beams to the brain and spinal cord, with additional radiation to the tumor. Because there is a high risk the tumor cells can spread beyond the initial site to other areas of the central nervous system, radiation therapy directed to the entire brain and spinal cord is recommended for children older than 3.

After Radiation therapy

If your child is having radiotherapy as an outpatient, they will be able to go home after each session. If they need to remain in hospital for another treatment, a nurse will take them back to their ward. Your child will NOT be radioactive after treatment. It is safe for them to be around people, including other children. After the whole course of treatment, your child will have regular check-ups to monitor the effects of the radiotherapy on the tumour and any side-effects you child may get.

side-effects of radiotherapy?

  • Tiredness: This can continue for a number of weeks after treatment
    There is also a form of extreme tiredness that can occur several weeks after finishing radiotherapy, just as you think your child is getting over the treatment. This is called 'somnolence syndrome'.
  • Hair loss: This usually starts 2-3 weeks after treatment starts and is generally only in the areas where the radiotherapy bean enters and leaves the head. Most will grow back, but it can be permanent - see the Resources section in the fact sheet below for practical suggestions for coping with hair loss
  • Skin sensitivity - on the scalp : Take extra care in the sun (long-term) or strong winds, or when swimming
  • Feeling nauseous: This can start from an hour after treatment and may last some weeks. Your child may be given anti-sickness tablets
  • Reduced appetite: Giving them several smaller, healthy snacks may be better than three regular meals
  • Myelosuppression (slower production of blood cells): This can lead to anaemia, increased risk of infection and/or bleeding, such as bruising or nosebleeds.

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. Chemotherapy may be recommended after surgery or radiation therapy in children with pineoblastoma. In some cases, it's used at the same time as radiation therapy. For larger tumors, chemotherapy may be used before surgery to shrink the tumor and make it easier to remove.

Radiosurgery

Technically a type of radiation and not an operation, stereotactic radiosurgery focuses multiple beams of radiation on precise points to kill the tumor cells. Radiosurgery is sometimes used to treat pineoblastoma that recurs.

complications of Radiosurgery

Early complications may include:

  • Common side effects: local pain and swelling in the scalp and headache
  • Rare complications: skin reddening and irritation, nausea and seizure

Delayed complications may include:

  • Uncommon complications: local loss of hair in superficial lesions, local brain swelling in the treatment site and local tissue necrosis in the treatment site
  • Rare complications: visual loss (dependent on diagnosis and areas treated) and hearing loss (dependent on diagnosis and areas treated)