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CASE REPORT
Year : 2020  |  Volume : 16  |  Issue : 6  |  Page : 1532-1534

A rare presentation of solitary pineal region metastasis in a case of lung cancer


1 Department of Radiation Oncology, Institute of Oncology, SRM Institute for Medical Sciences, Chennai, Tamil Nadu, India
2 Department of Neurosurgery, Institute of Neurosciences, SRM Institute for Medical Sciences, Chennai, Tamil Nadu, India
3 Department of Medical Oncology, Institute of Oncology, SRM Institute for Medical Sciences, Chennai, Tamil Nadu, India
4 Department of Surgical Oncology, HCG Kauvery Cancer Center, Chennai, Tamil Nadu, India

Date of Submission17-Sep-2019
Date of Decision19-Nov-2019
Date of Acceptance08-Jan-2020
Date of Web Publication18-Dec-2020

Correspondence Address:
Manikandan Lakshmanan
HCG Kauvery Cancer Center, Chennai - 600 035, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_762_19

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 > Abstract 


Pineal gland metastasis accounts for approximately 0.4% of all intracranial metastases from lung primary. Our patient was a 60-year-old female presenting with intermittent headache and altered sensorium. Magnetic resonance imaging brain showed a 21 mm × 18 mm × 16 mm pineal lesion with obstructive hydrocephalus. She underwent endoscopic third ventriculostomy and drainage. Fluorodeoxyglucose-PET showed a left lung primary tumor with nodal metastasis and solitary pineal gland metastasis. Biopsy of lung lesion revealed poorly differentiated non-small-cell carcinoma which was treated with focal pineal radiation and chemotherapy. This patient's presentation is unique because she presented with pineal symptoms rather than lung symptoms. Pineal gland metastasis from lung primary is mostly associated with small-cell carcinoma histology, but this patient had a non-small-cell carcinoma of lung primary. The age above 60 years is in favor of a metastatic lesion to the pineal gland. Our experience suggests that systemic evaluation of all patients presenting initially with an isolated pineal gland tumor is mandatory.

Keywords: Metastatic lung cancer, pineal gland metastasis, pineal gland radiation, solitary pineal metastasis


How to cite this article:
Mohan B, Bapu S, Mahapatra RK, Lakshmanan M. A rare presentation of solitary pineal region metastasis in a case of lung cancer. J Can Res Ther 2020;16:1532-4

How to cite this URL:
Mohan B, Bapu S, Mahapatra RK, Lakshmanan M. A rare presentation of solitary pineal region metastasis in a case of lung cancer. J Can Res Ther [serial online] 2020 [cited 2021 Nov 27];16:1532-4. Available from: https://www.cancerjournal.net/text.asp?2020/16/6/1532/303911




 > Introduction Top


Metastases to the brain are the most common tumors of the central nervous system. The most common cause of metastasis to the brain is bronchogenic carcinoma, which accounts for approximately 19.9% of brain metastasis.[1] Pineal gland metastasis accounts for approximately 0.4% of all intracranial metastases from lung primary.[2] In children, pineal gland neoplasms account for 3%–8% of all brain tumors, while in adults, the incidence is <1%. [3,4] Of all pineal gland lesions, the incidence in patients over the age of 60 years is approximately 20%.[5] Pineal gland metastasis is usually asymptomatic.[6] Here, we report an uncommon presentation of symptomatic solitary pineal region metastasis from non-small-cell lung cancer.


 > Case Report Top


Sixty-year-old female presented with an intermittent headache for 2 weeks and giddiness for 4 days. On examination, the patient had a performance score of Eastern Cooperative Oncology Group (ECOG) 2 with normal higher mental function and had no focal neurological deficits. On fundoscopy, the patient had papilledema Frisen Scale Stage 1. During workup, magnetic resonance imaging (MRI) of the brain and spine with contrast was suggestive of a 21 mm × 18 mm × 16 mm well-defined heterogeneously enhancing diffusion restricting lesion arising in the pineal gland region with obstructive hydrocephalus [Figure 1]. For symptomatic relief, she was treated with navigation-guided endoscopic third ventriculostomy with attempted biopsy and extraventricular drainage. The biopsy was abandoned, as the lesion was highly vascular. Following the procedure, the patient had relief of symptoms. A subsequent fluorodeoxyglucose whole-body positron-emission tomography (PET)–computed tomography (CT) with MRI screening was done; it showed a left lung primary tumor measuring 43 mm × 42 mm (maximum standardized uptake value [SUVmax] = 16.5) in the posterior segment of the left upper lobe with disseminated nodal metastasis and solitary pineal gland metastasis measuring 20 mm × 16 mm (SUVmax = 19) [Figure 2]. We did a CT-guided core-needle biopsy of a left lung primary tumor. It revealed a poorly differentiated non-small-cell carcinoma histology. Mutational testing showed the tumor to be positive for EGFR T790M mutation. She was treated with focal radiation to the involved pineal gland to deliver a dose of 30 Gy in ten fractions [Figure 3]. Following the radiation, the patient was started on tablet osimertinib 80 mg once a day. After 4 months of the treatment, the patient is doing well with no signs of disease progression.
Figure 1: Magnetic resonance imaging of the brain T1 with contrast showing a mass in the pineal region with obstructive hydrocephalus

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Figure 2: Fluorodeoxyglucose whole-body positron-emission tomography computed tomography showing primarily in the left lung with regional nodal and pineal gland metastasis

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Figure 3: Dose-color wash, dose distribution, and beam alignment targeting the pineal lesion

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 > Discussion Top


The pineal gland is a small midline structure measuring 5–8 mm in diameter, found posterior to the third ventricle. The blood supply to the gland is from the choroidal branches of the posterior cerebral artery. In general, pineal gland neoplasms are uncommon compared to other brain tumors.

Primary pineal gland neoplasms are mainly of two types, germ-cell tumors (GCTs) and pineal parenchymal tumors. GCT is the most common histology and corresponds to more than 50% of pineal gland tumors. They are common in children and young adults. GCTs are again grouped into nongerminomatous (teratoma, embryonal carcinoma, choriocarcinoma, and yolk sac carcinoma) and germinomatous. GCTs are more common in males. [7,8] Primary pineal parenchymal tumors (pineocytoma, pineoblastoma, pineal parenchymal tumor of intermediate differentiation [PPTID], and papillary tumor of the pineal region [PTPR]) account for 14%–27% of all pineal tumors.[9] The rest of the pineal gland tumors are comprised lesions such as glioma, meningioma, metastases, lipoma, and arachnoid cyst.

Solitary pineal region metastasis from lung primary is a rare occurrence. The presentation of this patient is made more unique by the fact that she presented to us with symptoms related to the pineal gland metastasis instead of symptoms related to the lung primary. Pineal gland metastasis from lung primary is most commonly associated with small-cell carcinoma histology,[10] but this patient was found to have a non-small-cell carcinoma of lung primary. The pathway of spread to the pineal gland is usually hematogenous. This is facilitated by the presence of plenty of sinusoidal vessels and lack of blood–brain barrier in the pineal gland region relative to the rest of the brain parenchyma. The fact that the patient was 60 years of age at presentation is more in favor of a metastatic lesion to the pineal gland rather than a pineal gland primary.

MRI of the brain is the investigation of choice in diagnosing pineal gland masses. It helps in identifying the extent of disease and can distinguish primary pineal masses from masses originating in the parapineal region. Pineal gland tumors have a propensity to disseminate through cerebrospinal fluid (CSF) and develop drop metastasis. Hence, MRI of the entire neurospinal axis is recommended in all patients with pineal gland tumors. In CSF, alpha-fetoprotein (AFP) is increased in yolk sac tumors and human chorionic gonadotropin (HCG) in choriocarcinoma. In immature teratoma, both AFP and HCG are elevated.

In this patient, MRI of the brain and spine with contrast was suggestive of a well-defined heterogeneously enhancing diffusion restricting lesion arising from pineal gland region with obstructive hydrocephalus. There was no other metastasis in the neurospinal axis. Considering the age of the patient and normal tumor marker levels in CSF, a whole-body PET-CT with MRI screening was done to rule out metastasis from an extracranial site. The scan showed a left lung primary with extensive mediastinal lymphadenopathy and solitary pineal metastasis.

For control of symptoms, an endoscopic ventriculostomy with extraventricular drainage was done. This was followed by radiation to the affected pineal region to address the mass. The lung primary was treated with chemotherapy. The patient tolerated treatment well and is currently on follow-up with no disease progression for the past 2 months.

A review of the literature identified multiple case reports of solitary pineal gland metastasis from lung primary, but there are not enough data to predict the treatment outcome. The patient will be kept on follow-up with periodic PET-CT scans.


 > Conclusion Top


Symptomatic solitary pineal region metastasis from non-small-cell carcinoma of lung primary is an exceedingly rare presentation. Our experience suggests that a thorough systemic evaluation of older patients presenting initially with an isolated pineal gland tumor is mandatory. In general, in children and young patients, the probability of pineal parenchymal tumors (pineocytomas, pineoblastoma, and PPTID) or a GCT is high. In older patients, as in our case, the probability of metastasis or PTPR should be considered and accordingly evaluated.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Gavrilovic IT, Posner JB. Brain metastases: Epidemiology and pathophysiology. J Neurooncol 2005;75:5-14.  Back to cited text no. 1
    
2.
Nemoto K, Aoshiba K, Itoh M, Semba S, Tsuji T, Adachi H, et al. Isolated pineal region metastasis from lung adenocarcinoma with obstructive hydrocephalus: A case report. J Med Case Rep 2013;7:71.  Back to cited text no. 2
    
3.
Shibui S, Narita Y, Kayama T, Suzuki M, Saito N, Kawahara N, et al. Report of Brain tumor registry of Japan (1969-1993). Neurol Med Chir (Tokyo) 2000;40:1-106.  Back to cited text no. 3
    
4.
Matsutani M, Sano K, Takakura K, Fujimaki T, Nakamura O, Funata N, et al. Primary intracranial germ cell tumors: A clinical analysis of 153 histologically verified cases. J Neurosurg 1997;86:446-55.  Back to cited text no. 4
    
5.
The committee of the brain tumor registry of Japan. Brain tumor registry of Japan 2001-2004. Neurol Med Chir (Tokyo) 2014;54:1-102.  Back to cited text no. 5
    
6.
Samanci Y, Iplikcioglu C, Ozek E, Ozcan D, Marangozoglu B. Lung carcinoma metastasis presenting as a pineal region tumor. Neurocirugia (Astur) 2011;22:579-82.  Back to cited text no. 6
    
7.
Villano JL, Propp JM, Porter KR, Stewart AK, Valyi-Nagy T, Li X, et al. Malignant pineal germ-cell tumors: An analysis of cases from three tumor registries. Neuro Oncol 2008;10:121-30.  Back to cited text no. 7
    
8.
Goodwin TL, Sainani K, Fisher PG. Incidence patterns of central nervous system germ cell tumors: A SEER Study. J Pediatr Hematol Oncol 2009;31:541-4.  Back to cited text no. 8
    
9.
Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, Burger PC, Jouvet A, et al. The 2007 WHO classification of tumours of the central nervous system. Acta Neuropathol 2007;114:97-109.  Back to cited text no. 9
    
10.
Brasseur P, Sukkarieh F, Dupont H, Brohèe D. Pineal body metastasis. J Belge Radiol 1994;77:162-3.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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