Journal of Neuro-Oncology 54: 251–261, 2001.

© 2001 Kluwer Academic Publishers. Printed in the Netherlands.

MRI of pineal region tumors

Yukunori Korogi1 , Mutsumasa Takahashi1 and Yukitaka Ushio2

1
Department of Radiology, 2 Department of Neurosurgery, Kumamoto University School of Medicine,
Kumamoto, Japan

Key words: pineal region tumor, germ cell tumor (GCTs), MRI

Summary

The pineal region is a heterogeneous area that includes the pineal gland and several parapineal structures. Pineal
region masses include germ cell tumors (GCTs), pineal parenchymal cell tumors, glioma, meningioma, metastases,
and non-neoplastic masses such as pineal cysts, lipoma, epidermoid, vascular malformations. Although MRI has
allowed an improvement in distinguishing true pineal masses from parapineal masses impinging into the region of
the gland, it is still difficult to differentiate the pineal GCTs from pineal parenchymal tumors with only images, and
the clinical informations such as age, sex, and the tumor markers are very important.

Introduction high incidence in Japan [3]. The age-adjusted GCTs

The pineal region is a histologically heterogeneous
area that includes the pineal gland itself, the posterior
third ventricle and aqueduct, the supraclinoid cisterns
(quadrigeminal plate, ambient cisterns, and the velum
interpositium), brain (tectum and brainstem, thalami,
corpus callosum splenium), dura (tentorial apex) and
vessels (internal cerebral veins and vein of Galen, and
posterior choroidal and posterior cerebral arteries) [1].
The list of possible pineal region masses is exten-
sive and includes germ cell tumors (GCTs), pineal
parenchymal cell tumors, glioma, meningioma, metas-
tases, and non-neoplastic masses such as pineal cysts,
lipoma, epidermoid, vascular malformations. Pineal
gland neoplasms are relatively uncommon tumors.
Pineal cysts, on the other hand, are remarkably com-
mon as incidental findings. GCTs are also not so
uncommon in the oriental countries. MRI has allowed a
marked improvement in the preoperative delineation of
benign and malignant pineal masses and in distinguish-
ing true pineal masses from parapineal masses imping-
ing into the region of the gland [2]. In this chapter,
we will briefly review the radiological findings of the
pineal region tumors focusing on the MR findings.
Germ cell tumors
GCTs account for 0.5–3.2% of primary intracranial
tumors in adults and 11.8% in children, with a relative
incidence in Japan is reported to be 0.17 per 100,000
population per year (male 0.3, female 0.07) [4]. Most
patients with GCTs are between 10 and 30 years old;
the peak age of presentation is the second decade.
They can be classified into six types: germinoma,
teratoma (mature teratoma and immature teratoma),
embryonal carcinoma, choriocarcinoma, yolk sac
tumor (endodermal sinus tumor), and mixed GCT
which contains more than two components of above.
Germinomas are the least differentiated of the germ
cell group, whereas teratomas differentiate along all
three cell lines (ectoderm, mesoderm, and endoderm).
York sac tumor, choriocarcinoma, and embryonal cell
tumor represent other less common GCTs.
GCTs are most commonly located in the pineal
region; their next most frequent site of occurrence is the
hypothalamic–neurohypophyseal region. In the latter
case, the earliest symptom is diabetes insipidus. Pineal
GCTs affected males predominantly, while suprasellar
GCTs have no preponderance of sex.
Pineal GCTs
In our series, germinomas, teratomas, and mixed GCTs
occupy 36%, 36%, and 18% of all pineal GCTs, respec-
tively. Teratoma mainly locates in this region. The
pineal lesions tend to protrude anteroinferiorly to the
tectal plate and posterior portion of the third ventricle,
leading to hydrocephalus despite of the small mass. It
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Figure 1. Germinoma with the synchronous lesions in the pineal

and suprasellar regions in an 11-year-old boy. Postcontrast
T1-weighted midsagittal image shows enlargement and mild
homogeneous enhancement of the pituitary stalk (arrowhead) as
well as a small mass at the pineal region (arrow).

is difficult to differentiate the pineal GCTs from pineal

parenchymal tumors with only images, and age, sex,
tumor markers as well as presence of cystic components
are important. Pineal gland calcification seems to be
the common characteristic of all pineal region tumors
and not necessarily very helpful in the differential
diagnosis. B
In our series, 16% of all intracranial GCTs
are the synchronous lesions in pineal and neuro-
hypophyseal regions, the prevalence of which is
similar to the previous report [5]. This kind of
tumor often shows some similarity: the small pineal
mass and the symmetric infundibular thickening
(Figure 1). Early detection of mass may be caused
by early complaint of diabetes insipidus. There have
been two hypotheses about the synchronous masses:
dissemination theory and multicentric origination
theory [5].

Imaging findings of GCTs

The solid components of the GCTs are iso- to slightly C

hypointense relative to the gray matter on T1-weighted
image (T1WI), and mixed iso- and hyperintense on
T2-weighted image (T2WI) [6–11]. In particular, ger-
minomas are usually mildly hypointense on T1WI and
mildly hyperintense on T2WI, and may be isointense
on both pulse sequence (Figures 1, 2). GCTs, espe-
cially germinomas, are typically demonstrated as a
Figure 2. Pineal germinoma in a 15-year-old boy. (A) Sagit-
tal T1WI. (B) Sagittal T2WI. (C) Sagittal T1WI with contrast
enhancement. Intrinsic pineal mass with cyst displaces superior
colliculi and obstructs the aqueduct (arrowhead). Solid compo-
nent of mass is mildly hyperintense on T2WI, and enhanced dif-
fusely after contrast administration (arrow).
 253

A B

Figure 3. Mature teratoma in an 11-year-old boy. (A) Axial T1WI. (B) Axial T2WI. (C) Axial T1WI with contrast enhancement. Pineal
mass shows higher heterogeneity, a typical honeycomb-like appearance with multiple cystic components (arrowheads).
254

A
B

Figure 4. (Continued)
 255

hyperdense mass on precontrast CT images. Teratomas be observed, probably representing high protein liquid.
of the pineal are strikingly heterogeneous (Figure 3), Detection of fatty tissues is relatively uncommon in the
and often have dense calcification within them. Marked intracranial teratomas. The high hemorrhagic tendency
high intensity of teratoma on both T1WI and T2WI can of choriocarcinoma has been reported. Peritumoral

A B

Figure 5. Pineoblastoma in an 11-year-old boy. (A) Axial T1WI. (B) Axial T2WI. (C) Sagittal T1WI with contrast enhancement. Pineal
mass shows low intensity on T2WI (arrow). Contrast enhancement of the mass is remarkable.

←
Figure 4. Immature teratoma in a 9-year-old boy. (A) Axial T1WI. (B) Axial T2WI. (C) Axial T1WI with contrast enhancement.
Heterogeneous mass with high intensity on both T1WI and T2WI is observed (arrowheads). High intensity is probably representing high
protein liquid. Peritumoral edema is also seen (arrow).
256

edema can be seen in the huge or malignant tumors
(Figure 4).
Contrast MR images are essential for evaluation
of GCT; in particular, small masses may be equiv-
ocal on plain MR. After IV injection of Gd-DTPA,
almost all lesions are enhanced markedly and
heterogeneously. The heterogeneity varied from mildly
to severely. Unlike the previous contrast CT and MRI
reports, which showed homogeneous enhancement
[6,7,12–14], the heterogeneous enhancement is com-
mon findings. The tumors with cystic components
demonstrate high heterogeneity. Pathological hetero-
geneity of tumor tissue may also cause heterogeneous
enhance. With a high-resolution MRI, cystic compo-
nents are more frequently seen than reported before;
about 50% of germinomas and 90% of other GCTs in
our series have cystic components. The lesions reveal
either multiple microcystic components or several
macrocystic components. Teratomas are characteristic
compared with other GCTs because of its higher het-
erogeneity with honeycomb-like appearance due to
multiple cystic components, high incidence of calcifi-
cation, and fatty substances [11] (see Figure 3).
Pineal parenchymal cell tumors:
pineocytoma and pineoblastoma
Tumors that arise from pineal parenchymal cell account
for less than 15% of all pineal region neoplasms
[2]. Unlike germinomas these tumors may be found
in patients beyond the third decade of life. There

A B

Figure 6. Pineocytoma in a 32-year-old man. (A) Sagittal T1WI. (B) Sagittal T2WI. (C) Sagittal T1WI with contrast enhancement. Intrinsic
pineal mass fills pineal cistern and compressing vermis (arrowheads). Mass shows hyperintense on T2WI, and relatively homogeneous
enhancement.
 257

are two types of pineal cell neoplasms: pineocytoma
and pineoblastoma. Pineocytomas are benign, well-
delineated tumors with mature cells that are histo-
logically almost indistinguishable from normal pineal
parenchyma. Pineoblastomas are malignant neoplasms
that are composed of undifferentiated or immature
pineal cells. The reports of image findings for pineal
parenchymal tumors varied greatly [11,15,16]. The
specific diagnosis of histopathologic type in pineal
cell tumors is often not possible with MRI [2]. MRI
depicts pineal neoplasms as lobulated, solid tumors
which enhance densely with contrast. MR signal inten-
sities vary, but generally pineoblastomas are essentially
isointense to gray matter on T2WI (Figure 5), possibly
related to the known paucity of cytoplasm and over-
all dense cellularity seen in these lesions. Pineoblas-
tomas may also show brain edema or invasion in the
surrounding brain parenchyma. Pineocytomas, with
a higher degree of cytoplasm, should have relatively
higher signal intensity on T2WI (Figure 6).
Pineal cyst
Non-neoplastic pineal cysts are benign cystic lesions
that are lined by collagenous fibers, glial cells, and
normal pineal parenchymal cells [1]. Small asymp-
tomatic non-neoplastic pineal gland cysts are common
incidental findings, seen in up to 40% of routine
autopsies. Occasionally, the imaging appearance of
benign pineal cyst is indistinguishable from small cys-
tic neoplasms. The pineal cyst is round and smoothly
marginated on MRI (Figure 7). It can be small and lie
within a small portion of the gland, or it can replace
the entire structure. The contents of the pineal cyst
are homogeneous, and are either isointense to cere-
brospinal fluid (CSF) or diffusely hyperintense. The

C
B

Figure 7. Large pineal cyst in a 67-year-old women. (A) Sagittal T1WI. (B) Axial T2WI. (C) Sagittal T1WI (MPRAGE) with contrast
enhancement. Round, homogeneous mass in pineal compresses superior colliculi without obstruction of the aqueduct (arrowhead). Mass
is only slightly higher intensity than CSF on T2WI. No enhancement is seen.
258

relative hyperintensity of the cyst fluid may relate to Miscellaneous lesions

factors such as isolation form flow, high protein con-
tent, or even old hemorrhage [2]. The pineal cyst usu- Glioma
ally does not enhance, but surrounding residual pineal Pineal region glial cell tumor usually extend from brain
tissue will. parenchymal structures that lie in close proximity to

A B

Figure 8. Anaplastic glioma in a 54-year-old woman. (A) Axial T1WI. (B) Axial T2WI. (C) Sagittal T1WI with contrast enhancement.
Pineal region mass compresses superior colliculi just like an intrinsic pineal mass. However, swelling and invasion in the corpus callosum
splenium is clearly seen (arrow). Note dissemination in the posterior fossa (arrowhead).
 259

B C

Figure 9. Meningioma of the tentorial apex in a 40-year-old woman. (A) Sagittal T1WI. (B) Coronal T2WI. (C) Axial T1WI with contrast
enhancement. Large tumor with typical signal intensities as meningioma markedly compresses midbrain, cerebellum, and corpus callosum
(arrowheads).

the pineal gland, such as brainstem, corpus callosum
as well as thalamus, and only rarely originate from
the stroma of the pineal gland itself (Figure 8).
Tectal gliomas are usually low-grade astrocytomas that
enlarge the tectum. The aqueduct may be engulfed and
occluded, resulting in obstructive hydrocephalus. The
gliomas from thalami or corpus callosum tend to be
higher grade: anaplastic astrocytoma or glioblastoma.
Meningioma
Pineal region meningiomas usually extend from adja-
cent tentorial apex. Compared with white matter,
meningiomas on T1WI are almost always hypointense.
On T2WI, approximately one-half are isointense
and one-half hyperintense, with a rare tumor being
hypointense in relationship to the cerebral cortex.
Contrast enhancement is usually strong and relatively
homogeneous (Figure 9). Relationship to the falx and
tentorium as well as the thickening of the adjacent dura
are important for differential diagnosis.
Metastatic disease
Specific locations of intracerebral metastases gener-
ally coincide with the respective lobar volumes. Very
rarely, metastasis to the pineal parenchyma can occur
and mimic the primary pineal gland masses. Signal
intensity patterns and contrast enhancement of pineal
metastases on MRI are usually non-specific and basi-
cally the same as in other locations (Figure 10).
Vascular lesions
The most common vascular mass in the pineal region
is an elongated, tortuous basilar artery that elevates
and compresses the third ventricle. Occasionally,
260
C B
Figure 10. Metastatic adenocarcinoma to the pineal gland in a 61-year-old man. (A) Sagittal T1WI. (B) Axial T2WI. (C) Sagittal T1WI
with contrast enhancement. Relatively hypointense mass on T2WI locates at pineal region (arrows). Differential diagnosis may include
the pineal cell tumor, glioma, and meningioma; in this case, however, multiple intracerebral metastases also exited.
aneurysms of the P2 or P3 segments of the posterior
cerebral artery occur here.
6.
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Address for offprints: Yukunori Korogi, Department of Radiology,
Kumamoto University School of Medicine, 1-1-1 Honjo,
Kumamoto 860, Japan; Tel.: 81-96-373-5262; Fax: 81-96-362-4330;
E-mail: yuku@kaiju.medic.kumamoto-u.ac.jp