Anatomy and Surgical Approaches to Pineal Region Tumors (PRTs)

Tumors of the pineal region (PRTs) are rare and account for 1% of all intracranial tumors in adults and 3–8% in pediatrics. Their management imposes a major challenge to the treating team and is governed by age of the patient, clinical presentation, tumor markers, pathology, location and extension, as well as the surgeon’s preference and experience. The options available for treatment of PRTs include surgery, radiotherapy, and chemotherapy. Evolution in modern imaging and advances in surgical facilities have facilitated the introduction of safer and less invasive surgical interventions. The most commonly adopted ones in our contemporary practice are the Endoscopic Assisted Paramedian Supracerebellar Infratentorial Approach (PM-SCITA) or its standard midline version (M-SCITA), the Occipital Transtentorial Approach (OTA), and the Posterior Interhemispheric Transcallosal Approach (PITA). However, the Endoscopic Third Ventriculoscopy with concomitant biopsy (EVS + BX) is the gold standard primary surgical intervention for management of PRTs with hydrocephalus, positive tumor markers, and suspected germ cell tumors or other radiosensitive and chemotherapy sensitive neoplasms. Obviously, each one of these surgical approaches has its own merits, indications, and limitations and their selection should be individualized and based on defined management strategies.