J Korean Neurosurg Soc.  2014 Dec;56(6):504-508. 10.3340/jkns.2014.56.6.504.

Primary Malignant Melanoma in the Pineal Region

• Park JH
• Hong YK

• KMID: 2191145
• DOI: http://doi.org/10.3340/jkns.2014.56.6.504

Abstract

A 59-year-old male patient had 5-month history of gait disturbance and memory impairment. His initial brain computed tomography scan showed 3.5x2.8 cm sized mass with high density in the pineal region. The tumor was hypointense on T2 weighted magnetic resonance images and hyperintense on T1 weighted magnetic resonance images with heterogenous enhancement of central portion. The tumor was totally removed via the occipital transtentorial approach. Black mass was observed in the operation field, and after surgery, histopathological examination confirmed the diagnosis of malignant melanoma. Whole spine magnetic resonance images and whole body 18-fluoro-deoxyglucose positron emission tomography could not demonstrate the primary site of this melanoma. Scrupulous physical examination of his skin and mucosa was done and dark pigmented lesion on his left leg was found, but additional studies including magnetic resonance images and skin biopsy showed negative finding. As a result, final diagnosis of primary pineal malignant melanoma was made. He underwent treatment with the whole brain radiotherapy and extended local boost irradiation without chemotherapy. His preoperative symptoms were disappeared, and no other specific neurological deficits were founded. His follow-up image studies showed no recurrence or distant metastasis until 26 weeks after surgery. Primary pineal malignant melanomas are extremely rare intracranial tumors, and only 17 cases have been reported since 1899. The most recent case report showed favorable outcome by subtotal tumor resection followed by whole brain and extended local irradiation without chemotherapy. Our case is another result to prove that total tumor resection with radiotherapy can be the current optimal treatment for primary malignant melanoma in the pineal region.

Keyword

Primary melanoma; Pineal melanoma; Malignant melanoma

MeSH Terms

Biopsy
Brain
Diagnosis
Drug Therapy
Follow-Up Studies
Gait
Humans
Leg
Male
Melanoma*
Memory
Middle Aged
Mucous Membrane
Neoplasm Metastasis
Physical Examination
Positron-Emission Tomography
Radiotherapy
Recurrence
Skin
Spine

Figure

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  Fig. 1 Initial computed tomography scan showing a high density mass in the pineal region with minimal obstructive hydrocephalus suspected.

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  Fig. 2 Preoperative magnetic resonance imaging. The tumor showed dense hypointense rim on T2 weighted images (A) and FLAIR images (C), which was hyperintense on T1 weighted images (B). It contained heterogenous enhancement of central portion (D).

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  Fig. 3 Intraoperative photograph (left occipital transtentorial approach) showing basal vein of Rosenthal and black tumor mass in the pineal region after opening the tentorium. The tumor was adhered to midbrain.

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  Fig. 4 Postoperative magnetic resonance imaging. Grossly total resection of the tumor was done and there was no evidence of remnant tumor nor ventriculomegaly and no other complications. Only minimal postoperative change was noted at the tumor bed area.

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  Fig. 5 Histologic finding of tumor specimen. Histopathological examination revealed anaplastic spindled or epithelioid cells with large amounts of melanin pigmentations (H&E ×40).

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