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Table of Contents    
LETTER TO EDITOR
Year : 2016  |  Volume : 64  |  Issue : 2  |  Page : 351-354

Vanishing tumor of the tectal plate – stressing the need for a stringent radiological surveillance: A review of possible pathogenetic mechanisms


1 Department of Neurosurgery, Apollo Specialty Hospital, Nellore, Andhra Pradesh; Department of Neurosurgery, MaxCure Hospitals, Hyderabad, Telangana, India
2 Department of Radiology, MaxCure Hospitals, Hyderabad, Telangana, India

Date of Web Publication3-Mar-2016

Correspondence Address:
Ravi Dadlani
Department of Neurosurgery, Apollo Specialty Hospital, Nellore, Andhra Pradesh; Department of Neurosurgery, MaxCure Hospitals, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.177614

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How to cite this article:
Dadlani R, Kumar L V. Vanishing tumor of the tectal plate – stressing the need for a stringent radiological surveillance: A review of possible pathogenetic mechanisms. Neurol India 2016;64:351-4

How to cite this URL:
Dadlani R, Kumar L V. Vanishing tumor of the tectal plate – stressing the need for a stringent radiological surveillance: A review of possible pathogenetic mechanisms. Neurol India [serial online] 2016 [cited 2020 Nov 25];64:351-4. Available from: https://www.neurologyindia.com/text.asp?2016/64/2/351/177614


Sir,

A spontaneously regressing intracranial tumor, in the absence of any intervention known to cause its regression, is called a 'vanishing tumor' or a 'ghost tumor.' It is reported in 1:60,000 to 1:100,000 cases of malignant tumors.[1],[2],[3],[4],[5] The commonest pathology in these spontaneously resolving lesions is usually presumed to be a primary CNS lymphoma[PCNSL].[1],[2],[3],[4],[5],[6],[7]

A 22-year-old male student from Kenya presented with a 9-month history of diplopia and headaches. His initial magnetic resonance imaging (MRI) revealed a pineal lesion [Figure 1], for which he received a tapering course of oral steroids only. He had partial remission of the clinical symptoms and was planned for a surgical excision based on the original MRI when he was seen at our institute. However, a repeat MRI [Figure 2] was recommended, which revealed the near-complete resolution of the tumor. He was managed non-surgically and has been advised surveillance MRI scan in 6 months. Cerebrospinal fluid (CSF) test results and blood markers such as human chorionic gonadotropin (hCG), β-subunit of hCG, alpha fetoprotein (AFP), and carcinoembryonic antigen (CEA) were within normal range.
Figure 1: Initial MRI study of the patient. The top panel depicts the plain images: (a) T1-weighted (W) sagittal, (b) T2W coronal, and (c) T2W axial. The tumor is seen as a well-defined lesion in the pineal region iso- to hyperintense to the gray matter. A few cysts are visualized in b and c. There was no significant hydrocephalus. The bottom panel demonstrates corresponding MRI sections after gadolinium administration revealing a signifi cant postcontrast enhancement. (d) Sagittal, (e) Coronal and (f) Axial images define the relationship of the lesion to the deep venous system

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Figure 2: Follow-up MRI study of the patient. The top panel depicts the plain images: (a) T2W sagittal, (b) T2W coronal, and (c) T2W axial. The lesion demonstrates more than 90% resolution. (d-f) Postcontrast images, with a small tumor seen in the axial section

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Recently, an attempt was made at classifying 'ghost tumors' into tumor-like lesions spontaneously regressing on follow-up ('vanishing tumors'), space-occupying lesions that are non-neoplastic ('tumor-like lesions'), and variations in normal anatomy mimicking a tumor ('false tumors').[2]

However, a 'vanishing' brain tumor has generally been defined as a tumor that undergoes a spontaneous reduction in size of more than 70% without any definitive treatment (other than steroids).[1],[3],[4],[5],[6]

A review of literature was undertaken in three databases, viz., MEDLINE, Scopus, and EMBASE, and only five articles were identified that fit the search criteria [Table 1].
Table 1: Review of literature of spontaneous regression of germinomas in proximity to the pineal region

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Approximately, 60%–70% of all pineal region tumors are known to be germinomas, with 90% occurring in the young adult male population.[7] Although the present case lacked a histological diagnosis, the patient profile and radiological findings strongly favored the possibility of a germinoma.

There have been several theories proposed for the spontaneous regression of tumors, most notably, immunological responses, spontaneous apoptosis, possible effect of diagnostic X-rays (CT scans), effects of CSF drainage, and corticosteroid therapy.[5] Infection and fever have also been implicated as possible stimuli for regression.[3]

Surgical intervention, most often a biopsy, associated with tumor regression in approximately 40% of tumors, is another proposed hypothesis.[3],[4]

The etiopathogenesis of the vanishing tumor remains conjectural. Although histological diagnosis is not always possible, as illustrated in this case and in the literature reviewed, stringent radiological surveillance of patients with tumors in the pineal region is recommended, especially just prior to biopsy or surgical excision, to avoid intraoperative surprises.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Okita Y, Narita Y, Miyakita Y, Ohno M, Fukushima S, Maeshima A, et al. Long-term follow-up of vanishing tumors in the brain: How should a lesion mimicking primary CNS lymphoma be managed? Clin Neurol Neurosurg 2012;114:1217-21.  Back to cited text no. 1
    
2.
Frassanito P, Tamburrini G, Massimi L, Caldarelli M, Di Rocco C. Ghost tumors of the central nervous system: Definition, clinical implications and proposal of classification. World Neurosurg 2015;84:663-70.  Back to cited text no. 2
    
3.
Ide M, Jimbo M, Yamamoto M, Hagiwara S, Aiba M, Kubo O. Spontaneous regression of primary intracranial germinoma. A case report. Cancer 1997;79:558-63.  Back to cited text no. 3
    
4.
Murai Y, Kobayashi S, Mizunari T, Ohaki Y, Adachi K, Teramoto A. Spontaneous regression of a germinoma in the pineal body after placement of a ventriculoperitoneal shunt. J Neurosurg 2000;93:884-6.  Back to cited text no. 4
    
5.
Ono H, Shin M, Takai K, Oya S, Mukasa A, Saito N. Spontaneous regression of germinoma in the pineal region before endoscopic surgery: A pitfall of modern strategy for pineal germ cell tumors. J Neurooncol 2011;103:755-8.  Back to cited text no. 5
    
6.
Fujimaki T, Mishima K, Asai A, Suzuki I, Kirino T. Spontaneous regression of a residual pineal tumor after resection of a cerebellar vermian germinoma. J Neurooncol 1999;41:65-70.  Back to cited text no. 6
    
7.
Fang AS, Meyers SP. Magnetic resonance imaging of pineal region tumours. Insights Imaging 2013;4:369-82.  Back to cited text no. 7
    


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