Indian Journal of Nuclear Medicine

: 2017  |  Volume : 32  |  Issue : 3  |  Page : 239--240

Extraneural metastases in an operated case of pinealoblastoma identified on fluorodeoxyglucose positron emission tomography/computed tomography

Piyush Chandra, Sneha Shah, Archi Agrawal, Nilendu Purandare, Venkatesh Rangarajan 
 Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India

Correspondence Address:
Venkatesh Rangarajan
Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Dr. E. Borges Road, Parel, Mumbai - 400 012, Maharashtra


Extraneural (EN) metastases and leptomeningeal (LM) metastases from certain primary central nervous system (CNS) tumors, such as pinealoblastomas, are not very common and mostly detected on autopsy. Clinical detection of this entity is, however, very rare and can be attributed to increasing overall survival or probably increased use of surveillance imaging in patients with brain tumors. We demonstrate through this case the potential adjunctive role of positron emission tomography/computed tomography in the identification of asymptomatic LM/EN metastases in high-risk primary CNS tumors.

How to cite this article:
Chandra P, Shah S, Agrawal A, Purandare N, Rangarajan V. Extraneural metastases in an operated case of pinealoblastoma identified on fluorodeoxyglucose positron emission tomography/computed tomography.Indian J Nucl Med 2017;32:239-240

How to cite this URL:
Chandra P, Shah S, Agrawal A, Purandare N, Rangarajan V. Extraneural metastases in an operated case of pinealoblastoma identified on fluorodeoxyglucose positron emission tomography/computed tomography. Indian J Nucl Med [serial online] 2017 [cited 2021 Apr 16 ];32:239-240
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Full Text

Patient is a 13-year-old female child, a known case of pineoblastoma, who underwent ventriculoperitoneal shunt diversion followed by a surgical decompression and adjuvant radiation to the brain and spine 2 years back. Baseline spinal magnetic resonance imaging (MRI) was negative for disease (images not shown here). The patient was currently asymptomatic, and routine follow-up MRI survey of the brain and spine revealed a T2 hypointense and enhancing intradural lesion in sacral region at S1–S2 level [T2-weighted sagittal, [Figure 1]a and T1-weighted postcontrast sagittal, [Figure 1]b, long white arrows]. Rest of the spine and brain was reported as normal. Positron emission tomography/computed tomography (PET/CT) was done for restaging the disease and revealed 2-fluorodeoxyglcose uptake in the intraspinal metastases in the sacral region [sagittal fused PET/CT, [Figure 1]c, long white arrows]. In addition, PET/CT identified intracranial metastases in the left pontomedullary cistern, which was not reported on initial read of the brain MRI [transaxial PET; [Figure 1]d, black arrow, transaxial magnetic resonance (MR); [Figure 1]e and fused PET/MR, obtained using an integrated registration software; [Figure 1]f, white arrowhead], multiple skeletal metastases [maximum intensity projection; [Figure 2]a black arrows, and transaxial PET/CT; [Figure 2]b, white arrow], and peritoneal deposit in the pelvis with associated ascites [sagittal PET/CT; [Figure 2]c, white arrow].{Figure 1}{Figure 2}

Extraneural (EN) spread from primary central nervous system (CNS) tumors is very rare and seen only in about 0.98% of the patients. In children, primary CNS tumors which have propensity for EN spread includes medulloblastoma, ependymoma, glioblastoma multiforme, pinealoblastoma, and germ cell tumors, with the highest incidence seen in medulloblastomas.[1] The most common sites of metastases include liver, lung, bone, and bone marrow.[2] Studies have also shown an increased incidence of EN metastases in patients with diversion ventriculoperitoneal shunts.[3] Pineoblastomas, a supratentorial primitive neuroectodermal tumor, constitutes 3%–4% of all pediatric brain tumors and considered to have worse clinical outcomes compared to infratentorial primitive neuroectodermal tumors (medulloblastoma).[4] Pineoblastomas have a propensity to spread along cerebrospinal fluid with leptomeningeal (LM) dissemination seen in up to 23% of patients at initial staging and about 44% patients at disease recurrence in one of the case series.[5] EN skeletal metastases from pineoblastomas have also been previously reported.[6] Few case studies have shown the potential clinical utility of PET/CT in diagnosing LM metastases in non-CNS malignancies although its role in identifying LM/EN metastases from primary CNS tumors remains yet to be explored.[7],[8] PET/CT imaging in addition to MRI can be of potential clinical utility in planning appropriate treatment in high-risk aggressive CNS tumors (such as medulloblastoma/pineoblastoma), as shown in the case above. Early diagnosis and treatment initiation through such precision imaging, although by no means curative, may nonetheless better the quality of life.

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