Complications of Therapies for Pineal Region Tumors in Children

Complications After Surgery

• Biopsy: Zacharia and Bruce recently performed an extensive review of all major series of stereotactic biopsy for pineal region lesions;they report an overall morbidity rate of 1.3% and an overall mortality rate of 8.1% (99). Possible complications include postoperative hemorrhage, infection, and CSF dissemination of tumor cells. If ETV is performed for CSF diversion, additional potential complications include vascular injury, subdural hematoma formation, and persistent hydrocephalus requiring shunt placement.
• Surgical resection: Open resection of tumors of the pineal region has an overall mortality rate of up to 8% and a morbidity rate less than 10%, with permanent morbidity in up to 3% of patients. The most common complications include ataxia, altered mental status, and impaired extraocular movements including intranuclear palsy, Parinaud syndrome, impaired upward gaze, and/or fourth cranial nerve palsy. Other potential complications of surgery include infection, shunt failure or dysfunction, hemorrhage, and venous infarct due to manipulation of venous sinuses and large draining veins. Preoperative radiation treatment, preoperative neurological deficit, and malignant or infiltrative histology are associated with increased risk of postoperative complications, particularly postoperative hemorrhage. Seizure, hemianopia, and sensory or motor deficits may result if a supratentorial approach is used; however, deficits are most often transient. Venous air embolism and hypotension may occur if the sitting position is used.

Complications After Radiotherapy

The risk of sequelae due to the toxic effects of ionizing radiation on the developing CNS increases in younger patients and those receiving greater doses and larger radiation fields. 

• Endocrine dysfunction and intellectual retardation: These adverse effects occur in up to 25% of children who undergo radiotherapy for pineal germinomas (40, 75). 
• Impaired wound healing, wound dehiscence, or CSF leak

Complications After Chemotherapy

Although chemotherapy is well tolerated in children, it is not without side effects.  The European international cooperative trial demonstrated a mortality rate of 10% (7 of 71 patients receiving chemotherapy as a main arm of treatment secondary to toxic effects of chemotherapy (6).The most common side effects are as follows:

• Infections: Infectious complications due to leukopenia are the most common side effect of chemotherapeutic treatment for pineal region tumors.
• Bone marrow suppression: Bone marrow suppression can lead to anemia, thrombocytopenia, and leukopenia, resulting in fatigue, increased susceptibility to infection, and bruising.
• Secondary cancer: The rate of secondary cancer, particularly leukemia, is low and does not alter the risk-to-benefit ratio of chemotherapy for patients with malignant germ cell tumors.