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{{SK}} Pineal teratomas; Pineal teratoblastoma; Pineal teratoid tumor; Pineal germ cell tumors; Pineal gland tumors; Brain tumor
{{CMG}}{{AE}}{{SR}} {{AE }}{{NA}}
{{SI}}
{{SK}} Pineal teratomas; Pineal teratoblastoma ; Pineal teratoid tumor; Pineal germ cell tumors; Pineal gland tumors; Brain tumor


==Overview==
=Overview=
*Pineal teratoma is an uncommon extra-axial intracranial cancer, which can have varied components and thus a wide range of appearances.<ref name=overviewpt1>Intracranial teratomas. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015</ref>
Pineal teratoma is an uncommon [[extra-axial intracranial]] cancer, which can have varied components and thus a wide range of appearances.<ref name="overviewpt1">Intracranial teratomas. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015</ref> The most frequent location of these tumors is [[pineal]] and [[suprasellar]] region. Clinical signs and symptoms depend on the localization of the tumor. Most commonly include signs of increased [[intracranial pressure]], [[Parinaud's syndrome]], [[bitemporal hemianopsia]] and signs of endocrine deficiency. Mature teratomas are [[benign]], mature, well-differentiated [[Cyst|cystic]] lesions; whereas immature teratomas are poorly differentiated lesions with solid components and malignant transformation. Symptoms of pineal teratoma include [[headache]], [[vomiting]], [[somnolence]], and [[weakness]]. Compression of the superior colliculi by pineal teratoma can lead to a characteristic gaze palsy, known as [[Parinaud syndrome]].
*Pineal teratoma may be classified into three subtypes: mature, immature, and mature with malignant transformation.
 
*Mature teratomas are benign, mature, well-differentiated cystic lesions; whereas immature teratomas are poorly differentiated lesions with solid components and malignant transformation.<ref name=overviewteratoma1>Teratoma. Dr Jeremy Jones and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/teratoma. Accessed on December 10, 2015</ref>
= Classification =
*On other occasions, mature teratomas contain elements that undergo malignant transformation (most commonly squamous components).
 
:*Fat
* Pineal teratoma may be [[Classification|classified]] into three sub-types:
:*Cystic spaces due to mucous production or other exocrine products
** Mature
:*Soft-tissue from any part of the body
** Immature
:*Calcification, including teeth
** Mature with [[malignant]] transformation
*On microscopic histopathological analysis, pineal teratoma is characterized by cells originating from at least two and usually all three embryonic layers ([[ectoderm]], [[mesoderm]], and [[endoderm]]). The histological subtype may not necessarily determine the biological behavior.<ref name=pathpt1>Pathology of extra-axial intracranial teratoma. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015</ref>
* Mature teratomas are [[benign]], mature, well-differentiated [[Cyst|cystic]] lesions; whereas immature teratomas are poorly differentiated lesions with solid components and malignant transformation.<ref name="overviewteratoma1">Teratoma. Dr Jeremy Jones and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/teratoma. Accessed on December 10, 2015</ref>
*Pineal teratomas may be associated with elevated levels of [[AFP|serum alpha fetoprotein (AFP)]] or [[CEA|serum carcinoembryonic antigen (CEA)]].<ref name=pathpt1>Pathology of extra-axial intracranial teratoma. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015</ref>
* On other occasions, mature teratomas contain elements that undergo malignant transformation (most commonly squamous components).
*Pineal teratoma must be differentiated from [[lipoma|pineal lipoma]], [[Dermoid cyst|pineal dermoid]], and other [[pineal gland tumors]].<ref name=ddxpt1>Differential diagnosis of extra-axial intracranial teratomas. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015</ref>
** Fat
*Pineal teratoma is a rare disease that tends to affect the children and young adult population.<ref name=clinpt1>Clinical presentation of extra-axial intracranial teratoma. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015</ref>
** Cystic spaces due to [[mucus]] production or other [[exocrine]] products
*Common complications of pineal teratoma include:<ref name=clinpt1>Clinical presentation of extra-axial intracranial teratoma. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015</ref>
** Soft-tissue from any part of the body
:*[[Obstructive hydrocephalus]]
** Calcification, including teeth
*The clinical presentation of pineal teratoma is mainly from the [[obstructive hydrocephalus]] secondary to compression of the [[tectum]] of the [[midbrain]] and obstruction of the aqueduct. Symptoms of pineal teratoma include [[headache]], [[vomiting]], [[somnolence]], and [[weakness]].<ref name=clinpt1>Clinical presentation of extra-axial intracranial teratoma. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015</ref>
 
*Compression of the superior colliculi by pineal teratoma can lead to a characteristic gaze palsy, known as [[Parinaud syndrome]].
= Pathophysiology =
*Head CT scan and brain MRI may be helpful in the diagnosis of pineal teratoma.<ref name=radiopt1>Radiographic features of intracranial teratoma. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015</ref> Given their extremely variable histological components, CT/MRI imaging also tends to be heterogeneous, with tumors typically demonstrating a mixture of tissue densities and signal intensity. Fat, if present, is helpful in narrowing the differential.
 
*On head CT scan, pineal teratoma is characterized bya mass with fat and calcification, which is usually solid / "clump-like". It usually has cystic and solid components, contributing to an irregular outline. Solid components demonstrate variable enhancement on contrast administration.<ref name=radiopt1>Radiographic features of intracranial teratoma. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015</ref>
* On microscopic histopathological analysis, pineal teratoma is characterized by cells originating from at least two and usually all three embryonic layers ([[ectoderm]], [[mesoderm]], and [[endoderm]]). The histological subtype may not necessarily determine the biological behavior.<ref name="pathpt1">Pathology of extra-axial intracranial teratoma. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015</ref>
*On brain MRI, pineal teratoma is characterized by:<ref name=radiopt1>Radiographic features of intracranial teratoma. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015</ref>
 
= Natural history, complications, and Prognosis =
 
* Pineal teratomas may be associated with elevated levels of [[AFP|serum alpha fetoprotein (AFP)]] or [[CEA|serum carcinoembryonic antigen (CEA)]].<ref name="pathpt1">Pathology of extra-axial intracranial teratoma. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015</ref>
* Pineal teratoma must be differentiated from [[lipoma|pineal lipoma]], [[Dermoid cyst|pineal dermoid]], and other [[pineal gland tumors]].<ref name="ddxpt1">Differential diagnosis of extra-axial intracranial teratomas. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015</ref>
* Pineal teratoma is a rare disease that tends to affect the children and young adult population.<ref name="clinpt1">Clinical presentation of extra-axial intracranial teratoma. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015</ref>
* Common complications of pineal teratoma include:<ref name="clinpt1">Clinical presentation of extra-axial intracranial teratoma. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015</ref>
**[[Obstructive hydrocephalus]]
* Head CT scan and brain MRI may be helpful in the diagnosis of pineal teratoma.<ref name="radiopt1">Radiographic features of intracranial teratoma. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015</ref> Given their extremely variable histological components, CT/MRI imaging also tends to be heterogeneous, with tumors typically demonstrating a mixture of tissue densities and signal intensity. Fat, if present, is helpful in narrowing the differential.
* On head CT scan, pineal teratoma is characterized by a mass with fat and calcification, which is usually solid / "clump-like". It usually has cystic and solid components, contributing to an irregular outline. Solid components demonstrate variable enhancement on contrast administration.<ref name="radiopt1">Radiographic features of intracranial teratoma. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015</ref>
* On brain MRI, pineal teratoma is characterized by:<ref name="radiopt1">Radiographic features of intracranial teratoma. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015</ref>


{| style="border: 0px; font-size: 90%; margin: 3px; width:1200px align=center"
{| style="border: 0px; font-size: 90%; margin: 3px; width:1200px align=center"
|valign=top|
| valign="top" |
|+
|+
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|MRI component}}
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|MRI component}}
! style="background: #4479BA; width: 900px;" | {{fontcolor|#FFF|Findings}}
! style="background: #4479BA; width: 900px;" | {{fontcolor|#FFF|Findings}}
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" align=center |
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" align="center" |
T1
T1
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
*Hyperintense components due to fat and proteinaceous/lipid-rich fluid
* Hyperintense components due to fat and proteinaceous/lipid-rich fluid.
*Intermediate components of soft tissue
* Intermediate components of [[soft tissue]].
*Hypointense components due to calcification and blood products
* Hypointense components due to calcification and blood products.
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" align=center|
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" align="center" |
T1 with contrast
T1 with contrast
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |


*Solid soft tissue components show enhancement
* Solid soft tissue components show enhancement.
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" align=center|
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" align="center" |
T2
T2
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
*Mixed signal from differing components
* Mixed signal from differing components.
|}
==History and Symptoms==
 
* The clinical presentation of pineal teratoma is mainly from the [[obstructive hydrocephalus]] secondary to compression of the [[tectum]] of the [[midbrain]] and obstruction of the aqueduct.
*Symptoms of pineal teratoma include [[headache]], [[vomiting]], [[somnolence]], and [[weakness]].<ref name="clinpt1" />
* Compression of the superior colliculi by pineal teratoma can lead to a characteristic gaze palsy, known as [[Parinaud syndrome]].
 
==Treatment==
 
* The mainstay of therapy for immature pineal teratoma is combined [[radiotherapy]] and [[chemotherapy]].
*The residual or mature component is removed surgically.<ref name="pmid11270541">{{cite journal| author=Friedman JA, Lynch JJ, Buckner JC, Scheithauer BW, Raffel C| title=Management of malignant pineal germ cell tumors with residual mature teratoma. | journal=Neurosurgery | year= 2001 | volume= 48 | issue= 3 | pages= 518-22; discussion 522-3 | pmid=11270541 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11270541  }} </ref>
 
{| class="wikitable"
|+
! colspan="2" |Management Options of Penial Gland Tumors
|-
!'''[[CSF]] diversion'''
|
* The optimal surgical strategy to treat acute [[hydrocephalus]] in patients with [[Pineal tumor|pineal tumors]] is uncertain.
*[[CSF]] diversion [[Ventriculoperitoneal shunt|ventriculoperitoneal [VP] shunt]] or third [[ventriculostomy]] may be necessary in symptomatic patients, although debulking surgery may obviate the need for this procedure.
* When [[CSF]] diversion is necessary, endoscopic third [[ventriculostomy]] can be carried out at the same time as the biopsy and is preferred over [[Ventriculoperitoneal shunt|VP shunts]], which can be complicated by infection, shunt malfunction, [[subdural hematoma]], and rarely, tumor seeding.
|-
!'''Surgical resection'''
|
* Some series report long-term survival with surgery alone, even in patients with [[pineoblastomas]].
* Indeed, for [[pineoblastomas]], gross total surgical resection appears to correlate with improved survival.
* Patients with symptomatic recurrent [[pineocytomas]] should also be considered for surgical resection of the lesion.
|-
!'''Radiation'''
|
* Postoperative adjuvant [[radiation therapy]] (RT) is frequently (but not universally) recommended, and local control is dose-dependent.
* The incidence of leptomeningeal recurrence was significantly lower among patients receiving CSI compared with those who did not.
* The five-year survival rates were 86 and 49 percent for [[pineocytomas]] and non-pineocytomas, respectively.
* Adjuvant RT is not universally recommended after gross total resection of a [[pineocytoma]].
|-
!'''Stereotactic radiosurgery'''
|
*[[Stereotactic radiosurgery|Stereotactic radiosurgery (SRS)]] is emerging as a useful treatment alternative for [[pineocytomas]], although experience is limited.
* The precise radiation fields that are defined by MRI or CT-computerized treatment planning minimize damage to the surrounding brain, and the risks of general anesthesia and [[craniotomy]] are avoided.
 
*[[Stereotactic surgery|SRS]] is increasingly being used to treat [[Pineal gland|pineal region]] tumors, either as an additional therapy after conventional treatments or as a primary treatment.
* Due to the low rate of side effects, [[Stereotactic surgery|SRS]] may develop into an attractive alternative to microsurgery in de novo diagnosed [[pineocytomas]]. In malignant tumors, [[Stereotactic surgery|SRS]]<nowiki/>may be routinely applied in a multimodality treatment schedule supplementary to conventional irradiation.
|-
!'''Chemotherapy as part of multimodality therapy'''
|
* The similarity of [[Pineoblastoma|pineoblastomas]] to [[medulloblastomas]] in terms of their clinical behavior and tendency for leptomeningeal seeding has led to the use of similar [[chemotherapy regimens]] in patients with [[pineoblastoma]] as part of a multimodality approach.
*[[Chemotherapy]] has been used to delay radiation therapy in very young children, for whom the long-term neurocognitive and developmental side effects of craniospinal irradiation (CSI) are a major concern.
* The importance of radiation therapy as a component of the initial treatment of [[Primitive neuroectodermal tumor|supratentorial primitive neuroectodermal tumors (PNETs)]] is also supported by the German HIT-SKK87 and HIT-SKK92 protocols, as well as the Canadian pediatric brain tumor protocol.
|}
|}
*The mainstay of therapy for immature pineal teratoma is combined [[radiotherapy]] and [[chemotherapy]]. The residual or mature component is removed surgically.<ref name="pmid11270541">{{cite journal| author=Friedman JA, Lynch JJ, Buckner JC, Scheithauer BW, Raffel C| title=Management of malignant pineal germ cell tumors with residual mature teratoma. | journal=Neurosurgery | year= 2001 | volume= 48 | issue= 3 | pages= 518-22; discussion 522-3 | pmid=11270541 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11270541  }} </ref>


==References==
==References==

Latest revision as of 21:51, 14 October 2019


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sujit Routray, M.D. [2] Associate Editor(s)-in-Chief: Nabeel Ahmed, M.B.B.S

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Synonyms and keywords: Pineal teratomas; Pineal teratoblastoma ; Pineal teratoid tumor; Pineal germ cell tumors; Pineal gland tumors; Brain tumor

Overview

Pineal teratoma is an uncommon extra-axial intracranial cancer, which can have varied components and thus a wide range of appearances.[1] The most frequent location of these tumors is pineal and suprasellar region. Clinical signs and symptoms depend on the localization of the tumor. Most commonly include signs of increased intracranial pressure, Parinaud's syndrome, bitemporal hemianopsia and signs of endocrine deficiency. Mature teratomas are benign, mature, well-differentiated cystic lesions; whereas immature teratomas are poorly differentiated lesions with solid components and malignant transformation. Symptoms of pineal teratoma include headache, vomiting, somnolence, and weakness. Compression of the superior colliculi by pineal teratoma can lead to a characteristic gaze palsy, known as Parinaud syndrome.

Classification

  • Pineal teratoma may be classified into three sub-types:
    • Mature
    • Immature
    • Mature with malignant transformation
  • Mature teratomas are benign, mature, well-differentiated cystic lesions; whereas immature teratomas are poorly differentiated lesions with solid components and malignant transformation.[2]
  • On other occasions, mature teratomas contain elements that undergo malignant transformation (most commonly squamous components).
    • Fat
    • Cystic spaces due to mucus production or other exocrine products
    • Soft-tissue from any part of the body
    • Calcification, including teeth

Pathophysiology

  • On microscopic histopathological analysis, pineal teratoma is characterized by cells originating from at least two and usually all three embryonic layers (ectoderm, mesoderm, and endoderm). The histological subtype may not necessarily determine the biological behavior.[3]

Natural history, complications, and Prognosis

  • Pineal teratomas may be associated with elevated levels of serum alpha fetoprotein (AFP) or serum carcinoembryonic antigen (CEA).[3]
  • Pineal teratoma must be differentiated from pineal lipoma, pineal dermoid, and other pineal gland tumors.[4]
  • Pineal teratoma is a rare disease that tends to affect the children and young adult population.[5]
  • Common complications of pineal teratoma include:[5]
  • Head CT scan and brain MRI may be helpful in the diagnosis of pineal teratoma.[6] Given their extremely variable histological components, CT/MRI imaging also tends to be heterogeneous, with tumors typically demonstrating a mixture of tissue densities and signal intensity. Fat, if present, is helpful in narrowing the differential.
  • On head CT scan, pineal teratoma is characterized by a mass with fat and calcification, which is usually solid / "clump-like". It usually has cystic and solid components, contributing to an irregular outline. Solid components demonstrate variable enhancement on contrast administration.[6]
  • On brain MRI, pineal teratoma is characterized by:[6]
MRI component Findings

T1

  • Hyperintense components due to fat and proteinaceous/lipid-rich fluid.
  • Intermediate components of soft tissue.
  • Hypointense components due to calcification and blood products.

T1 with contrast

  • Solid soft tissue components show enhancement.

T2

  • Mixed signal from differing components.

History and Symptoms

Treatment

  • The mainstay of therapy for immature pineal teratoma is combined radiotherapy and chemotherapy.
  • The residual or mature component is removed surgically.[7]
Management Options of Penial Gland Tumors
CSF diversion
Surgical resection
  • Some series report long-term survival with surgery alone, even in patients with pineoblastomas.
  • Indeed, for pineoblastomas, gross total surgical resection appears to correlate with improved survival.
  • Patients with symptomatic recurrent pineocytomas should also be considered for surgical resection of the lesion.
Radiation
  • Postoperative adjuvant radiation therapy (RT) is frequently (but not universally) recommended, and local control is dose-dependent.
  • The incidence of leptomeningeal recurrence was significantly lower among patients receiving CSI compared with those who did not.
  • The five-year survival rates were 86 and 49 percent for pineocytomas and non-pineocytomas, respectively.
  • Adjuvant RT is not universally recommended after gross total resection of a pineocytoma.
Stereotactic radiosurgery
  • Stereotactic radiosurgery (SRS) is emerging as a useful treatment alternative for pineocytomas, although experience is limited.
  • The precise radiation fields that are defined by MRI or CT-computerized treatment planning minimize damage to the surrounding brain, and the risks of general anesthesia and craniotomy are avoided.
  • SRS is increasingly being used to treat pineal region tumors, either as an additional therapy after conventional treatments or as a primary treatment.
  • Due to the low rate of side effects, SRS may develop into an attractive alternative to microsurgery in de novo diagnosed pineocytomas. In malignant tumors, SRSmay be routinely applied in a multimodality treatment schedule supplementary to conventional irradiation.
Chemotherapy as part of multimodality therapy
  • The similarity of pineoblastomas to medulloblastomas in terms of their clinical behavior and tendency for leptomeningeal seeding has led to the use of similar chemotherapy regimens in patients with pineoblastoma as part of a multimodality approach.
  • Chemotherapy has been used to delay radiation therapy in very young children, for whom the long-term neurocognitive and developmental side effects of craniospinal irradiation (CSI) are a major concern.
  • The importance of radiation therapy as a component of the initial treatment of supratentorial primitive neuroectodermal tumors (PNETs) is also supported by the German HIT-SKK87 and HIT-SKK92 protocols, as well as the Canadian pediatric brain tumor protocol.

References

  1. ↑ Intracranial teratomas. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015
  2. ↑ Teratoma. Dr Jeremy Jones and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/teratoma. Accessed on December 10, 2015
  3. ↑ 3.0 3.1 Pathology of extra-axial intracranial teratoma. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015
  4. ↑ Differential diagnosis of extra-axial intracranial teratomas. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015
  5. ↑ 5.0 5.1 5.2 Clinical presentation of extra-axial intracranial teratoma. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015
  6. ↑ 6.0 6.1 6.2 Radiographic features of intracranial teratoma. Dr Alexandra Stanislavsky and Frank Gaillard et al. Radiopaedia 2015. http://radiopaedia.org/articles/intracranial-teratoma. Accessed on December 10, 2015
  7. ↑ Friedman JA, Lynch JJ, Buckner JC, Scheithauer BW, Raffel C (2001). "Management of malignant pineal germ cell tumors with residual mature teratoma". Neurosurgery. 48 (3): 518–22, discussion 522-3. PMID 11270541.


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