Synchronous pineal and suprasellar pineoblastoma in a child mimicking bifocal germinoma

Bifocal pineal and suprasellar lesions in children are classically associated with intracranial germinoma, and empirical treatment without histological confirmation has been advocated in selected protocols. Pineoblastoma, however, is a rare and highly aggressive embryonal tumor requiring fundamentally different management. We report the case of a 10-year-old girl who presented with signs of subacute intracranial hypertension. Brain magnetic resonance imaging (MRI) demonstrated synchronous pineal and suprasellar masses associated with obstructive hydrocephalus. Both lesions were isointense on T1- and T2-weighted sequences and exhibited homogeneous contrast enhancement. Serum and cerebrospinal fluid levels of alpha-fetoprotein and β-human chorionic gonadotropin were within normal limits. Given the characteristic bifocal distribution and negative tumor markers, a presumptive diagnosis of bifocal germinoma was initially considered. The patient underwent endoscopic third ventriculostomy with tumor biopsy, which unexpectedly revealed a pineoblastoma (WHO grade 4). Although her clinical condition initially improved and craniospinal irradiation was planned, she developed recurrent acute hydrocephalus and died 6 weeks later. This case highlights the limitations of relying solely on imaging features and tumor markers when evaluating bifocal pineal and suprasellar lesion. Histopathological confirmation remains essential to avoid misdiagnosis and inappropriate treatment of aggressive tumors such as pineoblastoma.