case_images: PMC10026104_01
case_images: Patient 1
  pre-treatment (A-D, I), post-treatment (E-H, J), and recurrence (K-L) MR
  images. Prior to CSI, (A) axial T1 post-contrast, (B) axial T2, and (C)
  sagittal T1 post-contrast MR images demonstrate PPTID occluding the
  aqueduct of Sylvius, causing obstructive hydrocephalus and enlarging the
  lateral ventricles. (D) The thoracic spinal cord displayed extensive
  lesions suspicious of drop metastases, which are outlined in arrows. (I)
  An axial T1 post-contrast MR image is provided of the circled region in
  (D) the thoracic spine, which shows a cluster of drop metastases in the
  thoracic spinal cord. After CSI, (E) axial T1 post-contrast, (F) axial
  T2, and (G) sagittal T1 post-contrast MR images demonstrated no residual
  disease and relief from the obstructive hydrocephalus, resulting in
  smaller lateral ventricles. (H) The thoracic spinal cord post-treatment
  no longer showed the previously seen lesions. (J) An axial T1
  post-contrast MR image is provided at the level of the circled region in
  (H) the thoracic spine, an area that had previously shown a cluster of
  drop metastases but now shows no lesions. However, (L) a focus of
  enhancement on the left lateral aspect of the cervical cord at level
  C6-7 appeared 3 and a half years after completion of CSI treatment and
  increased by 3 mm over the course of 3 months. (K) The axial T1
  post-contrast MR image is provided at the level of the circled region in
  (L) the cervical spine. The lesion responded well to SBRT for 9 months
  (data not shown).
case_images: 10.1177_11795735231160036-fig1.jpg
case_images: PMC10026104_01_10.1177_11795735231160036-fig1.jpg
case_images: fig1-11795735231160036
case_images: Magnetic resonance (MR) images of the brain demonstrated a 3.7 cm maximum dimension tumor in the pineal region with suspicious nodules in the cerebellum, causing obstructive hydrocephalus (Figure 1A-C). MR images of the spinal cord demonstrated nodular enhancement in the cervical, thoracic (Figure 1D and I), and lumbar spine, which were suspicious for drop metastases. Surveillance imaging showed no evidence of disease for 3 years (Figure 1E-H and J). Repeat imaging 3 months later demonstrated that the lesion grew to 8.3 mm x 5 mm x 3.6 mm as the only site of progression (Figure 1K-L).
case_images: PMC10026104_02
case_images: Patient 2 pre-treatment (A-C), post-treatment (D-F),
  and recurrence (G-L) MR images. At time of diagnosis, (A) axial T1
  post-contrast, (B) axial T2, and (C) sagittal T1 post-contrast MR images
  demonstrate PPTID occluding the aqueduct of Sylvius, causing obstructive
  hydrocephalus and enlarging the lateral ventricles. He underwent a right
  posterior occipital craniotomy to excise the pineal mass followed by
  focused adjuvant RT to the pineal tumor bed. For the next 5 years, MR
  images demonstrated no evidence of disease and relief from the
  obstructive hydrocephalus, resulting in smaller lateral ventricles, as
  seen in (D) the axial T1 post-contrast, (E) axial T2, and (F) sagittal
  T1 post-contrast MR images. Within the year following his last clean MR
  images, he exhibited recurrence of the PPTID, as seen in (G) the axial
  T1 post-contrast, (H) axial T2, and (I) sagittal T1 post-contrast MR
  images, and extensive dissemination of disease (outlined in arrows) in
  the (I) cervical, (J) thoracic, and (K) lumbar spine. (L) An axial T1
  post-contrast image of the largest drop metastasis, which was seen
  circled in (K) the lumbar spine, is provided.
case_images: 10.1177_11795735231160036-fig2.jpg
case_images: PMC10026104_02_10.1177_11795735231160036-fig2.jpg
case_images: fig2-11795735231160036
case_images: MR images of the brain demonstrated a 3.1 cm maximum dimension pineal lesion obstructing the aqueduct of Sylvius, causing obstructive hydrocephalus (Figure 2A-C). Surveillance MR images of the brain demonstrated no evidence of disease (Figure 2D-F) but no spine MRI was performed after. MR images showing no evidence of disease progression and 6 years after the initial diagnosis/craniotomy, with 3 months of worsening back pain associated with bilateral radiation to the feet. MR images of the brain demonstrated a 1.8 x 1.6 x 1.2 cm contrast-enhancing pineal region mass (Figure 2G-H). Another enhancing mass was seen in the floor of the fourth ventricle, and multifocal enhancing masses were observed along the medulla and upper cervical spinal cord (Figure 2I). MR images of the spinal cord demonstrated diffuse leptomeningeal disease (LMD), with the largest drop metastasis measuring 2.1 cm at the L3-4 spinal level (Figure 2J-L).
case_images: Patient
  timelines for (A) patient 1 and (B) patient 2. (A) Patient 1 received
  CSI therapy, went into remission for 39 months, recurred but was treated
  successfully with stereotactic body radiation therapy, and is now
  presently in remission. (B) Patient 2 received a craniotomy followed by
  focused adjuvant radiation therapy, went into remission for 72 months,
  recurred with diffuse leptomeningeal disease (LMD) that could not be
  fully treated by therapy, and died at 120 months.
case_images: 10.1177_11795735231160036-fig3.jpg
case_images: PMC10026104_02_10.1177_11795735231160036-fig3.jpg
case_images: fig3-11795735231160036