Optimal clinical management of pineal region tumors can vary greatly, depending upon which of a variety of histological subtypes is present. An open surgical procedure is the preferred method for obtaining sufficient tumor specimen, since it minimizes errors in histological diagnosis and can be safely accomplished through one of several surgical approaches. Stereotactic biopsy is a reasonable alternative to open surgery in patients with metastatic tumors or extensive underlying medical disease. Cranial radiation is given for malignant pineal tumors, with chemotherapy added for nongerminomatous ma lignant germ cell tumors. The use of prophylactic spinal radiation is controversial, but is generally not given except when spinal metastases are demonstrated radiographically. Nearly one-third of pineal tumors are benign and have a cure rate approaching 100% with surgery alone. Aggressive treatment of most malignant pineal tumors with a combination of surgery and adjuvant therapy has greatly improved their long-term prognosis. Current studies involving radiosurgery and new forms of chemotherapy for germinomas and pineal cell tumors are likely to improve present management strategies.