Metastases to the pineal gland are rare and reported cases have consisted mainly of lung and gastrointestinal primary malignancies. Here we report the third case in the literature of pineal gland metastasis from renal cell carcinoma.A 69-year-old man, status post excision of right renal cell carcinoma 20 years ago, presented with a onemonth history of urinary incontinence. Images revealed a solitary mass in the pineal region with obstructive hydrocephalus. Endoscopic third ventriculostomy (ETV) and biopsy of pineal mass were performed. The histological diagnosis of the biopsy was inconclusive. The patient was scheduled for a follow-up and readmission for a repeat biopsy, however, was lost to follow-up. No attempts were made by the hospital team or patient relations department to contact him. Eventually, the patient presented after 18 months to the emergency room (ER) with confusion, forgetfulness, gait disturbance, weakness of lower extremities, and vision loss due to enlarged pineal mass. Another ETV and biopsy were performed. The histological findings were compatible with metastasis from renal cell carcinoma. The patient died after three months due to rapid general deterioration in his condition.The lessons that have been learned from this case are: 1) Metastatic tumor should be considered in the differential diagnosis of pineal region tumors, particularly in elderly patients and with a known history of malignancy; 2) If the first biopsy is inconclusive, a rapid plan and a strict follow-up for a repeat biopsy should be made; 3) Elderly patients should have special care; they should be well informed about their condition and should be contacted regularly to ensure that they receive the optimal management plan.

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