Endoscopic Third Ventriculostomy and Pineal Biopsy from a Single Entry Point
Summary
Pineal neoplasms frequently cause obstructive hydrocephalus and require histopathological diagnosis to decide the treatment regimen. They might be treated by surgical resection or chemoradiotherapy according to the pathological diagnosis. As a minimally invasive initial treatment, an endoscopic approach from Kocher’s point enables both third ventriculostomy and biopsy.
Abstract
Pineal neoplasms have a significant impact on children although they are relatively uncommon. They account for approximately 3-11% of all childhood brain tumors, which is considerably higher than the <1% seen in adult brain tumors. These tumors can be divided into three main categories: germ cell tumors, parenchymal pineal tumors, and tumors arising from related anatomical structures. Obtaining an accurate and minimally invasive tissue diagnosis is crucial for selecting the most appropriate treatment regimen for patients with pineal gland tumors. This is due to the diverse treatment options available and the potential risks associated with complete resection. In cases where patients present with acute obstructive hydrocephalus caused by a pineal gland tumor, immediate treatment of the hydrocephalus is necessary. The urgency stems from the potential complications of hydrocephalus, including increased intracranial pressure and neurological deficits. To address these challenges, a minimally invasive endoscopic approach provides a valuable opportunity. This technique allows clinicians to promptly relieve hydrocephalus and obtain a histological diagnosis simultaneously. This dual benefit enables a more comprehensive understanding of the tumor and assists in determining the most effective treatment strategy for the patient.
Introduction
The pineal gland is a neuroendocrine gland located in the epithalamus that is responsible for regulating biological rhythms in vertebrates. Its anatomical boundaries include the posterior surface of the wall of the third ventricle, which forms the base of the gland, the splenium of the corpus callosum superiorly, and the thalamus surrounding both sides. It has a pinecone shape and extends posteriorly and inferiorly in the quadrigeminal cistern1,2.
Pineal neoplasms are relatively rare tumors and are predominantly childhood malignancies, accounting for 3-11% of all childhood brain tumors compared with <1% of adult brain tumors1,3,4. Age, sex, and ethnicity can modify the relative incidence of pineal neoplasms5. Pineal tumors are classified into three types: germ cell tumors, pineal parenchymal tumors, and tumors arising from neighboring anatomical regions. Germinomas are the most frequent pineal tumors, accounting for up to 50% of pineal tumors in Europe1,3.
Tumors of the pineal gland are pathologically diverse and their optimal management remains controversial6. Advances in neuroendoscopy have significantly contributed to treating pineal region tumors. Neuroendoscopic techniques are minimally invasive, effective, and safe in treating these tumors. With this technique, it is possible to treat hydrocephalus and obtain a biopsy simultaneously7. In most cases, simultaneous endoscopic third ventriculostomy (ETV) and tumor biopsy is the first-choice surgical procedure for pineal region tumors due to the effectiveness of radiotherapy and chemotherapy in most histopathological subtypes. Various techniques for simultaneous ETV and biopsy have been described, and there is currently no standard technique for performing this procedure8.
Protocol
Representative Results
Discussion
The description of the ETV and biopsy for pineal tumors was first described in the 1970s. Historically, the fear of uncontrolled hemorrhage has always existed. However, owing to advances in endoscopic surgery techniques, bleeding control is not a major complication for experienced surgeons nowawadays9,10. According to several cases in the literature, endoscopic management has been found to be effective as an initial step for pineal region tumors presenting with h…
Declarações
The authors have nothing to disclose.
Acknowledgements
This study did not receive any funding.
Materials
| Adson periosteal elevator | Ruggles-Redmond | RO263 | Semi-sharp, 5 mm, curved 6-3/8, length 164 mm |
| Automatic skin retractors | Integra | 3,72,245 | Heiss Automatic Skin Retractor Length – Overall (mm): 102 Length 1 – Tip/Jaw (mm): 8 |
| Balloon catheter | Edwards Fogarty | 120804FP | Length (cm): 80, Catheter size (F): 4, Inflated balloon diameter (mm): 9 |
| Biopsy Forceps | Karl Storz LOTTA CLICKLINE Grasping Forceps | 28164 LE | Rotating, dismantling, single action jaws, diameter 2.7 mm, working length 30 cm |
| Bipolar coagulation electrode | Karl Storz LOTTA | 28161 SF | Diameter 1.3 mm, working length 30 cm |
| Bisture | Beybi | 24,02,502 | Beybi Bisture Tip. No: 20 and No: 11 |
| High-speed drill | Medtronic Midas Rex MR8 | MR8™ Electric Plus EM850 | Perforator tip used |
| Obturator | Karl Storz LOTTA | 28164 LLO | Use with Operating Sheaths for ventricular puncture |
| Operating sheath | Karl Storz LOTTA | 28164 LSB | Graduated, rotating, outer diameter 6.8 mm, working length 13 cm |
| Ventriculoscope | Karl Storz LOTTA Ventriculoscope with HOPKINS | 28164 LAB | Wide angle telescope 30°, angled eyepiece, outer diameter 6.1 mm, length 18 cm, working channel diameter 2.9 mm, irrigation/suction channel diameter 1.6 mm |
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