Endoscopic Third Ventriculostomy and Tumor Biopsy for Pineal region tumor

• Reclassification of pineal tumor as high-grade astrocytoma with piloid features through methylation profiling: illustrative case
• The microsurgical infratentorial supracerebellar approach for lesions of the pineal gland: feasibility, morbidity, and functional outcomes from a single-center experience
• Letter to the Editor Regarding "Simultaneous Single-Trajectory Endoscopic Biopsy and Third Ventriculostomy in Pineal Region Tumors: A Systematic Review and Single Arm Meta-Analysis"
• Endoscopic Third Ventriculostomy and Pineal Biopsy from a Single Entry Point
• Good clinical outcomes and the necessity of CSF drainage in patients undergoing simultaneous biopsy and endoscopic third ventriculostomy in the region of pineal tumors: A systematic review and meta-analysis
• Supracerebellar Infratentorial Keyhole Approach in Sitting Position Using 3-Dimensional Exoscope and Angled Endoscope for a Giant Pineal Tumor
• A case of a pineal parenchymal tumor of intermediate differentiation with bifocal lesions differentiated by negative placental alkaline phosphatase in the spinal fluid
• Evolution of Surgical Management of Pineal Region Tumors in the Pediatric Population: A 17-Year Experience at a Single Institution

Endoscopic Third Ventriculostomy (ETV) is a surgical procedure that creates a new opening in the floor of the third ventricle of the brain to allow the cerebrospinal fluid (CSF) to flow freely, and it can be used to treat hydrocephalus caused by pineal region tumors. A tumor biopsy is a diagnostic procedure that involves the removal of a small sample of tissue from the tumor for laboratory analysis. It is commonly performed during surgery to help determine the type of tumor and guide treatment decisions. Both ETV and tumor biopsy can be performed in combination as part of a single surgical procedure for the treatment of pineal region tumors.

A comprehensive, systematic literature search was performed in compliance with the updated PRISMA 2020 guidelines within electronic databases MEDLINE/PubMed, EMBASE, PLOS, and Cochrane Library. Statistical analysis was performed with IBM SPSS 28.0.1.1 (14), using Kendall's and Spearman's tests, and a p < 0.05 was considered significant. 25 studies were selected and included in this review, for a total of 368 patients (mean age, 20.6 years; range, 1-86; SD, 17.5). More than two-thirds of the procedures were operated with a rigid endoscope whereas 27.6% were performed with either a flexible or a combination of the two or not otherwise specified. Germinoma represented the most frequent diagnosis (20.1%) followed by astrocytoma (12.9%) and pineocytoma (9.9%). The single-entry approach allowed a correct histological diagnosis in 88,7% of the examined cases. Summing up, concomitant ETV and TB represent a valuable option for the management of non-communicating hydrocephalus and the initial assessment of pineal region tumors. The histological confirmation rate was 88.7% in the examined cohort, with only 10% of the biopsies yielding inconclusive results ¹⁾.

In three patients, ventriculostomy and endoscopic biopsies were conducted. There was no death or morbidity throughout the 45-min procedure. All of the patients' histological findings were confirmed. Germinoma was diagnosed in two patients who received postoperative radiotherapy, and the third patient was diagnosed with a pineocytoma. Magnetic resonance imaging with flow-sensitive sequences was used to confirm ventriculostomy patency in all patients 6 months after the surgery.

Conclusion: Biportal endoscopic approach enables better visual control of both procedures. Furthermore, it allows the surgeon to safely pass the ventriculoscope via the foramen of monro, even if it is narrow. Moreover, during endoscopic tumor biopsy and third ventriculostomy, the intracranial pressure can be smoothly managed using the outlet tubes accessible. This treatment may be an alternative to traditional uniportal endoscopic operations in certain patients.