Neuroendoscopic management of posterior third ventricle and pineal region tumors: technique, limitation, and possible complication avoidance

S. Chibbaro; F. Di Rocco; O. Makiese; A. Reiss; P. Poczos; G. Mirone; F. Servadei; B. George; P. Crafa; M. Polivka; A. Romano

doi:10.1007/s10143-011-0370-1

Neurosurgical Review

July 2012, Volume 35, Issue 3, pp 331–340 | Cite as

Neuroendoscopic management of posterior third ventricle and pineal region tumors: technique, limitation, and possible complication avoidance

Authors
Authors and affiliations

S. ChibbaroEmail author
F. Di Rocco
O. Makiese
A. Reiss
P. Poczos
G. Mirone
F. Servadei
B. George
P. Crafa
M. Polivka
A. Romano

Original Article

First Online: 19 January 2012

Received: 02 April 2011

Revised: 03 August 2011

Accepted: 08 October 2011

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26 Citations

Abstract

The endoscopic approach has gained an increased popularity in recent years for the biopsy and, in selected cases, the removal of tumors of the posterior third ventricle and pineal region. The authors report their experience on a series of 20 patients discussing also the technical limitations and complication avoidance. This is a prospective study of 20 patients with posterior third ventricle and pineal region tumors surgically managed by endoscopic biopsy and/or excision and simultaneous third ventriculostomy. The removal of the lesion could be achieved in 12 cases whereas in 8, only a biopsy could be performed. A histological diagnosis could be obtained in all cases. No delayed third ventricular stoma failures were recorded in any patient at the latest follow-up (mean follow-up, 39 months). Severe postoperative complications were recorded in 2 out of 12 cases of tumor removal attempt and in zero out of eight cases of biopsy. A delayed (3 weeks) postoperative mortality occurred in a patient harboring a GBM that developed an intratumoral hematoma 48 h postoperatively, one patient was in a vegetative state. Transient postoperative complications included: nausea and vomiting (five cases) and diplopia (two cases). One patient developed a bilateral ophthalmoplegia that recovered within 6 months due to residual tumor hemorrhage. Higher rate of complications was found in the case of vascularized and/or larger lesions. Endoscopic management of posterior third ventricle lesions may represent an effective option. However, though biopsies remain often a safe procedure, tumor excision should be limited to highly selected cases (cystic, poorly vascularized, and/or smaller than 2.5-cm lesions).

Keywords

Posterior third ventricle tumor Pineal tumor Neuroendoscopy Laser Complications Minimally invasive neurosurgery

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Notes

Comments

Marc Sindou, Lyon, France

We do agree with the authors' conclusion that “endoscopic management of posterior third ventricle lesions may represent an effective option.”

We, even more, estimate that with the exception of meningiomas and other similar tumors, endoscopic approach should be the first option, as it affords the possibility to get CSF sampling for cytologic and marker studies, as well as to harvest tumor tissue for histopathologic diagnosis. It also allows performing ventriculo-cisternostomy in the (frequent) eventuality of coexisting hydrocephalus.

As regards tumor removal, at least at the first stage, we think that indications should be very restricted, not only because of the risk of not being able to control hemostasis, but also because the histopathologic nature of the lesion has to be firmly ascertained before deciding resection. We all know that the number of tumors is well controllable with radio- and/or chemotherapies.

Restriction by the authors of attempts at endoscopic removal to only those tumors which are cystic or poorly vascularized and smaller than 2–5 cm in diameter seems wise.

For tumors posteriorly located in the pineal region, besides the endoscopic procedure through the transfrontal–interventricular foramen of Monro route, a trans-posterior fossa approach was recently developed, namely infratentorial–supracerebellar, that may be applied to the posteriormost pineal region tumors.

So, neurosurgeons are fortunate to have these endoscopic approaches that may be offered to the patients, besides the microsurgical open approaches, the later ones being either suboccipital (i.e., infratentorial–supracerebellar) or supraoccipital–transtentorial especially when the tentorium is stiff.

Dattatraya Muzumdar, Mumbai, India

Chibbaro et al report their experience in the neuroendoscopic management of pineal region tumors. They conclude that neuroendoscopy in pineal region tumors requires skill and expertise. They propose that tumor excision should be limited to highly selected cases (cystic, poorly vascularized, and/or smaller than 2.5-cm lesions).

Neuroendoscopy for pineal region tumors has been described during the last decade, and gradually, the procedure has been refined to make it more safe and smooth. In neurosurgical centers with expertise in neuroendoscopy, it has become a routine procedure in experienced hands. The decision to perform ETV is universal, but biopsy and/or tumor excision has been decided on individualized cases preoperatively. The extent of resection has to be judicious, philosophical, and patient centric. Pineal region tumors have diverse etiologies, and hence, there are likely to be large-scale variations in the consistency and vascularity of the tumors.

Although the sample size is small, the present study is prospective and well conducted. The high selection of cases for neuroendoscopy is self-explanatory. There is no statistical analysis performed. It is worthwhile to know that all patients had a patent stoma and there was no need for any conversion to VP shunt. The follow-up period is adequate.

The present study echoes the sentiments expressed in the previous case studies reported in literature. However, the present study may be considered as an adjunct to the existing information on the topic. A larger sample size or multiinstitutional study would be worthwhile.

Tamas Doczi, Pecs, Hungary

The authors present a series of 20 patients with third ventricle neoplasms and associated obstructive hydrocephalus. They introduce the two-burr hole approach by neuronavigation guidance of two separate endoscope routes for (1) performance of tumor removal or biopsy for histological confirmation and guidance of further therapy and (2) definitive management of hydrocephalus by third ventriculostomy with avoidance of a shunt. Their technique of a “minimally invasive approach” and its complication rate may be contrasted with open craniotomy for performance of excisional biopsy and with shunting for control of the associated hydrocephalus. The authors series argues the usefulness of the minimally invasive approach with an elegant solution of the clinical problems and an accurate diagnosis leading to further appropriate management. Performance of an endoscopic biopsy under direct visualization must improve sampling yield for accurate histological assessment, as well as diminishing the risks for bleeding by the avoidance of tumor-related vessels compared with blind stereotactic needle biopsy approaches. As shown, bleeding is the major obstacle of endoscopic radical tumor removal. Obstructive hydrocephalus can almost always be managed by this approach, without the significant long-term complications and difficulties of shunting. Two ports of cranial entry are required to provide a direct, linear approach to two separate targets within the third ventricle. This is necessary because the authors use rigid lens scopes. The low frontal approach through the foramen of Monro to the posterior third ventricle region could be more safely achieved with direct visualization with a separately passed, simultaneously imaging coronal endoscope at the foramen of Monro as we have shown earlier [9]. Although the approach below the hairline requires only a small incision and burr hole, it certainly demonstrates cosmetic impact in the visualized face of the patient. The “minimally invasive” philosophy would necessitate the use and development of tools that make this surgery achievable through a single burr hole. In contrast with thoraco-abdominal spinal endoscopic procedures, minimal invasiveness in intracranial neurosurgery is imperative: in the future, the right coronal burr hole approach may be used with a steerable fiberscope in the third ventricle for performing a safe biopsy. Angle-view rigid lens scopes of 30° and 70° already allow visualization of the suprapineal recess, posterior commissure, and aqueduct regions via the coronal approach toward the floor of the third ventricle. If the frontal below the hairline approach is necessary, another alternative to third ventriculostomy for management of hydrocephalus could be aquaductoplasty, i.e., reopening the aqueduct and placement of a third ventricle–fourth ventricle stent to circumvent the obstruction through the normal cerebrospinal fluid flow pathway. Endoscopy has undoubtedly become established in neurosurgery. The ascertaining of indications, however, is still a problem and, at times, controversial. Further technical improvements are needed to be able to perform a safe tumor removal.

Mikhail Chernov, Yoshihiro Muragaki, Hiroshi Iseki, Tokyo, Japan

Chibbaro et al. have reported their experience with neuroendoscopic management of pineal region and posterior third ventricle tumors. The results obtained in the series of 20 consecutive patients treated in two neurosurgical centers are definitely valuable because they reflect several very important issues.

First, it seems that nowadays neuroendoscopic biopsy has become the standard option for patients with intraventricular tumors, which can be successfully applied even in cases without accompanied hydrocephalus. While technical nuances and devices used for tissue sampling are varied from one center to another, the procedure typically provides a high level of safety and efficacy. The morbidity rate is not low, but the vast majority of complications are mild, temporary, and self-resolving. In the referenced series, no one severe side effect was encountered in eight patients who underwent pure biopsy of the neoplasm, and the diagnostic yield of the procedure was 100%. The latter definitely was reached due to a large quantity of obtained pathological material with at least eight tissue samples per case and because of constant use of the intraoperative histopathological investigation on the frozen sections. In the recently appeared national survey of the neuroendoscopic procedures for management of ventricular and paraventricular tumors in Japan, which had incorporated 714 patients operated on in 123 different centers, the diagnostic yield was slightly lower (92.8%), and the main reason for inability to establish the diagnosis was insufficient tumor sampling [1]. It should be mentioned, however, that high diagnostic yield does not necessarily reflect sufficient diagnostic accuracy, particularly in cases of histologically heterogeneous neoplasms, which are frequently encountered in the pineal region and posterior third ventricle. In fact, neuroendoscopic tissue sampling represents a modification of the open biopsy, which is accompanied by the highest rate of diagnostic errors [4]. Possible incorporation of the neurochemical navigation with 5-aminolevulinic acid may increase the diagnostic efficacy of the neuroendoscopic procedures [8].

Second, contrary to pure biopsy, the endoscopic resection of the pineal region and posterior third ventricle tumors in the presented series was associated with significant risk of major morbidity. Out of 12 patients, one died, another one has remained in the vegetative state, and the third one had prolonged bilateral ophthalmoplegia. It should be specifically emphasized, that two out of four patients who underwent partial tumor resection had experienced postoperative hemorrhage in the neoplastic remnants with very serious clinical consequences. Based on this limited experience, it can be concluded that partial endoscopic removal of the pineal and posterior third ventricle neoplasms should be definitely avoided. It necessitates careful selection of the surgical candidates. The authors critically analyzed their own results and suggested that endoscopic resection should be recommended only in cases of small (less than 2.5 cm in diameter), avascular, soft and/or cystic tumors, which generally corresponded to the opinion of others [6, 7]. Certainly, surgical experience, appropriate training, and advanced equipment are equally important for attainment of good outcome.

From the technical standpoint, the authors used the standard approach for rigid endoscope with the separate entries for tumor biopsy or removal and for third ventriculostomy (ETV). However, it does not seem absolutely necessary. Careful planning of the procedure can identify the optimal single trajectory, which can be effectively used for both manipulations [2, 3]. On the other hand, use of the rigid endoscope for tumor sampling and a flexible one inserted through the same shield for ETV (so-called “mother and daughter” technique) may also limit the procedure to the single entry. We agree that creation of the communication between basal cisterns and ventricular system not before, but after completion of the tumor sampling, may prevent possible subarachnoid seeding of the neoplasm. While the risk of this complication is rather low (6.8% [1]) and it was never met in the referenced series, every attempt should be done for its avoidance. Finally, it is important to mention that use of neuronavigation system based on the preoperative images for guidance of the endoscopic resection of the intraventricular tumors should be done with great caution due to high risk of mislocalization errors caused by the brain shift phenomenon [5].

References

1. Hayashi N, Murai H, Ishihara S, Kitamura T, Miki T, Miwa T, Miyajima M, Nishiyama K, Ohira T, Ono S, Suzuki T, Takano S, Date I, Saeki N, Endo S (2011) Nationwide investigation of the current status of therapeutic neuroendoscopy for ventricular and paraventricular tumors in Japan. J Neurosurg 115: 1147–1157

2. Mohanty A, Santosh V, Devi BI, Satish S, Biswas A (2011) Efficacy of simultaneous single-trajectory endoscopic tumor biopsy and endoscopic cerebrospinal fluid diversion procedures in intra- and paraventricular tumors. Neurosurg Focus 30 (4): E4

3. Morgenstern PF, Osbun N, Schwartz TH, Greenfield JP, Tsiouris AJ, Souweidane MM (2011) Pineal region tumors: an optimal approach for simultaneous endoscopic third ventriculostomy and biopsy. Neurosurg Focus 30 (4): E3

4. Murphy M, Loosemore A, Ferrer I, Wesseling P, Wilkins PR, Bell BA (2002) Neuropathological diagnostic accuracy. Br J Neurosurg 16: 461–464

5. Ozawa N, Muragaki Y, Nakamura R, Hori T, Iseki H (2009) Shift of pyramidal tract during resection of the intraaxial brain tumors estimated by intraoperative diffusion-weighted imaging. Neurol Med Chir (Tokyo) 49: 51–56

6. Qiao L, Souweidane MM (2011) Purely endoscopic removal of intraventricular brain tumors: a consensus opinion and update. Minim Invasive Neurosurg 54: 149–154

7. Souweidane MM, Luther N (2006) Endoscopic resection of solid intraventricular brain tumors. J Neurosurg 105: 271–278

8. Tamura Y, Kuroiwa T, Kajimoto Y, Miki Y, Miyatake S, Tsuji M (2007) Endoscopic identification and biopsy sampling of an intraventricular malignant glioma using a 5-aminolevulinic acid-induced protoporphyrin IX fluorescence imaging system: Technical note. J Neurosurg 106: 507–510

9. Veto F, Horváth Z, Dóczi T (1997) Biportal endoscopic management of third ventricle tumors in patients with occlusive hydrocephalus: technical note. J Neurosurg 40 (4): 871–5

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Authors and Affiliations

S. Chibbaro
- 1
- 6
Email author
F. Di Rocco
- 3
O. Makiese
- 1
A. Reiss
- 1
P. Poczos
- 1
G. Mirone
- 1
F. Servadei
- 4
B. George
- 1
P. Crafa
- 5
M. Polivka
- 2
A. Romano
- 4

1.Department of NeurosurgeryLariboisiere University HospitalParisFrance
2.Department of HistopathologyLariboisiere University HospitalParisFrance
3.Department of NeurosurgeryNecker University HospitalParisFrance
4.Department of NeurosurgeryParma University HospitalParmaItaly
5.Department of HistopathologyParma University HospitalParmaItaly
6.Service de NeurochirurgieHopital LariboisièreParis Cedex 10France

Neuroendoscopic management of posterior third ventricle and pineal region tumors: technique, limitation, and possible complication avoidance

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