Endoscopic combined third ventriculostomy and biopsy of pineal region lesions: a review of diagnostic yield and complications. Charlotte Burford. 1.
Endoscopic combined third ventriculostomy and biopsy of pineal region lesions: a review of diagnostic yield and complications Charlotte 1Faculty
1 Burford ,
John
1 Hanrahan
and Bassel
2 Zebian
of Life Sciences and Medicine, King’s College London, 2Department of Neurosurgery, King’s College Hospital
Background
Results – diagnostic yield
• Pineal region lesions include a wide differential with varying management strategies which depend on histology. • When tumour markers do not provide the necessary diagnosis a biopsy is essential to direct management. • Obstructive hydrocephalus is a common consequence of tumours in this region, requiring CSF diversion; this is increasingly by means of an endoscopic third ventriculostomy (ETV). • Combined approaches for CSF diversion and biopsy are being increasingly used for patients presenting with hydrocephalus secondary to a pineal region lesion (Ahmed et al., 2015). • The optimal trajectory for biopsy and ETV differs (Figure 1).
• Overall diagnostic yield ranged from 75% - 100%. • Diagnostic yield did not differ significantly when comparing approach (p = 0.095) or endoscope choice (p = 0.825). • No significant difference when comparing all four combinations of approach and endoscope type (p = 0.368, one-way ANOVA). • These findings suggest that endoscope choice or number of burr-holes does not impact on the diagnostic yield.
ETV ETV
Biopsy Biopsy
Diagnostic yield (%)
B.
A.
100 95 90
Single Dual
85 80 75 Rigid Rigid
Flexibe Flexible
Figure 2: Comparison of diagnostic yields between scope type and approach. Figure 1. A – Optimal trajectories for biopsy and ETV through two burr-holes. B. Trajectory for the single burrhole approach
Aims • To review literature evaluating endoscopic combined third ventriculostomy and biopsy procedures. • Compare the diagnostic yield and complications according to approach and choice of endoscope. • A literature search from 1997-2016 was conducted using PubMed for the terms “endoscop*, biopsy, pineal”. • Studies with patients who underwent endoscopic combined third ventriculostomy and biopsy were included. • Single case studies excluded from analysis of diagnostic yield.
Results – endoscope and approach choice • Out of 161 studies, 23 were included in the analysis. • Single burr hole was more popular (59.9%) than two burr holes (29.3%). • Rigid scopes were more popular (59.9%) than flexible scope (27.5%). • However, this is heavily weighted by one study with a large number of cases (Ahmed et al., 2015) and may not reflect the most popular choice among surgeons. • No association between burr hole number and scope type (p = 0.476, Fisher’s exact). No. of studies Flexible endoscope Rigid endoscope (No. of cases) Single burr-hole 5 (16) 3 (65) 1 (23)
• No significant difference was observed according to approach type (p = 0.578) or endoscope choice (p = 0.250). • The most common complication was transient fever, predominantly reported by Chernov et al., which may have not been considered a significant complication in other studies. No. of studies
Methods
Two burr-holes
Results - complications
3 (20)
Table 1: The number of studies and cases reporting choice of endoscope and approach.
Flexible endoscope
Rigid endoscope
Single burr-hole
18.8%
15.4%
Two burr-holes
82.6%
0
Table 2: Complication rate according to scope type and approach.
Pyrexia Intraoperative haemorrhage Diplopia Nausea/vomiting Memory deficits Other
Figure 3: Pie chart presenting the most common complications reported.
Conclusion • Whilst the surgeon’s preference dictates the approach and type of endoscope, the use of a single burr-hole approach does not seem to compromise the diagnostic yield or increase complication rate. • The use of a flexible endoscope seems to be associated with a higher complication rate.
1. Ahmed et al. Endoscopic biopsy and third ventriculostomy for the management of pineal region tumors. World Neurosurg. 2015;83:543–547. 2. Chernov, M et al. Neurofiberscopic biopsy of tumors of the pineal region and posterior third ventricle: indications, technique, complications, and results. Neurosurgery. 2006;59:267–277.
