Neuroendoscopic Biopsy of Ventricular Tumors

A Multicentric Experience

Piero Andrea Oppido, M.D., Ph.D.; Alessandro Fiorindi, M.D., Ph.D.; Lucia Benvenuti, M.D.; Fabio Cattani, M.D.; Saverio Cipri, M.D.; Michelangelo Gangemi, M.D.; Umberto Godano, M.D.; Pierluigi Longatti, M.D.; Carmelo Mascari, M.D.; Enzo Morace, M.D.; Luigino Tosatto, M.D.


Neurosurg Focus. 2011;30(4):e2 

In This Article

Abstract and Introduction


Object. Although neuroendoscopic biopsy is routinely performed, the safety and validity of this procedure has been studied only in small numbers of patients in single-center reports. The Section of Neuroendoscopy of the Italian Neurosurgical Society invited some of its members to review their own experience, gathering a sufficient number of cases for a wide analysis.
Methods. Retrospective data were collected by 7 centers routinely performing neuroendoscopic biopsies over a period of 10 years. Sixty patients with newly diagnosed intraventricular and paraventricular tumors were included. No patient harboring a colloid cyst was included. Data regarding clinical presentation, neuroimaging findings, operative techniques, pathological diagnosis, postoperative complications, and subsequent therapy were analyzed.
Results. In all patients, a neuroendoscopic tumor biopsy was performed. In 38 patients (64%), obstructive hydrocephalus was present. In addition to the tumor biopsy, 32 patients (53%) underwent endoscopic third ventriculostomy (ETV), and 7 (12%) underwent septum pellucidotomy. Only 2 patients required a ventriculoperitoneal shunt shortly after the endoscopy procedure because ETV was not feasible. The major complication due to the endoscopy procedure was ventricular hemorrhage noted on the postoperative images in 8 cases (13%). Only 2 patients were symptomatic and required medical therapy. Infection occurred in only 1 case, and the other complications were all reversible. In no case did clinically significant sequelae affect the patient's outcome. Tumor types ranged across the spectrum and included glioma (low- and high-grade [27%]), pure germinoma (15%), pineal parenchymal tumor (12%), primary neuroectodermal tumor (4%), lymphoma (9%), metastasis (4%), craniopharyngioma (6%), and other tumor types (13%). In 10% of patients, the pathological findings were inconclusive. According to diagnosis, specific therapy was performed in 35% of patients: 17% underwent microsurgical removal, and 18% underwent chemotherapy or radiotherapy.
Conclusions. This is one of the largest series confirming the safety and validity of the neuroendoscopic biopsy procedure. Complications were relatively low (about 13%), and they were all reversible. Neuroendoscopic biopsy provided meaningful pathological data in 90% of patients, making subsequent tumor therapy feasible. Cerebrospinal fluid pathways can be restored by ETV or septum pellucidotomy (65%) to control intracranial hypertension. In light of the results obtained, a neuroendoscopic biopsy should be considered a possible alternative to the stereotactic biopsy in the diagnosis and treatment of ventricular or paraventricular tumors. Furthermore, it could be the only surgical procedure necessary for the treatment of selected tumors.


The use of endoscopy in the biopsy of ventricular tumors was first reported by Fukushima[7] in 1978. Subsequently, the increasing experience with this technique has clearly shown its advantage in visualizing the tumors during removal of biopsy samples while simultaneously avoiding highly vascularized structures. In ventricular tumors causing obstructive hydrocephalus, neuroendoscopy has gained even more appeal as a first-choice procedure since it is possible to simultaneously perform tumor biopsy and ETV or septostomy.[8,17,21,24] The immediate relief of intracranial hypertension and the availability of specimens for a pathological diagnosis allow time for planning the most suitable treatment strategy based on histological diagnosis and CSF tumor markers.[14] In fact, in a subset of ventricular or paraventricular tumors, further surgical ablation is not required, and the endoscopic procedure may be the only surgical procedure necessary.[18]

Unfortunately, due to the infrequency of these lesions, comprising about 2% of all primary CNS tumors,[13,23] only limited series have been reported in the literature[2,3,6,16,26] and some questions remain unanswered. In light of this observation, the Section of Neuroendoscopy of the Italian Neurosurgical Society (SINCH) invited some expert members to review their own experience, gathering a sufficient number of cases for a wide analysis.[1]


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