Expanded Endoscopic Endonasal Transtuberculum Approach for Resection of Germ Cell Tumor

Abstract

We present the case of a 16-year-old with short stature, fatigue, memory impairment, and pituitary gland failure. Imaging and cerebrospinal fluid (CSF) studies supported the diagnosis of a suprasellar nongerminomatous germ cell tumor with no clear radiologic disease in the spine; however, a single atypical cell was present in the CSF. After a period of external drainage via an Ommaya device, he was treated with chemotherapy, followed by craniospinal radiation. Three months post completion of chemoradiotherapy, he had ongoing residual macroscopic enhancing disease anatomically located in the basal third ventricle and intimately related to pituitary stalk and basal thalamoperforators. In order to maximize his chance of progression-free survival, a decision was made to surgically resect the lesion via an expanded endoscopic endonasal approach with planned stalk sacrifice because of the known pituitary gland failure. In Video 1, the technical nuances underpinning the use of an expanded endoscopic endonasal transtuberculum transchiasmatic sulcus approach to resect the adherent lesion in a postradiated field in its entirety are presented. We emphasize the strategies for perforator preservation including thalamoperforators and superior hypophyseal arteries to avoid ischemic injury and visual dysfunction, respectively. Postoperative scans demonstrated gross total resection without any ischemic injury. The patient was discharged without any neurologic deficit, visual dysfunction, or CSF leak.