Single-institution case series of pituitary biopsy for suspected germinoma in the pediatric population: diagnostic utility, operative risks, and biopsy approaches

Emily L Day,Edward R Smith,Katie P Fehnel

doi:10.1038/s41598-020-71988-7

Abstract

Little has been reported on the safety and efficacy of pituitary biopsy in the pediatric population for suspected germinoma. An updated review is needed. Patients who underwent biopsy (endoscopic endonasal vs. open craniotomy) for isolated pituitary stalk thickening were identified. Age, pre- and post-operative endocrine status, surgical approach, length of surgery, estimated blood loss, surgical morbidity, length of ICU stay, total length of stay, and pathology reports were reviewed. Nine patients met inclusion criteria. Germinoma diagnosis was rendered in 7 of 9 patients; 1 patient required two biopsy attempts. Two-patients had histology consistent with inflammation and a subsequently self-limited disease course. Average operative time, blood loss, ICU stay and overall length of stay was just over 2 h, 28 mL, 1.6 days and 3.7 days respectively. There were no intraoperative complications and all patients were discharged home. One patient developed new diabetes insipidus post-operatively. Patients who underwent endoscopic biopsy had decreased operative times and shorter hospitalizations. Biopsy for isolated pituitary stalk thickening for suspected germinoma is generally safe with high diagnostic utility. Importantly, 22% of presumed germinomas on imaging yielded alternative diagnoses on biopsy, adding support for pathology-proven data to guide treatment in relevant cases.

Highlights

Little has been reported on the safety and efficacy of pituitary biopsy in the pediatric population for suspected germinoma
We retrospectively review all patients for whom a pituitary stalk biopsy was indicated based on the aforementioned criteria and report the primary outcomes of diagnostic yield (% confirmed pathology) and operative morbidity as well as secondary outcome measures pertaining to surgical morbidity with respect to open versus endoscopic biopsy, with the paired goals of (1) demonstrating the efficacy and risk of the transsphenoidal approach versus craniotomy and (2) generating specific inclusion criteria that may help surgeons to appropriately select patients for the transsphenoidal approach when faced with this clinical scenario
No patient had previously undergone operative intervention or biopsy and only one patient had been empirically treated with chemotherapy prior to undergoing biopsy for medically refractory tumor progression

Summary

Introduction

Little has been reported on the safety and efficacy of pituitary biopsy in the pediatric population for suspected germinoma. Isolated pituitary stalk thickening and/or progressive thickening in setting of pituitary dysfunction in the pediatric population is often most worrisome for germ cell tumor, germinoma. The diagnostic algorithm for GCTs affecting the pineal recess has been more standardized than for the pituitary-specific lesions due to the fact these patients often present with hydrocephalus from mass effect on the posterior third ventricle with aqueductal obstruction. For this subset of patients, in the setting of negative tumor markers, surgical treatment includes a combination of CSF diversion by endoscopic third ventriculostomy and endoscopic biopsy of the mass in the posterior third v entricle[12]. Thickening on MRI (defined as > 2.6 mm) in the setting of either anterior pituitary dysfunction or with evidence of progressive stalk thickening on serial pituitary imaging[13,14]

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