In recent years, the use of the endoscope is a valid alternative to the classical microscopical approaches for the treatment of the pineal tumors. It can be used for endoscopic tumor biopsy (ETB) as well as endoscopic-assisted complete tumor removal in some cases. At the same time, if there is coexisting hydrocephalus, this can be treated endoscopically with endoscopic third ventriculostomy (ETV). The management of pineal region tumors can be summarized as follows: 1. In case of suspected germinoma or pineoblastoma with accompanying hydrocephalus and normal values of AFP and β-hCG, we propose endoscopic tumor biopsy and third ventriculostomy. If the biopsy provides tumor-type diagnosis, further oncological management is pursued as the next step. 2. In case of suspected mature teratoma, non-germinomatous malignant germ cell tumor (NGMGCT), or other tumors, we propose radical excision of the tumor, endoscopically assisted when needed and navigation assisted if necessary. 3. In case of midbrain tumors, we propose endoscopic third ventriculostomy combined with biopsy in selected cases. In some cases an endoscopic removal of the tumor can be achieved. Endoscopic third ventriculostomy has a high success rate in dealing with the hydrocephalus caused by pineal region tumors. At the same time, biopsy samples can be obtained with the endoscope from tumors which protrude in the third ventricle, with good yield rate, comparable to stereotactic biopsy. In selected cases, endoscopy-assisted surgical techniques can be employed to remove pineal region tumors. Complication rate for these procedures is low.
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