Original Paper
Received: November 15, 2000
Pediatr Neurosurg 2001;34:215–217
Ventriculoscope Tract Recurrence after
Endoscopic Biopsy of Pineal Germinoma
Charles Haw Paul Steinbok
Division of Pediatric Neurosurgery, Department of Surgery, University of British Columbia and
British Columbia’s Children’s Hospital, Vancouver, Canada
Key Words
Pineal tumor W Germinoma W Endoscopy W Tract
recurrence
Abstract
Recurrence along an endoscope tract has been de-
scribed after endoscopic biopsy and resection of malig-
nant tumors arising in multiple organ systems. We de-
scribe a case of tract recurrence following the ventricu-
loscopic biopsy of a central nervous system tumor. A ret-
rospective review of the patient’s clinical course, radiolo-
gy and pathology was undertaken to formulate a case
report. A 14-year-old boy was treated with endoscopic
third ventriculostomy and endoscopic biopsy of a pineal
germinoma associated with hydrocephalus. Persistent
hydrocephalus required repeat third ventriculostomy.
The patient subsequently received focal external beam
radiotherapy. Seventeen months after the first third ven-
triculostomy, a routine MRI revealed a 2-cm enhancing
mass in the ventriculoscope tract. This was removed via
a right frontal craniotomy. Again the pathology was ger-
minoma. Serum and CSF markers were negative at initial
presentation and at the time of recurrence. The potential
for tract recurrence and CSF dissemination should be
considered following the endoscopic biopsy of pineal
germ cell tumors as this could affect the extent of radio-
therapy and/or chemotherapy.
Copyright © 2001 S. Karger AG, Basel
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Accepted: February 6, 2001
Introduction
Recurrence along an endoscope tract has been de-
scribed after endoscopic biopsy and resection of malig-
nant tumors arising in the pulmonary, gastrointestinal,
urologic and gynecological organ systems [1] (Sartorelli,
1996, No. 1852). A case of tract recurrence following the
ventriculoscopic biopsy of a pineal region tumor is de-
scribed. The implications for management of tumors in
this location are discussed.
Case Report
A 14-year-old boy presented with a 2-month history of blurred
vision, headaches and intermittent vomiting. On examination, there
was papilledema, convergence retraction nystagmus, light near disso-
ciation and limited upgaze. A CT scan revealed an enhancing, calci-
fied pineal mass associated with marked hydrocephalus (fig. 1). The
patient underwent an endoscopic third ventriculostomy via a right
frontal burrhole. By angling the endoscope more posteriorly, the
pineal region mass was visualized under its ependymal covering. It
was biopsied using grasping forceps. Some bleeding was stopped with
irrigation. A temporary external ventricular drain was placed
through the frontal burrhole. Postoperative MRI of the spine was
normal. Three weeks later, the patient presented with persistent
hydrocephalus at which time a repeat third ventriculostomy was per-
formed. At both operations, a 12-french peel-away sheath was placed
in the lateral ventricle prior to the introduction of the ventriculo-
scope.
The pathology was consistent with pure germinoma. There were
no giant cells. Beta human chorionic gonadotrophin (ß-hCG) was
Paul Steinbok
Division of Neurosurgery, British Columbia’s Children’s Hospital
4480 Oak Street, Vancouver, BC V6H 3V4 (Canada)
Tel. +1 604 875 2094, Fax +1 604 875 3109
E-Mail psteinbok@cw.bc.ca
 1

Fig. 1. Axial CT scan with contrast, showing

the pineal region tumor at time of initial
diagnosis.
Fig. 2. Sagittal MR scan 12 months after ini-
tial diagnosis, showing the ventriculostomy
tract in the frontal lobe with no tumor
noted.

Fig. 3. Sagittal (a), coronal (b) and axial (c) MR scans at 17 months after initial diagnosis, showing metastatic tumor
in the frontal ventriculostomy tract.

negative on immunohistochemical stains. Serum and cerebrospinal
fluid (CSF) markers for ß-hCG and ·-fetoprotein were similarly neg-
ative. The patient was treated with focal radiotherapy. Forty-five
grays were administered in 25 fractions over 5 weeks using a lateral
parallel opposed pair technique. This was well tolerated although the
patient subsequently required growth hormone and cortisol supple-
mentation. Follow-up MRI showed disappearance of the pineal
tumor.
Seventeen months after the initial third ventriculostomy, a rou-
tine follow-up MRI detected a 2-cm enhancing mass along the ventri-
culoscopy tract (fig. 2, 3). In addition, a small focus of abnormal
enhancement related to the left caudate head was visualized. The
patient was clinically well. Spine MRI was normal. Serum tumor
markers were negative. A right frontal craniotomy and gross total
resection of the right frontal mass were performed. The histopatholo-
gy was again consistent with pure germinoma and was similar to the
original tumor (fig. 4). The patient was treated with chemotherapy,
comprising cisplatin, bleomycin and etoposide, and additional cran-
iospinal radiotherapy of 15 Gy in 10 fractions. He was disease-free at
the latest follow-up 12 months later.
Discussion
Endoscopy has become a diagnostic and therapeutic
option in the management of oncologic lesions through-
out the body. However, this has been associated with the
recognition of endoscope port-site metastases in the ab-
dominal or thoracic walls. The first port-site metastasis
was described by Dobronte et al. [2] in 1978 following the

216 Pediatr Neurosurg 2001;34:215–217 Haw/Steinbok


Fig. 4. Specimen taken from the metastatic frontal tumor, showing
findings typical of a germinoma. The tumor is composed of lobules of
large cells with vacuolated cytoplasm, round nuclei and prominent
nucleoli. Mitotic activity is brisk. There are lymphocytes in the peri-
vascular areas. HE. !100.
laparoscopic biopsy of an ovarian tumor. Further reports
described port-site metastases after laparoscopic chole-
cystectomy for unsuspected gallbladder carcinomas, colo-
rectal laparoscopic surgery for cancers, thoracoscopic sur-
gery for esophageal or pulmonary cancers, and urologic
laparoscopic surgery for bladder or prostatic cancers [1].
The most widely accepted hypothesis for this phenome-
non is that viable tumor cells are implanted into the tract
during unprotected tissue retrieval or by contaminated
instruments used for tumor dissection.
In the central nervous system, where stereotactic biop-
sy has been used for a much longer period of time than
endoscopy, implantation metastases have been described
along the needle tract after the stereotactic biopsy of
intrinsic and metastatic tumors [3, 4]. In the pineal
region, tract recurrence has been reported after the stereo-
tactic biopsy of a pineoblastoma [5].
We describe what we believe to be the first reported
case of endoscope tract recurrence in the central nervous
system following third ventriculostomy and biopsy of a
pineal germinoma. As most patients with tumors in this
region present with hydrocephalus secondary to aqueduc-
tal compression, the role of endoscopic third ventriculos-
tomy and biopsy is likely to increase. However, by breach-
ing the ependymal barrier between the tumor and the
third ventricle, CSF dissemination is possible. This could
lead to port-site recurrence, not merely by CSF dissemina-
tion, but also by the mechanical action of pulling tumor
cells into the endoscope tract. In our case, the use of a
sheath did not prevent this complication.
This phenomenon of tumor dissemination along the
endoscopy tract is of potential significance for the man-
agement of pineal germinomas. Focal radiotherapy, as
was employed in our patient, is an accepted treatment for
nondisseminated germinoma [6, 7] and was used in this
patient. However, if the tumor has been biopsied in a way
that might disseminate tumor cells via the CSF, it may be
that the field of radiotherapy should be extended or che-
motherapy added to avoid the complication noted in our
case.
Acknowledgment
We wish to thank Dr. Glenda Hendson, who provided the pho-
tomicrograph of the tumor.

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Ventriculoscope Tract Recurrence after Pediatr Neurosurg 2001;34:215–217 217

Endoscopic Biopsy of Pineal Germinoma
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