The “extended” endoscopic endonasal approach for the removal of a mixed intrasuprasellar germinoma: Technical case report
A 12-year-old girl was admitted to our hospital with a few-month history of polyuria, polydipsia, and secondary amenorrhea. A neurological examination, including visual field exam and visual acuity, showed amaurosis in the left eye and rapidly worsening temporal hemianopsia in the right eye. A complete preoperative endocrinological assessment revealed mild elevation of the serum prolactin level (76 ng/mL, n.v. 2-25 ng/mL), secondary hypothyroidism (TSH: 0.15 mUI/ml, n.v. 0.4-4 and FT4: 0.52 ng/dl, n.v. 0.9-1.7) and secondary hypocortisolism (morning cortisol: 31 ng/ml, n.v. 50-200). Neuroradiological investigation, by means of magnetic resonance imaging (MRI) scans, demonstrated a large mass arising from the sella with a significant suprasellar component, compressing the optic chiasm and extending into the third ventricle, showing nonhomogeneous enhancement after intravenous contrast administration [Figure –].\nOur diagnostic hypothesis were either a craniopharyngioma or a GCT. However, the evidence of diabetes insipidus as a presenting symptom in a pediatric patient was more suggestive of a germinoma. Unfortunately, it was not possible for technical reasons to perform the serum and/or CSF assay of Alpha-fetoprotein (AFP) and Human chorionic gonadotropin (beta-HCG) before surgery.\nAfter careful consideration of many factors, including patient age, daily progressive visual impairment, lesion size and midline location without any parasellar extension, it was decided to treat the tumor by using an extended endoscopic endonasal transtuberculum/transplanum approach,[] few days after the admittance.\nThe postoperative course was marked by a conspicuous improvement of temporal hemianopsia in the right eye and light perception was reported in the left eye. No postoperative infection or CSF leak was detected. The patient was discharged without any neurological defect of new onset. The postoperative serum level of AFP was 103.9 UI (n.v. 0-5.5 UI) while level of beta-HCG was 165.7 mUI (n.v. <3.5 mUI). Afterwards, the patient was referred to the pediatric oncologist for the adjunctive chemotherapy and radiation therapy treatment. One month postoperative MRI confirmed near-total tumor removal [Figure –]. Three months after surgery, the girl was still being medicated with desmopressin acetate for the diabetes insipidus, but her condition was otherwise normal.