• Work-up should include serum markers including alpha-fetoprotein (alpha-FP), beta-human chorionic gonadotropin (beta-hCG), carcinoembryonic antigen, acid phosphatase
  
• Total imaging of the central nervous system is recommended if there is a suspicion for drop metastasis
  
• Cerebrospinal fluid (CSF) markers as above should be sent if CSF is easily accessible

Operative Planning

• Review imaging (magnetic resonance imaging with or without contrast, computed tomography)
  
• Spinal imaging to review for possible drop metastasis along spinal axis
  
• Confirm CSF and serum for tumor markers (beta-hCG, alpha-FP)
  
• Preoperative steroids for significant vasogenic edema
  
• Treat hydrocephalus if present and symptomatic
  
• Wide diversity in pathology of pineal region tumors, tissue diagnosis is critical for diagnosis and to guide therapy

Hydrocephalus Treatment

External Ventricular Drain

Ventriculoperitoneal Shunt

• Advantages
  
  
  
  • Definitive treatment
  
  
• Disadvantages
  
  
  
  • May not be needed postresection
    
  • Risk of shunt obstruction, malfunction, and infection

Third Ventriculostomy

• Advantages
  
  
  
  • Avoids permanent hardware
    
  • Decreased long-term risk of infection as compared with shunting procedures
    
  • May be able to endoscopically biopsy some pineal region lesions after third ventriculostomy in the same surgical session
    
  • Decreased risk of subdural hematoma (as compared with ventriculoperitoneal shunt) because of less drastic ventricular size reduction
  
  
• Disadvantages
  
  
  
  • Not possible in all case (e.g., tumor filling third ventricle, anatomy not favorable)
    
  • Difficult to assess patency because ventricle may not change in size
    
  • There is potential for ventriculostomy closure or failure
  
  
• We prefer stereotactic endoscopic third ventriculostomy over CSF diversion by ventriculoperitoneal shunt when possible

Operative Options

Stereotactic Biopsy