Endoscopic Endonasal Transsphenoidal Surgery for Intrasellar Mixed Germ Cell Tumors

A mixed germ cell tumor (MGCT) in the neurohypophysis is very rare, with only a few reported cases^1-4 but none with surgical videos. In this report, the endoscopic endonasal transsphenoidal approach for MGCT in the neurohypophysis is presented (Video 1). A 12-year-old girl with ocular pain, fatigue, and nausea presented with gradual onset of quadrant hemianopsia and left oculomotor palsy. Magnetic resonance imaging showed an enhanced mass in the sella turcica with multiple components involving the pituitary gland and stalk. Her endocrinological examination showed decreased levels of pituitary hormones and simultaneously elevated serum levels of alpha-fetoprotein and beta-human chorionic gonadotropin. After pituitary hormone replacement, endoscopic endonasal transsphenoidal surgery was planned. The tumor was strongly adherent to the surrounding structures, and gross total resection was achieved. The histological diagnosis was MGCT with a teratoma component. Postoperatively, her vision and oculomotor palsy improved swiftly, and adjuvant chemotherapy and radiotherapy were administered. In this case, 3-dimensional computer graphics were created from the preoperative computed tomography and magnetic resonance imaging studies. Preoperative simulation with the 3-dimensional computer graphic images and intraoperative verification with indocyanine green images facilitated our understanding of the surrounding anatomy, including the tumor components, pituitary gland, and internal carotid arteries.⁵ After removal of the tumor, multilayer fascial closure was performed for skull base reconstruction.⁶ MGCT in the neurohypophysis can be strongly adherent to the surrounding structures, requiring careful dissection and resection under endoscopy. At the last follow-up (8 months after surgery), the tumor was successfully controlled, and the patient had no neurological symptoms with pituitary hormone replacement therapy.