The Endoscopic ExtraForaminal TransChoroid (EFTC) Approach in the Management of Pineal Tumors: Gross Total Resection through a Single Burr Hole.

Pineal region tumors pose a significant surgical challenge due to their deep location and proximity to critical neurovascular structures. Endoscopic techniques, particularly the transchoroid approach, have expanded the possibilities for minimally invasive access to the posterior third ventricle. In select cases, this route may not only allow simultaneous biopsy and third ventriculostomy but also meaningful tumour resection while limiting morbidity. We report the case of an 11-year-old male presenting with headache, drowsiness, vomiting and diplopia. Imaging demonstrated a heterogeneous pineal mass with features suggestive of teratoma. Serum markers revealed markedly elevated β-HCG with normal AFP. The radiological picture coupled with the tumour markers was consistent with a mixed malignant germ cell tumour. An endoscopic third ventriculostomy (ETV) and endoscopic extraforaminal transchoroid (EFTC) approach were planned through a single burr hole with the aim of cerebrospinal fluid (CSF) diversion, providing a tissue sample and debulking if possible and appropriate. The identification of mature teratomatous components on smear and a favorable dissection plane enabled and justified gross total resection through the single burr hole. Histopathology confirmed mature and immature teratomatous tissue with a 5-10% germinomatous component. The postoperative course was uneventful, and the patient completed chemotherapy followed by proton beam radiotherapy, remaining recurrence-free at the latest follow-up of over two years. This case represents the first reported gross total resection (GTR) of a pineal tumour achieved via an endoscopic EFTC approach and highlights its potential as a safe and effective minimally invasive route for lesions in the posterior third ventricle, enabling complete resection in select patients.