Surgical management of pineal region tumors in Italy: a SINch (SINch®) National Survey with systematic review

The management of pineal gland tumors poses unique surgical challenges, with varying approaches and outcomes across centers. The existing data on surgical strategies for these tumors are limited, with conflicting information regarding treatment protocols and complications. This survey aimed to explore the current practices in the surgical management of pineal gland tumors in Italy, comparing national trends with literature. A comprehensive survey addressing treatment options, surgical techniques, and management protocols was developed on behalf of SINch® (Società Italiana di Neurochirurgia) and distributed to all Chiefs of Neurosurgical Departments across Italy, from March 2024 to March 2025. A literature review was conducted for studies published between January 2000 and July 2025 following PRISMA guidelines. A total of 67 Italian neurosurgeons participated in the national survey. Most respondents had worked in academic (53.7%) or public hospitals (41.8%). Microsurgery was universally available (100%), whereas endoscopic and stereotactic approaches were offered in 85.1% and 76.1% of centers, respectively. Hydrocephalus was treated preoperatively in 77.6% of patients, mostly via endoscopic third ventriculostomy (68.7%). The supracerebellar infratentorial route was the preferred surgical approach (68.7%), with semisitting and park-bench positions most commonly used. The literature review identified 36 studies (1744 patients). The supracerebellar infratentorial approach was most commonly employed, followed by the occipital interhemispheric transtentorial and other interhemispheric approaches. Hydrocephalus is present in more than 75% of patients, managed predominantly with endoscopic third ventriculostomy or ventriculoperitoneal shunts. The follow-up protocols varied, with early postoperative imaging within 48-72 hours and subsequent MRI at 3-12-month intervals. This study provides the first overview of surgical management trends in Italy. The heterogeneous treatment practices emphasize the lack of standardized guidelines, with a growing need for a more integrated and multidisciplinary approach. Future prospective studies are essential to further refine surgical management strategies.