Pituitary stalk biopsy - A systematic review of the safety and efficacy of stalk lesion biopsy.

INTRODUCTION: A myriad of pathological process may involve the pituitary stalk (infundibulum), and despite extensive investigations, biopsy is often required. Due to the rarity of the procedure, the risks and yield of stalk biopsy are not well known, with important implications for clinical decision making. METHODS: A systematic review was performed in accordance with the PRISMA statement. Studies that reported diagnostic yield and complication rates after stalk biopsy were included. Bias was assessed using ROBINS-V2. RESULTS: A total of 13 studies, including 832 patients and 406 biopsies were included. Mean time from diagnosis to biopsy was 11 months. Preoperative visual symptoms were seen in 29.1%, AVP-deficiency (diabetes insipidus) in 71.0%, and hypopituitarism in 66.3%. Biopsy was predominately performed through the endoscopic transsphenoidal approach (70.9%). Diagnostic yield was 95.8%, and complications included postoperative CSF leak (1.6%), visual worsening (1.6%), new cranial nerve palsy (1.2%), new permanent AVP-deficiency (9.0%), new hypopituitarism (15.7%), and meningitis (2.7%). CONCLUSION: Pituitary stalk biopsy is a high yield and safe diagnostic test, with low periprocedural morbidity. The rate of new endocrinopathy compares favourably to the natural history of progressive stalk disease. Stalk biopsy could be considered earlier in the workup of undifferentiated progressive or symptomatic stalk lesions to avoid unnecessary delays in diagnosis and treatment.