An analysis of clinical characteristics and postoperative complications in children craniopharyngioma

Neuroendocrine Deficits and Weight Development Before and After Proton Therapy in Children With Craniopharyngioma

AIMS

Our objective was to analyse tumour- and treatment-related factors influencing endocrine morbidity and obesity pre- and post-proton beam therapy (PBT) in paediatric patients with craniopharyngioma.

MATERIALS AND METHODS

A total of 65 patients at the onset of PBT were included in the analysis within our prospective registry study. The data pertaining to endocrine deficits and BMI prior to PBT were retrieved from the medical records on a retrospective basis. Cumulative incidences (CI) of endocrinopathies, age- and sex-adjusted BMI standard deviation scores (BMI-SDS) were calculated.

RESULTS

Before PBT, 90.8% had ≥1 neuroendocrine deficit. Diabetes insipidus (DI) was attributed to surgery in 96%. Patients with postoperative DI had a higher 3-year CI of adrenocorticotropic hormone and thyroid-stimulating hormone deficiency rates compared to those without DI (p < .001). At PBT start, 47.7% had already panhypopituitarism compared to 67.7% at the last follow-up (FU). Median FU post-PBT was 3.2 years (range, 1.0-9.6). Post-PBT, 38.2% remained free of additional hormone deficiencies. A trend towards lower endocrine morbidity scores for patients who received PBT during their primary treatment compared to irradiation at progression did not reach statistical significance (p = .068). The BMI-SDS increase from diagnosis to the start of radiotherapy was significantly greater than from the start of PBT to the end of FU (mean BMI-SDS increase: 0.61, ±1.16 vs. 0.13, ±0.84, p = 0.019), with a median time of 10.2 and 38.4 months, respectively. In the multivariate analysis, hypothalamic involvement (p = .042) and the BMI-SDS level at diagnosis (p = .006) were identified as clinical factors indicating severe obesity at FU (BMI-SDS ≥+2).

CONCLUSIONS

Panhypopituitarism is frequently observed in paediatric patients with craniopharyngioma prior to PBT. The potential benefits of early PBT on endocrine outcomes require further investigation through longer FU periods. The greatest increase in weight occurred before radiotherapy. Endocrine deficiencies and weight gain are multifactorial and require close monitoring.

Outcome After Modern Proton Beam Therapy in Childhood Craniopharyngioma: Results of the Prospective Registry Study KiProReg

PURPOSE

Craniopharyngiomas (CPs) are rare tumors of the sellar region often leading to significant comorbidities due to their close proximity to critical structures. The aim of this study was to analyze survival outcome and late toxicities after surgery and proton beam therapy (PBT) in childhood CPs.

METHODS AND MATERIALS

Within the prospective registry study "KiProReg" (DRKS0000536), data of 74 childhood patients with CP, receiving PBT between August 2013 to June 2022 were eligible. Late toxicities were analyzed according to the grading system of the Common Terminology Criteria for Adverse Events, version 4.0.

RESULTS

Median follow-up since first diagnosis was 4.3 years (range, 0.8-14.7). In addition, 75.7% of patients received PBT at time of disease progression or recurrence, whereas 24.3% as part of their primary therapy (definitive or adjuvant). Predominantly (85.1%), pencil beam scanning technique was used. The median total dose and initial tumor volume were 5400 cGy relative biologic effectiveness (RBE) and 17.64 cm³ (range, 3.07-300.59), respectively. The estimated (±SE) 3-year overall survival, progression-free, and cystic failure-free survival rate after PBT were 98.2% (±1.7), 94.7% (±3.0), and 76.8% (±5.4), respectively. All local failures (n = 3) were in-field relapses necessitating intervention and occurred exclusively in patients receiving PBT at progression or recurrence. Early cystic enlargements after PBT were typically asymptomatic and self-limiting. Fatigue, headaches, vision disorders, obesity, and endocrinopathies were the predominant late toxicities. No high-grade (≥3) new-onset visual impairment or cognitive deterioration occurred compared with baseline. The presence of cognitive impairments at the end of follow-up correlated with size of the planning target volume (P = .034), Dmean dose to the temporal lobes (P = .032, P = .045) and the number of surgical interventions before PBT (P = .029).

CONCLUSIONS

Our findings demonstrate favorable local control rates using modern PBT with acceptable late toxicities. Cyst growth within 12 months after radiation therapy is typically not associated with tumor progression. Longer follow-up must be awaited to confirm results.

Analysis of KLRB1-Mediated Immunosuppressive Regulation in Adamantinomatous Craniopharyngioma

BACKGROUND

 Adamantinomatous craniopharyngioma (ACP) is the most common type of craniopharyngioma (CP). Under the current surgery and/or radiotherapy strategies, the survival rate is high, but the long-term quality of life is poor because of the relationship between the hypothalamic-pituitary axis and the tumor. Many studies had shown that endocrine deficiencies caused by craniopharyngiomas of the hypothalamic-pituitary axis persist throughout almost the entire life of the patients after surgery, requiring them to receive hormone replacement therapy. Thus, we need to explore new treatments to improve the prognosis of patients. In recent years, there are more and more studies on the immunotherapy of various tumors. However, due to the rarity of the disease, immunotherapy for ACP is rarely researched. The discovery of the tumor immune-suppressive checkpoint KLRB1 (killer cell lectinlike receptor B1), which encodes CD161, may provide a novel target for the treatment of ACP.

METHODS

 Data analysis of retrospective RNA sequencing was conducted in a cohort of 51 pediatric samples in the GSE94349 dataset, and the results were well validated in the GSE68015 dataset including 31 pediatric samples. We used R language as the main tool for statistical analysis and graphical work.

RESULTS

 Our research showed that KLRB1 was enriched in ACP. Additionally, the expression of KLRB1 was positively related to immune functions and most inflammatory responses of ACP. We found that most of the T lineage-related immune responses were positively correlated with KLRB1 expression, and KLRB1 played an important role in the activation of inflammatory processes.

CONCLUSIONS

 KLRB1 is a promising target for immunotherapeutic strategies.

Central precocious puberty secondary to postoperative craniopharyngioma: two case reports and a literature review

BACKGROUND

Craniopharyngioma is a common intracranial tumour in children. Clinical manifestations are related to hypothalamic/pituitary deficiencies, visual impairment, and increased intracranial pressure. Defects in pituitary function cause shortages of growth hormone, gonadotropin, corticotropin, thyrotropin, and vasopressin, resulting in short stature, delayed puberty, feebleness, lethargy, polyuria, etc. However, manifestations involving precocious puberty (PP) are rare.

CASE REPORT

In both patients, surgical resection was performed after the diagnosis of craniopharyngioma, and breast development occurred postoperatively at one month in one patient and at one year and three months in the other patient. Central precocious puberty (CPP) was diagnosed via relevant examinations. Leuprorelin was injected subcutaneously every 28 days, and changes in height, weight, bone age, gonadal ultrasound and sex hormones were recorded. During the follow-up of the two children, the sex hormone levels were significantly reduced, and significant acceleration in bone age was not observed.

CONCLUSIONS

CPP was induced by craniopharyngioma surgery, and treatment with gonadotropin-releasing hormone analogues (GnRHa) inhibited sexual development and bone age progression. More attention should be given to monitoring for CPP during long-term follow-up of craniopharyngiomas in the clinic.

Visual outcomes after treatment of craniopharyngioma in children: A systematic review

OBJECTIVE

Craniopharyngiomas (CP) are rare brain tumors that often result in visual impairment due to their proximity to the optic pathway. The optimal management approach to preserve visual function in these patients remains controversial. We sought to investigate visual outcomes of children with craniopharyngiomas based on treatment modality.

METHODS

A systematic review was performed according to PRISMA guidelines. PubMed, Embase, and Scopus databases were searched in December 2022 for relevant articles. Articles were screened by title/abstract for relevance, then by full-text. Relevant demographic, intervention, and outcome data were extracted from included studies.

RESULTS

A total of 59 studies were included, representing 2655 patients. The overall visual status (OVS) of patients receiving surgery alone was improved in 27.6% of reported outcomes, unchanged in 50.3%, and deteriorated in 22.1%. The OVS for patients receiving radiation alone was improved in 21.1%, unchanged in 42.1%, and deteriorated in 36.8%. Patients receiving surgery plus adjuvant radiotherapy had OVS improvement in 27.4%, unchanged in 63.2%, and deteriorated in 9.4%. Of those receiving intracystic bleomycin, 23.1% had improvement in OVS, 46.2% remained unchanged, and 30.8% deteriorated. Of patients receiving interferon-α, 34.8% improved, 54.5% remained unchanged, and 10.6% deteriorated.

CONCLUSION

OVS most frequently remained unchanged regardless of intervention. The greatest improvement in OVS was seen in those receiving interferon-α or surgery alone. The greatest OVS deterioration was noted with radiation alone. Future standardized, randomized, large-scale studies with focused assessment of ophthalmologic findings are key to further understanding the impact different interventions have on visual outcomes in these children.

Vascular complications in craniopharyngioma-resected paediatric patients: a single-center experience

Background

Craniopharyngioma (CP), although slow growing and histologically benign, has high morbidity, mostly related to hypothalamus-pituitary dysfunction and electrolyte imbalance. Increased risk of vascular complications has been described. However, data are still poor, especially in the paediatric population. The aim of our study was to evaluate the occurrence, timing, and predisposing factors of deep venous thrombosis (DVT) and other vascular alterations in neurosurgical paediatric CP patients.

Materials and Methods

In a single-centre, retrospective study, we investigated 19 CP patients (11 males, 8 females, mean age 10.5 ± 4.3 years), who underwent neurosurgery between December 2016 and August 2022, referred to Meyer Children's Hospital IRCCS in Florence.

Results

Five patients (26.3%) presented vascular events, which all occurred in connection with sodium imbalances. Three DVT (two with associated pulmonary embolism, in one case leading to death) developed in the post-operative period, most frequently at 7-10 days. Elevated D-dimers, a reduced partial activated thrombin time and a prolonged C-reactive protein increase were highly related to thrombotic vascular events. One case of posterior cerebral artery pseudoaneurysm was described soon after neurosurgery, requiring vascular stenting. Superficial vein thrombophlebitis was a late complication in one patient with other predisposing factors.

Conclusion

CP patients undergoing neurosurgery are at risk of developing DVT and vascular alterations, thus careful follow-up is mandatory. In our study, we found that the phase of transition from central diabetes insipidus to a syndrome of inappropriate antidiuretic hormone secretion may be a period of significant risk for DVT occurrence. Careful vascular follow-up is mandatory in CP-operated patients.

The Price of Success-The Long-Term Outcomes of Children with Craniopharyngioma-Two Institutions' Experience

An analysis of patients below 21 years old treated due to craniopharyngioma in the years 1979-2022 was performed with the aim of evaluating the long-term outcome and treatment side-effects. The standard statistical tests were used, and 56 patients with a median age of 11 years were evaluated. Surgery was the primary treatment in 55 patients; however, in only 29 it was the only neurosurgical intervention. Eighteen children were treated with radiotherapy (RTH) in primary treatment. The most common neurosurgical side effects observed were visual and endocrine deficits and obesity, which were diagnosed in 27 (49%), 50 (91%), and 25 (52%) patients, respectively. Complications after RTH were diagnosed in 14 cases (32%). During the median follow-up of 8.4 years (range: 0.4-39.8 years), six patients died and the 5- and 10-year overall survival was 97% and 93%, respectively. Five-year progression-free survival for gross total resection, resection with adjuvant RTH, and non-radical resection alone was 83%, 68%, and 23%, respectively (p = 0.0006). Surgery combined with RTH provides comparable results to gross tumor resection in terms of oncologic outcome in craniopharyngioma patients. Adjuvant irradiation applied in primary or salvage treatment improves disease control. The rate of complications is high irrespective of improved surgical and radiotherapeutic management.

Surgical Treatment of Pediatric Incidentally Found Brain Tumors: A Single-Center Experience

There remains much debate about the correct management of incidentally found brain tumors in the pediatric population. This study aimed to evaluate the efficacy and safety of surgical treatment of incidentally found pediatric brain tumors. A retrospective analysis of pediatric patients who underwent surgical resection of incidentally found brain tumors between January 2010 and April 2016 was performed. A total of seven patients were included. The median age at the time of diagnosis was 9.7 years. The reasons for performing neuroimaging were as follows: impeded speech development (n = 2), shunt control (n = 1), paranasal sinuses control (n = 1), behavior changes (n = 1), head trauma (n = 1), and preterm birth (n = 1). Five patients underwent gross total tumor resection (71.4%), while subtotal resection was performed in two patients (28.6%). There was no surgery-related morbidity. Patients were followed up for a mean of 79 months. One patient with atypical neurocytoma experienced tumor recurrence 45 months following primary resection. All patients remained neurologically intact. The majority of pediatric incidentally found brain tumors were histologically benign. Surgery remains a safe therapeutic approach associated with favorable long-term outcomes. Considering the expected long lifetime of pediatric patients, as well as the psychological burden associated with having a brain tumor as a child, surgical resection can be considered an initial approach.

Risk Factor and Replacement Therapy Analysis of Pre- and Postoperative Endocrine Deficiencies for Craniopharyngioma

BACKGROUND

Pituitary hormone deficiency (PHD) is one of the most common symptoms and postoperative complications of craniopharyngiomas (CPs). However, the risk factors for PHD in CPs are little known. The purpose of this study was to analyze the risk factors of pre- and postoperative PHD and to investigate replacement therapy for CP patients.

METHODS

A retrospective study of 126 patients diagnosed with CP was performed. Univariate analysis was performed using Pearson's chi-squared test or Fisher's exact test, and a multiple logistic binary regression model was used to identify the influencing factors of pre- and postoperative PHD in craniopharyngioma.

RESULTS

Children and patients with hypothalamic involvement were more likely to have preoperative PHD. Patients with suprasellar lesions had a high risk of postoperative PHD, and preoperative PHD was a risk factor for postoperative PHD.

CONCLUSION

Children have a high incidence of preoperative PHD. Preoperative PHD can serve as an independent risk factor for postoperative PHD. Preoperative panhypopituitarism can serve as an indication of pituitary stalk sacrifice during surgery. The management of replacement therapy for long-term postoperative endocrine hormone deficiency in patients with craniopharyngioma should be enhanced.

Keyhole surgery for giant basal brain tumors. Theoretical explanation with an example of trans-eyebrow subraorbital approach

BACKGROUND

Improvement of modern neurosurgical technology has given rise to keyhole surgery for a wide range of pathologies. Supraorbital trans-eyebrow approach has been described in detail for small tumors of anterior cranial fossa and suprasellar neoplasms. Can we use this small and less traumatic approach for a more complex tumor extending beyond the suprasellar region?

OBJECTIVE

To analyze own experience of surgical treatment of large and giant parasellar tumors via supraorbital approach, to identify the principles of such operations, indications and possible limitations.

MATERIAL AND METHODS

There were 58 resections of parasellar tumors via mini-supraorbital approach had been performed between 2016 and 2021 at the 2nd pediatric neurosurgical department. We selected 42 patients with large and giant tumors extending beyond the chiasmal-sellar zone and causing occlusive hydrocephalus (mean volume 44.2 cm³). Preoperative status of patients, postoperative clinical data and logistics of in-hospital treatment were analyzed.

RESULTS

Total resection was performed in all cases. No redo surgeries or revisions were required. There were no cases of wound infection, CSF leakage and damage to large vessels.

CONCLUSION

We standardized planning of surgeries for large neoplasms considering available knowledge about the nature of diseases, analysis of clinical and X-ray data, goals and objectives of surgery. The reader is offered a theoretical substantiation of applicability of keyhole surgery for chiasmal-sellar tumors on the example of well-known mini-supraorbital approach. We gave certain advices on planning such operations and illustrated clinical examples.