Histological findings at the boundary of craniopharyngiomas

Papillary Craniopharyngioma: An Integrative and Comprehensive Review

Papillary craniopharyngioma (PCP) is a rare type of tumor, comprising ∼20% of all craniopharyngioma (CP) cases. It is now recognized as a separate pathological entity from the adamantinomatous type. PCPs are benign tumors, classified as World Health Organization grade 1, characterized by nonkeratinizing squamous epithelium. They typically grow as solid and round papillomatous masses or as unilocular cysts with a cauliflower-like excrescence. PCPs primarily occur in adults (95%), with increased frequency in males (60%), and predominantly affect the hypothalamus. Over 80% of these tumors are located in the third ventricle, expanding either above an anatomically intact infundibulum (strictly third ventricle tumors) or within the infundibulo-tuberal region of the third ventricle floor. Clinical manifestations commonly include visual deficits and a wide range of psychiatric disturbances (45% of patients), such as memory deficits and odd behavior. Magnetic resonance imaging can identify up to 50% of PCPs by the presence of a basal duct-like recess. Surgical management is challenging, requiring complex approaches to the third ventricle and posing significant risk of hypothalamic injury. The endoscopic endonasal approach allows radical tumor resection and yields more favorable patient outcomes. Of intriguing pathogenesis, over 90% of PCPs harbor the somatic BRAFV600E mutation, which activates the mitogen-activated protein kinase signaling pathway. A phase 2 clinical trial has demonstrated that PCPs respond well to proto-oncogene B-Raf/MAPK/ERK kinase inhibitors. This comprehensive review synthesizes information from a cohort of 560 well-described PCPs and 99 large CP series including PCP cases published from 1856 to 2023 and represents the most extensive collection of knowledge on PCPs to date.

Finger-like protrusions in adamantinomatous craniopharyngiomas: implications for recurrence and prognosis following complete tumor resection and predictive factors

Finger-like protrusions (FPs) extending into the hypothalamus in adamantinomatous craniopharyngiomas (ACPs) pose surgical challenges and their link to tumor recurrence and patient prognosis following gross total resection (GTR) is unclear. This study aims to determine the association between FPs, tumor recurrence, and prognosis after GTR, while identifying predictors for the presence of FPs. A total of 149 ACP patients undergoing GTR at our institution between January 2015 and December 2023 were retrospectively analyzed and were categorized into FP and non-FP groups based on the histology of the interface between ACP and the hypothalamus. Various parameters were compared, and logistic regression analyses were conducted to identify predictors for the presence of FPs in ACPs. The FP group (n = 50) had higher rates of meningitis (p = 0.020), postoperative hydrocephalus (p = 0.014), pneumonia (p < 0.001), perioperative mortality (p = 0.036), radiological hypothalamic injury (p < 0.001), and hypothalamic dysfunction (p < 0.001) during follow-up. They also showed inferior recurrence-free survival (p = 0.012) and overall survival (p = 0.023). Predictors for FPs in ACPs included solid tumor (OR 5.28, 95% CI 1.81-15.40; p = 0.002) and preoperative MRI without an upward eagle sign (OR 27.65, 95% CI 8.93-85.65; p < 0.001). FPs in ACPs pose challenges for achieving safe radical tumor resection and are linked to higher recurrence rates and unfavorable patient outcomes after GTR. Solid tumor consistency and preoperative MRI without an upward eagle sign could predict the presence of FPs in ACPs involving the hypothalamus. For ACPs demonstrating these characteristics, a more conservative resection should be considered. Additionally, rigorous postoperative monitoring for tumor recurrence is essential for ACPs with FPs, even after GTR.

Early diagnosis and postoperative follow-up of 50 Chinese children with craniopharyngioma

BACKGROUND

Craniopharyngioma is a relatively common congenital intracranial tumor for children. But only few available studies focused on the endocrine evaluation before diagnosis and postoperative endocrine evaluations of children with craniopharyngioma. The aim of this study was to aid in the early diagnosis of craniopharyngioma (CP) and follow-up postoperative children suffered from craniopharyngioma.

METHODS

Craniopharyngioma patients, as the CP group (N.=50), and healthy children, as the control group (N.=30), the symptoms and pituitary hormone levels were reviewed and investigated.

RESULTS

The preoperative levels of peak of GH, IGF-1, FT4, ACTH, COR and PRL of CP patients were significantly lower than those of the control group (all the P≤0.001). Levels of pituitary-hormones after surgery were significantly lower than both those before surgery and those of the control group (all the P≤0.001). HGH treatment could significantly improve the growth velocity of postoperative children (3.8±1.5 cm/year vs 13.0±3.4 cm/year for males, P≤0.001; 4.0±1.3 cm/year vs 12.7±1.8 cm/year for females, P≤0.001).

CONCLUSIONS

Children presenting with endocrine disturbance symptoms combined with pituitary hormone deficits should be assessed by MRI to exclude craniopharyngioma earlier. Also, long-term follow-up study was very essential to craniopharyngioma survivors.

Long-term outcomes of multidisciplinary treatment combining surgery and stereotactic radiotherapy with Novalis for craniopharyngioma

Craniopharyngiomas are difficult to resect completely, recurrence is frequent, and hypothalamic/pituitary function may be affected after surgery. Therefore, the ideal treatment for craniopharyngiomas is local control with preservation of hypothalamic and pituitary functions. The purpose of this study is to retrospectively evaluate the long-term efficacy and adverse events of stereotactic radiotherapy (SRT) with Novalis for craniopharyngioma. This study included 23 patients with craniopharyngiomas who underwent surgery between 2006 and 2021 and underwent SRT as their first irradiation after surgery. The median post-irradiation observation period was 88 months, with the overall survival rates of 100 % at 10 years and 85.7 % at 20 years. One patient died of adrenal insufficiency 12 years after irradiation. The local control rate of the cystic component was 91.3 % at 5 years, 83.0 % at 15 years, with no increase in the solid component. No delayed impairment of visual or pituitary function due to irradiation was observed. No new hypothalamic dysfunction was observed after radiation therapy. No delayed adverse events such as brain necrosis, cerebral artery stenosis, cerebral infarction, or secondary brain tumors were also observed. SRT was safe and effective over the long term in patients irradiated in childhood as well as adults, with no local recurrence or adverse events. We believe that surgical planning for craniopharyngioma with stereotactic radiotherapy in mind is effective in maintaining a good prognosis and quality of life.

Risk-benefit analysis of surgical treatment strategies for cystic craniopharyngioma in children and adolescents

Objective

Treatment strategies for craniopharyngiomas are still under debate particularly for the young population. We here present tumor control and functional outcome data after surgical treatment focusing on stereotactic and microsurgical procedures for cystic craniopharyngiomas in children and adolescents.

Methods

From our prospective institutional database, we identified all consecutive patients less than 18 years of age who were surgically treated for newly-diagnosed cystic craniopharyngioma between, 2000 and, 2022. Treatment decisions in favor of stereotactic treatment (STX) or microsurgery were made interdisciplinary. STX included aspiration and/or implantation of an internal shunt catheter for permanent cyst drainage. Microsurgery aimed for safe maximal tumor resections. Study endpoints were time to tumor recurrence (TTR) and functional outcome including ophthalmological/perimetric, endocrinological, and body-mass index (BMI) data.

Results

29 patients (median age 9.9 yrs, range 4-18 years) were analyzed. According to our interdisciplinary tumor board recommendation, 9 patients underwent stereotactic treatment, 10 patients microsurgical resection, and 10 patients the combination of both. Significant volume reduction was particularly achieved in the stereotactic (p=0.0019) and combined subgroups (p<0.001). Improvement of preoperative visual deficits was always achieved independent of the applied treatment modality. Microsurgery and the combinational treatment were associated with higher rates of postoperative endocrinological dysfunction (p<0.0001) including hypothalamic obesity (median BMI increase from 17.9kg/m2 to 24.1kg/m2, p=0.019). Median follow-up for all patients was 93.9 months (range 3.2-321.5 months). Recurrent tumors were seen in 48.3% and particularly concerned patients after initial combination of surgery and STX (p=0.004). In here, TTR was 35.1 ± 46.9 months. Additional radiation therapy was found indicated in 4 patients to achieve long-lasting tumor control.

Conclusion

In children and adolescents suffering from predominantly cystic craniopharyngiomas, stereotactic and microsurgical procedures can improve clinical symptoms at low procedural risk. Microsurgery, however, bears a higher risk of postoperative endocrine dysfunction. A risk-adapted surgical treatment concept may have to be applied repeatedly in order to achieve long-term tumor control even without additional irradiation.

Endoscopic versus Nonendoscopic Surgery for Resection of Craniopharyngiomas

OBJECTIVE

While surgery is a critical treatment option for craniopharyngiomas, the optimal surgical approach remains under debate. Herein, we studied a large cohort of craniopharyngioma patients to identify predictors of endoscopic surgery (ES) and to compare survival outcomes between patients undergoing ES versus nonendoscopic surgery (NES).

METHODS

The National Cancer Database was queried for patients receiving definitive surgical treatment in 2010-2016. Cox proportional hazards and propensity score-adjusted Kaplan-Meier analyses assessed mortality risk and overall survival, respectively. Predictors of surgical approach were evaluated via logistic regression.

RESULTS

Of 1721 patients, 508 (29.5%) underwent ES, 877 (50.9%) were female, and the average age was 41.8 ± 21.3 years. Matched ES and NES cohorts exhibited 5-year overall survival rates of 88.0% and 79.8%, respectively (P = 0.004). ES was associated with reduced mortality (Hazard Ratio = 0.634; 95% confidence interval [CI], 0.439-0.914; P = 0.015). Patients treated at academic facilities (Odds Ratio [OR] = 2.095; 95% CI, 1.529-2.904; P < 0.001) or diagnosed recently (OR = 1.132; 95% CI, 1.058-1.211; P < 0.001) were more likely to undergo ES, while those with tumor sizes >3 cm (OR = 0.604; 95% CI, 0.451-0.804; P < 0.001) or receiving adjuvant radiotherapy (OR = 0.641; 95% CI, 0.454-0.894; P = 0.010) were more likely to receive NES. Surgical inpatient stays were significantly shorter with ES compared to NES (8.0 vs. 10.5 days, P < 0.001). On linear regression, ES usage increased by 82.4% and NES usage decreased by 23.4% between 2010 and 2016 (R2 = 0.575, P = 0.031).

CONCLUSIONS

ES of craniopharyngioma was associated with reduced mortality and shorter inpatient stays compared to NES. Factors including tumor size, extent of resection, facility type, and year of diagnosis may predict receiving ES. There is a trend towards increased usage of ES for surgical management of craniopharyngiomas.

Fornix alterations induce the disruption of default mode network in patients with adamantinomatous craniopharyngiomas

Adamantinomatous craniopharyngioma (ACPs) are rare embryonic tumors and often involve the hypothalamus. The underlying neural substrate of the hypothalamic involvement (HI)-related cognitive decline in patients with ACP is still unclear. We aimed to combine the multi-modal neuroimaging and histological characteristics of the ACP to explore the potential neural substrate of the HI-related cognitive decline. 45 patients with primary ACPs (invasive, 23; noninvasive, 22) and 52 healthy control subjects (HCs) were admitted to the cross-sectional study. No significant difference in cognitive domains was observed between HCs and patients with noninvasive ACPs (NACP). Patients with invasive ACPs (IACP) showed significantly lower working memory performance (WM, p = 0.002) than patients with NACP. The WM decline was correlated with the disruption of the medial temporal lobe (MTL) subsystem in the default mode network (DMN) (r = 0.45, p = 0.004). The increased radial diffusivity of the fornix, indicating demyelinating process, was correlated with the disruption of the MTL subsystem (r = -0.48, p = 0.002). Our study demonstrated that the fornix alterations link DMN disruption to HI-related cognitive decline in patients with ACPs. ACPs that invade the hypothalamus can provide a natural disease model to investigate the potential neural substrate of HI-related cognitive decline.

Exploring the pathological relationships between adamantinomatous craniopharyngioma and contiguous structures with tumor origin

PURPOSE

Identifying relationships between craniopharyngiomas (CPs) and contiguous structures, and tumor origin are crucial for treatments. This study attempted to explore the relationships and tumor origin.

METHODS

CPs that underwent endoscopic surgeries were enrolled. The interfacial specimens of CPs attaching the hypothalamus, pituitary stalk (PS), pituitary grand (PG), optic chiasma (OC) and brain tissue (BT) were pathologically examined. Boundaries between CPs and these structures were observed during operations. Expression of β-catenin and stem cell markers were analyzed to explore the tumor origin. Outcomes of patients were assessed.

RESULTS

A total of 34 CPs were categorized into two groups based on the locations of finger-like protrusions (FP). Group A comprised 18 CPs with FP only present in the specimens attaching to hypothalamus. The surface of these CPs was fused with hypothalamus under endoscopic videos. However, the specimens attaching to the PS, PG, OC, and BT showed no FP. Clear boundaries was observed between these CPs and these structures. Group B comprised 16 CPs with FP only present in the specimens attaching to PS. The tumor surface was fused with PS. Specimens attaching to the hypothalamus, PG, OC and BT showed no FP. Clear boundary was observed among these CPs with these structures. These results implied CPs only invaded a certain part of hypothalamic-pituitary axis. β-catenin and stem cells markers mainly distributed in the FP tissues of both groups. Patients in group B achieved better outcomes than group A.

CONCLUSIONS

CPs only invade the hypothalamic-pituitary axis with FP and the FP would be the tumor origin.

A multi-task two-path deep learning system for predicting the invasiveness of craniopharyngioma

BACKGROUND AND OBJECTIVE

Craniopharyngioma is a kind of benign brain tumor in histography. However, it might be clinically aggressive and have severe manifestations, such as increased intracranial pressure, hypothalamic-pituitary dysfunction, and visual impairment. It is considered challenging for radiologists to predict the invasiveness of craniopharyngioma through MRI images. Therefore, developing a non-invasive method that can predict the invasiveness and boundary of CP as a reference before surgery is of clinical value for making more appropriate and individualized treatment decisions and reducing the occurrence of inappropriate surgical plan choices.

METHODS

The MT-Brain system has consisted of two pathways, a sub-path based on 2D CNN for capturing the features from each slice of MRI images, and a 3D sub-network for capturing additional context information between slices. By introducing the two-path architecture, our system can make full use of the fusion of the above 2D and 3D features for classification. Furthermore, position encoding and mask-guided attention also have been introduced to improve the segmentation and diagnosis performance. To verify the performance of the MT-Brain system, we have enrolled 1032 patients with craniopharyngioma (302 invasion and 730 non-invasion patients), segmented the tumors on postcontrast coronal T1WI and randomized them into a training dataset and a testing dataset at a ratio of 8:2.

RESULTS

The MT-Brain system achieved a remarkable performance in diagnosing the invasiveness of craniopharyngioma with the AUC of 83.84%, the accuracy of 77.94%, the sensitivity of 70.97%, and the specificity of 80.99%. In the lesion segmentation task, the predicted boundaries of lesions were similar to those labeled by radiologists with the dice of 66.36%. In addition, some explorations also have been made on the interpretability of deep learning models, illustrating the reliability of the model.

CONCLUSIONS

To the best of our knowledge, this study is the first to develop an integrated deep learning model to predict the invasiveness of craniopharyngioma preoperatively and locate the lesion boundary synchronously on MRI. The excellent performances indicate that the MT-Brain system has great potential in real-world clinical applications.

Non-Invasive Radiomics Approach Predict Invasiveness of Adamantinomatous Craniopharyngioma Before Surgery

Purpose

Craniopharyngiomas (CPs) are benign tumors, complete tumor resection is considered to be the optimal treatment. However, although histologically benign, the local invasiveness of CPs commonly contributes to incomplete resection and a poor prognosis. At present, some advocate less aggressive surgery combined with radiotherapy as a more reasonable and effective means of protecting hypothalamus function and preventing recurrence in patients with tight tumor adhesion to the hypothalamus. Hence, if a method can be developed to predict the invasiveness of CP preoperatively, it will help in the development of a more personalized surgical strategy. The aim of the study was to report a radiomics-clinical nomogram for the individualized preoperative prediction of the invasiveness of adamantinomatous CP (ACPs) before surgery.

Methods

In total, 1,874 radiomics features were extracted from whole tumors on contrast-enhanced T1-weighted images. A support vector machine trained a predictive model that was validated using receiver operating characteristic (ROC) analysis on an independent test set. Moreover, a nomogram was constructed incorporating clinical characteristics and the radiomics signature for individual prediction.

Results

Eleven features associated with the invasiveness of ACPs were selected by using the least absolute shrinkage and selection operator (LASSO) method. These features yielded area under the curve (AUC) values of 79.09 and 73.5% for the training and test sets, respectively. The nomogram incorporating peritumoral edema and the radiomics signature yielded good calibration in the training and test sets with the AUCs of 84.79 and 76.48%, respectively.

Conclusion

The developed model yields good performance, indicating that the invasiveness of APCs can be predicted using noninvasive radiological data. This reliable, noninvasive tool can help clinical decision making and improve patient prognosis.

Craniopharyngiomas primarily affecting the hypothalamus

The concept of craniopharyngiomas (CPs) primarily affecting the hypothalamus, or "hypothalamic CPs" (Hy-CPs), refers, in a restrictive sense, to the subgroup of CPs originally developing within the neural tissue of the infundibulum and tuber cinereum, the components of the third ventricle floor. This subgroup, also known as infundibulo-tuberal CPs, largely occupies the third ventricle and comprises up to 40% of this pathological entity. The small subgroup of strictly intraventricular CPs (5%), lesions wholly developed within the third ventricle above an anatomically intact third ventricle floor, can also be included within the Hy-CP category. The remaining types of sellar and/or suprasellar CPs may compress or invade the hypothalamic region during their growth but will not be considered in this review. Hy-CPs predominantly affect adults, causing a wide range of symptoms derived from hypothalamic dysfunction, such as adiposogenital dystrophy (Babinski-Fröhlich's syndrome), diabetes insipidus (DI), abnormal diurnal somnolence, and a complex set of cognitive (dementia-like, Korsakoff-like), emotional (rage, apathy, depression), and behavioral (autism-like, psychotic-like) disturbances. Accordingly, Hy-CPs represent a neurobiological model of psychiatric disorders caused by a lesion restricted to the hypothalamus. The vast majority (90%) of squamous-papillary CPs belong to the Hy-CP category. Pathologically, most Hy-CPs present extensive and strong adhesions to the surrounding hypothalamus, usually formed of a thick band of gliotic tissue encircling the central portion of the tumor ("ring-like" attachment) or its entire boundary ("circumferential" attachment). CPs with these severe adhesion types associate high surgical risk, with morbidity and mortality rates three times higher than those for sellar/suprasellar CPs. Consequently, radical surgical removal of Hy-CPs cannot be generally recommended. Rather, Hy-CPs should be accurately classified according to an individualized surgery-risk stratification scheme considering patient age, CP topography, presence of hypothalamic symptoms, tumor size, and, most importantly, the CP-hypothalamus adhesion pattern.

Management of hypothalamic disease in patients with craniopharyngioma

Patients with craniopharyngioma experience excess morbidity and mortality when compared with the background population and with other hypopituitary patients. Large, suprasellar tumours which form micropapillae into surrounding structures can cause hypothalamic damage before any therapeutic intervention; attempted gross total resection can lead to hypothalamic obesity, sleep disorders, thirst disorders and dysregulation of temperature as well as panhypopituitarism. The management of tumour bulk and the pathophysiology of hypothalamic complications have been reviewed extensively. We present a practical, clinical approach to management of hypothalamic disease in a patient with craniopharyngioma and highlight potential targets for future pharmacological or surgical intervention.

Impact of neutrophil-lymphocyte ratio on long-term outcome in patients with craniopharyngioma

Neutrophil-lymphocyte ratio (NLR) is a poor prognostic factor in many tumors including glioblastoma multiforme (GBM), colorectal, and prostate cancer. The aim of this study was to investigate the prognostic value of preoperative NLR in patients with craniopharyngioma.Around 149 patients of craniopharyngioma surgically were treated at the Department of Neurosurgery, West China Hospital from January 2008 to December 2010, including 84 males and 65 females aged from 6 to 70 years were retrospectively reviewed, and preoperative NLR was analyzed. Overall survival (OS), progression free survival (PFS), and quality of life (QOL) were evaluated.The 5-year OS and PFS rates were 81.21% and 75.84%. Preoperative NLR was significantly correlated with OS (HR = 1.44, 95% CI 1.16-1.79, P = .001) and PFS (HR = 1.46, 95% CI 1.22-1.74, P < .001). The best cut-off value of NLR was found to be 4 based on the receiver operator characteristics (ROC) curve. Patients with NLR ≥4 had a significantly worse QOL (P = .039), lower OS rate (P = .009), and PFS rate (P < .001).Preoperative NLR may be a simple, readily available, and valid predictor of long-term outcome in craniopharyngioma. We suggest that the NLR can provide effective guidance to neurosurgeons for more information about the tumor and prognostic evaluation.

A novel endoscopic classification for craniopharyngioma based on its origin

Endoscopic endonasal approach for craniopharyngioma (CP) resection provides a wide view and direct observation of hypothalamus and origin of tumor. Under endoscopy, 92 CPs were classified into 2 types: Peripheral and Central, according to its relation to pituitary stalk. Peripheral type was further divided into 3 subtypes: Hypothalamic stalk, Suprasellar stalk and Intrasellar stalk CP, according to the different origin site along hypothalamus-pituitary axis. Peripheral type arisen from the stalk but expanded and grown laterally in an exophytic pattern, accounting for 71.7% of all CPs, preservation rate of stalk was higher (76.0%). Central type grew within and along pituitary stalk and located strictly in the midline. The pituitary stalk was hardly preserved (only15.4%). Hypothalamic stalk CPs (n = 36, 54.6%) developed from the junction of hypothalamus and stalk, hypothalamus damage was found in all of this subtype after surgery. Suprasellar stalk CPs (n = 14, 21.2%) originated from the lower portion of stalk and displaced hypothalamus upward rather than infiltrated it. Intrasellar stalk CPs (n = 16, 24.2%) arose from the subdiaphragma portion of the stalk, with less hypothalamus damage. Recoginzing the origin of CP is helpful to understand its growth pattern and relation to hypothalamus, which is critical in planning the most appropriate surgical approach and degree of excision.

Cystic Craniopharyngiomas: Microsurgical or Stereotactic Treatment?

BACKGROUND

Prognosis and treatment of cystic craniopharyngiomas are poorly defined.

OBJECTIVE

To analyze progression-free survival (PFS) and safety profile of cystic craniopharyngiomas undergoing resection or minimally invasive drainage procedures. We compared further outcome measurements for cystic and solid tumors undergoing resection to elucidate the impact of the initial tumor composition on both PFS and the toxicity profile.

METHODS

All patients with craniopharyngiomas consecutively treated between 1999 and 2014 were included. A treatment decision in favor of microsurgery or stereotactic treatment was made interdisciplinarily. For stereotactic drainage, a catheter was implanted, allowing both permanent upstream (into ventricular spaces) and downstream (into prepontine cistern) drainage. Study endpoints were tumor progression, functional outcome, and treatment toxicity. Functional endocrinological and visual outcome analyses referred to data obtained preoperatively and 6 weeks after treatment. The Kaplan-Meier method was used for survival analysis. Prognostic factors were obtained from proportional hazard models.

RESULTS

Seventy-nine patients were included. The distribution of clinical and tumor-related data was well balanced among patients with solid (n = 35) and cystic (n = 44) tumors and those undergoing microsurgical or stereotactic treatment. Cystic tumors had shorter PFS (5-year PFS: 53.6% vs 66.8%, P = .10) and needed significantly more therapeutic interventions, which was independent of the initial treatment mode. The endocrinological deterioration rate was high for both solid and cystic tumors after microsurgery (59.4% and 85.7%, respectively), whereas it was significantly lower for cystic tumors undergoing stereotactic treatment (23.1%, P < .001).

CONCLUSION

Stereotactic bidirectional drainage of cystic craniopharyngiomas is effective and provides a better endocrinological outcome than conventional microsurgery.

Epithelial-mesenchymal transition and clinicopathological correlation in craniopharyngioma

AIMS

To assess the immunophenotypic changes associated with epithelial-mesenchymal transition (EMT) in craniopharyngioma, especially at the tumour invasive front, and to correlate the findings with clinicopathological features and patient outcomes.

METHODS AND RESULTS

Forty-two craniopharyngiomas were investigated for the presence of EMT markers (vimentin, E-cadherin and β-catenin) by immunohistochemistry and western blot. The relationships between expression of these markers and various clinicopathological indicators and clinical outcomes of the tumours were analysed. There were statistically significant differences in the expression of vimentin and E-cadherin-β-catenin between adamantinomatous and papillary variants. The expression of vimentin and E-cadherin (but not that of β-catenin) in whole tumour sections was associated with tumour recurrence, and with postoperative weight and hypothalamic disturbances; the expression of vimentin and E-cadherin-β-catenin at the tumour invasive front was also associated with tumour recurrence, postoperative weight, and hypothalamic disturbances. The results from western blotting closely matched those of immunohistochemistry.

CONCLUSION

Our study demonstrates, for the first time, the potential prognostic implications of vimentin, E-cadherin and β-catenin expression in craniopharyngiomas. EMT may represent a crucial mechanism in the progression of craniopharyngiomas.

Ultrastructural characterization of craniopharyngioma at the tumor boundary: A structural comparison with an experimental toxic model using "oil machinery" fluid, with emphasis on Rosenthal fibers

Craniopharyngiomas (CPs) are cystic, encapsulated, slow-growing epithelial tumors. CPs can be aggressive forms invading and resorting surrounding structures of adjacent brain tissue, where Rosenthal fibers (RFs) are expressed. The aim of this study was to investigate the ultrastructure of these fibers in human biopsies and compare it with an experimental toxic model produced by the cortical infusion of the oil cyst fluid ("Oil machinery" fluid or OMF) from CPs to rats. For this purpose, the CPs from ten patients were examined by light and electron microscopy. OMF was administered to rats intracortically. Immunohistochemical detection of glial fibrillary acidic protein (GFAP) and vimentin was assessed. In both freshly obtained CPs and rat brain tissue, the presence of abundant cellular debris, lipid-laden macrophages, reactive gliosis, inflammation and extracellular matrix destruction were seen. Ultrastructural results suggest focal pathological disturbances and an altered microenvironment surrounding the tumor-brain junction, with an enhanced presence of RFs in human tumors. In contrast, in the rat brain different degrees of cellular disorganization with aberrant filament-filament interactions and protein aggregation were seen, although RFs were absent. Our immunohistochemical findings in CPs also revealed an enhanced expression of GFAP and vimentin in RFs at the peripheral, but not at the central (body) level. Through these findings we hypothesize that the continuous OMF release at the CPs boundary may cause tissue alterations, including damaging of the extracellular matrix, and possibly contributing to RFs formation, a condition that was not possible to reproduce in the experimental model. The presence of RFs at the CPs boundary might be considered as a major criterion for the degree of CPs invasiveness to normal tissue. The lack of RFs reactivity in the experimental model reveals that the invasive component of CPs is not present in the OMF, although the fluid per se can exert tissue damage.

Management of Craniopharyngioma - Perspectives beyond Surgery and Endocrinology

The excess mortality in craniopharyngiomas is attributable to their size, site and the traditional surgical approach; aggressive resection predisposes to hypothalamic complications such as obesity, somnolence, thirst disorders and neurocognitive dysfunction. Recently, treatment has been modified to partial resection and radiotherapy. The role of the endocrinologist has expanded from identification and replacement of hormone deficits to include management of hypothalamic disease. Future treatment of craniopharyngioma with neo-adjuvant chemotherapy to minimise surgical resection may improve the outcomes for these patients.

Identification of targets for rational pharmacological therapy in childhood craniopharyngioma

Introduction

Pediatric adamantinomatous craniopharyngioma (ACP) is a histologically benign but clinically aggressive brain tumor that arises from the sellar/suprasellar region. Despite a high survival rate with current surgical and radiation therapy (75–95 % at 10 years), ACP is associated with debilitating visual, endocrine, neurocognitive and psychological morbidity, resulting in excheptionally poor quality of life for survivors. Identification of an effective pharmacological therapy could drastically decrease morbidity and improve long term outcomes for children with ACP.

Results

Using mRNA microarray gene expression analysis of 15 ACP patient samples, we have found several pharmaceutical targets that are significantly and consistently overexpressed in our panel of ACP relative to other pediatric brain tumors, pituitary tumors, normal pituitary and normal brain tissue. Among the most highly expressed are several targets of the kinase inhibitor dasatinib – LCK, EPHA2 and SRC; EGFR pathway targets – AREG, EGFR and ERBB3; and other potentially actionable cancer targets – SHH, MMP9 and MMP12. We confirm by western blot that a subset of these targets is highly expressed in ACP primary tumor samples.

Conclusions

We report here the first published transcriptome for ACP and the identification of targets for rational therapy. Experimental drugs targeting each of these gene products are currently being tested clinically and pre-clinically for the treatment of other tumor types. This study provides a rationale for further pre-clinical and clinical studies of novel pharmacological treatments for ACP. Development of mouse and cell culture models for ACP will further enable the translation of these targets from the lab to the clinic, potentially ushering in a new era in the treatment of ACP.

Fetal brain tumors: Prenatal diagnosis by ultrasound and magnetic resonance imaging

Congenital central nervous system tumors diagnosed during pregnancy are rare, and often have a poor prognosis. The most frequent type is the teratoma. Use of ultrasound and magnetic resonance image allows the suspicion of brain tumors during pregnancy. However, the definitive diagnosis is only confirmed after birth by histology. The purpose of this mini-review article is to describe the general clinical aspects of intracranial tumors and describe the main fetal brain tumors.

Predictive factors for craniopharyngioma recurrence: a systematic review and illustrative case report of a rapid recurrence

BACKGROUND

Recurrence of craniopharyngiomas (CPs) represents a frequent and unpredictable incident. Rapid tumor recurrence within a few months after surgery has been rarely reported. Nondefinitive predictive factors for rapid CP recurrence have been identified to date. We have systematically analyzed the tumor factors that presumably influence in CP recurrence.

METHODS

We present the histologic and immunohistochemical analysis of an infundibulo-tuberal CP that was operated twice within a 3-month interval due to rapid recurrence. We investigated the differential characteristics of the subgroup of CPs that recurred in large surgical series published in the literature, along with cases reporting rapid tumor recurrence after surgery.

RESULTS

Specimens of our patient showed an adamantinomatous CP with whorl-like arrays and thick peritumoral gliosis. Ki-67 labeling index in primary and recurrent samples was 20% and 15%, respectively. p53 labeling index was 18% and 15%, respectively. The thorough analysis of literature showed that presence of tumor remnants and missing radiotherapy treatment after subtotal removal are strong predictors of tumor recurrence. Third ventricle involvement, large tumor size, tight adherence to surrounding structures, and presence of whorl-like arrays might also foster recurrence. High Ki-67 levels, p53 expression, and an intense reactive gliosis might point to rapid tumor growth.

CONCLUSIONS

Reliable tumor markers that predict CP recurrence are still lacking. The CP features presumably related to a higher risk of its recurrence are thought to be a larger tumor size, a tight adherence to the hypothalamus, the presence of whorl-like arrays, and high Ki-67 and p53 levels.

Expression of matrix metalloproteinase-9, type IV collagen and vascular endothelial growth factor in adamantinous craniopharyngioma

To explore the expression of matrix metalloproteinase 9 (MMP-9), type IV collagen (Col IV) and vascular endothelial growth factor (VEGF) in adamantinomatous craniopharyngioma (ACP) and analyze the correlation between the level of these markers and adamantimous craniopharyngiomas recurrence. Expressions of MMP-9, Col IV and VEGF were tested by immunohistochemistry (IHC) in 40 cases of ACP, including 24 cases of primary group and 16 cases of recurred group. The expression level of MMP-9 and VEGF in recurred group were significantly higher than primary group (93.7% vs. 41.7%, P < 0.05, 87.5% vs. 45.8%, P < 0.05, respectively). The expression of Col IV in the recurred group was significant different from the primary group (Z = -2.619, P < 0.05). MMP-9, Col IV and VEGF may be the potential specific bio-marker related to the recurrence of ACP.

Anterior interhemispheric approach for 100 tumors in and around the anterior third ventricle

OBJECTIVE

We report our experience with anterior interhemispheric approach for tumors in and around the anterior third ventricle, including surgical technique, instrumentation, pre- and postoperative hormonal disturbances, and resection rate.

METHODS

One hundred patients with 46 craniopharyngiomas, 12 hypothalamic gliomas, 12 meningiomas, 6 hypothalamic hamartomas, and 24 other lesions were operated on using an anterior interhemispheric approach with or without opening of the lamina terminalis. This surgical approach involves no frontal sinus opening; a narrow (approximately 15-20 mm in width) access between the bridging veins, which is sufficient to remove the tumor totally; and sparing of the anterior communicating artery. Specially designed long bipolar forceps and scissors are necessary for this approach, and concomitant use of angled instruments (endoscope, aspirator, and microforceps) is required frequently. The postsurgical follow-up period varied from 4 months to 18 years.

RESULTS

Total removal of the neoplasm was accomplished in 37 of 46 patients with craniopharyngiomas (80.4%), whereas subtotal resection was performed in hypothalamic gliomas. No significant differences in pre- and postoperative hormonal disturbances were observed in 37 craniopharyngiomas and 10 hypothalamic gliomas. There was no operative mortality. Visual acuity was preserved or improved in 68 of 75 patients assessed. The Karnofsky Performance Scale score did not deteriorate in 72 of 75 patients tested.

CONCLUSION

The minimally invasive anterior interhemispheric approach, with or without opening of the lamina terminalis, is useful for removal of tumors in and around the anterior third ventricle, such as craniopharyngiomas and hypothalamic gliomas.

Optimal treatment strategy for craniopharyngiomas based on long-term functional outcomes of recent and past treatment modalities

Although many authors have described treatment strategies for craniopharyngiomas, the optimal treatment of craniopharyngiomas remains controversial. This study aimed to define an adequate surgical strategy for craniopharyngiomas by reviewing the long-term functional performance of patients treated by current and past treatment modalities. Fifty-five patients with longer than 5 years of follow-up were selected for the present long-term study. The duration of follow-up ranged from 5.5 to 33 years (median, 14.8 years). There were 28 adult patients (14 males; median age, 44.4 years) and 27 children younger than 16 years of age (15 males; median age, 8.1 years). The patients were divided into the following treatment groups: single surgery (group A; n=14 multiple surgeries (group B; n=8), surgery or surgeries followed by radiotherapy (group C; n=23), surgery or surgeries (partial removal) followed by radiotherapy + additional treatments (multiple surgeries and/or re-irradiation; group D; n=10). In addition to the routine assessments of neurological, endocrine, and visual outcomes, the level of daily functioning was analyzed using the Karnofsky Performance Scale (KPS). Statistical analysis of relationship between KPS score and treatment mode demonstrated that group D had a significantly lower KPS score (F=5.82, p=0.0017). Furthermore, mortality, cognitive function, and visual function were significantly better in groups A, B, and C than in group D. Multiple regression analysis demonstrated that cognitive dysfunction, visual disturbance, and treatment mode were independent covariates that significantly affected postoperative KPS score. Adequate primary treatment for craniopharyngiomas is important to avoid subsequent multiple treatments. Craniopharyngiomas should be removed surgically as far as possible but without further deteriorating cognitive and visual functions, either as total resection or subtotal resection with a small remnant that is controllable by radiation therapy.

Diagnostic clues and more from photographs

During over 50 years of the first author's career in neuropathology at Montefiore Medical Center in New York, we have come across certain interesting neuropathological findings. In this communication, some photographs showing macroscopic, microscopic and electron microscopic significant findings are selected to illustrate usefulness not only for the diagnosis but also for understanding of the nervous system. The six topics presented in this paper are: (i) unattached presynaptic terminals in cerebellar neuroblastoma; (ii) neurofibrillary tangle formation in the nucleus basalis of Meynert ipsilateral to a massive cerebral infarct; (iii) orderly arrangement of tumor cells in leptomeningeal carcinomatosis; (iv) interface between craniopharyngioma and brain tissue; (v) neurofibrillary tangles and Lewy bodies in a single neuron; and (vi) Cu/Zn superoxide dismutase positive Lewy body-like hyaline inclusions in anterior horn cells in familial motor neuron diseases. Analyses of these findings are presented for an educational purpose.