Craniopharyngioma: A comprehensive review of the clinical presentation, radiological findings, management, and future Perspective

Recent advances in craniopharyngioma pathophysiology and emerging therapeutic approaches

Craniopharyngiomas are rare intracranial tumors originating from the Rathke's pouch, affecting the sellar and parasellar regions. Despite their benign nature, they cause significant morbidity and mortality due to their proximity to vital structures such as the optic pathways and the hypothalamic-pituitary axis, resulting in endocrine, visual, neurological impairment, and hypothalamic syndrome. Classified into adamantinomatous (ACP) and papillary (PCP), these tumors differ in epidemiology, histology, and pathophysiology. ACP, the most common type, presents a bimodal peak incidence between 5 and 15 years of age and 45 and 60 years of age, while PCP is more restricted to adults. Traditional treatments such as surgery and radiotherapy face significant challenges, including high recurrence rates. Intracystic chemotherapy is used in monocystic ACP but with limited efficacy and adverse effects related to toxicity. Recent advances in molecular biology have introduced targeted therapies, such as BRAF and MEK inhibitors, which show potential benefits in craniopharyngioma patients, particularly in the PCP. For ACP, however, therapeutic outcomes remain limited despite advances in molecular understanding, including mutations in the CTNNB1 gene and growth factors. Increasing investigation into the inflammatory microenvironment and immune response of these tumors presents new therapeutic possibilities and promising alternatives for tumor control, such as the use of anti-IL-6R, anti-VEGF agents and immune checkpoints inhibitors. This review aims to synthesize advancements in the pathophysiology of craniopharyngiomas and explore emerging therapeutic implications, focusing on precision medicine approaches for the management of this challenging disease.

Artificial Intelligence-Based Radiomic Model in Craniopharyngiomas: A Systematic Review and Meta-Analysis on Diagnosis, Segmentation, and Classification

BACKGROUND

Craniopharyngiomas (CPs) are rare, benign brain tumors originating from Rathke's pouch remnants, typically located in the sellar/parasellar region. Accurate differentiation is crucial due to varying prognoses, with adamantinomatous CPs having higher recurrence and worse outcomes. Magnetic resonance imaging struggles with overlapping features, complicating diagnosis. This study evaluates the role of artificial intelligence (AI) in diagnosing, segmenting, and classifying CPs, emphasizing its potential to improve clinical decision-making, particularly for radiologists and neurosurgeons.

METHODS

This systematic review and meta-analysis assess AI applications in diagnosing, segmenting, and classifying on CP patients. A comprehensive search was conducted across PubMed, Scopus, Embase, and Web of Science for studies employing AI models in patients with CP. Performance metrics such as sensitivity, specificity, accuracy, and area under the curve were extracted and synthesized.

RESULTS

Eleven studies involving 1916 patients were included in the analysis. The pooled results revealed a sensitivity of 0.740 (95% confidence interval [CI]: 0.673-0.808), specificity of 0.813 (95% CI: 0.729-0.898), and accuracy of 0.746 (95% CI: 0.679-0.813). The area under the curve for diagnosis was 0.793 (95% CI: 0.719-0.866), and for classification, it was 0.899 (95% CI: 0.846-0.951). The sensitivity for segmentation was found to be 0.755 (95% CI: 0.704-0.805).

CONCLUSIONS

AI-based models show strong potential in enhancing the diagnostic accuracy and clinical decision-making process for CPs. These findings support the use of AI tools for more reliable preoperative assessment, leading to better treatment planning and patient outcomes. Further research with larger datasets is needed to optimize and validate AI applications in clinical practice.

Targeted treatment for craniopharyngioma

INTRODUCTION

Craniopharyngioma is a rare solid-cystic tumor of the hypothalamopituitary region. Two distinct craniopharyngioma types (formerly subtypes), adamantinomatous and papillary, have been described. These tumors often manifest with neuroendocrine dysfunction, vision problems, hydrocephalus, and cognitive changes. Despite efforts to spare vital brain structures, conventional treatments such as surgery and radiation can exacerbate preceding deficits and contribute to permanent neurologic impairment. Recent studies have identified BRAF-V600E mutations in nearly all papillary craniopharyngiomas (PCP), and CTNNB1/Wnt pathway alterations in adamantinomatous craniopharyngiomas (ACP). These discoveries have advanced our understanding of craniopharyngioma pathogenesis and have opened opportunities for targeted biological treatments.

PURPOSE

The primary objective of this article is to review the current landscape of targeted treatments in papillary and adamantinomatous craniopharyngioma.

RESULTS

Treatment of PCP with BRAF/MEK inhibition has demonstrated durable tumor response in the adjuvant and neoadjuvant settings in multiple case studies and one phase II clinical trial. Although treatment advances are more limited for ACP, CTNNB1/Wnt pathway inhibitors showed promising results in pre-clinical studies and are under continued investigation.

CONCLUSION

The efficacy of BRAF/MEK inhibition in PCP supports the use of targeted therapy in patients with newly diagnosed PCP. The optimal targeted treatment combinations and their timing, duration, long-term effects, and sequencing with traditional therapeutic modalities have not been established and warrant further study. Targeted therapies represent a significant advancement in the field of oncology, and craniopharyngiomas are viable candidates for these approaches pending further research.

A Fusion Model of MRI Deep Transfer Learning and Radiomics for Discriminating between Pilocytic Astrocytoma and Adamantinomatous Craniopharyngioma

RATIONALE AND OBJECTIVES

This study aimed to develop and validate a fusion model combining MRI deep transfer learning (DTL) and radiomics for discriminating between pilocytic astrocytoma (PA) and adamantinomatous craniopharyngioma (ACP) in the sellar region.

METHODS

This study included 348 patients with histologically confirmed PA (n = 139) and ACP (n = 209). Data were randomly divided into training and testing cohorts in a 7:3 ratio. Pre-trained ResNet50 network was utilized to extract DTL features from T1WI, T2WI, and CET1, while radiomics features (Rad) were extracted from manually delineated images of the same modalities. The fusion feature set (DLR) was constructed by integrating these features. Semantic features were used to develop clinical models. Pearson rank correlation and The least absolute shrinkage and selection operator regression were used for feature selection, and K-nearest neighbor algorithm was applied to establish the model. The performance of the model was evaluated using receiver operating characteristic curve. DeLong's test was performed to assess differences between models, and decision curve analysis was conducted to evaluate the clinical utility of the models.

RESULTS

The DLR model achieved AUC values of 0.945 (95% CI, 0.9149-0.9760) in the training cohort and 0.929 (95% CI, 0.8824-0.9762) in the testing cohort, significantly higher than those of models using DTL features, Rad features, or clinical features alone.

CONCLUSION

The fusion model based on MRI deep transfer learning and radiomics (DLR) demonstrated high accuracy and clinical utility in discriminating between PA and ACP, providing an effective tool for the non-invasive diagnosis of these two diseases.

Endoscopic endonasal versus open approach for craniopharyngioma treatment: a systematic review of clinical characteristics

BACKGROUND

Craniopharyngiomas are rare tumors found in the suprasellar region of the brain. Untreated, they have the potential to cause debilitating complications, including vision loss and cognitive decline. Craniopharyngiomas can be resected through several surgical options including endoscopic endonasal (EEA) and open, transcranial approaches, cystic drainage, and ventricular neuroendoscopic approaches. Here, we seek to review the literature and compare characteristics of lesions resected by the EEA versus open approach.

METHODS

A comprehensive database search was performed on PubMed, Google Scholar, and Embase using key terms. Included studies utilized both EEA and open approaches for craniopharyngioma resection.

RESULTS

No studies reported a significant difference in tumor location, consistency, pathology, or presence of calcification. One study reported an increased preoperative tumor volume with the open approach. The open approach was significantly associated with a longer follow-up period (4/16) and hospital length of stay (2/16), as well as a greater rate of recurrence (2/16) and mortality (1/16). New-onset diabetes insipidus (3/16) and vision deterioration (3/16) following surgery were significantly more common following an open approach.

CONCLUSION

Inherent in the surgical decision-making regarding approach are the anatomical considerations of the tumor. Through our literature search, we found tumors were not substantially different for the different approaches, consistent with our clinical experience. This may be related to the refinement of endonasal techniques, allowing larger, suprasellar tumors to be amenable to GTR more than in the past.

Advances in the Management of Craniopharyngioma: A Narrative Review of Recent Developments and Clinical Strategies

Craniopharyngiomas (CPs) are rare intracranial tumors arising from remnants of Rathke's pouch. Despite their benign histology, CPs present considerable clinical challenges due to their tendency to exert mass effect and adherence to critical neurovascular structures. There remains no clear consensus on the most effective management of CPs. We explore the latest developments in targeted treatment approaches, examining how innovations in surgery, radiation therapy, and emerging therapies are improving outcomes and management for these challenging tumors. In addition to providing our experience, we reviewed previously reported case series and reviews relevant to CPs. Studies show a bimodal age distribution for CP diagnosis, with peak incidence occurring in children aged 5-14 years and in adults aged 50-74 years. Surgical resection is the typical initial treatment for CPs, and adjuncts, including radiation therapy and intracavitary treatments, have been proven effective for tumor control. Additionally, genetic mutations associated with CPs offer an opportunity for novel strategies that address the underlying molecular mechanisms driving tumor growth through targeting the Wnt/β-catenin and/or MAPK/ERK pathways to disrupt the aberrant signaling that promotes tumor proliferation and survival. Survival rates for CPs are generally favorable (five-year survival of 80%), with recent studies showing improved outcomes and higher survival rates in children. CPs remain rare and challenging tumors. Although surgical resection is the main treatment, surgeons must weigh the benefits of achieving a gross total resection with the risks of iatrogenic injury. Adjuncts, including intracavitary and radiation treatments, may assist with subtotal resections and recurrences, as well as approved BRAF inhibitor therapy for the papillary variant. Many improvements in diagnostic and therapeutic methods were made after Dr. Cushing coined the term "craniopharyngioma". Ongoing experiments, investigations, and advances in radiation techniques and molecular targeted therapies will provide patients with promise for safer and more effective treatments.

Effectiveness of bariatric surgery on acquired hypothalamic obesity: a systematic review and meta-analysis

Acquired hypothalamic obesity (HO) is a rare type of obesity caused by acquired disease-related and/or treatment-related damage to the hypothalamus, most commonly craniopharyngiomas. Effective management of HO is critical due to its significant impact on quality of life and resistance to conventional treatments. This systematic review and meta-analysis aims to evaluate the 12-month, 24-month and 60-month outcomes of bariatric surgery for HO caused by CPs compared with patients with common obesity (CO). Relevant studies were identified in MEDLINE and EMBASE databases until May 2024. A total of four matched case-control studies were included. The results indicated that bariatric surgery significantly reduced weight in patients with HO (22.98 ± 14.22/21.47 ± 9.61/19.07 ± 16.12% total weight loss, 12/24/60 months after surgery), but the effect was significantly less than that in CO controls (-6.17/-6.41/-7.72% total weight loss 12/24/60 months after surgery). Bariatric surgery can significantly reduce body weight in craniopharyngiomas-related HO, but the effect is less than that in matched patients with common obesity. Further studies are necessary to determine the best surgical or multidisciplinary approach to the treatment of acquired HO.

Perioperative Management of a Child With Pre-existing Diabetes Insipidus Undergoing Craniopharyngioma Excision: A Case Report

Craniopharyngiomas are rare tumors arising in the suprasellar area of the brain and are more common in the pediatric age group. Due to the involvement of the hypothalamus, central diabetes insipidus (DI) is usually associated with such lesions. Patients with DI are at risk for significant electrolyte disturbances due to high urine output and the potential for sodium imbalance. Perioperative management of a patient with co-existing DI is challenging due to the imbalances in the fluid and electrolyte status. We reported a rare case of successful intraoperative anesthetic management of a pediatric patient undergoing craniopharyngioma excision with pre-existing central DI. The main anesthetic concerns were intraoperative fluid and electrolyte disbalance, and further risk of hypothalamic damage with the possibility of seizure, hyperthermia, and hemodynamic instability. Intraoperatively, a meticulous fluid management strategy was employed, keeping a strict watch on urine output and serum electrolyte levels. Intraoperative DI was treated with low-dose vasopressin infusion. Intensive monitoring of the fluid and electrolyte status in a patient during craniopharyngioma surgery is of utmost importance. A proper collaborative team effort between the neurosurgeons, neuroanesthesiologists, and the neuroendocrine team is essential for a successful outcome.

An Update on Advances in Hypopituitarism: Etiology, Diagnosis, and Current Management

This article provides an updated review of hypopituitarism (HP), an endocrine disorder characterized by a deficiency of one or more pituitary hormones. The various etiologies are reviewed, including pituitary neuroendocrine tumors (PitNETs), hypothalamic lesions, genetic mutations, and acquired factors such as head trauma, medications, neoplasms, and infiltrative diseases. It is noted that PitNETs are responsible for approximately half of the cases in adults, whereas in children the causes are predominantly congenital. Diagnosis is based on clinical evaluation and hormonal testing, with identification of the specific hormonal deficiencies essential for effective treatment. Laboratory tests present challenges and limitations that must be understood and addressed. Hormone replacement therapy is the mainstay of treatment, significantly improving patients' quality of life. It is important to know the possible interactions between hormone replacement therapies in HP. Recent advances in understanding the pathophysiology of HP and the importance of a multidisciplinary approach to the management of associated complications are discussed. This article emphasizes the need for comprehensive evaluation and continuous follow-up to optimize outcomes in patients with HP and highlights the importance of ongoing research to improve diagnostic and treatment strategies.

Beyond Epistaxis: A Rare Case of Ectopic Sinonasal Adamantinomatous Craniopharyngioma

Adamantinomatous craniopharyngioma (ACP) is one of the two types of craniopharyngioma recognized by the World Health Organization (WHO), the other being papillary craniopharyngioma (PCP). These rare, benign tumours of the pituitary region are classified as Grade 1 central nervous system (CNS) tumours. ACP predominantly affects adolescents aged 5-15 years and adults over 50 years. It is usually located in the sellar and suprasellar regions. We present the case of an 18-year-old Malaysian female with a six-year history of persistent epistaxis and progressive nasal obstruction, an atypical presentation of ACP. This report highlights an entirely ectopic location of ACP in the sinonasal region. The tumour encompassed the left nasal cavity, the left anterior and posterior ethmoid sinuses, and the bilateral frontal sinuses. The unusual presentation of this tumour was detected with the aid of CT and MRI and confirmed by histopathological examination. In this case report, we discuss a rare presentation, an unusual location, and the strategies employed to overcome these challenges.