Acute and fatal hyponatraemia after resection of a craniopharyngioma: a preventable tragedy

A systematic review of the results of surgery and radiotherapy on tumor control for pediatric craniopharyngioma

OBJECTIVE

Craniopharyngiomas are rare tumors with bimodal incidence in the pediatric and adult age groups. Treatment strategies range from aggressive resection to planned limited resection combined with adjuvant therapies. Currently there is no consensus for standard of care for pediatric craniopharyngioma.

MATERIALS AND METHODS

We performed a systematic review of the published literature on pediatric craniopharyngioma. Patients were grouped based on extent of resection into gross total resection (GTR), subtotal resection (STR), and biopsy procedures. These groups were compared with respect to tumor control. Chi square was used to compare rates of recurrence. Kaplan-Meier was used to generate progression-free survival (PFS) estimates. Cox proportional hazard modeling was used to evaluate risk of progression. Each extent of resection group was also subdivided based on adjuvant therapy and compared.

RESULTS

A total of 109 studies described extent of resection resulting in a cohort of 531 patients. Recurrence data were available for 377 patients. There was no difference in 1- or 5-year PFS between the groups who underwent GTR and STR combined with radiation (XRT; log-rank; p = 0.76; 1-year PFS 89 vs 84%; 5-year PFS 77 vs 73%, respectively). One-year PFS was 84% for STR+XRT compared to 76% for STR alone while 5-year PFS was 73% for STR+XRT compared to 43% for STR alone (log-rank; p = 0.003).

CONCLUSION

Although there are limitations of a systematic review of retrospective data, our results suggest that STR+XRT of pediatric craniopharyngioma is associated with similar rates of tumor control as GTR.

Treatment-related morbidity and the management of pediatric craniopharyngioma: a systematic review

OBJECT

Craniopharyngiomas are benign tumors but their close anatomical relationship with critical neurological, endocrine, and vascular structures makes gross-total resection (GTR) with minimal morbidity difficult to achieve. Currently, there is controversy regarding the extent, timing, and modality of treatment for pediatric craniopharyngioma.

METHODS

The authors performed a systematic review of the published literature on pediatric craniopharyngioma to determine patterns of clinical practice and the reported outcomes of standard treatment strategies. This yielded 109 studies, which contained data describing extent of resection for a total of 531 patients. Differences in outcome were examined based upon extent of resection and choice of radiation treatment.

RESULTS

Gross-total resection was associated with increased rates of new endocrine dysfunction (OR 5.4, p < 0.001), panhypopituitarism (OR 7.8, p = 0.006), and new neurological deficits (OR 9.9, p = 0.03) compared with biopsy procedures. Subtotal resection (STR) was not associated with an increased rate of new neurological deficits. Gross-total was associated with increased rates of diabetes insipidus (OR 7.7, p = 0.05) compared with the combination of STR and radiotherapy (RT). The addition of RT to STR was associated with increased rates of panhypopituitarism (OR 9.9, p = 0.01) but otherwise similar rates of morbidities.

CONCLUSIONS

Although subject to the limitations of a literature review, this report suggests that GTR is associated with increased rates of endocrinopathies compared with STR + RT, and this should be considered when planning goals of surgery.

Craniopharyngioma: a comparison of tumor control with various treatment strategies

OBJECT

Craniopharyngiomas have a propensity to recur after resection, potentially causing death through their aggressive local behavior in their critical site of origin. Recent data suggest that subtotal resection (STR) followed by adjuvant radiotherapy (XRT) may be an appealing substitute for gross-total resection (GTR), providing similar rates of tumor control without the morbidity associated with aggressive resection. Here, the authors summarize the published literature regarding rates of tumor control with various treatment modalities for craniopharyngiomas.

METHODS

The authors performed a comprehensive search of the English language literature to identify studies publishing outcome data on patients undergoing surgery for craniopharyngioma. Rates of progression-free survival (PFS) and overall survival (OS) were determined through Kaplan-Meier analysis.

RESULTS

There were 442 patients who underwent tumor resection. Among these patients, GTR was achieved in 256 cases (58%), STR in 101 cases (23%), and STR+XRT in 85 cases (19%). The 2- and 5-year PFS rates for the GTR group versus the STR+XRT group were 88 versus 91%, and 67 versus 69%, respectively. The 5- and 10-year OS rates for the GTR group versus the STR+XRT group were 98 versus 99%, and 98 versus 95%, respectively. There was no significant difference in PFS (log-rank test) or OS with GTR (log-rank test).

CONCLUSIONS

Given the relative rarity of craniopharyngioma, this study provides estimates of outcome for a variety of treatment combinations, as not all treatments are an option for all patients with these tumors.

Endocrinologic, neurologic, and visual morbidity after treatment for craniopharyngioma

Craniopharyngiomas are locally aggressive tumors which typically are focused in the sellar and suprasellar region near a number of critical neural and vascular structures mediating endocrinologic, behavioral, and visual functions. The present study aims to summarize and compare the published literature regarding morbidity resulting from treatment of craniopharyngioma. We performed a comprehensive search of the published English language literature to identify studies publishing outcome data of patients undergoing surgery for craniopharyngioma. Comparisons of the rates of endocrine, vascular, neurological, and visual complications were performed using Pearson’s chi-squared test, and covariates of interest were fitted into a multivariate logistic regression model. In our data set, 540 patients underwent surgical resection of their tumor. 138 patients received biopsy alone followed by some form of radiotherapy. Mean overall follow-up for all patients in these studies was 54 ± 1.8 months. The overall rate of new endocrinopathy for all patients undergoing surgical resection of their mass was 37% (95% CI = 33–41). Patients receiving GTR had over 2.5 times the rate of developing at least one endocrinopathy compared to patients receiving STR alone or STR + XRT (52 vs. 19 vs. 20%, χ²P < 0.00001). On multivariate analysis, GTR conferred a significant increase in the risk of endocrinopathy compared to STR + XRT (OR = 3.45, 95% CI = 2.05–5.81, P < 0.00001), after controlling for study size and the presence of significant hypothalamic involvement. There was a statistical trend towards worse visual outcomes in patients receiving XRT after STR compared to GTR or STR alone (GTR = 3.5% vs. STR 2.1% vs. STR + XRT 6.4%, P = 0.11). Given the difficulty in obtaining class 1 data regarding the treatment of this tumor, this study can serve as an estimate of expected outcomes for these patients, and guide decision making until these data are available.

Intraoperative hyponatremia during craniofacial surgery

BACKGROUND

Hyponatremia is an important cause of morbidity in some groups of hospitalized children. Our aim is to describe the incidence and severity of intraoperative hyponatremia in children undergoing craniofacial surgery, and determine the associated risk factors.

METHODS

A descriptive retrospective study of children who underwent primary craniofacial surgery between March 1994 and February 2008 was performed. All administered fluids contained a minimum sodium concentration of 140 mmol.l(-1). Hyponatremia was classified as follows: severe < or =125 mmol.l(-1); moderate 126-130 mmol.l(-1); and, mild 131-134 mmol.l(-1).

RESULTS

Hundred and seven cases are reported. Severe, moderate and mild intraoperative hyponatremia occurred in 14 (13%), 21 (19%) and 23 (22%) children respectively. Mannitol was given to 31 (29%) children, but was not associated with the development of hyponatremia. Neither the type nor duration of surgery, type of fluid replacement nor hourly urinary output, was associated with development of hyponatremia. Most episodes of significant intraoperative hyponatremia (44%) were detected between the 2nd and the 4th hour of surgery. There were no identified neurological sequelae (e.g. coma, neurological deficit) attributable to the hyponatremia.

CONCLUSION

Despite strict avoidance of low sodium solutions (<140 mmol.l(-1)), hyponatremia occurs frequently in children undergoing craniofacial surgery in our practice; and is unrelated to the administration of mannitol. Although the mechanisms are yet to be determined, anesthesiologists should be aware of this issue and be prepared to monitor and treat this potentially serious complication.

Acute diabetes insipidus in severe head injury: a prospective study

BACKGROUND

The incidence and risk factors for acute diabetes insipidus after severe head injury and the effect of this complication on outcomes have not been evaluated in any large prospective studies.

STUDY DESIGN

We conducted a prospective study of all patients admitted to the surgical ICU of a Level I trauma center with severe head injury (head Abbreviated Injury Score [AIS] >or= 3). The following potential risk factors with p < 0.2 on bivariate analysis were included in a stepwise logistic regression to identify independent risk factors for diabetes insipidus and its association with mortality: age, mechanism of injury (blunt or penetrating), blood pressure, Glasgow Coma Scale, Injury Severity Score, head and other body area AIS, skull fracture, cerebral edema and shift, intracranial hemorrhage, and pneumocephaly.

RESULTS

There were 436 patients (blunt injuries, 392; penetrating injuries, 44); 387 patients had isolated head injury. Diabetes insipidus occurred in 15.4% of all patients (blunt, 12.5%; penetrating, 40.9%; p < 0.0001) and in 14.7% of patients with isolated head injury (blunt, 11.8%; penetrating, 39.5%; p < 0.0001). The presence of major extracranial injuries did not influence the incidence of diabetes insipidus. Independent risk factors for diabetes insipidus in isolated head injury were Glasgow Coma Scale<or=8, cerebral edema, and head AIS>3. Diabetes insipidus was an independent risk factor for death (adjusted odds ratio, 3.96; 95% CI [1.65, 9.72]; adjusted p value = 0.002).

CONCLUSIONS

The incidence of acute diabetes insipidus in severe head injury is high, especially in penetrating injuries. Independent risk factors for diabetes insipidus include a Glasgow Coma Scale<or=8, cerebral edema, and head AIS>3. Acute diabetes insipidus was associated with significantly increased mortality.

Tumor-related hyponatremia

Hyponatremia is an important and common electrolyte disorder in tumor patients and one that has been reported in association with a number of different primary diagnoses. The correct diagnosis of the pathophysiological basis for each patient is important because it significantly alters the treatment approach. In this article, we review the epidemiology and presentation of patients with hyponatremia, the pathophysiologic groups for the disorder with respect to sodium and water balance and the diagnostic measures for determining the correct pathophysiologic groups. We then present the various treatment options based on the pathophysiologic groups including a mathematical approach to the use of hypertonic saline in management. In cancer patients, hyponatremia is a serious comorbidity that requires particular attention as its treatment varies by pathophysiologic groups, and its consequences can have a deleterious effect on the patient's health.

Diabetes insipidus as a complication after pituitary surgery

BACKGROUND

A 28-year-old woman presented with new-onset vertigo and diplopia that had started 2 weeks previously. An MRI scan of the brain revealed an 11 x 9 x 9 mm sellar mass that extended into the suprasellar region. Evaluation of pituitary function showed mild central hypothyroidism and secondary adrenal insufficiency. The patient underwent trans-sphenoidal resection of the mass without any significant intraoperative complications. On postoperative day 1 she abruptly developed polyuria, hypernatremia and urine hypo-osmolality.

INVESTIGATIONS

Measurements of plasma and urine osmolality, urine specific gravity, and serum sodium levels.

DIAGNOSIS

Postoperative diabetes insipidus with a triphasic pattern.

MANAGEMENT

The patient's diabetes insipidus was initially treated with intravenous desmopressin, and her fluid status, serum sodium levels, and serum and urine osmolality were carefully monitored. During the second, antidiuretic phase, desmopressin was discontinued and the patient's fluid intake was restricted. After recurrence of diabetes insipidus during the third phase, the patient was treated with intranasal desmopressin and was discharged. She remains on desmopressin therapy for chronic diabetes insipidus.