Caregiver Burden and Its Relationship to Health-Related Quality of Life in Craniopharyngioma Survivors

Economics of hypothalamic obesity in patients with craniopharyngioma and other rare sellar/suprasellar tumors

BACKGROUND

Rapid and abnormal weight gain resulting in severe persistent obesity due to physical, tumor- and/or treatment-related damage to the hypothalamus, is called acquired hypothalamic obesity (aHO), and is often linked to craniopharyngioma and/or sellar/suprasellar tumors. Here, we examine the healthcare resource use (HCRU) and costs of aHO following treatment of these tumors.

METHODS

We used a retrospective matched cohort design with German statutory health insurance data on 5.42 million people from 2010 to 2021. We applied a novel three-step approach using diagnostic and prescription data to identify patients with treatment- or tumor-related (TTR)-aHO. We measured HCRU and costs across hospitalizations, outpatient visits, visits per specialist group, and outpatient prescription medications.

RESULTS

Compared to non-HO obesity, TTR-aHO is associated with increased hospitalizations, increased outpatient physician visits, and increased prescription use in the two years after incident tumor surgery/radiotherapy. Excess costs of TTR-aHO are €19,900 per patient in the first year and €10,700 in the second, driven by inpatient costs. Cost-intensive hormone replacement therapies like somatropin lead to a sharp increase in prescription costs in the second year.

CONCLUSIONS

This study provides the first real-world analysis of TTR-aHO economics, emphasizing the importance of HCRU and costs for decision-making. Previously, economic evaluations have been missing due to the lack of a standard method to identify patients with aHO in retrospective studies. Using a new identification approach, the study reveals that TTR-aHO poses a significant burden in extensive treatment requirements for patients and high related costs for the healthcare system.

BMI trajectories in the first 3 months after childhood craniopharyngioma resection: a plea for early management of BMI changes

Objective

Hypothalamic obesity (HO) is a severe condition following childhood craniopharyngioma (cCP) treatment. Despite multidisciplinary and centralized care, severe body mass index (BMI) changes are still often encountered after cCP surgery. We aimed to perform an in-depth analysis of BMI trajectories in our cCP cohort in the first year after surgery and to identify characteristics associated with BMI change.

Methods

Data were collected of cCP patients diagnosed since January 2018. Change (Δ) in BMI standard deviation scores (SDSs) from treatment to 3, 6, 9 and 12 months after and latest follow-up was assessed. Secondary outcomes were patient, tumor and treatment characteristics associated with ΔBMI SDS and interventions for postoperative weight gain.

Results

Of the 35 cCP patients, the most significant BMI SDS change was observed within the first three months following cCP resection, with almost half of the patients developing an increase of ≥1.0 BMI SDS. Of patients with the most severe BMI change within the first three months, 87% were overweight or obese at 12 months after cCP resection. Pharmacological intervention for obesity started on average 10.8 months postresection. Development of arginine vasopressin deficiency was positively correlated with ΔBMI SDS in the first three months (P = 0.017). Barriers for obesity intervention in the first months following treatment are discussed.

Conclusions

Following cCP resection, increase in BMI due to hypothalamic damage is most severe already in the first three months postoperatively. Postoperative rapid weight gain should be acknowledged as a consequence of hypothalamic damage and requires more early intervention aiming to prevent the development of HO.

Risk Factors for MAFLD and Advanced Liver Fibrosis in Adult-Onset Craniopharyngioma Patients: A Cross-Sectional Study

Purpose

To investigate the prevalence of and risk factors for metabolic dysfunction-associated fatty liver disease (MAFLD) and advanced liver fibrosis (ALF) in postoperative adult-onset craniopharyngioma (AOCP) patients.

Patients and Methods

This cross-sectional study included 242 postoperative AOCP patients at Huashan Hospital (Shanghai, China). Clinical characteristics were compared between patients with and without MAFLD and ALF. Independent risk factors for MAFLD and ALF were identified using binary logistic regression analysis.

Results

The prevalence of MAFLD in postoperative AOCP patients was 67.4% (95% CI 61.2-73.0%), and 32.5% (95% CI 25.8-40.0%) of patients with MAFLD were diagnosed with ALF. Body mass index (BMI) was independently associated with MAFLD (OR = 1.51, 95% CI 1.33-1.72, P < 0.001). In patients with MAFLD, hypertension (OR = 2.33, 95% CI 1.04-5.20, P = 0.040), glycated hemoglobin (HbA1c) (OR = 1.34, 95% CI 1.01-1.78, P = 0.044), daily hydrocortisone dose (OR = 1.08, 95% CI 1.01-1.15, P = 0.026), and insulin-like growth factor-1 (IGF-1)(OR = 0.99, 95% CI 0.97-0.99, P = 0.011) were independently associated with the presence of ALF.

Conclusion

MAFLD is a common comorbidity in postoperative AOCP patients and is associated with a high risk of ALF. MAFLD is closely related to BMI, while ALF is significantly associated with hypertension, HbA1c levels, IGF-1 levels, and daily hydrocortisone dose. Strategies such as controlling weight gain, maintaining optimal blood glucose and blood pressure levels, appropriate hormone replacement, and avoiding excessive glucocorticoid use should be implemented to prevent and delay the onset and progression of MAFLD and ALF.

Daytime sleepiness and health-related quality of life in patients with childhood-onset craniopharyngioma

Overall survival rates after craniopharyngioma (CP) are high (92%), but frequently quality of life (QoL) is impaired in patients with CP involving hypothalamic structures. Tumour- and/or treatment-related hypothalamic lesions may result in disturbances of circadian rhythms including increased daytime sleepiness. We investigated the relationship between health-related QoL and daytime sleepiness in patients with childhood-onset CP. After a median follow-up of 10 years (range: 1-39), 119 CP patients (63 female), who were recruited 2000-2022 in the KRANIOPHARYNGEOM 2000/2007 and KRANIOPHARYNGEOM Registry 2019 trials, were assessed for daytime sleepiness using the Epworth Sleepiness Scale (ESS) and for QoL by EORTC QLQ-C30 questionnaire. CP patients with increased daytime sleepiness (ESS score > 10, n = 34) had worse self-assessment of QoL (p = 0.003), when compared to CP patients with normal ESS scores (n = 85). Increased daytime sleepiness was negatively correlated with QoL (r=-0.395; p < 0.001). Surgical hypothalamic lesions, detectable after surgical intervention in 92.9% of the reference-assessed patients, were associated with significantly higher ESS scores, whereas such impact could not be observed for presurgical hypothalamic involvement of the CP (72.4% of the reference-assessed patients). Compared to patients with an ESS score in the normal range, patients with increased daytime sleepiness suffered from impaired QoL in all functional scales and the global QoL scale of the EORTC QLQ-C30. As increased daytime sleepiness plays an important role for QoL in survivors of CP, hypothalamus-sparing surgical treatment strategies should be considered as state of the art in patients with CP for prevention of increased daytime sleepiness.Clinical trial registration NCT01272622; NCT04158284, NCT00258453.

Treatment of patients with tumor/treatment-related hypothalamic obesity in the first two years following surgical treatment or radiotherapy

Survivors of sellar/suprasellar tumors involving hypothalamic structures face a risk of impaired quality of life, including tumor- and/or treatment-related hypothalamic obesity (TTR-HO) defined as abnormal weight gain resulting in severe persistent obesity due to physical, tumor- and/or treatment related damage of the hypothalamus. We analyze German claims data to better understand treatment pathways for patients living TTR-HO during the two years following the index surgical treatment. A database algorithm identified patients with TTR-HO in a representative German payer claims database between 2010 and 2021 (n = 5.42 million patients). Claims from 37 patients with TTR-HO were analyzed on a quarterly basis over 2 years. The analysis considered inpatient, outpatient, and prescription data. In the follow-up period, patients with TTR-HO are hospitalized 3.68 times on average; 37% of hospitalizations in year 1 and 31% in year 2 are due to TTR-HO. On average, patients see a general practitioner 12.27 times and various specialists 20.45 times. The need for complex neuroendocrine therapy develops quickly, with most patients having 2-3 neuroendocrine prescriptions in any given quarter. The management of patients with TTR-HO requires frequent inpatient and outpatient visits for tumor follow-up and management of incident comorbidities, and most patients with TTR-HO require intense polytherapy.

Inflammatory mediator contributes to leptin resistance and obesity in craniopharyngioma

Obesity presents a significant challenge in managing patients with craniopharyngioma (CP). Cyst fluid (CF), rich in inflammatory mediators, is implicated in CP-related obesity, though the precise mechanism remains unclear. This study investigated the impact of CF or C-X-C motif chemokine ligand-1 (CXCL1) injections on body weight, Lee index, plasma lipid profiles, hepatic lipid accumulation, leptin levels, NF-κB pathway, the suppressor of cytokine signaling 3 (SOCS3) expression, and leptin sensitivity in rats. Bioinformatics was employed to identify differentially expressed genes (DEGs) between CF/CXCL1-treated and control SY5Y cells, as well as to confirm enriched pathways. Western blotting was used for experimental validation, including the effects of sodium salicylate (SS) on leptin sensitivity in SY5Y cells. Injecting CF or CXCL1 into the brain, without hypothalamic damage, led to increased body weight, Lee index, and hepatic lipid accumulation in rats, alongside elevated fasting blood glucose, triglycerides, and total cholesterol, while high-density lipoprotein cholesterol levels decreased. Additionally, CF and CXCL1 could induce elevated leptin levels, a higher leptin-to-body weight ratio, and resistance to exogenous leptin by activating the NF-κB pathway and upregulating the expression of SOCS3 in rats. Further validation confirmed that CF and CXCL1 suppress leptin signaling by activating the NF-κB pathway and upregulating SOCS3. Moreover, SS mitigated the inhibitory effects of CF or CXCL1 on leptin signaling, preserving leptin sensitivity in SY5Y cells. These results highlight the obesogenic role of CF and CXCL1, offering insights into the development of morbid obesity through inflammatory factor-mediated leptin resistance, independent of hypothalamic damage. SS may serve as a promising therapeutic approach for CP-associated obesity, though additional clinical studies are necessary to confirm its efficacy.

Approach to the Patient: New Era Emerges for Craniopharyngioma Management

Papillary craniopharyngioma (PCP) and adamantinomatous craniopharyngioma (ACP) are distinct, slow-growing tumors of the suprasellar region. Their location, composition, and biology have historically evaded successful surgical radiation and medical therapy. Meanwhile compromise of critical structures either by tumor or treatments increase morbidity, impacting patient and carer quality of life. There has been a paradigm shift in the management of PCP, stemming from the discovery of BRAFV600E mutation in its tumorigenesis. Such a treatment breakthrough may soon be the case for ACP, changing the landscape of craniopharyngioma management. We use a case of ACP partially responding to ERK inhibitor therapy to demonstrate chronicity of disease progression and discuss modern management strategies highlighting the importance of access to tumor agnostic clinical trials, and future directions.

Impact of parental body mass index at diagnosis on obesity in survivors of pediatric craniopharyngioma

Objective

It is well known that both genetic background and lifestyle influence the development of 'general' obesity. However, the role of parental body mass index (BMI) on the development of obesity in long-term survivors of childhood-onset craniopharyngioma (CP) is not well understood. This study analyzed the correlation of patients' BMI at diagnosis and last visit and parental BMI at CP diagnosis and further explored potential risk factors for obesity in CP patients.

Design

This is a registry-based retrospective cohort study.

Methods

In total,291 CP patients and their parents recruited in the German KRANIOPHARYNGEOM studies were included. Correlations between patient's BMI SDS at CP diagnosis and last visit and parental BMI at CP diagnosis were analyzed. The associations between hypothalamic damage, maternal/paternal BMI and CP patients' obesity at last visit were analyzed by multivariable logistic regression.

Results

At follow-up, 52% of CP patients developed obesity (BMI > 3SDS). Patient's BMI SDS at last visit was moderately correlated with BMI-SDS at CP diagnosis (r = 0.48, 95% CI: 0.38-0.58, P < 0.001), and also with maternal BMI at diagnosis (r = 0.28, 95% CI: 0.17-0.38, P < 0.001) and paternal BMI at diagnosis (r = 0.3, 95% CI: 0.19-0.41, P < 0.001). However, the contributing role of parental BMI to the pathogenesis of obesity was small compared to the impact of hypothalamic damage.

Conclusion

We conclude that besides hypothalamic damage, parental disposition for obesity is associated with the development of obesity in patients after CP. Our results indicate that also the family situation could have an influence on the development of obesity after CP and might be a therapeutic target.

Significance statement

Survivors of childhood-onset craniopharyngioma are at risk of developing morbid obesity. So far, patients with posterior hypothalamic involvement and lesion were identified as a high risk group. With this study, the influence of parental body mass index on the risk of obesity was investigated. Patient's body-mass-index at last visit was correlated with maternal and paternal body mass index at diagnosis. With increasing maternal or paternal body mass index, the likelihood of obesity in individuals with CP increased. Nevertheless, the parents' weight had only a small effect on the development of patients' obesity compared to hypothalamic damage.

Vision-related quality of life in patients with childhood-onset craniopharyngioma

Quality of life (QoL) is a critical component of aftercare in survivors of childhood-onset craniopharyngioma (CP). Visual impairment adversely affects QoL after CP. This study assessed the frequency of visual impairment in patients with CP and its association with QoL. This study analyzed vision-related QoL in patients recruited 2000-2019 in the prospective cohort studies KRANIOPHARYNGEOM 2000/2007. Ophthalmologic examinations were performed at diagnosis, three, 12, and 36 months, respectively after the diagnosis. The QoL (PEDQOL) scores, were also evaluated at three, 12, and 36 months, respectively after the CP diagnosis. Multivariable logistic regression was used to analyze factors associated with visual impairment during follow-up. One-hundred twenty patients were included in this study. On ophthalmological examination, visual impairment was observed in the majority of the patients (n = 84, 70%) at CP diagnosis. After surgery, vision was restored in 27 patients (32%) with visual impairment at diagnosis. In the first (p = 0.017) and third (p = 0.011) year after diagnosis, parents of patients with visual impairment reported lower social functioning (family). Reduced autonomy was found three years after diagnosis in self- (p = 0.029) and parental (p = 0.048) assessments. Next to visual impairment at diagnosis, no additional risk factors for visual impairment during follow-up could be identified. Visual impairment has a clinically relevant impact on QoL after CP. The visual status at CP diagnosis determines the visual outcome during follow-up. Early detection of visual impairment, regular QoL assessments, and risk-appropriate aftercare are recommended.Clinical Trial Registration KRANIOPHARYNGEOM 2000 (Clinical trial registration number: NCT00258453) and KRANIOPHARYNGEOM 2007 (Clinical trial registration number: NCT01272622).