Neurological and psychophysiological sequelae following different treatments of craniopharyngioma in children

Awake Surgical Management of Third Ventricular Tumors: A Preliminary Safety, Feasibility, and Clinical Applications Study

BACKGROUND

Endoscopic and microneurosurgical approaches to third ventricular lesions are commonly performed under general anesthesia.

OBJECTIVE

To report our initial experience with awake transsulcal parafascicular corridor surgery (TPCS) of the third ventricle and its safety, feasibility, and limitations.

METHODS

A total of 12 cases are reviewed: 6 colloid cysts, 2 central neurocytomas, 1 papillary craniopharyngioma, 1 basal ganglia glioblastoma, 1 thalamic glioblastoma, and 1 ependymal cyst. Lesions were approached using TPCS through the superior frontal sulcus. Pre-, intra-, and postoperative neurocognitive (NC) testing were performed on all patients.

RESULTS

No cases required conversion to general anesthesia. Awake anesthesia changed intraoperative management in 4/12 cases with intraoperative cognitive changes that required port re-positioning; 3/4 recovered. Average length of stay (LOS) was 6.1 d ± 6.6. Excluding 3 outliers who had preoperative NC impairment, the average LOS was 2.5 d ± 1.2. Average operative time was 3.00 h ± 0.44. Average awake anesthesia time was 5.05 h ± 0.54. There were no mortalities.

CONCLUSION

This report demonstrated the feasibility and safety of awake third ventricular surgery, and was not limited by pathology, size, or vascularity. The most significant factor impacting LOS was preoperative NC deficit. The most significant risk factor predicting a permanent NC deficit was preoperative 2/3 domain impairment combined with radiologic evidence of invasion of limbic structures – defined as a “NC resilience/reserve” in our surgical algorithm. Larger efficacy studies will be required to demonstrate the validity of the algorithm and impact on long-term cognitive outcomes, as well as generalizability of awake TPCS for third ventricular surgery.

Korsakoff syndrome from retrochiasmatic suprasellar lesions: rapid reversal after relief of cerebral compression in 4 cases

Korsakoff syndrome is a chronic memory disorder caused by a severe deficiency of thiamine that is most commonly observed in alcoholics. However, some have proposed that focal structural lesions disrupting memory circuits—in particular, the mammillary bodies, the mammillothalamic tract, and the anterior thalamus—can give rise to this amnestic syndrome. Here, the authors present 4 patients with reversible Korsakoff syndromes caused by suprasellar retrochiasmatic lesions compressing the mammillary bodies and adjacent caudal hypothalamic structures.

Three of the patients were found to have large pituitary macroadenomas in their workup for memory deficiency and cognitive decline with minimal visual symptoms. These tumors extended superiorly into the suprasellar region in a retrochiasmatic position and caused significant mass effect in the bilateral mammillary bodies in the base of the brain. These 3 patients had complete and rapid resolution of amnestic problems shortly after initiation of treatment, consisting of resection in 1 case of nonfunctioning pituitary adenoma or cabergoline therapy in 2 cases of prolactinoma. The fourth patient presented with bizarre and hostile behavior along with significant memory deficits and was found to have a large cystic craniopharyngioma filling the third ventricle and compressing the midline diencephalic structures. This patient underwent cyst fenestration and tumor debulking, with a rapid improvement in his mental status. The rapid and dramatic memory improvement observed in all of these cases is probably due to a reduction in the pressure imposed by the lesions on structures contiguous to the third ventricle, rather than a direct destructive effect of the tumor, and highlights the essential role of the caudal diencephalic structures—mainly the mammillary bodies—in memory function.

In summary, large pituitary lesions with suprasellar retrochiasmatic extension and third ventricular craniopharyngiomas can cause severe Korsakoff-like amnestic syndromes, probably because of bilateral pressure on or damage to mammillary bodies, anterior thalamic nuclei, or their major connections. Neuropsychiatric symptoms may rapidly and completely reverse shortly after initiation of therapy via surgical decompression of tumors or pharmacological treatment of prolactinomas. Early identification of these lesions with timely treatment can lead to a favorable prognosis for this severe neuropsychiatric disorder.

Risk-adapted, long-term management in childhood-onset craniopharyngioma

PURPOSE

This report is a review of findings on the diagnosis, treatment, clinical course, follow-up, and prognosis of craniopharyngioma patients with special regard to clinical trials and long-term management.

METHODS

Literature search on Pubmed for paper published after 1994.

RESULTS

Craniopharyngiomas are rare, embryonic malformations of the sellar/parasellar region with low histological grade. Clinical manifestations are related to increased intracranial pressure, visual impairment, and hypothalamic/pituitary deficiencies. If the tumor is favorably localized, therapy of choice is complete resection, with care taken to preserve hypothalamic and optic functions. In patients with unfavorable tumor location (i.e. involvement of hypothalamic areas), recommended therapy is limited hypothalamus-sparing surgical strategy followed by irradiation. Irradiation has proven effective in treatment of recurrences and progression. Surgical lesions and/or anatomical involvement of posterior hypothalamic areas can result in serious sequelae, mainly hypothalamic syndrome.

CONCLUSIONS

It is crucial that craniopharyngioma be managed as a frequently chronic disease, providing ongoing care of pediatric and adult patients' by experienced multidisciplinary teams in the context of multicenter trials.

Hypothalamic tumors impact gray and white matter volumes in fronto-limbic brain areas

Patients with hypothalamic involvement of a sellar/parasellar tumor often suffer from cognitive and social-emotional deficits that a lesion in the hypothalamus cannot fully explain. It is conceivable that these deficits are partly due to distal changes in hypothalamic networks, evolving secondary to a focal lesion. Focusing on childhood-onset craniopharyngioma patients, we aimed at investigating the impact of hypothalamic lesions on gray and white matter areas densely connected to the hypothalamus, and to relate structural changes to neuropsychological deficits frequently observed in patients. We performed a voxel-based morphometric analysis based on data of 11 childhood-onset craniopharyngioma patients with hypothalamic tumor involvement, and 18 healthy controls (median age: 17.2 and 17.4 yrs.). Whole-brain analyses were used to test for volumetric differences between the groups (T-tests) and subsequent regression analyses were used to correlate neuropsychological performance with gray and white matter volumes within the patient group. Patients compared to controls had significantly reduced gray matter volumes in areas of the anterior and posterior limbic subsystems which are densely connected with the hypothalamus. In addition, a reduction in white matter volumes was observed in tracts connecting the hypothalamus to other limbic areas. Worse long-term memory retrieval was correlated with smaller gray matter volumes in the posterior cingulate cortex. Our data provide the first evidence that hypothalamic tumor involvement impacts gray and white matter volumes in limbic areas, outside the area of tumor growth. Notably, the functional range of the two limbic subsystems affected, strikingly parallels the two major domains of psychological complaints in patients i.e., deficits in episodic memory and in socio-emotional functioning. We suggest that focal hypothalamic lesions may trigger distal changes in connected brain areas, which then contribute to the impairments in cognitive, social and emotional performance often observable in patients, and not explicable by a hypothalamic lesion alone.

A case study of the neuropsychological outcomes following microsurgery, conventional radiotherapy and stereotactic radiotherapy for an adult's recurrent craniopharyngioma

OBJECTIVE

To examine the neuropsychological outcomes for an adult patient, 2 years after receiving microsurgery and conventional radiotherapy for a recurrent craniopharyngioma; and the impact of a further intervention, stereotactic radiotherapy, on this level of neuropsychological functioning.

PARTICIPANT

JD, a 30 year old male whose recurrent craniopharyngioma had 2 years earlier been treated with two operations and conventional radiotherapy.

DESIGN

JD was assessed (using standardized clinical tests) before and after a course of stereotactic radiotherapy.

RESULTS

Prior to stereotactic radiotherapy (and 2 years after microsurgery and conventional radiotherapy) JD's IQ was intact, but considerable impairments were present in executive functioning, memory, theory of mind and processing speed. Fifteen months after stereotactic radiotherapy, all neuropsychological domains remained largely static or improved, supporting the utility of this treatment option in the neuropsychological domain. However, deficits in executive functioning, memory and processing speed remained.

CONCLUSION

These findings suggest that, even after multiple treatments, substantial cognitive impairments can be present in an adult patient with a recurrent craniopharyngioma. This profile of deficits underlines the inadequacy of relying purely on IQ as a marker for cognitive health in this population and emphasizes the need to include neuropsychological impairments as a focus of rehabilitation with these patients.

Postoperative cerebral glucose metabolism in pediatric patients receiving proton therapy for craniopharyngioma

OBJECT The aim of the study was to document postoperative cerebral glucose distribution before proton therapy using F-18 fluorodeoxyglucose positron emission tomography (FDG PET) in children with craniopharyngioma. METHODS Between August 2011 and April 2014, 50 patients (20 males, 30 females) enrolled in a prospective trial for craniopharyngioma underwent FDG PET imaging before proton therapy. Proton therapy was delivered using doublescattered beams with a total prescribed dose of 54 cobalt gray equivalent. Tracer uptake in each of 63 anatomical regions was computed after warping PET images to a 3D reference template in Talairach coordinates. Regional uptake was deemed significantly low or high if it exceeded age-corresponding 95% prediction intervals of the normal population. The reference group included 132 children with non-CNS-related diseases and normal-appearing cerebral FDG PET scans. RESULTS Median patient age at diagnosis was 8.5 years (range 2-18 years). Forty-eight patients underwent 1-4 tumor-related surgeries before proton therapy, including placement of an Ommaya reservoir in 14 patients. Sixteen patients had symptomatic hydrocephalus that was treated with temporary (external ventricular drain, n = 16) or permanent CSF shunting (ventriculoperitoneal shunt, n = 1). The most commonly seen PET abnormalities in patients before proton therapy were significantly reduced uptake in subregions of the frontal lobe (often involving more than 1 gyrus), medial and ventral portions of the temporal lobe, cingulate gyrus, and caudate nucleus. A significantly high uptake was frequently observed on the contralateral side, including the superior, medial, and inferior temporal gyri and a large portion of the parietal lobe. Statistically significant predictor variables identified in the multivariate analysis for the extent of hypometabolism were sex (p = 0.005), hydrocephalus (p = 0.026), and the number of tumor-related surgeries (p = 0.017). CONCLUSIONS Postoperative FDG PET of patients with craniopharyngioma revealed metabolic abnormalities in specific regions of the brain. The ability to identify anatomical metabolic defects in individual patients facilitates the investigation of brain injury in children with craniopharyngioma.

A systematic review of cognitive performance in patients with childhood craniopharyngioma

Craniopharyngiomas are rare brain tumors of the sellar/suprasellar region, often adversely affecting patients' physical and psychosocial functioning. Until a few years ago, knowledge on cognitive deficits in craniopharyngioma patients was based on little valid evidence, with considerable inconsistencies across studies. Findings from recent research, with partly larger sample sizes, add to existing evidence to provide a more clear and reliable picture. The current review aims to summarize and systemize current findings on cognitive deficits in childhood craniopharyngioma, taking account of patient- and treatment-related variables where possible. Those studies were included that reported results of childhood craniopharyngioma patients tested with formalized neuropsychological tests (irrespective of their age at study, group size ≥10). A systematic assignment of test results to subcomponents of broader cognitive domains (e.g. to specific memory systems and processes) allows for a first comprehensive overview of patterns of spared and impaired cognitive functions. We show that episodic memory recall in particular is impaired, largely sparing other memory components. In accordance with recent knowledge on mammillary function, patients with hypothalamic involvement appear to be at particular risk. Deficits in higher cognitive processes, relying on the integrity of the prefrontal cortex and its subcortical pathways, may also occur, but results are still inconsistent. To gain deeper insight into the pattern of deficits and their association with patient- and treatment-related variables, further multi-site research with larger cohorts is needed.

Neuroendocrine Disorders in Pediatric Craniopharyngioma Patients

Childhood-onset craniopharyngiomas are partly cystic embryonic malformations of the sellar/parasellar region. The therapy of choice in patients with favorable tumor localization is complete resection with a specific focus on maintaining optical and hypothalamic neuroendocrine functions. In patients with unfavorable tumor localization (i.e., hypothalamic involvement), a limited hypothalamus-sparing surgical strategy followed by local irradiation is recommended. Involvement and/or surgical lesions of posterior hypothalamic areas cause major neuroendocrine sequelae. The overall survival rates are high (92%) but neuroendocrine disorders such as obesity and metabolic syndrome due to involvement and/or treatment-related hypothalamic lesions have major negative impact on survival and quality of life. Recurrences and progressions are frequent post-surgical events. Because irradiation is efficient in preventing tumor progression, appropriate timing of post-surgical irradiation is currently under investigation in a randomized multinational trial (KRANIOPHARYNGEOM 2007). Childhood-onset craniopharyngioma should be recognized as a chronic disease requiring treatment and constant monitoring of the clinical and quality of life consequences, frequently impaired due to neuroendocrine disorders, by experienced multidisciplinary teams in order to provide optimal care of surviving patients.

Craniopharyngioma

This report is a review of findings on the diagnosis, treatment, clinical course, and prognosis of craniopharyngioma patients. Craniopharyngiomas are rare, partly cystic and calcified embryonic malformations of the sellar/parasellar region with low histological grade (WHO I°). A bimodal age distribution has been shown, with peak incidence rates in childhood-onset at 5-14 years and adult-onset craniopharyngioma at 50-74 years. Clinical manifestations are related to hypothalamic/pituitary deficiencies, visual impairment, and increased intracranial pressure. If the tumor is favorably localized, the therapy of choice is complete resection, with care taken to preserve optical and hypothalamic functions. In patients with unfavorable tumor localization (i.e., hypothalamic involvement), recommended therapy is a limited hypothalamus-sparing surgical strategy followed by local irradiation. Although overall survival rates are high (92%), recurrences and progressions are frequent. Irradiation has proven effective in reducing recurrences and progression, and timing of postsurgical irradiation in childhood-onset cases is currently under investigation in a randomized multinational trial (KRANIOPHARYNGEOM 2007). Anatomical involvement and/or surgical lesions of posterior hypothalamic areas can result in serious quality of life-compromising sequelae such as hypothalamic obesity, psychopathological symptoms, and/or cognitive problems. It is crucial that craniopharyngioma be managed as a frequently chronic disease, providing ongoing care of pediatric and adult patients' clinical and quality of life consequences by experienced multidisciplinary teams.

Neuropsychological outcome in patients with childhood craniopharyngioma and hypothalamic involvement

OBJECTIVE

To test memory performance and executive functions in patients with childhood craniopharyngioma and hypothalamic involvement.

STUDY DESIGN

Using standardized neuropsychological tests, we compared cognitive performance in a group of 15 patients with childhood craniopharyngioma and known hypothalamic involvement and a group of 24 age- and intelligence-matched control subjects. In addition, we compared individual patients' results with normative data to detect abnormal performance in the clinically relevant range. Within the patient group, we further tested whether the grade of hypothalamic involvement had an impact on cognitive performance and quality of life.

RESULTS

Relative to healthy controls, the patients demonstrated significantly lower performance scores in tests of memory and executive functioning. On the individual performance level, delayed recall performance was severely impaired in one-third of the patients. Compared with patients with low-grade hypothalamic involvement, those with high-grade hypothalamic involvement showed worse performance in executive functions and reduced functional capabilities for daily life actions, indicating lower quality of life.

CONCLUSION

Our findings demonstrate that hypothalamic involvement is related to impairments in memory and executive functioning in patients with childhood craniopharyngioma and indicate that a high grade of hypothalamic involvement is related to worse outcomes.

Remote effects of hypothalamic lesions in the prefrontal cortex of craniopharygioma patients

Albeit histologically low grade (WHO I(o)) brain tumors, craniopharyngiomas and/or their surgical removal frequently affect the hypothalamus, amongst other brain regions at risk. Due to rich hypothalamic connections with prefrontal and limbic regions, hypothalamic injury may adversely affect neural substrates of emotion processing and higher cognitive control, including memory and executive functions. The current study is the first to investigate the consequences of hypothalamic involvement on neural substrates of emotional and cognitive functioning. Ten patients with childhood craniopharyngioma and known hypothalamic involvement and fifteen age- and intelligence matched control subjects (median age: 17.8 and 17.3 yrs.) were studied with functional magnetic resonance imaging and an emotional face recognition task. During encoding, participants were asked to classify neutral and emotional faces. In a subsequent recognition phase, participants had to recognize these old faces within a set of new faces. Behavioral performance was comparable between patients and controls. Neural activity revealed, however, differential recruitment of fronto-limbic brain regions during recognition. Patients exhibited an abnormal pattern of task-induced activation and deactivation in the anterior and posterior rostral medial prefrontal cortex and a higher functional coupling between anterior rostral medial prefrontal cortex and the thalamus. Additionally, we found a higher reactivity in the patients' amygdala to emotional relative to neutral faces when compared to healthy controls. Our data provide first evidence that hypothalamic damage impacts neural correlates of memory retrieval in medial prefrontal cortex, indicating a less efficient use of an area involved in executive control processes. We propose that the deactivation failure in the patients' anterior rostral medial prefrontal cortex is related to an increased coupling with the thalamus and reflects a reduced efficiency to flexibly adapt to task demands.

Childhood craniopharyngioma: treatment strategies and outcomes

Craniopharyngiomas are embryogenic malformations of the sellar region. With an overall incidence of 0.5-2.0 new cases per million population per year, approximately 30-50% of all cases represent childhood craniopharyngioma. Therapy of choice in patients with favorable tumor localization is complete resection with a specific focus on maintaining functions of the optical nerve and hypothalamic-pituitary axes. In patients whose unfavorable tumor localization makes maintaining hypothalamic functionality surgically challenging, a limited resection followed by local irradiation is recommended. The overall survival rates are high (92%) but relapses and reduced QoL in survivors are also frequent. Because irradiation is efficient in preventing tumor progression, appropriate timing of post-surgical irradiation is currently under investigation in a randomized trial (KRANIOPHARYNGEOM 2007). Childhood craniopharyngioma should be recognized as a chronic disease requiring constant monitoring of the clinical and QoL consequences in order to provide optimal care of surviving patients.

Craniopharyngioma

Craniopharyngiomas are partly cystic embryogenic malformations of the sellar and parasellar region. With an overall incidence of 0.5-2.0 new cases per million population per year, approximately 30-50% of all cases represent childhood craniopharyngioma. Typical manifestations at diagnosis are some combination of headache, visual impairment, polyuria/polydypsia, growth retardation, and significant weight gain. Therapy of choice in patients with favorable tumor localization is complete resection with specific focus on maintaining functions of the optic nerve and hypothalamic-pituitary axes. In patients whose unfavorable tumor localization makes maintaining hypothalamic functionality surgically challenging, a limited resection followed by local irradiation is recommended. The overall survival rates are high (92%) but occurrences of reduced quality of life are also high. Recurrences after complete resection and progressions of residual tumor after incomplete resection are frequent postsurgical events. Because irradiation is efficient in preventing tumor progression, appropriate timing of postsurgical irradiation is currently under investigation in the randomized multinational trial KRANIOPHARYNGEOM 2007 that analyzes quality of life as primary endpoint. Childhood craniopharyngioma should be recognized as a chronic disease requiring constant monitoring of the clinical and quality of life consequences in order to provide optimal care of surviving patients.

Minimally invasive management of adult craniopharyngiomas: An analysis of our series and review of literature

Background:

Craniopharyngiomas (CPs) are slow growing tumors with an incidence of between 1.2% and 4.6%, having a bimodal age distribution typically peaking in childhood and in adults between 45 and 60 years. Recurrences occur even after documented gross total resections necessitating a combination of therapeutic strategies. Obtaining a cure of this tumor in adults without producing major side effects continues to remain elusive.

Methods:

We describe our results in 11 patients with CP treated in a minimally invasive fashion using a combination of techniques like burr hole aspiration, Ommaya reservoir placement, ventriculo-peritoneal (VP) shunting and focal radiation (Gamma Knife stereotactic radiosurgery/Intensity modulated radiotherapy [GKRS/IMRT]).

Results:

Visual function remained intact in all patients; endocrine status remained stable with two patients developing new postoperative diabetes insipidus. There was no periprocedural morbidity or mortality, with hospital stays for any in-patient procedure being 48 hours or less.

Conclusions:

Minimally invasive techniques such as cyst aspiration, insertion of a catheter with Ommaya reservoir, when combined with stereotactic radiosurgery/IMRT is an effective and safe option for management and long-term control of adult CPs. We believe the Ommaya catheter by itself could act as a stent, creating a tract allowing gradual drainage of cyst fluid and stabilization without necessitating any further interventions in selected cases.

Pegylated interferon-α-2b for children with recurrent craniopharyngioma

OBJECT

Previous studies of systemic and intralesional administration of nonpegylated interferon have shown efficacy against craniopharyngioma. Pegylaion of interferon-α-2b (PI) prolongs the half-life, allowing sustained exposure of the drug over time, and enhances efficacy. The authors report the results of the use of PI in 5 children with recurrent craniopharyngiomas.

METHODS

Five children, ranging in age from 9 to 15 years, with recurrent craniopharyngiomas were treated for up to 2 years with subcutaneous injections of PI at a dose of 1-3 μg/kg/week. Tumor response was assessed using MRI.

RESULTS

All patients had stable disease or better in response to PI. One patient experienced a recurrence after gross-total resection (GTR). She initially showed an increase in the predominantly cystic tumor after 3 months of treatment, followed by a complete response. She required no further intervention and remains without evidence of disease 10 years after starting treatment. Another patient experienced recurrence 3.3 years after subtotal resection (STR) and radiation therapy. He had complete disappearance of the predominantly cystic component after 4 months of treatment, and a small residual calcified mass remains 5 years later. The third patient experienced recurrence after 3 GTRs. He had a complete response after 7 months of treatment and remains without evidence of disease 19 months after starting treatment. The fourth patient experienced recurrence after 2 STRs. He had a 30% decrease in tumor size after 4 months of treatment, which was maintained for 12 months at which point the cyst began to increase in size. The final patient experienced recurrence after GTR and has stable disease 6 months after starting treatment with PI.

CONCLUSIONS

The use of PI in children with recurrent craniopharyngiomas can result in significant and durable responses and potentially delay or avoid the need for radiation therapy.

Quality-of-life, mood and executive functioning after childhood craniopharyngioma treated with surgery and proton beam therapy

PRIMARY OBJECTIVE

Childhood craniopharyngioma, a benign tumour with a good survival rate, is associated with important neurocognitive and psychological morbidity, reducing quality-of-life (QoL).

METHOD

This retrospective study analysed QoL, mood disorders, everyday executive functioning and disease's impact on family life in 29 patients (mean age at diagnosis 7 years 10 months (SD = 4.1); mean follow-up period 6 years 2 months (SD = 4.5)) treated for childhood craniopharyngioma by surgery combined with radiotherapy using proton beam. Assessment included a semi-structured interview and standardized scales evaluating self-report of QoL (Kidscreen 52) and depression (MDI-C) and proxy-reports of QoL (Kidscreen 52), executive functioning (BRIEF) and disease's impact (Hoare and Russel Questionnaire).

RESULTS

Twenty-three families answered the questionnaires completely. Overall QoL self-report was within the normal range. QoL proxy-report was lower than self-report. Eleven patients reported depression; 24-38% had dysexecutive symptoms. A majority of families felt 'very concerned' by the disease. Depression and low parental educational level were associated with lower QoL and higher levels of executive dysfunction.

CONCLUSION

Given the high morbidity of childhood craniopharyngioma, screening for psychosocial outcome, cognitive functioning, including executive functions, mood and QoL should be systematic and specific interventions should be developed and implemented.

Treatment strategies in childhood craniopharyngioma

The surgical management of craniopharyngiomas in children remains one of the more controversial topics in pediatric neurosurgery. Theoretically, the benign histology implies that total surgical excision would be sufficient to provide a cure. It has been widely established however, that in certain cases total excision may lead to unacceptable hypothalamic injury. The therapeutic goals for pediatric craniopharyngiomas therefore, require not just cure of the disease but also preservation of function. Over the last 15 years, there has been a growing worldwide advocacy for less extensive resection and for the utilization of multimodality therapy to limit morbidity. With this in mind, risk-adapted strategies designed to preserve hypothalamic structures have been developed. The preliminary results of these strategies appear to be encouraging. However, the long-term clinical outcome in terms of post irradiation complications and management of relapses is currently unknown.

Craniopharyngioma in adults

Craniopharyngiomas are slow growing benign tumors of the sellar and parasellar region with an overall incidence rate of approximately 1.3 per million. During adulthood there is a peak incidence between 40 and 44 years. There are two histopathological types, the adamantinomatous and the papillary type. The later type occurs almost exclusively in adult patients. The presenting symptoms develop over years and display a wide spectrum comprising visual, endocrine, hypothalamic, neurological, and neuropsychological manifestations. Currently, the main treatment option consists in surgical excision followed by radiation therapy in case of residual tumor. Whether gross total or partial resection should be preferred has to be balanced on an individual basis considering the extent of the tumor (e.g., hypothalamic invasion). Although the overall long-term survival is good it is often associated with substantial morbidity. Preexisting disorders are often permanent or even exacerbated by treatment. Endocrine disturbances need careful replacement and metabolic sequelae should be effectively treated. Regular follow-up by a multidisciplinary team is a prerequisite for optimal outcome of these patients.

Cystic craniopharyngioma: intratumoral chemotherapy with alpha interferon

OBJECTIVE

To assess whether the cystic craniopharyngiomas can be controlled with the use of intratumoral applications of interferon alpha.

METHOD

Nineteen patients with the diagnosis of cystic craniopharyngioma were treated with intratumoral chemotherapy with interferon alpha from January 2002 to April 2006. All patients underwent placement of an intracystic catheter connected to an Ommaya reservoir. Through this reservoir were made applications during chemotherapy cycles. Each cycle corresponded to application of 3,000,000 units of interferon alpha three times per week on alternate days totalizing 36,000,000 units. Response to treatment was evaluated by calculating the tumor volume on MRI control after one, three and six months after the end of each cycle. Patients who developed worsening of symptoms or who had insignificant reduction in tumor volume during follow-up underwent repeat cycle chemotherapy.

RESULTS

Four patients received four cycles of chemotherapy, three patients received three cycles, six patients received two cycles and six patients received one. The lower percentage of reduction in tumor volume was 60% and the bigger reduction was 98.37%. Eleven patients had a reduction greater than 90%. Five patients had a tumor reduction between 75 and 90% and in three patients the tumors were reduced by less than 75%. No deaths occurred during treatment and side effects of interferon alpha were well tolerated. No treatment was discontinued. Follow-up after the last application ranged from one year and five months to three years and nine months.

CONCLUSION

The intratumoral chemotherapy with interferon alpha decreases the volume of cystic craniopharyngiomas and so far can be considered a new therapeutic alternative.

Long term sequelae of pediatric craniopharyngioma - literature review and 20 years of experience

Craniopharyngioma are rare histologically benign brain tumors that develop in the pituitary-hypothalamic area. They may invade nearby anatomical structures causing significant rates of neurological, neurocognitive, and endocrinological complications including remarkable hypothalamic damage. Information regarding long term implications of the tumors and treatment in the pediatric population is accumulating, and treatment goals appear to be changing accordingly. In this review we aim to present data regarding long term complications of craniopharyngioma in children and adolescents and our experience from a large tertiary center. Hypothalamic dysfunction was noted to be the most significant complication, adversely affecting quality of life in survivors. Obesity, fatigue, and sleep disorders are the most notable manifestations of this dysfunction, and treatment is extremely difficult. Changes in management in recent years show a potential for improved long term outcomes; we found a trend toward less aggressive surgical management and increasing use of adjuvant treatment, accompanied by a decrease in complication rates.

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.

Craniopharyngioma Clinical Status Scale: a standardized metric of preoperative function and posttreatment outcome

OBJECT

Controversy persists concerning the optimal treatment of craniopharyngiomas in children, and no standard outcome metric exists for comparison across treatment modalities, nor is there one that adequately reflects the multisystem dysfunction that may arise.

METHODS

The authors retrospectively analyzed the records of 86 consecutive children who underwent a uniform treatment paradigm of attempted radical resection performed by a single surgeon. Excluding 3 perioperative deaths and 3 patients with inadequate follow-up, 80 children (34 girls and 46 boys; mean age 9.56 years; mean follow-up 9.6 years) composed the study group (53 primary and 27 previously treated/recurrent tumors). Building on existing classification schemes proposed by De Vile for hypothalamic dysfunction and Wen for overall functional outcome, the authors devised a more nuanced classification system (Craniopharyngioma Clinical Status Scale [CCSS]) that assesses outcome across 5 axes, including neurological examination, visual status, pituitary function, hypothalamic dysfunction, and educational/occupational status at last follow-up (there is a 4-tiered grading scale in each domain, with increasing values reflecting greater dysfunction).

RESULTS

There was a significant increase in pituitary dysfunction following treatment-consistent with the high rates of diabetes insipidus and hypopituitarism common to the surgical management of craniopharyngiomas-and less dramatic deterioration in hypothalamic function or cognitive domains. Significant improvement in vision was also demonstrated, with no significant overall change in neurological status. Preoperative CCSS scores predicted postoperative outcome better than clinical characteristics like patient age, sex, tumor size, and the location or presence of hydrocephalus.

CONCLUSIONS

Preoperative CCSS scores predicted outcome with higher accuracy than clinical or imaging characteristics. In lieu of randomized trials, the CCSS may provide a useful outcome assessment tool for comparison across treatment paradigms and surgical approaches. Long-term follow-up is critical to the analysis of outcomes of craniopharyngioma treatment, given the often-delayed sequelae of all therapies and the high recurrence rates of 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.

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.

Radiation therapy for pediatric craniopharyngioma

Object

The treatment of craniopharyngioma is highly controversial. Continued advances in limited surgery and radiation therapy have maintained excellent local disease control while minimizing treatment-related sequelae. Further analyses of outcomes are necessary to characterize the long-term effects of radiation therapy.

Methods

An extensive literature review was performed for all studies including radiation therapy, with or without surgery, for pediatric craniopharyngioma.

Results

The authors identified 32 papers describing radiation therapy for treatment of pediatric craniopharyngioma, with disease control ranging from 44 to 100%. Modern studies report at least 90% disease control with 5-year follow-up. Fifteen studies reported outcomes, demonstrating that more than two-thirds of patients treated with surgery and radiation therapy have favorable outcomes, and this rate is more than 85% in the modern era.

Conclusions

Conservative surgery and radiation therapy results in long-term disease control in pediatric patients with craniopharyngioma that is comparable to results obtained with radical surgery alone. However, children with craniopharyngioma remain vulnerable to late treatment failures and side effects from radiation therapy, including endocrinopathies, vasculopathies, and secondary tumors, which may be detrimental to the quality of life. Long-term follow-up beyond 5–10 years is necessary to assess tumor control relative to functional outcomes.

Efficacy and safety of radical resection of primary and recurrent craniopharyngiomas in 86 children

OBJECT

Optimal treatment of primary and recurrent craniopharyngiomas remains controversial. Radical resection and limited resection plus radiation therapy yield similar rates of disease control and overall survival. The data are much less clear for recurrent tumors. The authors report their experience with radical resection of both primary and recurrent craniopharyngiomas in children and compare the outcomes between the 2 groups.

METHODS

A retrospective analysis was performed in 86 children younger than 21 years of age who underwent a total of 103 operations for craniopharyngioma between 1986 and 2008; these were performed by the senior author. The goal was resection with curative intent in all patients. Two patients were lost to follow-up and were excluded from analysis. The mean age at the time of surgery was 9.6 years, and the mean follow-up was 9.0 years.

RESULTS

All 57 children with primary tumors underwent gross-total resection (GTR). A GTR was achieved in significantly fewer children with recurrent tumors (18 [62%] of 29). There were 3 perioperative deaths (3%). Tumor recurred after GTR in 14 (20%) of 71 patients. Overall survival and progression-free survival were significantly better in patients with primary tumors at time of presentation to the authors' institution. There were no significant differences in the neurological, endocrinological, visual, or functional outcomes between patients with primary and those with recurrent tumors. Factors negatively affecting overall survival and progression-free survival include subtotal resection (recurrent tumors only), tumor size >or= 5 cm, or presence of hydrocephalus or a ventriculoperitoneal shunt. Prior radiation therapy and increasing tumor size were both risk factors for incomplete resection at reoperation.

CONCLUSIONS

In the hands of surgeons with experience with craniopharyngiomas, the authors believe that radical resection at presentation offers the best chance of disease control and potential cure with acceptable morbidity. While GTR does not preclude recurrence and is more difficult to achieve in recurrent tumors, especially large and previously irradiated tumors, radical resection is still possible in patients with recurrent craniopharyngiomas with morbidity similar to that of primary tumors.

Predicting behavioral problems in craniopharyngioma survivors after conformal radiation therapy

BACKGROUND

Although radiation therapy is a primary treatment for craniopharyngioma, it can exacerbate existing problems related to the tumor and pre-irradiation management. Survival is often marked by neurologic deficits, panhypopituitarism, diabetes insipidus, cognitive deficiencies, and behavioral and social problems.

PROCEDURE

The Achenbach Child Behavior Checklist (CBCL) was used to evaluate behavioral and social problems during the first 5 years of follow-up in 27 patients with craniopharyngioma treated with conformal radiation therapy.

RESULTS

All group averages for the CBCL scales were within the age-typical range at pre-irradiation baseline. Extent of surgical resection was implicated in baseline differences for the internalizing, externalizing, behavior problem and social scores. Significant longitudinal changes were found in internalizing, externalizing, behavior problem and school scores that correlated with tumor and treatment-related factors.

CONCLUSIONS

The most common variables implicated in post-irradiation behavioral and social problems were CSF shunting, presence of an Ommaya reservoir, diabetes insipidus, and low pre-irradiation growth hormone levels.

Successful surgical treatment of craniopharyngioma in very young children

OBJECT

Given the potential morbidity of cranial irradiation in young children, the risk-benefit analysis of limited surgery plus irradiation versus radical resection may favor the latter strategy. The purpose of this study was to assess the oncological, endocrinological, and functional outcomes of patients 5 years of age and younger who underwent radical resection of craniopharyngiomas.

METHODS

Between 1991 and 2008, 19 children age < or = 5 years were diagnosed with a craniopharyngioma and underwent radical resection by the senior author (J.H.W.). Data were retrospectively collected on these 19 patients (11 males, 8 females; mean age 3.2 years) to assess the efficacy and impact of surgical treatment.

RESULTS

Eighteen (95%) of 19 patients underwent gross-total resection (GTR) confirmed by intraoperative inspection and postoperative imaging. There was no operative death and 18 of (95%) 19 patients were alive at a mean follow-up of 9.4 years (median 8.3 years). Six patients (31%) had a total of 7 tumor recurrences treated by repeat GTR in 5 patients and Gamma knife surgery in 1 patient. No patient required conventional, fractionated radiation therapy. Disease control was achieved surgically in 17 (89.5%) patients and with surgery and Gamma knife surgery in 1 patient, yielding an overall rate of disease control of 95% without the use of conventional radiotherapy. New-onset diabetes insipidus occurred in 50% of patients. Vision worsened in 1 patient, and there was no long-term neurological morbidity.

CONCLUSIONS

In this retrospective series, children aged < or = 5 years with craniopharyngiomas can have excellent outcomes with minimal morbidity after radical resection by an experienced surgeon. Disease control in this population can be successfully achieved with GTR alone in the majority of cases, avoiding the detrimental effects of radiotherapy in this vulnerable population.

Management of cystic craniopharyngiomas with stereotactic endocavitary irradiation using colloidal 186Re: a retrospective study of 48 consecutive patients

OBJECTIVE

We retrospectively reviewed the results of stereotactic endocavitary irradiation with colloidal 186Re in the treatment of cystic craniopharyngiomas.

METHODS

Among 54 consecutive patients included in a 186Re stereotactic endocavitary irradiation procedure, 42 patients (29 male and 13 female; average age, 38.7 years) received therapeutic injection via intracystic catheter introduced under stereotactic conditions. The mean follow-up period was 43 months (range, 8-148 months). Endocavitary irradiation was the primary treatment for 15 patients and an adjuvant treatment for 27 patients. The mean volume before irradiation was 8.07 mm3, and the mean radiation dose was 381 MBq.

RESULTS

Cystic mean volume after irradiation was 2.6 cm3 (P < 0.001 with initial volume). The retraction of the cyst was complete for 17 patients (44%) and partial for 17 (44%). In partial retraction, cystic volume decreased more than 50% for 12 (3%) patients and less than 25% (13%) for 5. Cystic volume remained the same or increased for 5 (13%) patients. Concerning visual functions, 12 (44.5%) patients improved and 2 worsened, despite tumor control. No endocrinological deterioration occurred. Among 17 patients with preoperative cognitive dysfunction, 10 improved and 6 had no change. One patient showed memory alteration 4 months after stereotactic endocavitary irradiation despite cyst volume reduction. No mortality occurred.

CONCLUSION

186Re stereotactic endocavitary irradiation for the treatment of cystic craniopharyngiomas is a safe and effective procedure with a tumor control rate greater than 70%. This treatment can be used for first-intention treatment of pure cystic craniopharyngiomas or for second-intention treatment of cystic recurrences.

Neuropsychological functioning following craniopharyngioma removal

The neuropsychological functioning of patients who had undergone surgical removal of craniopharyngiomas was compared to that of an endocrine control group composed of patients with nontumor hypopituitarism, an obese control group, and a normal control group. Neuropsychological assessments consisting of measures of intelligence, memory, attention, and executive functioning were carried out. The craniopharyngioma group had lower Performance IQ than did the normal control group, but their Performance IQ was comparable to that of the hypopituitarism and obese control groups. The craniopharyngioma patients did not differ in Verbal or Full Scale IQs from the remaining groups. There were no group differences on measures of verbal or nonverbal memory, ability to sustain attention, or executive functioning including measures of verbal or figural fluency, nonverbal problem solving, ability to copy a complex geometric figure, and visual motor and visual sequencing skills. The group mean scores on the measures of intelligence and neuropsychological abilities for the craniopharyngioma patients were in the low-average to average range. While craniopharyngioma patients can have significant morbidity including endocrine and visual deficits as well as obesity resulting from hyperphagia, neuropsychological deficits are not always present. Their neuropsychological outcome is more benign than some previous studies have suggested.

Long-term outcome in children treated for craniopharyngioma with and without radiotherapy

OBJECT

The authors report the results of surgery alone or in combination with radiotherapy in the management of craniopharyngiomas in children.

METHODS

The authors retrospectively reviewed the outcomes in 31 patients treated for craniopharyngiomas at the Department of Radiation Oncology at Washington University in St. Louis and the St. Louis Children's Hospital. The median age at diagnosis was 8.1 years (range 1.1-21 years). Fourteen patients underwent gross-total resection (GTR) with observation, and 6 patients underwent subtotal resection (STR) with observation. Ten patients underwent STR or cyst aspiration followed by external-beam radiotherapy, and 1 patient underwent cyst aspiration followed by intracystic 32P installation.

RESULTS

The median follow-up for all surviving patients was 78.2 months. Overall survival and local control rates at 10 years were 96 and 58%, respectively. One patient died of the disease, and 12 patients had subsequent recurrences. Of those with recurrences, 6 patients had undergone initial STR with observation and 6 had been treated with GTR and observation. The median time to progression was 17.9 months in the patients who underwent limited resection, and 55 months for those who underwent GTR. There were no recurrences in the patients who received radiotherapy at the time of initial diagnosis.

CONCLUSIONS

Radiotherapy delivered as part of the initial management of craniopharyngiomas in children or at the time of recurrence provides effective local control.

Craniopharyngioma surgery

Ideal surgical treatment of craniopharyngiomas remains a major challenge for neurosurgeons. Craniopharyngiomas grow in the deep-seated hypothalamic area that is paramount for vegetative, emotional and endocrine function, and for maintaining worthwhile life. The benign histological nature of craniopharyngiomas belies their biological behavior and the propensity to recur is a major threat. Surgical treatment has to weigh the risk of hypothalamic damage against the risk of tumor recurrence or progression. Both aggressive surgery and conservative minor surgery followed by radiotherapy has been proclaimed by the proponents of different schools. During the past decade, the pendulum has swung back to surgery with the attempt at radical removal. Refined neurosurgical techniques and innovative approaches yielded improved surgical results. The contemporary neurosurgical strategy of treating craniopharyngiomas with early and late outcome data is presented. Neurosurgical therapy is only beneficial in the context of an interdisciplinary treatment concept as discussed here.

Craniopharyngioma

Craniopharyngiomas are benign slow growing tumours that are located within the sellar and para sellar region of the central nervous system. The point prevalence of this tumour is approximately 2/100,000. The onset of symptoms is normally insidious with most patients at diagnosis having neurological (headaches, visual disturbances) and endocrine (growth retardation, delayed puberty) dysfunctions. Craniopharyngiomas are thought to arise from epithelial remnants of the craniopharyngeal duct or Rathke's pouch (adamantinomatous type) or from metaplasia of squamous epithelial cell rests that are remnants of the part of the stomadeum that contributed to the buccal mucosa (squamous papillary type). The neuroradiological diagnosis is mainly based on the three components of the tumour (cystic, solid and calcified) in the characteristic sellar/para sellar location. Definitive diagnosis is made following histological examination of a surgical specimen. The differential diagnosis includes other tumours in this region (pituitary adenoma), infectious or inflammatory processes (eosinophilic granuloma), vascular malformations (aneurysm) and congenital anomalies (Rathke's cleft cyst). The current treatment is gross total excision of the tumour, if there is no hypothalamic invasion or, in the presence of hypothalamic invasion, a sub-total resection with post-operative radiotherapy. Endocrine disturbances are normally permanent and need careful replacement. Overall, there is an 80% 5 year survival, though this can be associated with marked morbidity (hypothalamic dysfunction, altered neuropsychological profile).

Neurocognitive effects of treatment for childhood cancer

We review research on the neuropsychological effects that central nervous system (CNS) cancer treatments have on the cognitive abilities of children and adolescents. The authors focus on the two most common malignancies of childhood: leukemias and brain tumors. The literature review is structured so as to separate out earlier studies, generally those published prior to 1995, as opposed to manuscripts that have been published within the past decade. This is an important distinction for both leukemia and brain tumors. Earlier studies were ground breaking in that they began to map out what could be expected in terms of intelligence and academic problems in survivors of pediatric malignancies. Survivorship in this population has and continues to markedly increase and this is largely due to changes in treatment protocols. Research on neurocognitive effects of disease and treatment in pediatric oncology has become increasingly sophisticated, and this literature review not only reflects this trend, but highlights the growing collaboration between neuropsychology, cognitive neuroscience, and neuro-imaging. Thus, our goal was to provide a historical foundation, lead the reader towards the progression of research methodology up to the current state of the art, and perhaps most importantly, discuss future directions. These directions are especially relevant to the concepts of remediation and treatment of cognitive problems, and this is emphasized at the conclusion of the review.

Pediatric craniopharyngiomas: classification and treatment according to the degree of hypothalamic involvement

OBJECT

The current treatment of craniopharyngiomas is evolving into one of a multimodal approach in which the aim is disease control and improved preservation of quality of life (QOL). To date, an appropriate classification system with which to individualize treatment is absent. The objectives of this study were to identify preoperative prognostic factors in patients with craniopharyngiomas and to develop a risk-based treatment algorithm.

METHODS

The authors reviewed data obtained in a retrospective cohort of 66 children (mean age 7.4 years, mean follow-up period 7 years) who underwent resection between 1984 and 2001. Postoperative recurrence rates, vision status, and endocrine function were consistent with those reported in the literature. The postoperative morbidity was related to hypothalamic dysfunction. The preoperative magnetic resonance imaging grade, clinically assessed hypothalamic function, and the sugeon's operative experience (p = 0.007, p = 0.047, p = 0.035, respectively) significantly predicted poor outcome. Preoperative hypothalamic grading was used in a prospective cohort of 22 children (mean age 8 years, mean follow-up period 1.2 years) treated between 2002 and 2004 to stratify patients according to whether they underwent gross-total resection (GTR) (20%), complete resection avoiding the hypothalamus (40%), or subtotal resection (STR) (40%). In cases in which residual disease was present, the patient underwent radiotherapy. There have been no new cases of postoperative hyperphagia, morbid obesity, or behavioral dysfunction in this prospective cohort.

CONCLUSIONS

For many children with craniopharyngiomas, the cost of resection is hypothalamic dysfunction and a poor QOL. By using a preoperative classification system to grade hypothalamic involvement and stratify treatment, the authors were able to minimize devastating morbidity. This was achieved by identifying subgroups in which complete resection or STR, performed by an experienced craniopharyngioma surgeon and with postoperative radiotherapy when necessary, yielded better overall results than the traditional GTR.

Changes in attentional performance of children and young adults with localized primary brain tumors after conformal radiation therapy

PURPOSE

To prospectively assess the impact of conformal radiation therapy (CRT) and demographic and clinical variables on four measures of attention in pediatric and young adult patients with localized primary brain tumors.

PATIENTS AND METHODS

We prospectively evaluated 120 patients with primary brain tumors, ages 2 to 24.4 years (median, 9.2 years). Evaluations were done using the computerized Conners' Continuous Performance Test (CCPT). We analyzed errors of omission (inattentiveness), errors of commission (impulsivity), reaction time, and an overall index of performance before CRT, weekly during CRT, and serially up to 60 months after the start of CRT.

RESULTS

Before CRT, patients exhibited mild inattentiveness. During CRT, impulsivity decreased significantly (P = .002). After CRT, inattentiveness increased significantly (P = .03), and global attention disorders were associated with craniopharyngioma (P < .0001), supratentorial tumors (P = .008), optic pathway and diencephalic tumors (P = .012), and subtotal resection of the tumor (P = .010).

CONCLUSION

Brain tumors and their treatment impair sustained attention and reaction time. A decline in impulsivity and relative stability of the other CCPT scores over the course of CRT demonstrated the absence of early radiation-related cognitive sequelae. Local tumor effects, initial surgical intervention, and focal irradiation of central structures contribute to long-lasting attentional problems in pediatric and young adult patients.

Craniopharyngiomas: an update

Craniopharyngiomas have been challenging practitioners for over 100 years. These benign cystic tumors are thought to be a part of a continuum of ectodermal cystic lesions found in the suprasellar region. They are rare tumors found in both the adult and pediatric populations. Patients most often present with findings associated with ventricular outflow obstruction causing hydrocephalus, optic chiasm compression resulting in visual dysfunction or hypothalamic/pituitary compression leading to endocrinopathy. The mainstay of treatment involves a combination of radical or limited surgery followed by radiotherapy. Other adjunctive strategies include cyst fenestration, Ommaya catheter implantation and brachytherapy. Patients in general have high long-term survival but can have significant tumor- and treatment-associated morbidity requiring a lifetime of medical and psychological management.

Craniopharyngiomas

Craniopharyngiomas are rare, mainly sellar/parasellar, epithelial tumors diagnosed during childhood or adult life. Histologically, two primary subtypes have been recognized (adamantinomatous and papillary) with an as yet, unclarified pathogenesis. They may present with a variety of manifestations (neurological, visual, and hypothalamo-pituitary). Despite their benign histological appearance, they often show an unpredictable growth pattern, which, combined with the lack of randomized studies, poses significant difficulties in the establishment of an optimal therapeutic protocol. This should focus on the prevention of recurrence(s), improvement of survival, reduction of the significant disease and treatment-related morbidity (endocrine, visual, hypothalamic, neurobehavioral, and cognitive), and preservation of the quality of life. Currently, surgical excision followed by external beam irradiation, in cases of residual tumor, is the main treatment option. Intracystic irradiation or bleomycin, stereotactic radiosurgery, or radiotherapy and systemic chemotherapy are alternative approaches; their place in the management plan remains to be assessed in adequately powered long-term trials. Apart from the type of treatment, the identification of clinical and imaging parameters that will predict patients with a better prognosis is difficult. The central registration of patients with these challenging tumors may provide correlates between treatments and outcomes and establish prognostic factors at the pathological or molecular level that may further guide us in the future.

Combined proton and photon irradiation for craniopharyngioma: Long-term results of the early cohort of patients treated at Harvard Cyclotron Laboratory and Massachusetts General Hospital

PURPOSE

We report the results of the early cohort of patients treated for craniopharyngioma with combined proton-photon irradiation at the Massachusetts General Hospital and the Harvard Cyclotron Laboratory.

METHODS AND MATERIALS

Between 1981 and 1988, 15 patients with craniopharyngioma were treated in part or entirely with fractionated 160 MeV proton beam therapy. The group consisted of 5 children (median age, 15.9 years) and 10 adults (median age, 36.2 years). Median dose prescribed to the tumor was 56.9 cobalt Gray equivalent (CGE; 1 proton Gray = 1.1 CGE). The median proton component was 26.9 CGE. Patients were treated after documented recurrence after initial surgery (n = 6) or after subtotal resection or biopsy (n = 9). None had had prior radiation therapy.

RESULTS

Median observation period of surviving patients (n = 11) was 13.1 years from radiotherapy. One patient was lost to follow-up with tumor control after 5.2 years. Actuarial 10-year survival rate was 72%. Four patients have died 5-9.1 years after treatment, two from local failure. Actuarial 5- and 10-year local control rates were 93% and 85%, respectively. The functional status of the living adult patients is unaltered from their preradiotherapy status; all of them continued leading normal or near normal working lives. None of the patients treated as a child had experienced recurrence of tumor. One child shows learning difficulties and slight retardation, comparable to his preradiotherapy status. The others have professional achievements within the normal range.

CONCLUSION

Results in terms of survival and local control are comparable with other contemporary series. Although no formal neuropsychological testing was performed, the surrogate measures of lifestyle and professional accomplishments appear to be satisfactory.

Craniopharyngioma in childhood

In summary, much progress has been made in our understanding of childhood craniopharyngiomas. These histologically benign but "geographically malignant" tumors are challenging to treat and require experienced clinicians from multiple disciplines including neurosurgery, radiology, hematology/oncology, ophthalmology, endocrinology, and general pediatrics to address the multiple issues that arise with diagnosis, treatment, and long-term follow-up of affected children. The study and close observation of patients who have craniopharyngiomas may also be beneficial for our general understanding of pathophysiologic processes such as the observed "growth without growth hormone" phenomenon or the well-described and studied hypothalamic obesity phenotypes.

Radiation therapy in the management of pediatric craniopharyngiomas--a review

Craniopharyngiomas are benign suprasellar tumors that arise from epithelial remnants of the Rathke's pouch. The two standard treatment options are primary total resection or limited surgery followed by external beam radiation. The 10- and 20-year progression-free survival rates following limited surgery and radiation therapy are superior to those achieved by primary surgery alone. The side effect profiles for these two treatment approaches are different. Following total resection there is a very high incidence of panhypopituitarism requiring lifelong multiple hormone replacement therapy. The other side effects include potential damage to adjacent structures such as optic chiasm, vasculature and hypothalamus. Following limited surgery and radiation therapy the incidence of endocrine deficits is significantly lower compared to radical surgery, as is the risk of neurovascular and hypothalamic injury. Optic neuropathy and brain necrosis are rare in modern radiation therapy series. Second malignant neoplasms, although rare, can occur. In children with recurrent craniopharyngiomas following radical surgery, the recommended salvage treatment is radiation therapy, as further surgical attempts at salvage are associated with high relapse rates and increased morbidity and mortality. There have been significant technological advances in the field of radiation treatment planning and delivery that have great potential for reducing the incidence of long-term irradiation sequelae in the developing brain. The general availability of megavoltage linear accelerators and modern radiotherapy innovations such as three-dimensional conformal radiation treatment (3D CRT), stereotactic radiosurgery (SRS), stereotactic radiotherapy (SRT), and intensity modulated radiation therapy (IMRT) should further limit the rate of complications and improve cure rates in children with primary or recurrent craniopharyngioma.

Early adjuvant radiotherapy toward long-term survival and better quality of life for craniopharyngiomas--a study in single institute

OBJECTIVES

The objective of the study is to compare survival and quality of life (QoL) by the delivery time of adjuvant radiotherapy (RT), early or late, for craniopharyngiomas.

METHODS AND MATERIALS

Fifty patients received RT between 1985 and 2002. Early RT (n=25) was delivered within 3 months after initial surgery, whereas late RT (n=25) was combined with or without reoperation after progression or relapse. Radiation dose ranged from 45 to 55.8 Gy with a median of 54 Gy. The median follow-up was 130 months.

RESULTS

Progression-free survival rates at 5 and 10 years were 95.9 and 91.2%, respectively. The overall or progression-free survival was not influenced by RT time. Initial tumor size was the only prognostic factor (p=0.034) for progression-free survival in univariate analysis. Better visual acuity or field was maintained, and diabetes insipidus was partly improved with early RT, but all were deteriorated as tumor progressed without early RT. Visual functions were not worsened after late RT.

CONCLUSIONS

The survival was excellent with adjuvant RT, early or late. Poor QoL with late RT resulted from relapsed tumor and repeated surgery but was not associated with RT itself. Thus, early RT with precision technique is highly recommended for better QoL and excellent survival, unless contraindicated.

Craniopharyngiomas of childhood: the CHLA experience

OBJECTIVE

To improve the outcome of children with craniopharyngiomas by analyzing how they were treated.

METHODS

The records of patients who underwent operation at Childrens Hospital of Los Angeles (CHLA) from 1993 to 2004 were reviewed.

RESULTS

Identified were 19 girls and 16 boys with an age range from 9 days to 16 years (mean 7 years, mode 3 years). Tumor control was achieved in 34 of 35 patients and was accomplished with reasonable outcome in terms of neurological deficits and overall level of function. In 25 patients, complete tumor resection was obtained with surgery alone, 18 with the first resection, and 7 with repeat operative intervention. Nine children received radiation therapy after the first or second recurrence. On retrospective review, there were no consistently identifiable features that would lead one to determine preoperatively which tumors would fall into a given category.

CONCLUSION

We believe that the surgeon must determine a preoperative plan that maximizes the chance for a gross total removal of the craniopharyngioma. The biggest challenge intraoperatively is to determine whether to continue with the attempt at gross total removal or stop short of that goal before producing a significant irreversible neurological deficit. A staged removal using different operative corridors also needs to be considered.

Craniopharyngioma in children: Marseille experience

OBJECTIVES

The management of craniopharyngioma in children represents a challenging problem. If radical excision is recommended by many authors as the initial treatment, in some cases, particularly in recurrent tumours, other methods (gamma knife surgery and intracystic bleomycin) can be very useful. Even if craniopharyngioma is a benign tumour, recurrences are frequent, and the aim of our study was to analyse our results, to try to determine some prognostic factors of recurrences and to discuss about a new strategy concerning the initial management of these tumours.

METHODS

Forty-seven children with craniopharyngioma were treated in the Department of Pediatric Neurosurgery. All of the patients, but five children treated by intracystic bleomycin, underwent a surgical resection of the tumour as initial treatment with the goal of achieving gross total removal (GTR) of the tumour. Two children had radiotherapy and gamma knife treatment, respectively, following surgery for a tumoural residue. All the children had a magnetic resonance imaging (MRI) study 3 months after surgery to evaluate the results of the initial treatment. Using statistical analysis, some prognostic factors (age, sex, location, aspect, size of the tumour and result of the first MRI) have been studied.

RESULTS

Forty-two children were operated on, but one died in the immediate postoperative period from a major stroke due to carotid spasm. GTR, defined as the absence of residue on the first MRI control, was achieved in 27 children (65.8%), but 7 patients (25.9%) presented recurrence. Subtotal removal (STR) was obtained in 14 children (34.2%), but 9 patients (64.3%) developed a recurrence defined as the growth of the residual tumour with or without clinical symptoms. Five children having a small- or moderate-size cystic craniopharyngioma were treated using one-stage (three cases) or two-stage (two cases) intracystic bleomycin and any presented recurrence. All the prognostic factors studied, except one (presence of a residue on the first MRI control), do not have a statistical significance.

CONCLUSION

Craniopharyngioma in children remains a formidable tumour, and regardless of whatever progress made in their management, the incidence of recurrences is still elevated and severe sequelae can be observed. There are no prognostic factors among those studied concerning the recurrences of these tumours except the quality of the exeresis confirmed by the first postoperative MRI.