Long-term neurological, visual, and endocrine outcomes following transnasal resection of craniopharyngioma

Advances in the treatment of Adamantinomatous craniopharyngioma: How to balance tumor control and quality of life in the current environment: a narrative review

Adamantinomatous craniopharyngioma (ACP) presents a significant challenge to neurosurgeons despite its benign histology due to its aggressive behavior and unique growth patterns. This narrative review explores the evolving landscape of ACP treatments and their efficacy, highlighting the continuous development in therapeutic approaches in recent years. Traditionally, complete resection was the primary treatment for ACP, but surgical -related morbidity have led to a shift. The invasive nature of the finger-like protrusions in the histological structure results in a higher recurrence rate for ACP compared to papillary craniopharyngioma (PCP), even after complete macroscopic resection. Given this, combining subtotal resection with adjuvant radiotherapy has shown potential for achieving similar tumor control rates and potentially positive endocrine effects. Simultaneously, adjuvant treatments (such as radiotherapy, intracystic treatment, and catheter implantation) following limited surgery offer alternative approaches for sustained disease control while minimizing morbidity and alleviating clinical symptoms. Additionally, advances in understanding the molecular pathways of ACP have paved the way for targeted drugs, showing promise for therapy. There is a diversity of treatment models for ACP, and determining the optimal approach remains a subject of ongoing debate in the present context. In order to achieve a good-term quality of life (QOL), the main goal of the cyst disappearance or reduction of surgical treatment is still the main. Additionally, there should be a greater emphasis on personalized treatment at this particular stage and the consideration of ACP as a potentially chronic neurosurgical condition. This review navigates the evolving landscape of ACP therapies, fostering ongoing discussions in this complex field.

Shifting Strategies in the Treatment of Pediatric Craniopharyngioma

PURPOSE OF REVIEW

Craniopharyngiomas represent one of the most challenging diseases to treat. Despite their benign histology, and after many decades of surgical experience and technological advancements, there is still no clear consensus regarding the most effective management for this tumor. Due to their location and aggressive local characteristics, purely surgical approaches all too often result in unacceptable morbidity.

RECENT FINDINGS

Partial resection combined with radiation therapy results in similar control rates when compared to aggressive surgery, while also minimalizing the neuro-endocrinological morbidity. In this manuscript, we describe the historical progression of the shifting strategies in the management of pediatric craniopharyngioma. Time has also altered our expectations for outcomes, evolving from purely morbidity and mortality to simple Glasgow Outcomes Scales, now to formal neuro-psychometric and quality of life data.

National UK guidelines for the management of paediatric craniopharyngioma

Although rare, craniopharyngiomas constitute up to 80% of tumours in the hypothalamic-pituitary region in childhood. Despite being benign, the close proximity of these tumours to the visual pathways, hypothalamus, and pituitary gland means that both treatment of the tumour and the tumour itself can cause pronounced long-term neuroendocrine morbidity against a background of high overall survival. To date, the optimal management strategy for these tumours remains undefined, with practice varying between centres. In light of these discrepancies, as part of a national endeavour to create evidence-based and consensus-based guidance for the management of rare paediatric endocrine tumours in the UK, we aimed to develop guidelines, which are presented in this Review. These guidelines were developed under the auspices of the UK Children's Cancer and Leukaemia Group and the British Society for Paediatric Endocrinology and Diabetes, with the oversight and endorsement of the Royal College of Paediatrics and Child Health using Appraisal of Guidelines for Research & Evaluation II methodology to standardise care for children and young people with craniopharyngiomas.

Endoscopic endonasal transsphenoidal approach for craniopharyngioma: A case report

Thanks to the rapid development and progress of endoscopic technology, the endoscopic endonasal transsphenoidal approach has become one of the best surgical methods for resection of sellar and suprasellar tumors. The craniopharyngioma is usually located in the sellar region or suprasellar region, which is suitable for resection through the endoscopic endonasal transsphenoidal approach. The present report describes 21 cases of craniopharyngioma treated by endoscopic endonasal transsphenoidal approach in the Department of Neurosurgery at the Chongqing General Hospital from February 2014 to September 2019. The characteristics of patients and tumors, including clinical symptoms, preoperative magnetic resonance imaging, intraoperative conditions, as well as postoperative and follow-up outcomes were evaluated. The main clinical symptoms were headache in 15 cases, visual deficiency in 13 cases and growth retardation in two cases. All 21 patients with craniopharyngioma underwent endoscopic endonasal transsphenoidal surgery. Of these, 20 patients achieved gross total resection and one case achieved subtotal resection. After surgery, headache symptoms improved in 11 patients without deterioration and the vision of 11 patients improved without deterioration. The primary postoperative complications were pituitary deficiency in eight cases and permanent diabetes insipidus in five cases. The patients were followed up from one to 52 months post-operation. There was no recurrence in all patients during the follow-up period. The endoscopic endonasal transsphenoidal approach is a safe and effective resection for craniopharyngioma. Moreover, the endoscopic endonasal trans-sphenoidal approach is one of the preferred surgical methods for treatment of sellar or suprasellar tumor.

Endoscopic Endonasal Transsphenoidal Surgery for Recurrent Craniopharyngiomas

Object

Although revision surgery for recurrent craniopharyngiomas is more challenging than primary surgery and often accompanies a higher risk of death and complications, endoscopic endonasal transsphenoidal surgery (EETS) is sometimes still an effective and reliable treatment option. In this study, we introduced the surgical outcomes of EETS for recurrent craniopharyngiomas and summarized the surgical experiences.

Methods

Between 2014 and 2018, 28 patients with recurrent craniopharyngiomas underwent 29 EETS in our department. We regarded the patient undergoing two EETS as two independent patients in statistical analysis. Of the 29 patients, 16 had undergone 1 previous surgery, 10 had undergone 2 previous surgeries, and the remaining 3 patients had undergone 3 surgeries. The extent of resection, visual and endocrine outcomes, and complications of all the patients were collected and analyzed.

Results

Gross total resection was accomplished in 16 patients (55.17%), subtotal resection in 11 patients (37.93%), and partial resection in 2 patients (6.9%). Among the 22 patients with preoperative visual acuity and visual field impairment, some degree of vision improvement was observed in 18 patients, 3 patients were without visual change, and perpetual deterioration of vision occurred in one patient. The remaining six patients had normal vision before and after surgery. Postoperative endocrine tests showed that, among five patients with normal preoperative pituitary hormone function, only one patient still had normal pituitary hormone function and the other four patients had one or more hypothalamic-pituitary axes involved. None of the patients with preoperative endocrine dysfunction had endocrine function improved. Diabetes insipidus was observed in six new cases postoperatively. Cerebrospinal fluid (CSF) leakage occurred in 1 patient. One patient had bacterial meningitis, which was cured with antibiotics and a lumbar drain. No serious morbidity and mortality occurred in all patients.

Conclusions

For recurrent craniopharyngiomas, a personalized treatment plan should be developed according to the tumor characteristics and the patient's situation. There is no omnipotent method to be used for all patients. The EETS still is a safe and effective way to treat recurrent craniopharyngiomas in appropriate patients.

Comparison between extended transsphenoidal and transcranial surgery for craniopharyngioma: focus on hypothalamic function and obesity

PURPOSE

Patients suffering from craniopharyngiomas currently have good survival rates, but long-term sequelae, such as development of obesity, worsen their quality of life. Optimal treatment is still controversial and changed during the decades, becoming less aggressive. Transcranial (TC) surgery was the first approach to be used, followed by extended transsphenoidal (eTNS) access. This study aims to compare the two approaches in terms of risk of hypothalamic damage leading to obesity.

METHODS

This is a monocentric retrospective analysis of post-puberal patients treated for primary craniopharyngioma. Postoperative obesity and percentual postsurgical BMI variation were considered proxy for hypothalamic function and used to fit regression models with basal BMI, type of surgery, tumor volume and hypothalamic involvement (anterior vs. anteroposterior).

RESULTS

No difference in radicality was observed between the two approaches; eTNS was more effective in ameliorating visual function but was significantly associated with CSF leaks. The TC approach was associated with a higher incidence of diabetes insipidus. Regression analysis showed only tumor volume and basal BMI resulted as independent predictors for both postoperative obesity (respectively, OR 1.15, P = 0.041, and OR 1.57, P < 0.001) and percentual BMI variation (respectively, + 0.92%, P = 0.005, and - 1.49%, P = 0.001).

CONCLUSIONS

Larger lesions portend a higher risk to develop postoperative obesity, independently of hypothalamic involvement. Interestingly, basal BMI is independent of lesional volume and is associated with postoperative obesity, but lesser postoperative BMI variation. The surgical approach does not influence the obesity risk. However, eTNS proves valid in managing large tumors with important hypothalamic invasion.

Endocrine Disorder in Patients With Craniopharyngioma

Craniopharyngioma is an intracranial congenital epithelial tumor growing along the pathway of the embryonic craniopharyngeal tube. The main clinical symptoms of patients with craniopharyngioma include high intracranial pressure, visual field defect, endocrine dysfunction, and hypothalamic dysfunction. At present, the preferred treatment remains the surgical treatment, but the recovery of endocrine and hypothalamic function following surgery is limited. In addition, endocrine disorders often emerge following surgery, which seriously reduces the quality of life of patients after operation. So far, research on craniopharyngioma focuses on ways to ameliorate endocrine dysfunction. This article reviews the latest research progress on pathogenesis, manifestation, significance, and treatment of endocrine disorders in patients with craniopharyngioma.

Neuroendoscopic Transventricular Approach for Cystic Craniopharyngioma

The literature is rich with many studies reporting different treatment modalities and approaches for cystic craniopharyngioma (CC), including microsurgery, neuroendoscopic transventricular approach, endoscopic transnasal surgery, stereotactic drainage, and Ommaya reservoir insertion. The goals of this manuscript are to report the successful treatment of an atypical case of CC using the neuroendoscopic transventricular approach (NTVA) as well as discuss the different surgical modalities for these tumors following a comprehensive review of the literature. Our patient is a nine-year-old female with a large CC who was managed using the NTVA. No complications or recurrence occurred over two years of follow-up. Results of our literature review showed lower recurrence and complication rates of the NTVA compared to other surgical modalities.The NTVA is potentially efficient, reliable, and safe for managing CC and cystic-dominant craniopharyngiomas, with low recurrence and complication rates compared to microsurgery and Ommaya reservoir insertion. Future randomized clinical studies comparing the various treatment modalities of CC are needed to solidify these conclusions.

Nomograms for Predicting Overall Survival Among Patients with Craniopharyngiomas at Initial Diagnosis: A SEER Population-Based Analysis

Background

Craniopharyngiomas (CPs) are relatively rare benign tumor located in the central nervous system (CNS). This study investigates the related risk factors of survival of craniopharyngiomas and develops a simple but detailed method predicting prognosis based on the Surveillance, Epidemiology, and End Results (SEER) database in order to improve the clinic management of CPs.

Methods

Between 2004 and 2017, 1213 patients diagnosed with craniopharyngiomas registered at the program and were included in the SEER-21 registry database. Overall survival (OS) curves were plotted with the Kaplan–Meier method and significance was determined by Log rank test. Single- and multiple-factor regression analyses were made using Cox proportional hazards model to identify independent predictors related to OS. Subsequently, we developed a nomogram with those factors to predict 3-, 5- and 10-year OS of craniopharyngiomas patients.

Results

We identified 1213 patients with craniopharyngioma. The OS rates at 3, 5, and 10 years after diagnosis were 89.1%, 86.2%, and 83%. Age, ethnicity, tumor size and radiation therapy were confirmed to be predictors correlating with OS at initial diagnosis. In multivariate analysis, we found that younger age (P<0.001), smaller tumor size (P<0.001), white ethnicity (P<0.001) and radiation therapy (P=0.004) were the factors that remained significantly associated with better survival. A nomogram was successfully constructed and validated by ROC, calibration plots and C-index of 0.773 (95% CI, 0.708–0.838).

Conclusion

The well-calibrated nomogram is the first clinical prediction model for predicting the prognosis for patients with craniopharyngiomas at initial diagnosis. Our study indicates that the surgical effect is not clear. Younger white patients with radiotherapy have a better prognosis, and the gross total resection (GTR) was not effective in prolonging the OS of a patient compared to no surgery and subtotal resection (STR).

Endoscopic endonasal approach for craniopharyngiomas

The operative management of craniopharyngiomas has evolved over the last two decades. Traditional transcranial microsurgical approaches were the only option until the advent of the endoscopic endonasal approach. It has given surgeons the ability to tackle a challenging entity from a new perspective with comparable if not superior results. In this review we outline the advancements in endoscopic endonasal approach for craniopharyngiomas, address controversies and review the current literature.

Diabetes insipidus secondary to sellar/parasellar lesions

Diabetes insipidus (DI) is a well-recognised transient or permanent complication following transsphenoidal surgery for pituitary adenomas or other sellar/parasellar lesions. However, data regarding the prevalence of pre-operative DI in sellar/parasellar lesions other than pituitary adenomas are scarce. We systematically reviewed the existing data for defining the prevalence of DI before any treatment in adult patients with sellar/parasellar lesions, excluding pituitary adenomas and metastatic lesions. In total, 646 patients with sellar/parasellar lesions presenting with DI at diagnosis were identified. The most common pathologies of sellar/parasellar lesions presenting with DI at diagnosis were lymphocytic hypophysitis (26.5%), craniopharyngiomas (23.4%), Langerhans's cell histiocytosis (18.9%) and Rathke's cleft cyst (12.7%), accounting for the vast majority (more than 80%) of these lesions. Overall, DI at diagnosis was found in 23.4% of all patients with sellar/parasellar lesions, albeit with a wide range from 10.6% to 76.7%, depending on the nature of the pathology. The highest prevalence of DI was found in less commonly encountered lesions namely germ-cell tumours (76.7%), abscesses (55.4%) and neurosarcoidosis (54.5%), each accounting for less than 3% of all sellar/parasellar lesions. Most DI cases (68.8%) were associated with anterior pituitary hormonal deficiencies, in contrast to pituitary adenomas that rarely present with DI. The enlargement and enhancement of the pituitary stalk were the most common findings on magnetic resonance imaging besides the loss of the high signal of the posterior pituitary on T1-weighted images. Resolution of DI spontaneously or following systemic and surgical management occurred in 22.4% of cases. Post-operative DI, not evident before surgery, was found in 27.8% of non-adenomatous sellar/parasellar lesions, and was transient in 11.6% of them. Besides distinctive imaging features and symptoms, early recognition of DI in such lesions is important because it directs the diagnosis towards a non-adenomatous sellar/parasellar tumour and the early initiation of appropriate treatment.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Gross Total Versus Subtotal Surgical Resection in the Management of Craniopharyngiomas

Craniopharyngiomas (CP) are suprasellar tumors that can grow into vital nearby structures and thus cause significant visual, endocrine, and hypothalamic dysfunction. Debate persists as to the optimal treatment strategy for these benign lesions, particularly with regards to the extent of surgical resection. The goals of tumor resection are to eliminate the compressive effect of the tumor on surrounding structures and minimize recurrence. It remains unclear whether a gross total resection (GTR) or subtotal resection (STR) with adjuvant therapy confers a better prognosis. Chemotherapy and radiation therapy (RT) have been explored as both neoadjuvant and adjuvant treatments to decrease tumor burden and prevent recurrence. The objective of this paper is to review the risks and benefits of GTR versus STR, specifically with regard to risk of recurrence and postoperative morbidity. Aggregated data suggest that STR monotherapy is associated with higher rates of recurrence relative to GTR (50.6% ± 22.1% vs 20.2% ± 13.5%), while STR combined with RT leads to recurrence rates similar to GTR. However, both GTR and RT are independently associated with higher rates of comorbidities including panhypopituitarism, diabetes insipidus, and visual deficits. The treatment strategy for CPs should ultimately be tailored to each patient's individual tumor characteristics, risk, symptoms, and therapeutic goals.

Recurrent Urinary Tract Infection in Craniopharyngioma: A Harbinger to a Sinister Diagnosis!

Craniopharyngiomas are benign tumors of neuroepithelial origin, believed to arise from remnants of Rathke’s pouch. Their proximity to vital structures of the visual pathway and hypothalamus leads to both neurological and endocrinological complications. Endocrinal complications are seen in 40%–87% of the affected and can develop at presentation or post-surgery and radiotherapy. Central diabetes insipidus (CDI) is a common endocrinopathy associated with craniopharyngioma, but rarely a presenting symptom before or after surgery. CDI most commonly presents with polyuria and polydipsia. Here, we report a postoperative child with craniopharyngioma where recurrent urinary tract infection and hydronephrosis were initial clues to diagnose CDI.

Approach selection and outcomes of craniopharyngioma resection: a single-institute study

Since there are many approaches for successful craniopharyngioma resection, how to choose a suitable approach remains problematic. The aim of this study was to summarize experience of approach selection and outcomes of craniopharyngioma resection in our institute. The data of 182 primary craniopharyngiomas between January 2013 and June 2019 were retrospectively reviewed. Craniopharyngiomas were classified into intrasellar, intra-suprasellar, suprasellar, and intra-third ventricle types based on the location. The surgical approaches, extent of resection, endocrine and ophthalmological outcomes, and complications were evaluated. Gross total resection (GTR) was achieved in 158 (86.8%) patients, near-total resection (NTR) in 20 (11%), and partial resection (PR) in 4 (2.2%). New-onset hypopituitarism occurred in 90 (49.5%) and new-onset diabetes insipidus in 48 (26.4%). Visual function was improved in 110 of the 182 patients, unchanged in 52, and deteriorated in 20. For intra-suprasellar and suprasellar tumors, patients in the endoscopic endonasal approach (EEA) group had higher GTR rate, lower incidence of new-onset hypopituitarism, and better visual outcome than patients in transcranial approach group, but no significant difference in the incidence of new-onset diabetes insipidus was found. There were no surgery-related deaths, and the common complications included permanent oculomotor nerve palsy, hemorrhage, and cerebrospinal fluid leaks. During the follow-up period, tumor recurrence or regrowth occurred in 6.6% of the cases. Tumor location is key for choosing an optimal surgical approach for craniopharyngioma resection. The EEA should be considered as the first choice for intra-suprasellar and suprasellar craniopharyngiomas to achieve better visual outcomes and fewer pituitary hormonal disorders.

Craniopharyngioma treatment: an updated summary of important clinicopathological concepts

INTRODUCTION

Craniopharyngiomas (CPs) are benign histological tumors that may develop at different positions along the hypothalamic-pituitary axis. Their close, heterogenous relationship to the hypothalamus makes surgical removal challenging even though this remains the primary treatment strategy.

AREAS COVERED

This article presents a critical overview of the pathological and clinical concepts regarding CPs that should be considered when planning treatment. Thus, we have performed a comprehensive review of detailed CP reports published between 1839 and 2020.

EXPERT OPINION

CP surgery should pursue maximal tumor resection while minimizing the risk of injuring the hypothalamus. Therefore, surgical strategies should be individualized for each patient. Accurate assessment of presenting symptoms and preoperative MRI has proven useful to predict the type of CP-hypothalamus relationship that will be found during surgery. CPs with dense and extensive adhesions to the hypothalamus should be highly suspected when MRI shows the hypothalamus positioned around the mid-third of the tumor and an amputated upper portion of the pituitary stalk. Symptoms related to functional impairment of the infundibulo-tuberal area of the third ventricle floor, such as obesity/hyperphagia, Fröhlich's syndrome, diabetes insipidus, and/or somnolence, also indicate risky CP-hypothalamic adhesions. In these cases, limited tumor removal is strongly advocated followed by radiation therapy.

The endoscopic endonasal approach for pediatric craniopharyngiomas: the key lessons learned

PURPOSE

The aim of this study is to highlight the role of the endoscopic endonasal approach (EEA) in pediatric craniopharyngiomas by reviewing our experience and the key lessons learned from the application of this approach in children.

METHODS

Between 1998 and 2017, 12 pediatric craniopharyngiomas were treated via EEA at our institution. Demographic data, preoperative assessment, tumor features, surgical results, complications, and recurrences were analyzed.

RESULTS

Visual defects were the most frequent presenting sign. Seven craniopharyngiomas were infradiaphragmatic, and five were supradiaphragmatic. The EEA was successfully performed in all cases with no complication related to children's sinonasal anatomy. Gross total resection (GTR) rate was of 75%. Endocrinological disturbances improved in one case (20%) and worsened in three (60%). New onset of diabetes insipidus was observed in four (36%) children. Visual defect improved in 91% of cases, with no new postoperative deficit. Postoperative cerebrospinal fluid (CSF) leak occurred in one patient (8%). Three patients (27%) experienced tumor regrowth, and one craniopharyngioma recurred (mean follow-up, 78 months).

CONCLUSIONS

The EEA offers a straight route to the sellar-suprasellar, making it the ideal approach for pediatric infradiaphragmatic craniopharyngiomas. In supradiaphragmatic craniopharyngiomas, the extended EEA provides a clearer and close-up visualization of the tumor-hypothalamus interface, which can grant better results in terms of quality of life. The pediatric skull base anatomy should not represent a contraindication for the endoscopic technique. Larger series encompassing a wider spectrum of pediatric craniopharyngiomas are needed to further support the benefits of this surgical approach.

Pediatric craniopharyngioma

BACKGROUND

Craniopharyngioma has historically been recognized to be a formidable pathology primarily due to its proximity to critical neurovascular structures and the challenging surgical corridors that surgeons have tried to reach this lesion.

FOCUS OF REVIEW

In this work, we review the medical and surgical management of these tumors with a focus on clinical presentation, diagnostic identification, surgical approach, and associated adjuvant therapies. We will also discuss our current treatment paradigm using endoscopic, open, and combined approaches to craniopharyngiomas. The management of craniopharyngiomas requires a multidisciplinary team of surgeons, endocrinologists, and neuroanesthesiologists as well as neurocritical care specialists to deliver the most comprehensive and safest surgical resection with minimal postoperative morbidity.

Outcomes following endoscopic endonasal resection of sellar and supresellar lesions in pediatric patients

PURPOSE

The endoscopic endonasal approach (EEA) is a credible surgical alternative for the resection of sellar and suprasellar lesions such as pituitary adenomas, craniopharyngiomas, and Rathke cleft cysts. However, its application to pediatric patients poses several unique challenges that have not yet been well evaluated. The authors evaluate the safety, efficacy, and outcomes associated with the use of the EEA for treatment of these pathologic entities in pediatric patients.

METHODS

Retrospective review of 30 patients between the ages of two and 24 who underwent endoscopic endonasal resection of sellar or suprasellar lesions between January 2010 and December 2015. Endocrinological and ophthalmological outcomes, as well as extent of resection and complications were all evaluated.

RESULTS

Gross total resection was achieved in eight of the nine pituitary adenomas, nine of the 12 craniopharyngiomas, and six of the nine Rathke cleft cysts. Of the 30 patients, 22 remained disease free at last follow-up. A total of six patients developed hypopituitarism and five developed diabetes insipidus. Eleven patients experienced improved vision, sixteen experienced no change, and one patient experienced visual worsening. Postoperative cerebrospinal fluid leak was seen in a single case and later resolved, vasospasm/stroke was experienced by 10% of patients, and new obesity was recorded in 10% of patients. There were no perioperative deaths.

CONCLUSIONS

Endoscopic endonasal resection is a safe and effective surgical alternative for the management of sellar and suprasellar pathologies in pediatric populations with excellent outcomes, minimal complications, and a low risk of morbidity.

Craniopharyngioma: a roadmap for scientific translation

OBJECTIVE Craniopharyngiomas are among the most challenging of intracranial tumors to manage because of their pattern of growth, associated morbidities, and high recurrence rate. Complete resection on initial encounter can be curative, but it may be impeded by the risks posed by the involved neurovascular structures. Recurrent craniopharyngiomas, in turn, are frequently refractory to additional surgery and adjuvant radiation or chemotherapy. METHODS The authors conducted a review of primary literature. RESULTS Recent advances in the understanding of craniopharyngioma biology have illuminated potential oncogenic targets for pharmacotherapy. Specifically, distinct molecular profiles define two histological subtypes of craniopharyngioma: adamantinomatous and papillary. The discovery of overactive B-Raf signaling in the adult papillary subtype has led to reports of targeted inhibitors, with a growing acceptance for refractory cases. An expanding knowledge of the biological underpinnings of craniopharyngioma will continue to drive development of targeted therapies and immunotherapies that are personalized to the molecular signature of each individual tumor. CONCLUSIONS The rapid translation of genomic findings to medical therapies for recurrent craniopharyngiomas serves as a roadmap for other challenging neurooncological diseases.

A regional Australasian experience of extended endoscopic transsphenoidal surgery for craniopharyngioma: Progression of the mentoring model

Endoscopic endonasal transsphenoidal approaches to craniopharyngioma has become increasingly popular over the last 15 years. We present the results of our retrospective series of craniopharyngiomata resected by an endoscopic, endonasal approach at a low-volume service in Australasia. Between the years of 2009 and 2017, 11 patients underwent pure endoscopic endonasal transsphenoidal resection for a craniopharyngioma at our institutions. The medical records, histopathology, intraoperative findings and patient imaging were retrospectively assessed. 11 patients were included with 5 male and 6 female patients. The mean age was 32.0 years (range 14-68 years). Of this patient series a gross total resection of the tumour was achieved in 8 of 11 patients (73%). In the immediate postoperative phase, 10 of the 11 patients developed diabetes insipidus (91%). The pituitary stalk was formally not seen in 4 patients and all were treated with vasopressin. Of the 7 patients where the pituitary stalk was identified it was formally divided in 6 and preserved in 1 patient where the tumour was separate to the stalk. The endoscopic endonasal transsphenoidal approach for excision of craniopharyngioma, utilising and progressing the surgical mentoring model, can achieve adequate decompression of critical structures. Furthermore, our aggressive approach to divide and remove the involved pituitary stalk results in high rates of gross macroscopic resection with excellent long-term disease control with a greater risk of postoperative diabetes insipidus and panhypopituitarism.

The Role of Definitive Radiotherapy in Craniopharyngioma: A SEER Analysis

OBJECTIVE

Assess patterns of care in the management of craniopharyngioma, especially with respect to the use of radiation therapy (RT) alone (which has been understudied to date) as compared with gross total resection (GTR) and subtotal resection (STR) with adjuvant RT.

MATERIALS AND METHODS

The epidemiology, treatment modalities, and outcomes of patients with craniopharyngioma were studied using the Surveillance Epidemiology and End Results (SEER) database from 2004 to 2012. Survival was compared between treatment groups using Kaplan-Meier analysis and log-rank tests.

RESULTS

In total, 1218 patients with craniopharyngioma were identified, with equal distribution across sex. There were bimodal incidence peaks, one 20 years old or below, and the other between 40 and 65 years. The majority of pediatric tumors with known histology were adamantinomatous type, which did not influence outcomes when adjusting for age (P=0.392). Overall survival/cause-specific death for patients that underwent RT, STR+RT, and GTR were not statistically different (P>0.05). There was improved survival between several modalities: RT only versus STR only (P=0.024), RT only versus observation (P=0.006), STR+RT versus observation (P=0.046), and GTR versus observation (P=0.046). Patients above 65 years old were more likely to undergo observation (P=0.002), with highest proportions of surgery (54%)/RT (21%) in the pediatric population. Multivariable analysis demonstrated that though age was associated with overall survival (P<0.001), treatment modality (RT/GTR/STR+RT) was not (P=0.119).

CONCLUSIONS

Although management of craniopharyngioma remains somewhat controversial, there were no observed differences in outcomes between definitive RT, GTR, and STR+RT. Although these data are hypothesis-generating, additional data are needed to validate these findings.

Intraoperative Flash Visual Evoked Potential Recording and Relationship to Visual Outcome

OBJECTIVE

To determine the relationship between intraoperative flash visual evoked potential (FVEP) monitoring and visual function.

METHODS

Intraoperative FVEPs were recorded from electrodes placed in the scalp overlying the visual cortex (Oz) after flashing red light stimulation delivered by Cadwell LED stimulating goggles in 89 patients. Restrictive filtering (typically 10-100 Hz), optimal reject window settings, mastoid reference site, total intravenous anesthetic (TIVA), and stable retinal stimulation (ensured by concomitant electroretinogram [ERG] recording) were used to enhance FVEP reproducibility.

RESULTS

The relationship between FVEP amplitude change and visual outcome was determined from 179 eyes. One eye had a permanent intraoperative FVEP loss despite stable ERG, and this eye had new, severe postoperative visual dysfunction. Seven eyes had transient significant FVEP change (&gt;50% amplitude decrease that recovered by the end of surgery), but only one of those had a decrease in postoperative visual acuity. FVEP changes in all eight eyes (one permanent FVEP loss plus seven transient FVEP changes) were related to surgical manipulation. In each case the surgeon was promptly informed of the FVEP deterioration and took remedial action. The other eyes did not have FVEP changes, and none of those eyes had new postoperative visual deficits.

CONCLUSIONS

Our FVEP findings relate to visual outcome with a sensitivity and specificity of 1.0. New methods for rapidly acquiring reproducible FVEP waveforms allowed for timely reporting of significant FVEP change resulting in prompt surgical action. This may have accounted for the low postoperative visual deficit rate (1%) in this series.

Comparative evaluation of neuroendocrine dysfunction in children with craniopharyngiomas before and after mass effects are removed

Objective To compare the effects of mass effects in situ (MEIS) and after neurosurgery (ANS) on neuroendocrine function in children with craniopharyngioma. Methods We retrospectively investigated 185 cases of children with craniopharyngioma who underwent neurosurgical treatment at the Beijing Tiantan Hospital from 2011 to 2016. The neuroendocrine function of patients was compared before and after tumor removal. Results Compared with the MEIS, the incidence of growth hormone insulin-like growth factor 1 axis dysfunction (47.03% vs. 57.30%), pituitary-thyroid axis dysfunction (20.00% vs. 50.27%), pituitary-adrenal axis dysfunction (18.38% vs. 43.78%) and diabetes insipidus (26.49% vs. 44.86%) was significantly increased in the ANS status. The incidence of hyperprolactinemia significantly decreased from 28.11% in the MEIS status to 20.54% in the ANS status. Compared with the MEIS group, changes in appetite, development of diabetes insipidus, body temperature dysregulation, sleeping disorders, personality abnormalities and cognitive abnormalities were more frequent after ANS, yet no statistically significant differences were found. Conclusions Endocrine dysfunction is common in children with craniopharyngioma. Both MEIS and ANS can be harmful to neuroendocrine function, and neurosurgical treatment may increase the level of neuroendocrine dysfunction.

Trans-eyebrow supraorbital keyhole approach in suprasellar and third ventricular craniopharyngioma surgery: the experience of 27 cases and a literature review

BACKGROUND

The trans-eyebrow supraorbital keyhole approach, a minimal transcranial approach, has been widely used in different types of surgery for sellar and parasellar lesions. In this study, we investigated the outcome of this approach in the surgical treatment of suprasellar and third ventricular craniopharyngioma.

METHODS

Twenty-seven patients with suprasellar and third ventricular craniopharyngioma underwent surgery via a supraorbital approach between June 2007 and June 2018. The medical data and follow-up results were retrospectively analyzed.

RESULTS

All tumors were located in the suprasellar region and the third ventricle. The mean tumor size was 29.1 mm. The mean follow-up period was 49.6 months. Gross total resection (GTR) was achieved in 23 patients (85.2%). Of 17 patients with preoperative visual impairment, 12 patients (70.6%) showed improvement. Following surgery, 11 patients exhibited new-onset anterior hypopituitarism, ten developed diabetes insipidus, and two became overweight. One residual tumor relapsed 1 year after surgery. No perioperative death, cerebrospinal fluid (CSF) rhinorrhea, or meningitis occurred. All patients exhibited satisfactory cosmetic results. At the last follow-up, the Extended Glasgow Outcome Scale Score was 8 in 25 patients (92.6%).

CONCLUSION

The supraorbital trans-eyebrow keyhole approach is characterized by minimal invasion and a satisfactory cosmetic outcome. According to our experience, craniopharyngiomas located in the suprasellar region and the third ventricle can be safely resected via a trans-eyebrow supraorbital keyhole approach.

Advances in the management of craniopharyngioma

Craniopharyngioma is a curable benign tumor, but owing to its intimate relationship to critical structures in the central brain—such as the optic apparatus, pituitary, hypothalamus, intracranial vasculature, brain stem, and temporal lobes—its management introduces the risk of long-term treatment morbidity. Today, the most common treatment approach is conservative subtotal resection followed by radiotherapy, and the goal is to limit long-term toxicity. Many recent advances in the treatment of craniopharyngioma are attributable to improved surgical techniques and radiotherapy technologies.

Microsurgical treatment of craniopharyngioma: Experiences on 183 consecutive patients

This study aimed to summarize the clinical experiences and postoperative effects of microsurgical approaches for craniopharyngioma.A total of 183 craniopharyngioma patients who underwent microsurgical treatment since March 2009 to March 2015 in our hospital were included in current research. Surgical approaches were selected based on preoperative evaluations, including tumor locations, sizes, and growth patterns. Active measurements to manage water-electrolyte disorder and insipidus were taken for postoperative treatments. During the follow-up, patients were monitored for residual or recurrent tumor by postoperative contrast MRI scans done 1 to 3 months after surgery.The used surgical approaches were as follows: frontopterional approach (76 cases), anterior interhemispheric approach (58 cases), transcallosal approach (10 cases), transsphenoidal approach (15 cases), unilateral subfrontal approach (15 cases), and combined approaches (9 cases). Around 124 cases (72.7%) received total tumor resection, 37 patients (20.2%) underwent subtotal resection, and 13 patients (7.1%) underwent partial removal. No significant difference was found on the postoperative complications among the different microsurgical approaches (all, P > .05). A total of 111 cases had an intact pituitary stalk preservation and 26 cases had partially preserved stalks during surgery. Visual improvement was achieved in 54 patients and visual deterioration occurred in 22 cases. Postoperative insipidus appeared in 114 cases and water-electrolyte disorder occurred in 99 cases. The postsurgical follow-up ranged from 3 to 69 months with a mean duration of 27.3 months and 23 patients suffered recurrence.Based on careful preoperative evaluation, microsurgical treatments may be safe and effective approach to improve postoperative outcomes of craniopharyngioma patients.

Therapeutic outcomes of transsphenoidal surgery in pediatric patients with craniopharyngiomas: a single-center study

OBJECTIVE The aim of this study was to analyze the outcomes of transsphenoidal surgery (TSS) in a single-center clinical series of pediatric craniopharyngioma patients treated with gross-total resection (GTR). METHODS The authors retrospectively reviewed the surgical outcomes for 65 consecutive patients with childhood craniopharyngiomas (28 girls and 37 boys, mean age 9.6 years) treated with TSS (45 primary and 20 repeat surgeries) between 1990 and 2015. Tumors were classified as subdiaphragmatic or supradiaphragmatic. Demographic and clinical characteristics, including extent of resection, complications, incidence of recurrence, pre- and postoperative visual disturbance, pituitary function, and incidence of diabetes insipidus (DI), as well as new-onset obesity, were analyzed and compared between the primary surgery and repeat surgery groups. RESULTS Of the 45 patients in the primary surgery group, 26 (58%) had subdiaphragmatic tumors and 19 had supradiaphragmatic tumors. Of the 20 patients in the repeat surgery group, 9 (45%) had subdiaphragmatic tumors and 11 had supradiaphragmatic tumors. The only statistically significant difference between the 2 surgical groups was in tumor size; tumors were larger (mean maximum diameter 30 mm) in the primary surgery group than in the repeat surgery group (25 mm) (p = 0.008). GTR was accomplished in 59 (91%) of the 65 cases; the GTR rate was higher in the primary surgery group than in the repeat surgery group (98% vs 75%, p = 0.009). Among the patients who underwent GTR, 12% experienced tumor recurrence, with a median follow-up of 7.8 years, and recurrence tended to occur less frequently in primary than in repeat surgery patients (7% vs 27%, p = 0.06). Of the 45 primary surgery patients, 80% had deteriorated pituitary function and 83% developed DI, whereas 100% of the repeat surgery patients developed these conditions. Among patients with preoperative visual disturbance, vision improved in 62% but worsened in 11%. Visual improvement was more frequent in primary than in repeat surgery patients (71% vs 47%, p < 0.001), whereas visual deterioration was less frequent following primary surgery than repeat surgery (4% vs 24%, p = 0.04). Among the 57 patients without preoperative obesity, new-onset postoperative obesity was found in 9% of primary surgery patients and 21% of repeat surgery patients (p = 0.34) despite aggressive resection, suggesting that hypothalamic dysfunction was rarely associated with GTR by TSS in this series. However, obesity was found in 25% of the repeat surgery patients preoperatively due to prior transcranial surgery. Although there were no perioperative deaths, there were complications in 12 cases (18%) (6 cases of CSF leaks, 3 cases of meningitis, 2 cases of transient memory disturbance, and 1 case of hydrocephalus). Postoperative CSF leakage appeared to be more common in repeat than in primary surgery patients (20% vs 4.4%, p = 0.2). CONCLUSIONS The results of TSS for pediatric craniopharyngioma in this case series suggest that GTR should be the goal for the first surgical attempt. GTR should be achievable without serious complications, although most patients require postoperative hormonal replacement. When GTR is not possible or tumor recurrence occurs after GTR, radiosurgery is recommended to prevent tumor regrowth or progression.

Extended endoscopic endonasal approach for recurrent or residual symptomatic craniopharyngiomas

OBJECTIVES

Removal of recurrent or residual symptomatic craniopharyngiomas is more challenging than the primary surgery. The extended endoscopic endonasal (EEE) approach has been proposed an alternative surgical route for removal of various suprasellar tumors including craniopharyngiomas currently. In this study, we summarized the operative experience and described the feasibility and advantages of this technique in recurrent or residual symptomatic craniopharyngiomas.

PATIENTS AND METHODS

A retrospective review of 15 patients (9 males and 6 females) whom underwent EEE approach between April 2012 and February 2017, were included in this study. The lesions included 8 purely suprasellar craniopharyngiomas (2 extraventricular, 6 intraextraventricular), 3 both intra- and suprasellar craniopharyngiomas, and 4 intrasellar craniopharyngiomas. The mean preoperative (that is, EEE approach) tumor volume was 10.54 cm³. The mean follow-up period was 23.1 months (range, 8-54). All patients were analyzed in terms of the treatment effect, complictions and follow-up results.

RESULTS

Total removal of tumors was achieved in 12 patients (80.0%) and subtotal removal in 3 cases (20.0%). The pituitary stalks were identified in 11 patients during operations and secured in 8 patients. Postoperative visual acuity was improved in 10 cases, and normalization of the impairment was achieved in 3 patients. There were no significant differences between pre and postoperative endocrine function, except in one patient with normal preoperative pituitary hormone function who suffered postoperative hypopituitarism. Postoperative diabetes insipidus (DI) occurred in 14 patients including 6 patients who had long-term DI and others reporting transient postoperative DI. No cerebrospinal fluid (CSF) leak was identified. There were no deaths or major complications. Obesity developed in 2 patients, with no deaths and recurrent cases during follow-up period.

CONCLUSION

The pure EEE approach is a safe, effective alternative for treatment of recurrent or residual symptomatic craniopharyngiomas owing to its advantages including wide-angle view, close observation and elimination of brain retraction. Larger studies with further follow-up is needed to assess the long-term efficacy of this minimal access approach.

Suprasellar and recurrent pediatric craniopharyngiomas: expanding indications for the extended endoscopic transsphenoidal approach

OBJECTIVE The expanded endonasal endoscopic transsphenoidal approach has become increasingly used for craniopharyngioma surgery in the pediatric population, but questions still persist regarding its utility in younger children, in recurrent and irradiated tumors, and in masses primarily located in the suprasellar region. The narrow corridor, incomplete pneumatization, and fear of hypothalamic injury have traditionally relegated this approach to application in older children with mostly cystic craniopharyngiomas centered in the sella. The authors present a series of consecutive pediatric patients in whom the endonasal endoscopic approach was used to remove craniopharyngiomas from patients of varied ages, regardless of the location of the tumor and previous treatments or surgeries, to ascertain if the traditional concerns about limitations of this approach are worth reevaluating METHODS Eleven consecutive pediatric patients (age ≤ 18 years) underwent surgery via an endoscopic transsphenoidal approach at NewYork-Presbyterian/Weill Cornell Medical Center from 2007 to 2016. The authors recorded the location, consistency, and size of the lesion, assessed for hypothalamic invasion radiographically, calculated skull base measurements, and assessed parameters such as extent of resection, visual function, endocrinological function, weight gain, and return-to-school status. RESULTS The average age at the time of surgery was 7.9 years (range 4-17 years) and the tumor sizes ranged from 1.3 to 41.7 cm³. Five cases were purely suprasellar, 5 had solid components, 4 were reoperations, and 5 had a conchal sphenoid aeration. Nevertheless, gross-total resection was achieved in 45% of the patients and 50% of those in whom it was the goal of surgery, without any correlation with the location, tumor consistency, or the age of the patient. Near-total resection, subtotal resection, or biopsy was performed intentionally in the remaining patients to avoid hypothalamic injury. Anterior pituitary dysfunction occurred in 81.8% of the patients, and 63.3% developed diabetes insipidus . Two patients (18%) had a greater than 9% increase in body mass index. Visual function was stable or improved in 73%. All children returned to an academic environment, with 10 of them in the grade appropriate for their age. There was a single case of each of the following: CSF leak, loss of vision unilaterally, and abscess. CONCLUSIONS The endoscopic transsphenoidal approach is suitable for removing pediatric craniopharyngiomas even in young children with suprasellar tumors, conchal sphenoid sinus, recurrent tumors, and tumors with solid components. The extent of resection is dictated by intrinsic hypothalamic tumor invasiveness rather than the approach. The endoscopic transsphenoidal approach affords the ability to directly inspect the hypothalamus to determine invasion, which may help spare the patient from hypothalamic injury. Irrespective of approach, the rates of postoperative endocrinopathy remain high and the learning curve for the approach to a relatively rare tumor is steep.

Adult Craniopharyngioma: Case Series, Systematic Review, and Meta-Analysis

BACKGROUND

The optimal therapeutic approach for adult craniopharyngioma remains controversial. Some advocate for gross total resection (GTR), while others advocate for subtotal resection followed by adjuvant radiotherapy (STR + XRT).

OBJECTIVE

To conduct a systematic review and meta-analysis assessing the rate of recurrence in the follow-up of 3 yr in adult craniopharyngioma stratified by extent of resection and presence of adjuvant radiotherapy.

METHODS

MEDLINE (1946-July 1, 2016) and EMBASE (1980-June 30, 2016) were systematically reviewed. From1975 to 2013, 33 patients were treated with initial surgical resection for adult onset craniopharyngioma at our center and were reviewed for inclusion in this study.

RESULTS

Data from 22 patients were available for inclusion as a case series in the systematic review. Eligible studies (n = 21) were identified from the literature in addition to a case series of our institutional experience. Three groups were available for analysis: GTR, STR + XRT, and STR. The rates of recurrence were 17%, 27%, and 45%, respectively. The risk of developing recurrence was significant for GTR vs STR (odds ratio [OR]: 0.24, 95% confidence interval [CI]: 0.15-0.38) and STR + XRT vs STR (OR: 0.20, 95% CI: 0.10-0.41). Risk of recurrence after GTR vs STR + XRT did not reach significance (OR: 0.63, 95% CI: 0.33-1.24, P = .18).

CONCLUSION

This is the first and largest systematic review focusing on the rate of recurrence in adult craniopharyngioma. Although the rates of recurrence are favoring GTR, difference in risk of recurrence did not reach significance. This study provides guidance to clinicians and directions for future research with the need to stratify outcomes per treatment modalities.

A reformed surgical treatment modality for children with giant cystic craniopharyngioma

OBJECTIVE

Surgical removal plays an important role in treating children's craniopharyngioma. For a safe and minimally invasive craniotomy, a reformed surgical modality was proposed in this paper by combining the insertion of an Ommaya reservoir system (ORS) by stereotactic puncture, aspiration of cystic fluid in 2-day interval for consecutive 7-10 days, and the delayed tumor resection.

PATIENTS AND METHODS

Eleven patients (aged from 5 to 9 years old) with giant cystic craniopharyngiomas who had undergone the reformed surgical modality during November 2014 and December 2015 were collected as group A. In contrast, seven patients (aged from 5 to 11 years old) who had undergone the traditional directed operation without any prior management from January 2014 to October 2014 were collected into group B. A retrospective analysis was performed for both groups at one institution. The preoperative and postoperative clinical presentations, neuroimaging, early postoperative outcome, and the surgery-related complications of both groups were reviewed.

RESULTS

For group A, the mean value of the maximum tumor diameters shank from 52.36 to 23.82 mm after implementing aspiration of the cystic fluid in 1-day interval for consecutive 8.23 days. Eight patients (72.73%) in group A underwent a gross total resection (GTR), while two (28.57%) patients underwent GTR in group B. The postoperative electrolyte disturbance rate and endocrine disorder rate of group B were significantly higher than those of group A (42.86 vs 36.36%; 71.43 vs 45.45%). Postoperative long-term diabetes insipidus only occurred in one patient of group B, and postoperative visual deterioration occurred in two patients of group B. Besides, one patient of group B died of severe postoperative hypothalamus dysfunction. Patients with residual tumors were applied with additional adjuvant radiotherapy, and no recurrence was observed in follow-up examinations.

CONCLUSION

A favorable outcome can be achieved by combining the insertion of an ORS by stereotactic puncture, aspiration of cystic fluid in 2-day interval for continuously 7-10 days, and the delayed tumor resection. This combined treatment modality maybe an effective method to treat children with giant cystic craniopharyngiomas.

Clinical Outcome After Extended Endoscopic Endonasal Resection of Craniopharyngiomas: Two-Institution Experience

BACKGROUND

The extended endoscopic endonasal approach (EEA) to the anterior cranial base is used for the resection of craniopharyngiomas.

OBJECTIVE

We present clinical experience and outcomes of using EEA for craniopharyngiomas.

METHODS

A total of 116 patients in 2 remote institutions were enrolled in this retrospective study. Surgical, endocrinologic, and ophthalmologic outcomes were assessed.

RESULTS

The mean follow-up was 35 months (range, 1-115). Gross total resection (GTR), near total resection (NTR, >95%), and subtotal resection (STR) were achieved in 46%, 39%, and 15% of the patients, respectively. Surgery performed after 2010 was the only variable significantly associated with greater extent of resection, which might be explained by the learning curve. Overall tumor recurrence rate was 15.5%, with a median interval until recurrence of 14.5 months (range, 3-58). Extent of resection was significantly associated with recurrence-free survival (P = 0.0116). Those who underwent NTR/STR followed by adjuvant radiotherapy had a similar median recurrence-free survival rate compared with those who underwent GTR (26.5 vs. 20 months, P = 0.167). Endocrinologic examination revealed that 47.4% of patients experienced worsening of anterior pituitary function following surgery while 25.5% developed new-onset diabetes insipidus. Of the 89 patients with preoperative visual deficits, 68 (76.4%) experienced improvement in visual field assessment.

CONCLUSION

EEA is effective for the surgical resection of craniopharyngiomas, resulting in high rates of visual improvement and low complication rates. Adjuvant radiotherapy is a useful method for tumor control after incomplete resection.

Aggressive surgery based on an anatomical subclassification of craniopharyngiomas

OBJECTIVE

Craniopharyngiomas remain a particularly formidable challenge in the neurosurgical field. Because these lesions involve the hypothalamus and ophthalmological systems, their resection is associated with either higher rates of mortality and recurrence or a lower rate of radical resection. The authors report the outcomes of aggressive surgeries based on an anatomical subclassification of craniopharyngiomas.

METHODS

Clinical and ophthalmological examinations, imaging studies, endocrinological studies, neuropsychological function, and surgical complications in all patients who had undergone microsurgical resection for craniopharyngioma at Osaka City University hospital between January 2000 and December 2014 were retrospectively reviewed through the medical records. Radical resections were planned in all of the patients. To help choose the correct surgical approach, craniopharyngiomas were classified based on tumor origin. The 4 possible groups included the intrasellar type, prechiasmatic type, retrochiasmatic type, and intra–third ventricle type. A multistage surgery was planned in some cases.

RESULTS

Seventy-two cases of craniopharyngioma were resected. Thirty-two patients (44.4%) had undergone previous surgical procedures at other institutions. Thirty-five cases (48.6%) were classified as retrochiasmatic, 19 (26.4%) as prechiasmatic, 12 (16.7%) as intra–third ventricle, and 6 (8.3%) as intrasellar. In 26 cases (36.1%), multistage surgery was required to complete the radical resection. Overall, 41 cases involved an orbitozygomatic approach; 21, a transpetrosal approach; 21, an interhemispheric approach; and 14, a transsphenoidal approach. In 3 cases, other approaches were applied. Gross-total resection was achieved in 43 patients (59.7%), near-total resection in 28 (38.9%), and partial resection in only 1 patient (1.4%). The mean follow-up period after resection was 4.7 years. Tumor recurrence or regrowth occurred in 15 (20.8%) of the 72 patients, with 14 of the 15 cases successfully controlled after additional resections and stereotactic radiosurgery. However, 1 patient died of uncontrollable tumor progression, and 2 patients died of unrelated diseases during the follow-up. Overall, disease in 69 (95.8%) of 72 patients was well controlled at the last follow-up.

CONCLUSIONS

Aggressive tumor resection is the authors' treatment policy for craniopharyngioma. Using an anatomical subclassification of craniopharyngioma to choose the most appropriate surgical approach is helpful in achieving that goal of aggressive resection.

Endoscopic Endonasal Management of Craniopharyngioma

Craniopharyngioma is a rare clinical entity that poses a significant management challenge given their location and propensity to recur. As part of a minimally disruptive treatment paradigm, the expanded endonasal approach has the potential to improve rates of resection, improve postoperative visual recovery, and minimize surgical morbidity. This article updates the otolaryngologic community on the basic principles and techniques regarding the incorporation of the endoscopic, endonasal approach in the management paradigm of craniopharyngioma.

Endoscopic transnasal external fistulation in recurrent cystic subdiaphragmatic craniopharyngioma: a novel technique

The authors present a technique for the persistent external drainage of intractable subdiaphragmatic cystic recurrences with the creation of a fistula between the cyst wall epithelium and epithelium on the nasal cavity, using a pedicled nasoseptal flap as a conduit. The long-term efficacy of endoscopic transnasal external fistulation (ETEF) in controlling cystic recurrences in this patient group is addressed through a retrospective observational review of 3 male patients aged 8, 22, and 45 years with the diagnosis of recurrent cystic subdiaphragmatic craniopharyngioma who underwent the ETEF procedure between 2006 and 2009. Clinical presentation, neuroimaging, surgical interventions, and follow-up were recorded. The main outcome measure was cyst reaccumulation on MRI. Patients had a mean follow-up of 76 months (range 5-8 years) with no incidence of cystic recurrence. Follow-up imaging revealed sustained cyst involution contrary to the usual recurrent enlargement commonly seen in this patient group. Symptoms of headache and visual field defects improved post-ETEF. Long-term theoretical complications of a persistent fistula such as intracranial abscess, meningitis, or CSF leak were not observed. ETEF promotes nasalization of cystic recurrences in subdiaphragmatic craniopharyngioma. It is safe and effective, causing long-term involution of cysts and can be considered a definitive procedure.

Comparative analysis of outcomes following craniotomy and expanded endoscopic endonasal transsphenoidal resection of craniopharyngioma and related tumors: a single-institution study

OBJECTIVE

Craniopharyngiomas and similar midline suprasellar tumors have traditionally been resected via transcranial approaches. More recently, expanded endoscopic endonasal transsphenoidal approaches have gained interest. Surgeons have advocated for both approaches, and at present there is no consensus whether one approach is superior to the other. The authors therefore compared surgical outcomes between craniotomy and endoscopic endonasal transsphenoidal surgery (EETS) for suprasellar tumors treated at their institution.

METHODS

A retrospective review of patients undergoing resection of suprasellar lesions at Cedars-Sinai Medical Center between 2000 and 2013 was performed. Patients harboring suspected craniopharyngioma were selected for extensive review. Other pathologies or predominantly intrasellar masses were excluded. Cases were separated into 2 groups, based on the surgical approach taken. One group underwent EETS and the other cohort underwent craniotomy. Patient demographic data, presenting symptoms, and previous therapies were tabulated. Preoperative and postoperative tumor volume was calculated for each case based on MRI. Student t-test and the chi-square test were used to evaluate differences in patient demographics, tumor characteristics, and outcomes between the 2 cohorts. To assess for selection bias, 3 neurosurgeons who did not perform the surgeries reviewed the preoperative imaging studies and clinical data for each patient in blinded fashion and indicated his/her preferred approach. These data were subject to concordance analysis using Cohen's kappa test to determine if factors other than surgeon preference influenced the choice of surgical approach.

RESULTS

Complete data were available for 53 surgeries; 19 cases were treated via EETS, and 34 were treated via craniotomy. Patient demographic data, preoperative symptoms, and tumor characteristics were similar between the 2 cohorts, except that fewer operations for recurrent tumor were observed in the craniotomy cohort compared with EETS (17.6% vs 42.1%, p = 0.05). The extent of resection was similar between the 2 groups (85.6% EETS vs 90.7% craniotomy, p = 0.77). An increased rate of cranial nerve injury was noted in the craniotomy group (0% EETS vs 23.5% craniotomy, p = 0.04). Postoperative CSF leak rate was higher in the EETS group (26.3% EETS vs 0% craniotomy, p = 0.004). The progression-free survival curves (log-rank p = 0.99) and recurrence rates (21.1% EETS vs 23.5% craniotomy, p = 1.00) were similar between the 2 groups. Concordance analysis of cases reviewed by 3 neurosurgeons indicated that individual surgeon preference was the only factor that determined surgical approach (kappa coefficient -0.039, p = 0.762) CONCLUSIONS: Surgical outcomes were similar for tumors resected via craniotomy or EETS, except that more CSF leaks occurred in the EETS cohort, whereas more neurological injuries occurred in the craniotomy cohort. Surgical approach appears to mostly reflect surgeon preference rather than specific tumor characteristics. These data support the view that EETS is a viable alternative to craniotomy, providing a similar extent of resection with less neurological injury.

Hypothalamic Obesity in Craniopharyngioma Patients: Disturbed Energy Homeostasis Related to Extent of Hypothalamic Damage and Its Implication for Obesity Intervention

Hypothalamic obesity (HO) occurs in patients with tumors and lesions in the medial hypothalamic region. Hypothalamic dysfunction can lead to hyperinsulinemia and leptin resistance. This review is focused on HO caused by craniopharyngiomas (CP), which are the most common childhood brain tumors of nonglial origin. Despite excellent overall survival rates, CP patients have substantially reduced quality of life because of significant long-term sequelae, notably severe obesity in about 50% of patients, leading to a high rate of cardiovascular mortality. Recent studies reported that both hyperphagia and decreased energy expenditure can contribute to severe obesity in HO patients. Recognized risk factors for severe obesity include large hypothalamic tumors or lesions affecting several medial and posterior hypothalamic nuclei that impact satiety signaling pathways. Structural damage in these nuclei often lead to hyperphagia, rapid weight gain, central insulin and leptin resistance, decreased sympathetic activity, low energy expenditure, and increased energy storage in adipose tissue. To date, most efforts to treat HO have shown disappointing long-term success rates. However, treatments based on the distinct pathophysiology of disturbed energy homeostasis related to CP may offer options for successful interventions in the future.

Multi-modality management of craniopharyngioma: a review of various treatments and their outcomes

Craniopharyngioma is a rare tumor that is expected to occur in ∼400 patients/year in the United States. While surgical resection is considered to be the primary treatment when a patient presents with a craniopharyngioma, only 30% of such tumors present in locations that permit complete resection. Radiotherapy has been used as both primary and adjuvant therapy in the treatment of craniopharyngiomas for over 50 years. Modern radiotherapeutic techniques, via the use of CT-based treatment planning and MRI fusion, have permitted tighter treatment volumes that allow for better tumor control while limiting complications. Modern radiotherapeutic series have shown high control rates with lower doses than traditionally used in the two-dimensional treatment era. Intracavitary radiotherapy with radio-isotopes and stereotactic radiosurgery may have a role in the treatment of recurrent cystic and solid recurrences, respectively. Recently, due to the exclusive expression of the Beta-catenin clonal mutations and the exclusive expression of BRAF V600E clonal mutations in the overwhelming majority of adamantinomatous and papillary tumors respectively, it is felt that inhibitors of each pathway may play a role in the future treatment of these rare tumors.

The expanding role of the endonasal endoscopic approach in pituitary and skull base surgery: A 2014 perspective

BACKGROUND

The past two decades have been the setting for remarkable advancement in endonasal endoscopic neurosurgery. Refinements in camera definition, surgical instrumentation, navigation, and surgical technique, including the dual surgeon team, have facilitated purely endonasal endoscopic approaches to the majority of the midline skull base that were previously difficult to access through the transsphenoidal microscopic approach.

METHODS

This review article looks at many of the articles from 2011 to 2014 citing endonasal endoscopic surgery with regard to approaches and reconstructive techniques, pathologies treated and outcomes, and new technologies under consideration.

RESULTS

Refinements in approach and closure techniques have reduced the risk of cerebrospinal fluid leak and infection. This has allowed surgeons to more aggressively treat a variety of pathologies. Four main pathologies with outcomes after treatment were identified for discussion: pituitary adenomas, craniopharyngiomas, anterior skull base meningiomas, and chordomas. Within all four of these tumor types, articles have demonstrated the efficacy, and in certain cases, the advantages over more traditional microscope-based techniques, of the endonasal endoscopic technique.

CONCLUSIONS

The endonasal endoscopic approach is a necessary tool in the modern skull base surgeon's armamentarium. Its efficacy for treatment of a wide variety of skull base pathologies has been repeatedly demonstrated. In the experienced surgeon's hands, this technique may offer the advantage of greater tumor removal with reduced overall complications over traditional craniotomies for select tumor pathologies centered near the midline skull base.

Gamma Knife surgery for craniopharyngioma: report on a 20-year experience

Object

Although craniopharyngiomas are benign intracranial tumors, their high recurrence rates and intimate associations with surrounding neurovascular structures make gross tumor resection challenging. Stereotactic radiosurgery has been introduced as a valuable adjuvant therapy for recurrent or residual craniopharyngiomas. However, studies with large patient populations documenting long-term survival and progression-free survival rates are rare in the literature. The current study aims to report the long-term radiosurgical results and to define the prognostic factors in a large cohort of patients with a craniopharyngioma.

Methods

A total of 137 consecutive patients who underwent 162 sessions of Gamma Knife surgery (GKS) treatments at the Taipei Veterans General Hospital between 1993 and 2012 were analyzed. The patients' median age was 30.1 years (range 1.5–84.9 years), and the median tumor volume was 5.5 ml (range 0.2–28.4 ml). There were 23 solid (16.8%), 23 cystic (16.8%), and 91 mixed solid and cystic (66.4%) craniopharyngiomas. GKS was indicated for residual or recurrent craniopharyngiomas. The median radiation dose was 12 Gy (range 9.5–16.0 Gy) at a median isodose line of 55% (range 50%–78%).

Results

At a median imaging follow-up of 45.7 months after GKS, the rates of tumor control were 72.7%, 73.9%, and 66.3% for the solid, cystic, and mixed tumors, respectively. The actuarial progression-free survival rates plotted by the Kaplan-Meier method were 70.0% and 43.8% at 5 and 10 years after radiosurgery, respectively. After repeated GKS, the actuarial progression-free survival rates were increased to 77.3% and 61.2% at 5 and 10 years, respectively. The overall survival rates were 91.5% and 83.9% at the 5- and 10-year follow-ups, respectively. Successful GKS treatment can be predicted by tumor volume (p = 0.011). Among the 137 patients who had clinical follow-up, new-onset or worsened pituitary deficiencies were detected in 11 patients (8.0%). Two patients without tumor growth had a worsened visual field, and 1 patient had a new onset of third cranial nerve palsy.

Conclusions

The current study suggests that GKS is a relatively safe modality for the treatment of recurrent or residual craniopharyngiomas, and it is associated with improved tumor control and reduced in-field recurrence rates. Acceptable rates of complications occurred.

Extended endoscopic endonasal approach for recurrent or residual adult craniopharyngiomas

BACKGROUND

The aim of this study was to evaluate the effectiveness of the extended endoscopic endonasal transsphenoidal approach (TSA) for recurrent or residual craniopharyngiomas, focusing on the extent of tumor resection and complications resulting from surgery at a single institution.

METHODS

Twelve adult patients (six men and six women) underwent extended endoscopic endonasal TSA for a recurrent or residual craniopharyngioma after a previous surgical intervention at a single institution by a single surgeon. The mean number of surgeries patients had undergone before TSA was 1.3 (range, 1-3). The mean period between patients' most recent surgery and extended TSA was 55.9 months (range, 1-184). The mean preoperative (that is, pre-extended TSA) tumor volume was 2.87 cm³. The mean follow-up period was 15.8 months (range, 4-32). We reviewed clinical and radiological features in each case, focusing on the degree of tumor resection as well as endocrinological and ophthalmological outcomes.

RESULTS

Gross total resection was achieved in ten patients (83.3 %), and the mean resection rate was 87 % in the other two cases. There were no significant differences between pre- and postoperative endocrine function, except in one patient who suffered postoperative panhypopituitarism resulting in pituitary stalk resection, which was necessary because of obvious tumor involvement. Three patients suffered transient diabetic insipidus (DI). With respect to ophthalmological outcomes, three patients showed improvement, two others showed decline, and the remainder showed no significant changes.

CONCLUSION

The extended endoscopic endonasal transsphenoidal approach is an effective and safe surgical approach for treating recurrent or residual craniopharyngioma.

Sellar and parasellar lesions - clinical outcome in 61 children

OBJECTIVE

To evaluate clinical outcome in a 10-year consecutive series of children operated for sellar and parasellar tumors with special focus on neuropsychology and endocrinology.

PATIENTS AND METHODS

We analyzed 61 children (30 female) under 18 years of age (mean age 9.9, range 1 month-17 years) operated between 2000 and 2010. Medical records were evaluated retrospectively; postoperative histologic diagnoses included 20 craniopharyngiomas, 17 gliomas, 6 pituitary adenomas and 18 rare tumor entities.

RESULTS

Of 61 patients, 58 (95%) were still alive at last follow-up. Three patients died, all due to progression of malignant rhabdoid tumors. Postoperative clinical morbidity consisted of endocrinological (66%), visual (60.7%) and other neurological deficits (55.9%) after a mean follow-up of 44 months. When compared to all other tumor entities in this series, craniopharyngiomas were associated with high rates of gross-total resection (p=0.008), frequent progression of residual tumor (p=0.005) scotomas (p=0.013), persistent diabetes insipidus (p<0.001), and panhypopituitarism (p<0.001). Surgically treated gliomas showed higher rates of motor weakness (p=0.004), double vision (p<0.001), and milder forms of endocrinopathy (single hormone deficits, p=0.02). In general, deterioration in school performance was associated with multiple surgeries (p=0.018) and radiotherapy (p=0.021).

CONCLUSION

Excellent overall survival in these patients is possible, however malignant rhabdoid tumors have a poor prognosis. Aggressive treatment is associated with significant morbidity. Children operated for craniopharyngioma showed an expected high rate of endocrine deterioration, whereas glioma patients had higher incidences of motor weakness and double vision. The treating physicians should be well aware of all these considerable postoperative deficits, especially when facing interdisciplinary management decisions, and for the informed consent discussions with the patient and the parents.

Craniopharyngioma: How to deal with?

Craniopharyngiomas are rare, highly complex tumors with bimodal incidence in the pediatric and adult age groups. In our opinion, depending on the means possible, total microscopic ablation offers the best chance of healing, or at least prolongs the time interval of recurrences.

Objective : The purpose of this paper is to add our surgical experience to in the last 11 years, in the context of the large debate from literature regarding the best therapeutically option concerning craniopharyngioma treatments.

Materials and Methods : We performed a retrospective analysis of 42 consecutive patients with craniopharyngioma who underwent surgical resection by one surgeon at the Neurosurgical Department of Cluj-Napoca County Emergency Hospital between January 2002 and December 2012. We perform a systematic review of the published review on goals and techniques associated with selected surgical strategies for the treatment of CPH.

Results : During this period a total of 42 patients with craniopharyngioma were treated in our institution by a single neurosurgeon, representing 12% from all cases of sellar and parasellar tumors respectively operated in last 11 years. There is a significant male preponderance. Nine patients were less than 18 years of age at admission. The patient age distribution showed a peak incidence between 10 and 15 years and another between 45 and 50 years. Considering the pediatric and adult populations together, the most common presenting symptom was visual disturbances with 60% of patients presenting in this manner, followed by severe headache in more than 50% of cases. Obstructive hydrocephalus occurred in 31% of cases. Calcifications were seen in 45% of cases, more frequently in children. All our cases underwent surgery by transcranial approach; extended frontotemporal, as the first choice, in 57% of cases. Gross total removal was achieved in over half of cases and near total resection was achieved in 40% of cases. The most frequent postoperative complications: diabetes insipidus and syndrome of inappropriate antidiuretic hormone secretion. No visual impairment was observed after surgery in the patients with normal visions at presentation. Only 3 of cases primarily operated by us recurred, in an interval of one to five years. The mortality rate in our cases treated by transcranial surgery was 2% in primary cases and 7% in cases of tumor recurrence.

Conclusions : Radical surgery offers the best chance for cure. Radical surgery is also associated with a higher risk of postoperative morbidity, being the reason for why many neurosurgeons recommend a subtotal resection followed by radiotherapy. In our opinion radical surgery is possible in large majority of the cases, fronto-temporal approach offering the most appropriate way to reach this objective. Every case must be judged with maximal attention based on preoperative neuroimagistic data but decisively, on intraoperative findings.