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Sharma R, Meena R, Ganeshkumar A, Narwal A, Doddamani R, Singh M, Chandra SP. Rathke's Cleft Cyst and Craniopharyngioma: A Continuum of the Same Spectrum? Insights from an Interesting Case and Previous Literature. Neurol India 2024; 72:403-407. [PMID: 38691485 DOI: 10.4103/ni.ni_1210_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 05/27/2022] [Indexed: 05/03/2024]
Abstract
Rathke's Cleft Cysts (RCCs) and Craniopharyngiomas (CPs) may represent disease entities on the same etio-pathological spectrum. We report the case of a 36-year-old female presenting with vision loss and menstrual irregularities, imaging shows a predominantly cystic lesion in the sellar region with suprasellar extension. She underwent a microscopic transnasal resection of the lesion. She later presented with recurrent symptoms and increased residual lesion size on imaging, a transcranial excision of the lesion was performed. Histopathology from the initial operative specimen revealed RCC with squamous metaplasia which was BRAF negative, while the specimen from the second surgery revealed BRAF positive papillary stratified squamous architecture suggestive of Papillary CP. This case adds to the evidence that both RCCs and papillary CPs may be the spectrum of the same disease. Further, papillary CPs may be an evolution from the RCCs.
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Affiliation(s)
- Ravi Sharma
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Meena
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Akshay Ganeshkumar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Anubhav Narwal
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Ramesh Doddamani
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Manmohan Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sarat P Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Gritsch D, Santagata S, Brastianos PK. Integrating Systemic Therapies into the Multimodality Therapy of Patients with Craniopharyngioma. Curr Treat Options Oncol 2024; 25:261-273. [PMID: 38300480 DOI: 10.1007/s11864-023-01156-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 02/02/2024]
Abstract
OPINION STATEMENT The integration of targeted therapy into the multimodal management of craniopharyngiomas represents a significant advancement in the field of neuro-oncology. Historically, the management of these tumors has been challenging due to their proximity to vital brain structures, necessitating a delicate balance between tumor control and the preservation of neurological function. Traditional treatment modalities, such as surgical resection and radiation, while effective, carry their own set of risks, including potential damage to surrounding healthy tissues and the potential for long-term side effects. Recent insights into the molecular biology of craniopharyngiomas, particularly the discovery of the BRAF V600E mutation in nearly all papillary craniopharyngiomas, have paved the way for a targeted systemic treatment approach. However, advances have been limited for adamantinomatous craniopharyngiomas. The success of BRAF/MEK inhibitors in clinical trials underscores the potential of these targeted therapies not only to control tumor growth but also to reduce the need for more invasive treatments, potentially minimizing treatment-related complications. However, the introduction of these novel therapies also brings forth new challenges, such as determining the optimal timing, sequencing, and duration of targeted treatments. Furthermore, there are open questions regarding which specific BRAF/MEK inhibitors to use, the potential need for combination therapy, and the strategies for managing intolerable adverse events. Finally, ensuring equitable access to these therapies, especially in healthcare systems with limited resources, is crucial to prevent widening healthcare disparities. In conclusion, targeted therapy with BRAF/MEK inhibitors holds great promise for improving outcomes and quality of life for patients with BRAF-mutated craniopharyngiomas. However, additional research is needed to address the questions that remain about its optimal use and integration into comprehensive treatment plans.
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Affiliation(s)
- David Gritsch
- Massachusetts General Hospital Cancer Center, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Sandro Santagata
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Priscilla K Brastianos
- Massachusetts General Hospital Cancer Center, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
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3
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Memon F, Humayun KN, Riaz Q, Arif M, Huda NU, Laghari AA, Hilal K, Mushtaq N. Pediatric craniopharyngioma: a 20-year study on epidemiological features, clinical presentation, and survival outcomes in a tertiary care center from LMIC. Childs Nerv Syst 2024; 40:427-434. [PMID: 37837454 DOI: 10.1007/s00381-023-06177-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/30/2023] [Indexed: 10/16/2023]
Abstract
INTRODUCTION Craniopharyngioma constitutes approximately 10% of primary brain tumors in children. It can cause considerable morbidity and mortality due to the local aggressiveness of the tumor itself or its management affecting the hypothalamus-pituitary axis and optic pathway involvement. There is very scarce data available from LMIC which makes the management controversial where multidisciplinary teams are already not available in most of the centers. This is a single-center cross-sectional retrospective review of 20-year record of 49 patients with craniopharyngioma treated between 2001 and 2020 at Aga Khan University Hospital, a tertiary care center in Karachi, Pakistan. METHODS We have assessed the epidemiological data of children presenting with the diagnosis of craniopharyngioma, treatment modalities used, and neurological, endocrine, and hypothalamic complications in these patients. The assessment involved a retrospective review of medical records and medical follow-up. RESULTS Out of a total of 49 patients, 26 (53%) were male, and 23 (46.9%) were female. The mean age was 9.5 years (SD ± 4.5 years). Most common symptoms at initial presentation were headache 41 (83.6%), visual deficit 40 (81.6%), nausea and vomiting 26 (53%), and endocrine abnormalities 16 (32%). Treatment modalities used at our center include gross total resection 11 (22%) and subtotal resection 38 (77%) out of total, while 6 (12.2%) patients received intracystic interferon. Histopathologic findings of the majority of patients (40 (81%)) revealed an adamantinomatous type of tumor. Only 23 (46.9%) children followed in clinic post-op. Median follow-up after craniopharyngioma presentation was 5 years (± 2.1 SD, range: 2-10 years). Pituitary hormone deficiencies (98%) and visual disturbances (75%) were the most common long-term health conditions observed. CONCLUSIONS Since pituitary hormone deficiencies and visual disturbance were the most common long-term health conditions observed in our study, these patients require a multidisciplinary team follow-up to improve their quality of life.
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Affiliation(s)
- Fozia Memon
- Department of Pediatrics, Aga Khan University, Karachi, Pakistan
| | | | - Quratulain Riaz
- Department of Pediatric Oncology, Indus Hospital, Karachi, Pakistan
| | - Muzna Arif
- Department of Pediatrics, Aga Khan University, Karachi, Pakistan
| | | | - Altaf Ali Laghari
- Section of Neurosurgery, Department of Surgery, Aga Khan University, Karachi, Pakistan
| | - Kiran Hilal
- Department of Radiology, Aga Khan University, Karachi, Pakistan
| | - Naureen Mushtaq
- Department of Oncology, Aga Khan University, Karachi, Pakistan.
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Pediatric Neurosurgery Group, Neurosurgery Branch of Chinese Medical Association. [Chinese expert consensus on diagnosis and treatment of craniopharyngioma (2024)]. Zhonghua Yi Xue Za Zhi 2024; 104:251-61. [PMID: 38246770 DOI: 10.3760/cma.j.cn112137-20231206-01302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Craniopharyngioma is a sellar tumor with benign pathology and malignant clinical manifestations. Partial resection plus radiotherapy, internal radiation therapy and chemotherapy are the conventional treatment strategies forcraniopharyngioma in most hospitals, which cause many patients to lose the best time to cure and make reoperation more difficult after recurrence. Therefore, the Pediatric Group of Chinese Society of Neurosurgery, Chinese Medical Association organized domestic experts from Pediatrics, Pediatric Neurosurgery, Genetics and Endocrinology to reach a consensus on the following topics: pathological and molecular genetic classification of craniopharyngioma, basic principles of curing tumors, surgical classification of tumors, surgical approach, perioperative and long-term treatment plan. This is expected to improve the quality of life and prognosis of patients, and further standardize the diagnosis and treatment of craniopharyngioma.
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Tang AR, Haizel-Cobbina J, Khalid MU, Peter-Okaka UI, Prosak OL, Mushtaq N, Dewan MC. Global pediatric craniopharyngioma management modalities and outcomes. Childs Nerv Syst 2024; 40:47-56. [PMID: 37466685 DOI: 10.1007/s00381-023-06088-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 07/17/2023] [Indexed: 07/20/2023]
Abstract
INTRODUCTION Pediatric craniopharyngioma is a complex pathology, with optimal management involving a multidisciplinary approach and thoughtful care coordination. To date, no studies have compared various treatment modalities and outcomes described in different global regions. We conducted a comprehensive systematic review to compare demographics, clinical presentation, treatment approach and outcomes of children diagnosed with craniopharyngioma globally. METHODS A systematic review was conducted in accordance with the Preferred Reporting Item for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Search terms included "craniopharyngioma" and country-specific terms. Inclusion criteria included full-text studies published between 2000-2022, primarily examining pediatric patients 18-years old or younger diagnosed with craniopharyngioma, and reporting management and outcomes of interest. Data extracted included country of origin, demographical data, initial presentation and treatment modality, and outcomes. Descriptive statistics and between-group comparisons based on country of origin were performed. RESULTS Of 797 search results, 35 articles were included, mostly originating from high-income countries (HIC) (n = 25, 71.4%). No studies originated from low-income countries (LIC). When comparing HIC to middle-income countries (MIC), no differences in patient demographics were observed. No differences in symptomatology at initial presentation, tumor type, surgical approach or extent of surgical resection were observed. HIC patients undergoing intracystic therapy were more likely to receive bleomycin (n = 48, 85.7%), while the majority of MIC patients received interferon therapy (n = 10, 62.5%). All MIC patients undergoing radiation therapy underwent photon therapy (n = 102). No statistically significant differences were observed in postoperative complications or mean follow-up duration between HIC and MIC (78.1 ± 32.2 vs. 58.5 ± 32.1 months, p = 0.241). CONCLUSION Pediatric craniopharyngioma presents and is managed similarly across the globe. However, no studies originating from LICs and resource-poor regions examine presentation and management to date, representing a significant knowledge gap that must be addressed to complete the global picture of pediatric craniopharyngioma burden and management.
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Affiliation(s)
- Alan R Tang
- Vanderbilt University School of Medicine, TN, Nashville, USA
| | - Joseline Haizel-Cobbina
- Department of Neurological Surgery, Division of Pediatric Neurological Surgery, Vanderbilt University Medical Center, 2200 Children's Way, 9226 Doctors Office Tower, TN, 37232-9557, Nashville, USA
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Muhammad Usman Khalid
- Department of Neurological Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | | | - Olivia L Prosak
- Vanderbilt University School of Medicine, TN, Nashville, USA
| | - Naureen Mushtaq
- Department of Oncology, Section of Pediatric Oncology, Aga Khan University Hospital, Karachi, Pakistan
| | - Michael C Dewan
- Department of Neurological Surgery, Division of Pediatric Neurological Surgery, Vanderbilt University Medical Center, 2200 Children's Way, 9226 Doctors Office Tower, TN, 37232-9557, Nashville, USA.
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA.
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Tse PKY, Basurto KS, VanLandingham H, Oh A, Alfonso D, Jennette K. A - 119 A Case Study: the Cognitive Functioning of an Adult Patient with Recurrent Craniopharyngiomas. Arch Clin Neuropsychol 2023; 38:1291. [PMID: 37807245 DOI: 10.1093/arclin/acad067.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
OBJECTIVE Craniopharyngiomas are extremely rare (incidence rate of 1.34 per million). Due to its proximity to the sellar/suprasellar prefrontal regions region, cognitive impairment, behavioral changes, and adverse endocrinological outcomes are common. Further, surgery and radiotherapy can further impact functioning. Currently, there is no parsimonious cognitive profile of adult patients following interventions. This case highlights the role of neuropsychological evaluations in monitoring global psychological functioning and frontal behavioral syndrome in an adult with recurrent craniopharyngioma. METHOD The patient is a 39-year-old Black female first evaluated as an inpatient prior to resection surgery. She was evaluated on four additional times post-surgically. At the most recent evaluation, she and her family reported memory problems, apathy, and gait instability. Complicating factors included hypothyroidism, chronic kidney disease, diabetes, obstructive sleep apnea, pulmonary embolism, hypotension, COVID-19, and recurrent tachycardia, with inconsistent adherence to treatment recommendations. RESULTS She displayed global cognitive deficits two years post-surgery, particularly in language and memory. Neurobehaviorally, she exhibited pervasive signs of severe frontal lobe syndrome, including, abulia, hypophonic and dysarthric speech, psychomotor retardation, bradyphrenia, and anosognosia. CONCLUSION Neuropsychological evaluations remain critical in monitoring the patient's neurocognitive status and provide valuable insights into treatment planning and need for additional support and care to optimize patients' quality of life in the context of significant cognitive disability.
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Gan HW, Morillon P, Albanese A, Aquilina K, Chandler C, Chang YC, Drimtzias E, Farndon S, Jacques TS, Korbonits M, Kuczynski A, Limond J, Robinson L, Simmons I, Thomas N, Thomas S, Thorp N, Vargha-Khadem F, Warren D, Zebian B, Mallucci C, Spoudeas HA. National UK guidelines for the management of paediatric craniopharyngioma. Lancet Diabetes Endocrinol 2023; 11:694-706. [PMID: 37549682 DOI: 10.1016/s2213-8587(23)00162-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/25/2023] [Accepted: 06/01/2023] [Indexed: 08/09/2023]
Abstract
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.
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Affiliation(s)
- Hoong-Wei Gan
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; University College London Great Ormond Street Institute of Child Health, London, UK.
| | - Paul Morillon
- King's College Hospital NHS Foundation Trust, London, UK
| | - Assunta Albanese
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Kristian Aquilina
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Chris Chandler
- King's College Hospital NHS Foundation Trust, London, UK
| | - Yen-Ching Chang
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Evangelos Drimtzias
- St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sarah Farndon
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Thomas S Jacques
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; University College London Great Ormond Street Institute of Child Health, London, UK
| | - Márta Korbonits
- William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Adam Kuczynski
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jennifer Limond
- Department of Psychology, College of Life and Environmental Sciences, University of Exeter, Exeter, UK
| | - Louise Robinson
- Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Ian Simmons
- St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nick Thomas
- King's College Hospital NHS Foundation Trust, London, UK
| | - Sophie Thomas
- Nottingham Children's Hospital, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nicola Thorp
- The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Bebington, UK
| | - Faraneh Vargha-Khadem
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; University College London Great Ormond Street Institute of Child Health, London, UK
| | - Daniel Warren
- St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Bassel Zebian
- King's College Hospital NHS Foundation Trust, London, UK
| | - Conor Mallucci
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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Apps JR, Muller HL, Hankinson TC, Yock TI, Martinez-Barbera JP. Contemporary Biological Insights and Clinical Management of Craniopharyngioma. Endocr Rev 2023; 44:518-538. [PMID: 36574377 DOI: 10.1210/endrev/bnac035] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 11/20/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022]
Abstract
Craniopharyngiomas (CPs) are clinically aggressive tumors because of their invasive behavior and recalcitrant tendency to recur after therapy. There are 2 types based on their distinct histology and molecular features: the papillary craniopharyngioma (PCP), which is associated with BRAF-V600E mutations and the adamantinomatous craniopharyngioma (ACP), characterized by mutations in CTNNB1 (encoding β-catenin). Patients with craniopharyngioma show symptoms linked to the location of the tumor close to the optic pathways, hypothalamus, and pituitary gland, such as increased intracranial pressure, endocrine deficiencies, and visual defects. Treatment is not specific and mostly noncurative, and frequently includes surgery, which may achieve gross total or partial resection, followed by radiotherapy. In cystic tumors, frequent drainage is often required and intracystic instillation of drugs has been used to help manage cyst refilling. More recently targeted therapies have been used, particularly in PCP, but also now in ACP and clinical trials are underway or in development. Although patient survival is high, the consequences of the tumor and its treatment can lead to severe comorbidities resulting in poor quality of life, in particular for those patients who bear tumors with hypothalamic involvement. Accordingly, in these patients at risk for the development of a hypothalamic syndrome, hypothalamus-sparing treatment strategies such as limited resection followed by irradiation are recommended. In this review, we provide an update on various aspects of CP, with emphasis on recent advances in the understanding of tumor pathogenesis, clinical consequences, management, and therapies.
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Affiliation(s)
- John Richard Apps
- Institute of Cancer and Genomics Sciences, University of Birmingham, Birmingham, B15 2TT, UK
- Developmental Biology and Cancer, Birth Defects Research Centre, GOS Institute of Child Health, University College London, London, WC1N 1EH, UK
- Oncology Department, Birmingham Women's and Children's NHS Foundation Trust, Birmingham B4 6NH, UK
| | - Hermann Lothar Muller
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children's Hospital, Carl von Ossietzky University, Klinikum Oldenburg AöR, 26133 Oldenburg, Germany
| | - Todd Cameron Hankinson
- Department of Neurosurgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado 80045, USA
- Department of Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado, Aurora, Colorado 80045, USA
- Morgan Adams Foundation Pediatric Brain Tumor Program, Aurora, Colorado, USA
| | - Torunn Ingrid Yock
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02115, USA
| | - Juan Pedro Martinez-Barbera
- Developmental Biology and Cancer, Birth Defects Research Centre, GOS Institute of Child Health, University College London, London, WC1N 1EH, UK
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Jiang Y, Yang J, Liang R, Zan X, Fan R, Shan B, Liu H, Li L, Wang Y, Wu M, Qi X, Chen H, Ren Q, Liu Z, Wang Y, Zhang J, Zhou P, Li Q, Tian M, Yang J, Wang C, Li X, Jiang S, Zhou L, Zhang G, Chen Y, Xu J. Single-cell RNA sequencing highlights intratumor heterogeneity and intercellular network featured in adamantinomatous craniopharyngioma. Sci Adv 2023; 9:eadc8933. [PMID: 37043580 PMCID: PMC10096597 DOI: 10.1126/sciadv.adc8933] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 03/10/2023] [Indexed: 06/19/2023]
Abstract
Despite improvements in microscopically neurosurgical techniques made in recent years, the prognosis of adamantinomatous craniopharyngioma (ACP) is still unsatisfactory. Little is known about cellular atlas and biological features of ACP. Here, we carried out integrative analysis of 44,038 single-cell transcriptome profiles to characterize the landscape of intratumoral heterogeneity and tumor microenvironment (TME) in ACP. Four major neoplastic cell states with distinctive expression signatures were defined, which further revealed the histopathological features and elucidated unknown cellular atlas of ACP. Pseudotime analyses suggested potential evolutionary trajectories between specific neoplastic cell states. Notably, a distinct oligodendrocyte lineage was identified in ACP, which was associated with immunological infiltration and neural damage. In addition, we described a tumor-centric regulatory network based on intercellular communication in TME. Together, our findings represent a unique resource for deciphering tumor heterogeneity of ACP, which will improve clinical diagnosis and treatment strategies.
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Affiliation(s)
- Yu Jiang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jinlong Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ruichao Liang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin Zan
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Rangrang Fan
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Baoyin Shan
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Hao Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Li Li
- Institute of Clinical Pathology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yue Wang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, 250000, China
| | - Min Wu
- Huaxi MR Research Center (HMRRC), Department of Radiology, Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin Qi
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Hongxu Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Qingqing Ren
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Zhiyong Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yuelong Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jing Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Peizhi Zhou
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Qiang Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Meng Tian
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jinhao Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Chaoyang Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xueying Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Shu Jiang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Liangxue Zhou
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Gao Zhang
- Faculty of Dentistry, The University of Hong Kong, Sai Ying Pun, 999077, Hong Kong
| | - Yaohui Chen
- Department of Thoracic Surgery/Institute of Thoracic Oncology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jianguo Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
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Abstract
Hypothalamic obesity (HO) is defined as abnormal weight gain due to physical destruction of the hypothalamus. Suprasellar tumors, most commonly craniopharyngiomas, are a classic cause of HO. HO often goes unnoticed initially as patients, families, and medical teams are focused on oncologic treatments and management of panhypopituitarism. HO is characterized by rapid weight gain in the first year after hypothalamic destruction followed by refractory obesity due to an energy imbalance of decreased energy expenditure without decreased food intake. Currently available pharmacotherapies are less effective in HO than in common obesity. While not a cure, dietary interventions, pharmacotherapy, and bariatric surgery can mitigate the effects of HO. Early recognition of HO is necessary to give an opportunity to intervene before substantial weight gain occurs. Our goal for this article is to review the pathophysiology of HO and to discuss available treatment options and future directions for prevention and treatment.
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Affiliation(s)
- Ashley H Shoemaker
- Pediatric Endocrinology, Vanderbilt University Medical Center, Nashville, TN 37212, USA
| | - Jaclyn Tamaroff
- Pediatric Endocrinology, Vanderbilt University Medical Center, Nashville, TN 37212, USA
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Beckhaus J, Friedrich C, Boekhoff S, Calaminus G, Bison B, Eveslage M, Timmermann B, Flitsch J, Müller HL. Outcome after pediatric craniopharyngioma: the role of age at diagnosis and hypothalamic damage. Eur J Endocrinol 2023; 188:7060061. [PMID: 36857103 DOI: 10.1093/ejendo/lvad027] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVE Craniopharyngiomas (CP) are rare malformational tumors. Clinical presentation and outcome of pediatric patients with CP with specific regard to age at diagnosis is not clear. The aim of this cohort study was to determine clinical presentation and outcome in these patients diagnosed at different ages at diagnosis. DESIGN Seven hundred and nine patients diagnosed with CP were recruited from 1999 to 2021 in HIT-Endo and KRANIOPHARYNGEOM 2000/2007/Registry 2019 and prospectively observed. METHODS Age at diagnosis was categorized as infants and toddlers (<2 years), early childhood (2-6 years), middle childhood (6-12 years), and early adolescence (12-18 years). Overall and event-free survival (EFS), functional capacity (FMH), and quality of life (QoL) (PEDQOL) were assessed. RESULTS Severe obesity (body mass index [BMI] >3 standard deviation score [SDS]) was prevalent in 45.4% at last visit. A lower EFS but better QoL was observed in children with age at diagnosis <6 years compared with ≥6 years. Reduced functional capacity percentiles were associated with increased BMI-SDS at last visit (rho = -0.125, 95% confidence interval [CI; -0.21; -0.04]) and age at diagnosis <2 years. Posterior hypothalamic involvement and hypothalamic lesion (HL) were independent risk factors for reduced EFS (hazard ratio = 1.59, 95% CI [1.12-2.26]) and obesity at last visit (odds ratio = 2.94, 95% CI [1.73-5.08]). Age at diagnosis did not contribute to severe obesity and reduced QoL. CONCLUSIONS Diagnosis of CP at age <6 years may help patients to adapt early to disabilities but may lead to a higher probability of CP relapse. Not age at diagnosis but posterior HL may be the contributing factor to severe obesity and a reduced QoL. CLINICAL TRIAL REGISTRATION NUMBERS NCT00258453; NCT01272622; NCT04158284.
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Affiliation(s)
- Julia Beckhaus
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children's Hospital, Carl von Ossietzky University, Klinikum Oldenburg AöR, Oldenburg 26133, Germany
| | - Carsten Friedrich
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children's Hospital, Carl von Ossietzky University, Klinikum Oldenburg AöR, Oldenburg 26133, Germany
| | - Svenja Boekhoff
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children's Hospital, Carl von Ossietzky University, Klinikum Oldenburg AöR, Oldenburg 26133, Germany
| | - Gabriele Calaminus
- Department of Pediatric Hematology/Oncology, University of Bonn Medical Center, Bonn, Germany
| | - Brigitte Bison
- Diagnostic and Interventional Neuroradiology, Faculty of Medicine, Department of Neuroradiology, University Hospital of Augsburg, Augsburg, Germany
| | - Maria Eveslage
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, Essen, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Hermann L Müller
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children's Hospital, Carl von Ossietzky University, Klinikum Oldenburg AöR, Oldenburg 26133, Germany
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12
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Abstract
Craniopharyngiomas are rare malignancies of dysembryogenic origin, involving the sellar and parasellar areas. These low-grade, epithelial tumors account for two main histological patterns (adamantinomatous craniopharyngioma and papillary craniopharyngioma), which differ in epidemiology, pathogenesis, and histomorphological appearance. Adamantinomatous craniopharyngiomas typically show a bimodal age distribution (5-15 years and 45-60 years), while papillary craniopharyngiomas are limited to adult patients, especially in the fifth and sixth decades of life. Recently, craniopharyngioma histological subtypes have been demonstrated to harbor distinct biomolecular signatures. Somatic mutations in CTNNB1 gene encoding β-catenin have been exclusively detected in adamantinomatous craniopharyngiomas, which predominantly manifest as cystic lesions, while papillary craniopharyngiomas are driven by BRAF V600E mutations in up to 95% of cases and are typically solid masses. Despite the benign histological nature (grade I according to the World Health Organization classification), craniopharyngiomas may heavily affect long-term survival and quality of life, due to their growth pattern in a critical region for the presence of eloquent neurovascular structures and possible neurological sequelae following their treatment. Clinical manifestations are mostly related to the involvement of hypothalamic-pituitary axis, optic pathways, ventricular system, and major blood vessels of the circle of Willis. Symptoms and signs referable to intracranial hypertension, visual disturbance, and endocrine deficiencies should promptly raise the clinical suspicion for sellar and suprasellar pathologies, advocating further neuroimaging investigations, especially brain MRI. The optimal therapeutic management of craniopharyngiomas is still a matter of debate. Over the last decades, the surgical strategy for craniopharyngiomas, especially in younger patients, has shifted from the aggressive attempt of radical resection to a more conservative and individualized approach via a planned subtotal resection followed by adjuvant radiotherapy, aimed at preserving functional outcomes and minimizing surgery-related morbidity. Whenever gross total removal is not safely feasible, adjuvant radiotherapy (RT) and stereotactic radiosurgery (SRS) have gained an increasingly important role to manage tumor residual or recurrence. The role of intracavitary therapies, including antineoplastic drugs or sealed radioactive sources, is predominantly limited to monocystic craniopharyngiomas as secondary therapeutic option. Novel findings in genetic profiling of craniopharyngiomas have unfold new scenarios in the development of targeted therapies based on brand-new biomolecular markers, advancing the hypothesis of introducing neoadjuvant chemotherapy regimens in order to reduce tumor burden prior to resection. Indeed, the rarity of these neoplasms requires a multispecialty approach involving an expert team of endocrinologists, neurosurgeons, neuro-ophthalmologists, neuroradiologists, radiotherapists, and neuro-oncologists, in order to pursue a significant impact on postoperative outcomes and long-term prognosis.
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Affiliation(s)
- Martina Piloni
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Filippo Gagliardi
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele Bailo
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Boari
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alfio Spina
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy.
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13
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Zou YF, Zhang SY, Li LW, Jing K, Xia L, Sun CX, Wu B. Hub genes for early diagnosis and therapy of adamantinomatous craniopharyngioma. Medicine (Baltimore) 2022; 101:e30278. [PMID: 36123899 PMCID: PMC9478218 DOI: 10.1097/md.0000000000030278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Adamantinomatous craniopharyngioma (ACP) is a subtype of craniopharyngioma, a neoplastic disease with a benign pathological phenotype but a poor prognosis in the sellar region. The disease has been considered the most common congenital tumor in the skull. Therefore, this article aims to identify hub genes that might serve as genetic markers of diagnosis, treatment, and prognosis of ACP. METHODS The procedure of this research includes the acquisition of public data, identification and functional annotation of differentially expressed genes (DEGs), construction and analysis of protein-protein interaction network, and the mining and analysis of hub genes by Spearman-rho test, multivariable linear regression, and receiver operator characteristic curve analysis. Quantitative real-time polymerase chain reaction was used to detect the level of mRNA of relative genes. RESULTS Among 2 datasets, a total of 703 DEGs were identified, mainly enriched in chemical synaptic transmission, cell adhesion, odontogenesis of the dentin-containing tooth, cell junction, extracellular region, extracellular space, structural molecule activity, and structural constituent of cytoskeleton. The protein-protein interaction network was composed of 4379 edges and 589 nodes. Its significant module had 10 hub genes, and SYN1, SYP, and GRIA2 were significantly down-regulated with ACP. CONCLUSION In a word, we find out the DEGs between ACP patients and standard samples, which are likely to play an essential role in the development of ACP. At the same time, these DEGs are of great value in tumors' diagnosis and targeted therapy and could even be mined as biological molecular targets for diagnosing and treating ACP patients.
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Affiliation(s)
- Yang-Fan Zou
- Department of Neurosurgery, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
- Key Laboratory of Head & Neck Cancer Translational Research of Zhejiang Province, Hangzhou, China
| | - Shu-Yuan Zhang
- Department of Neurosurgery, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
- Key Laboratory of Head & Neck Cancer Translational Research of Zhejiang Province, Hangzhou, China
| | - Li-Weng Li
- Department of Neurosurgery, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
- Key Laboratory of Head & Neck Cancer Translational Research of Zhejiang Province, Hangzhou, China
| | - Kai Jing
- Department of Neurosurgery, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
- Key Laboratory of Head & Neck Cancer Translational Research of Zhejiang Province, Hangzhou, China
| | - Liang Xia
- Department of Neurosurgery, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
- Key Laboratory of Head & Neck Cancer Translational Research of Zhejiang Province, Hangzhou, China
| | - Cai-Xing Sun
- Department of Neurosurgery, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
- Key Laboratory of Head & Neck Cancer Translational Research of Zhejiang Province, Hangzhou, China
| | - Bin Wu
- Department of Neurosurgery, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
- Key Laboratory of Head & Neck Cancer Translational Research of Zhejiang Province, Hangzhou, China
- *Correspondence: Bin Wu, Department of Neurosurgery, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, Zhejiang 310022, China (e-mail: )
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14
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Gao Q, Luo J, Pan J, Zhang L, Song D, Zhang M, Xu D, Guo F. Integrative analyses identify HIF-1α as a potential protective role with immune cell infiltration in adamantinomatous craniopharyngioma. Front Immunol 2022; 13:949509. [PMID: 36091021 PMCID: PMC9450013 DOI: 10.3389/fimmu.2022.949509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 07/18/2022] [Indexed: 11/15/2022] Open
Abstract
Craniopharyngiomas (CPs) are histologically benign tumors located in the sellar–suprasellar region. Although the transcriptome development in recent years have deepened our knowledge to the tumorigenesis process of adamantinomatous craniopharyngioma (ACP), the peritumoral immune infiltration of tumor is still not well understood. In this study, weighted gene coexpression network analysis (WGCNA) was applied to identify different gene modules based on clinical characteristics and gene expression, and then, the protein–protein interaction (PPI) network with the Cytohubba plug-in were performed to screen pivotal genes. In addition, immune cell infiltration (ICI) analysis was used to evaluate the immune microenvironment of ACP patients. In total, 8,568 differential expression genes were identified based on our datasets and two microarray profiles from the public database. The functional enrichment analysis revealed that upregulated genes were mainly enriched in immune-related pathways while downregulated genes were shown in the hormone and transduction of signaling pathways. The WGCNA investigated the most relevant modules, and 1,858 hub genes was detected, from which the PPI network identified 14 pivotal genes, and the Hypoxia-inducible factor 1-alpha (HIF-1α) pathway including four critical genes may be involved in the development of ACP. Moreover, naïve CD4+ and CD8+ T cells were decreased while specific subtypes of T cells were significantly increased in ACP patients according to ICI analysis. Validation by immunofluorescence staining revealed a higher expression of HIF-1α in ACP (ACP vs. control) and adult-subtype (adult vs. children), suggesting a possible state of immune system activation. Notably, children with low HIF-1α scores were related to the hypothalamus involvement and hydrocephalus symptoms. In this study, we successfully identified HIF-1α as a key role in the tumorigenesis and development of ACP through comprehensive integrated analyses and systematically investigated the potential relationship with immune cells in ACP. The results may provide valuable resources for understanding the underlying mechanisms of ACP and strengthen HIF-1α as a potential immunotherapeutic target in clinical application.
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Affiliation(s)
- Qiang Gao
- School of Medicine, Tsinghua University, Beijing, China
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, Beijing, China
| | - Jing Luo
- School of Medicine, Tsinghua University, Beijing, China
- Department of Rheumatology, Beijing Tsinghua Changgung Hospital, Beijing, China
| | - Jingjing Pan
- Department of Laboratory Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Longxiao Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dengpan Song
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mingchu Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dingkang Xu
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
- *Correspondence: Dingkang Xu, ; Fuyou Guo,
| | - Fuyou Guo
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Dingkang Xu, ; Fuyou Guo,
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15
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Gadelha MR, Wildemberg LE, Lamback EB, Barbosa MA, Kasuki L, Ventura N. Approach to the Patient: Differential Diagnosis of Cystic Sellar Lesions. J Clin Endocrinol Metab 2022; 107:1751-1758. [PMID: 35092687 DOI: 10.1210/clinem/dgac033] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Indexed: 02/13/2023]
Abstract
Cystic lesions arising in the sellar region are not uncommon and encompass cystic pituitary adenomas, Rathke cleft cysts, craniopharyngiomas, and arachnoid cysts. Their clinical presentation may be similar, including headache, visual field defects, and anterior pituitary hormone deficits, which makes differential diagnosis challenging. On the other hand, imaging features may indicate certain pathologies. In this approach to the patient, we describe the case of a patient who presented with right temporal hemianopsia and a sellar/suprasellar cystic lesion, which was determined to be Rathke cleft cyst. We discuss the imaging characteristics that may suggest a particular diagnosis between Rathke cleft cyst, cystic pituitary adenoma, craniopharyngioma, and arachnoid cyst and propose a flowchart for aiding in the imaging differential diagnosis.
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Affiliation(s)
- Mônica R Gadelha
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
- Neuroendocrine Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
| | - Luiz Eduardo Wildemberg
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
- Neuroendocrine Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
| | - Elisa Baranski Lamback
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
- Neuroendocrine Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
| | - Monique Alvares Barbosa
- Radiology Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
- Radiology Unit, Instituto Nacional de Câncer José Alencar Gomes da Silva, Rio de Janeiro, Brazil
- MRI Unit, Clínica de Diagnóstico por imagem, DASA, Rio de Janeiro, Brazil
| | - Leandro Kasuki
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
- Neuroendocrine Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
- Endocrinology Division, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil
| | - Nina Ventura
- Radiology Unit, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
- Neuroradiology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
- Neuroradiology Unit, Samaritano Hospital, Grupo Fleury, Rio de Janeiro, Brazil
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16
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Zucchini S, Di Iorgi N, Pozzobon G, Pedicelli S, Parpagnoli M, Driul D, Matarazzo P, Baronio F, Crocco M, Iudica G, Partenope C, Nardini B, Ubertini G, Menardi R, Guzzetti C, Iughetti L, Aversa T, Di Mase R, Cassio A. Management of Childhood-onset Craniopharyngioma in Italy: A Multicenter, 7-Year Follow-up Study of 145 Patients. J Clin Endocrinol Metab 2022; 107:e1020-e1031. [PMID: 34718649 DOI: 10.1210/clinem/dgab784] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Nationwide data on children diagnosed with craniopharyngioma (CP) are not available in Italy. OBJECTIVE This work aimed to identify patients' characteristics, type of surgical approach, complications and recurrences, number of pituitary deficits, and number of patients starting growth hormone (GH) treatment. METHODS A retrospective multicenter collection took place of 145 patients aged 0 to 18 years who underwent surgery for CP between 2000 and 2018, and followed up in 17 Italian centers of pediatric endocrinology. RESULTS Age at diagnosis was 8.4 ± 4.1 years. Duration of symptoms was 10.8 ± 12.5 months and headache was most frequent (54%), followed by impaired growth (48%) and visual disturbances (44%). Most lesions were suprasellar (85%), and histology was adamantinomatous in all cases but two. Surgical approach was transcranial (TC) in 67.5% of cases and transsphenoidal (TS) in 31.%. The TC approach was prevalent in all age groups. Postsurgery complications occurred in 53% of cases, with water-electrolyte disturbances most frequent. Radiotherapy was used in 39% of cases. All patients but one presented with at least one hormone pituitary deficiency, with thyrotropin deficiency most frequent (98.3%), followed by adrenocorticotropin (96.8%), arginine vasopressin (91.1%), and GH (77.4%). Body mass index (BMI) significantly increased over time. A hypothalamic disturbance was present in 55% of cases. GH therapy was started during follow-up in 112 patients at a mean age of 10.6 years, and 54 developed a recurrence or regrowth of the residual lesion. CONCLUSION CP is often diagnosed late in Italy, with TC more frequent than the TS surgical approach. Postsurgery complications were not rare, and hypopituitarism developed almost in all cases. BMI shows a tendency to increase overtime.
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Affiliation(s)
- Stefano Zucchini
- Pediatric Endocrine Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Endo-ERN Center for Rare Endocrine Conditions, 40138 Bologna, Italy
| | - Natascia Di Iorgi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, 16147 Genoa, Italy
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
| | - Gabriella Pozzobon
- Department of Paediatrics, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Endo-ERN Center for Rare Endocrine Conditions, 20132 Milan, Italy
| | - Stefania Pedicelli
- Dipartimento Pediatrico Universitario Ospedaliero, IRCCS "Bambino Gesù" Children's Hospital, 00165 Rome, Italy
| | - Maria Parpagnoli
- Auxo-Endocrinology and Gynecology Meyer Children's University Hospital, 50139 Florence, Italy
| | - Daniela Driul
- Division of Pediatrics, University Hospital Santa Maria della Misericordia, ASUFC, 33100 Udine, Italy
| | - Patrizia Matarazzo
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, University of Turin, 10126 Turin, Italy
| | - Federico Baronio
- Pediatric Endocrine Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Endo-ERN Center for Rare Endocrine Conditions, 40138 Bologna, Italy
| | - Marco Crocco
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, 16147 Genoa, Italy
- Neuro-Oncology Unit, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
| | - Giovanna Iudica
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, 16147 Genoa, Italy
| | - Cristina Partenope
- Department of Paediatrics, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Endo-ERN Center for Rare Endocrine Conditions, 20132 Milan, Italy
| | - Beatrice Nardini
- Auxo-Endocrinology and Gynecology Meyer Children's University Hospital, 50139 Florence, Italy
| | - Graziamaria Ubertini
- Dipartimento Pediatrico Universitario Ospedaliero, IRCCS "Bambino Gesù" Children's Hospital, 00165 Rome, Italy
| | - Rachele Menardi
- Division of Paediatrics, Department of Medicine (DAME) University of Udine, 33100 Udine, Italy
| | - Chiara Guzzetti
- Pediatric Endocrine Unit, Pediatric Hospital Microcitemico Antonio Cao, AO Brotzu, 09121 Cagliari, Italy
| | - Lorenzo Iughetti
- Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Tommaso Aversa
- Unit of Paediatrics, Department of Human Pathology of Adulthood and Childhood, University of Messina, 98124 Messina, Italy
| | - Raffaella Di Mase
- University Federico II, Department of Translational Medical Sciences, 80131 Naples, Italy
| | - Alessandra Cassio
- Pediatric Endocrine Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Endo-ERN Center for Rare Endocrine Conditions, 40138 Bologna, Italy
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Kobayashi S, Yamasaki F, Kojima M, Takayasu T, Takano M, Yonezawa U, Taguchi A, Hiyama E, Kinoshita Y. [Craniopharyngioma Mimicking Chordoid Glioma]. Brain Nerve 2022; 74:189-194. [PMID: 35108684 DOI: 10.11477/mf.1416202007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Entirely intrinsic third ventricular craniopharyngiomas showed characteristics of a round/oval shaped tumor, with rare calcification and cyst formation, and pathologically squamous-papillary type with a positive BRAFV600E mutation. We report an extremely rare case of entirely intrinsic third ventricular craniopharyngioma, pathologically adamantiomatous but with BRAFV600E mutation genetically, developed in a 35-year-old female. It was oval-shaped, with no calcification or cyst, and showed homogeneous enhancement. As shown in this case, it was difficult to differentiate this pathology from chordoid glioma of third ventricle, and the difficulty of this differential diagnosis has not been well documented in previous studies. Our case further implied the importance of molecular diagnosis for subclassification of craniopharyngioma. The BRAFV600E-mutated craniopharyngioma could be the target for the development of treatment with preoperative BRAF-inhibitors. Therefore, differentiation between entirely intrinsic third ventricular craniopharyngiomas and chordoid glioma could be new issue. In this report, we discuss about the preoperative differential diagnosis from chordoid glioma and the literature review. (Received 12 August, 2021; Accepted 21 September, 2021; Published 1 February, 2022).
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18
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Prieto R, Barrios L, Pascual JM. Papillary Craniopharyngioma: A Type of Tumor Primarily Impairing the Hypothalamus - A Comprehensive Anatomo-Clinical Characterization of 350 Well-Described Cases. Neuroendocrinology 2022; 112:941-965. [PMID: 35108706 DOI: 10.1159/000521652] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 12/22/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Papillary craniopharyngiomas (PCPs) represent a rare histological type of craniopharyngiomas (CPs) usually involving the hypothalamus. This study systematically analyzes the clinical-anatomical correlation between tumor topography and symptoms related to hypothalamic dysfunction in the largest series of PCPs ever gathered. METHODS From 5,346 CP reports published from 1856 to 2021, we selected 350 well-described cases of the squamous-papillary type. Clinical presentation, tumor topography, severity of hypothalamic adhesion, patient outcome, and tumor recurrence were thoroughly analyzed. RESULTS PCPs predominantly occur in adult (96.3%), male (61.7%) patients presenting with headache (63.4%), visual alterations (56.2%), and psychiatric disturbances (50.4%). Most PCPs are solid (50%), round (72%) lesions that occupy the third ventricle (3V, 94.8%) and show low-risk severity adhesions to the hypothalamus (66.8%). Two major topographical categories can be found: strictly 3V (57.5%), growing above an intact 3V floor, and not-strictly or infundibulo-tuberal (32.9%), expanding at the infundibulum and/or tuber cinereum. The hypothalamic syndrome predominated among strictly 3V PCPs (p < 0.001). Psychiatric symptoms (p < 0.001) and high-risk hypothalamic attachments (p = 0.031) related to unfavorable postoperative outcomes among patients treated from 2006 onwards. The not-strictly 3V topography was identified as the major predictor of high-risk hypothalamic attachments (71.2% correctly predicted), which, along with incomplete tumor removal (p = 0.018), underlies the higher tumor recurrence of this topography (p = 0.001). CONCLUSIONS This systematic review evidences that PCP topography is a major determinant of hypothalamic-related symptoms, type of hypothalamic attachments, and tumor recurrence rate. Accurate preoperative definition of PCP-hypothalamus relationships is essential for the judicious, safe management of these complex lesions.
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Affiliation(s)
- Ruth Prieto
- Department of Neurosurgery, Puerta de Hierro University Hospital, Madrid, Spain
| | - Laura Barrios
- Department of Statistics, Computing Center, CSIC, Madrid, Spain
| | - José M Pascual
- Department of Neurosurgery, La Princesa University Hospital, Madrid, Spain
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19
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Verweij T, Slagboom TNA, van Varsseveld NC, van der Lely AJ, Drent ML, van Bunderen CC. Cardiovascular risk profile in growth hormone-treated adults with craniopharyngioma compared to non-functioning pituitary adenoma: a national cohort study. Eur J Endocrinol 2021; 185:793-801. [PMID: 34605771 DOI: 10.1530/eje-21-0419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 10/04/2021] [Indexed: 11/08/2022]
Abstract
CONTEXT Cardiovascular (CV) risk profile might differ between growth hormone-treated patients with craniopharyngioma and non-functioning pituitary adenoma (NFPA), since patients with craniopharyngioma more frequently suffer from hypothalamic metabolic disruption. OBJECTIVE The aim of this study is to investigate the CV risk profile in adult patients with craniopharyngioma compared to NFPA before and after treatment with growth hormone (GH) replacement therapy due to severe GH deficiency. DESIGN A sub-analysis of the Dutch National Registry of Growth Hormone Treatment in Adults was performed, in which we compared 291 patients with craniopharyngioma to 778 patients with NFPA. CV risk profile and morbidity were evaluated at baseline and during long-term follow-up within and between both groups. RESULTS At baseline, patients with craniopharyngioma demonstrated higher BMI than patients with NFPA, and men with craniopharyngioma showed greater waist circumference and lower HDL compared to men with NFPA. During follow-up, BMI, as well as diastolic blood pressure among patients using antihypertensive drugs, deteriorated in the craniopharyngioma group compared to the NFPA group. Lipid profile improved similarly in both groups over time. No differences were found between groups in the occurrence of diabetes mellitus, cerebrovascular accidents, CV disease, or overall mortality. CONCLUSION This study suggests that overall CV risk profile is worse in craniopharyngioma patients with GH deficiency compared to patients with NFPA. During GH replacement therapy, patients with craniopharyngioma demonstrated an increase in BMI over time, where BMI remained stable in patients with NFPA. Also, diastolic blood pressure did not improve with antihypertensive drugs in craniopharyngioma patients as seen in patients with NFPA.
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Affiliation(s)
- Tim Verweij
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine, Section of Endocrinology, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Tessa N A Slagboom
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine, Section of Endocrinology, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | | | - Aart-Jan van der Lely
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Madeleine L Drent
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine, Section of Endocrinology, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Christa C van Bunderen
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine, Section of Endocrinology, Amsterdam Neuroscience, Amsterdam, the Netherlands
- Radboud University Medical Center, Division of Endocrinology, Department of Internal Medicine, Nijmegen, the Netherlands
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20
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Abstract
Craniopharyngiomas are rare embryonic malformational tumors of the sellar/parasellar region, classified by the World Health Organization (WHO) as tumors with low-grade malignancy (WHO I). The childhood adamantinomatous subtype of craniopharyngioma is usually cystic with calcified areas. At the time of diagnosis, hypothalamic/pituitary deficits, visual disturbances, and increased intracranial pressure are major symptoms. The treatment of choice in case of favorable tumor location (without hypothalamic involvement) is complete resection. It is important to ensure that optical and hypothalamic functionality are preserved. In case of unfavorable tumor location, that is with hypothalamic involvement, a hypothalamus-sparing surgical strategy with subsequent local irradiation of residual tumor is recommended. In the further course of the disease, recurrences and progression often occur. Nevertheless, overall survival rates are high at 92%. Severe impairment of quality of life and comorbidities such as metabolic syndrome, hypothalamic obesity, and neurological consequences can be observed in patients with disease- and/or treatment-related lesions of hypothalamic structures. Childhood-onset craniopharyngioma frequently manifests as a chronic disease so that patients require lifelong, continuous care by experienced multidisciplinary teams to manage clinical and quality of life consequences. For this review, a search for original articles and reviews published between 1986 and 2020 was performed in Pubmed, Science Citation Index Expanded, EMBASE, and Scopus. The search terms used were "craniopharyngioma, hypothalamus, pituitary obesity, irradiation, neurosurgery.
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Affiliation(s)
- Anna Otte
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children´s Hospital, Carl von Ossietzky University Oldenburg, Klinikum Oldenburg AöR, 26133 Oldenburg, Germany
| | - Hermann L Müller
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children´s Hospital, Carl von Ossietzky University Oldenburg, Klinikum Oldenburg AöR, 26133 Oldenburg, Germany
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21
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Fukuhara N, Iwata T, Inoshita N, Yoshimoto K, Kitagawa M, Fukuhara H, Tatsushima K, Yamaguchi-Okada M, Takeshita A, Ito J, Takeuchi Y, Yamada S, Nishioka H. Immunohistochemistry or Molecular Analysis: Which Method Is Better for Subtyping Craniopharyngioma? Endocr Pathol 2021; 32:262-268. [PMID: 32965631 DOI: 10.1007/s12022-020-09644-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2020] [Indexed: 10/23/2022]
Abstract
Craniopharyngioma (CP) is mainly classified into two pathological subtypes: adamantinomatous (ACP) and papillary (PCP). CTNNB1 (β-catenin) mutations are detected in ACPs, and the BRAF V600E mutation is detected in PCPs. However, genetic analysis is not always possible in general medical practice. In this study, we investigated whether immunohistochemistry could replace genetic analysis as an aid in subtype diagnosis. Here, 38 CP patients who had undergone their first tumor resection were included. Among the 38 cases, 22 were morphologically diagnosed as ACP, 10 cases were diagnosed as PCP, and six cases were diagnosed as undetermined CP that were morphologically difficult to classify as either ACP or PCP. Results of immunohistochemistry and genetic analysis and clinical features were compared. Based on the immunohistochemistry, 26 (22 ACPs and four undetermined CPs) showed nuclear β-catenin expression, 11 (nine PCPs and two undetermined CPs) exhibited positive BRAF V600E immunostaining, and one PCP showed membranous β-catenin expression and negative BRAF V600E immunostaining. Among the 26 nuclear β-catenin expression cases, 11 had CTNNB1 mutations; however, 15 cases had mutations of neither CTNNB1 nor BRAF V600E. All 11 BRAF V600E immunopositive cases had BRAF V600E mutations. When comparing clinical features, pediatric patients and those with tumor calcification and less solid components on MRI more commonly had nuclear β-catenin expression tumors than BRAF V600E immunopositive tumors, reflecting the differences in clinical features between ACP and PCP. Accordingly, immunohistochemistry can replace genetic analysis as an aid to determine the subtype diagnosis of CP in general medical practice.
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Affiliation(s)
- Noriaki Fukuhara
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo, Japan
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Takeo Iwata
- Department of Functional Morphology, Niigata University of Pharmacy and Applied life Sciences, Niigata, Japan
- Department of Medical Pharmacology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Naoko Inoshita
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo, Japan.
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
- Okinaka Memorial Institute for Medical Research, Tokyo, Japan.
- Department of Pathology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, 35-2 Sakae-cho, Itabashi-ku, Tokyo, 173-0015, Japan.
| | - Katsuhiko Yoshimoto
- Department of Medical Pharmacology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Masanobu Kitagawa
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hirokazu Fukuhara
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo, Japan
| | - Keita Tatsushima
- Department of Endocrinology and Metabolism, Toranomon Hospital, Tokyo, Japan
| | | | - Akira Takeshita
- Okinaka Memorial Institute for Medical Research, Tokyo, Japan
- Department of Endocrinology and Metabolism, Toranomon Hospital, Tokyo, Japan
| | - Junko Ito
- Department of Pediatrics, Toranomon Hospital, Tokyo, Japan
| | - Yasuhiro Takeuchi
- Okinaka Memorial Institute for Medical Research, Tokyo, Japan
- Department of Endocrinology and Metabolism, Toranomon Hospital, Tokyo, Japan
| | - Shozo Yamada
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo, Japan
- Department of Neurosurgery, Tokyo Neurological Center, Tokyo, Japan
| | - Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo, Japan
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22
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Abstract
Sellar region lesions include a broad range of benign and malignant neoplastic as well as non-neoplastic entities, many of which are newly described or have recently revised nomenclature. In contrast to other intracranial sites, imaging features are relatively less specific, and the need for histopathological diagnosis is of paramount importance. This review will describe pituitary adenomas, inflammatory lesions, and tumors unique to the region (craniopharyngioma) as well as tumors which may occur in but are not exclusively localized to the sellar location (schwannoma, metastasis, etc.).
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Affiliation(s)
- Katherine E Schwetye
- Department of Pathology, Saint Louis University, 1402 South Grand Boulevard, St Louis, MO 63104, USA
| | - Sonika M Dahiya
- Department of Pathology and Immunology, Washington University in St. Louis, 660 South Euclid Avenue, St Louis, MO 63110, USA.
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23
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Sowithayasakul P, Boekhoff S, Bison B, Müller HL. Pregnancies after Childhood Craniopharyngioma: Results of KRANIOPHARYNGEOM 2000/2007 and Review of the Literature. Neuroendocrinology 2021; 111:16-26. [PMID: 32074615 DOI: 10.1159/000506639] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 02/19/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Data on female fertility, pregnancy, and outcome of offspring after childhood-onset craniopharyngioma (CP) are rare. STUDY DESIGN Observational study on pregnancy rate and offspring outcome in female CP patients recruited in KRANIOPHARYNGEOM 2000/2007 since 2000. RESULTS A total of 451 CP patients (223 female) have been recruited, and 269 (133 female) were postpubertal at study. Six of 133 female CP patients (4.5%) with a median age of 14.9 years at CP diagnosis had 9 pregnancies, giving birth to 10 newborns. Three patients achieved complete surgical resections. No patient underwent postoperative irradiation. Five natural pregnancies occurred in 3 CP patients without pituitary deficiencies. Four pregnancies in 3 CP patients with hypopituitarism were achieved under assisted reproductive techniques (ART) (median 4.5 cycles, range: 3-6 cycles). Median maternal age at pregnancy was 30 years (range: 22-41 years). Six babies (60%) were delivered by caesarean section. Median gestational age at delivery was 38 weeks (range: 34-43 weeks); median birth weight was 2,920 g (range: 2,270-3,520 g), the rate of preterm delivery was 33%. Enlargements of CP cysts occurred in 2 women during pregnancy. Other complications during pregnancy, delivery, and postnatal period were not observed. CONCLUSIONS Pregnancies after CP are rare and were only achieved after ART in patients with hypopituitarism. Close monitoring by an experienced reproductive physician is necessary. Due to a potentially increased risk for cystic enlargement, clinical, ophthalmological, and MRI monitoring are recommended in patients at risk. Severe perinatal complications, birth defects, and postnatal morbidity of mothers and offspring were not observed.
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Affiliation(s)
- Panjarat Sowithayasakul
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children's Hospital, Klinikum Oldenburg AöR, Oldenburg, Germany
- Department of Pediatrics, Faculty of Medicine, Srinakharinwirot University, Bangkok, Thailand
| | - Svenja Boekhoff
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children's Hospital, Klinikum Oldenburg AöR, Oldenburg, Germany
| | - Brigitte Bison
- Department of Neuroradiology, University Hospital, Würzburg, Germany
| | - Hermann L Müller
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children's Hospital, Klinikum Oldenburg AöR, Oldenburg, Germany,
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24
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Iglesias P, Nocete I, Moure Rodríguez MD, Venegas-Moreno E, Ares J, Biagetti B, Rodríguez Berrocal V, Guerrero-Pérez F, Vicente A, Villar-Taibo R, Cordido F, Paja M, Glerean M, González Rivera N, Dios Fuentes E, Blanco C, Alvaréz-Escolá C, Martín T, Webb SM, Bernabéu I, Villabona C, Soto-Moreno A, Gaztambide S, Díez JJ. Craniopharyngioma in the Elderly: A Multicenter and Nationwide Study in Spain. Neuroendocrinology 2021; 111:925-936. [PMID: 33040060 DOI: 10.1159/000512161] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 10/03/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Craniopharyngioma (CP) is a rare tumor in the elderly whose clinical features and prognosis are not well known in this population. AIM To evaluate the clinicopathological features and therapeutic outcomes of CP diagnosed in the elderly. PATIENTS AND METHODS This was a retrospective, multicenter, national study of CP patients diagnosed over the age of 65 years and surgically treated. RESULTS From a total of 384 adult CP patients, we selected 53 (13.8%) patients (27 women [50.9%], mean age 72.3 ± 5.1 years [range 65-83 years]) diagnosed after the age of 65 years. The most common clinical symptoms were visual field defects (71.2%) followed by headache (45.3%). The maximum tumor diameter was 2.9 ± 1.1 cm. In most patients, the tumor was suprasellar (96.2%) and mixed (solid-cystic) (58.5%). The surgical approach most commonly used was transcranial surgery (52.8%), and more than half of the patients (54.7%) underwent subtotal resection (STR). Adamantinomatous CP and papillary CP were present in 51 and 45.1%, respectively, with mixed forms in the remaining. Surgery was accompanied by an improvement in visual field defects and in headaches; however, pituitary hormonal hypofunction increased, mainly at the expense of an increase in the prevalence of diabetes insipidus (DI) (from 3.9 to 69.2%). Near-total resection (NTR) was associated with a higher prevalence of DI compared with subtotal resection (87.5 vs. 53.6%, p = 0.008). Patients were followed for 46.7 ± 40.8 months. The mortality rate was 39.6% with a median survival time of 88 (95% CI: 57-118) months. DI at last visit was associated with a lower survival. CONCLUSION CP diagnosed in the elderly shows a similar distribution by sex and histologic forms than that diagnosed at younger ages. At presentation, visual field alterations and headaches are the main clinical symptoms which improve substantially with surgery. However, surgery, mainly NTR, is accompanied by worsening of pituitary function, especially DI, which seems to be a predictor of mortality in this population.
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Affiliation(s)
- Pedro Iglesias
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana (IDIPHISA), Madrid, Spain,
| | - Ignacio Nocete
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana (IDIPHISA), Madrid, Spain
| | - María Dolores Moure Rodríguez
- Department of Endocrinology, Hospital Universitario Cruces, Biocruces Bizkaia, EndoERN, Cruces Barakaldo.Bizkaia, Barakaldo, Spain
| | - Eva Venegas-Moreno
- Department of Endocrinology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Jessica Ares
- Department of Endocrinology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Betina Biagetti
- Department of Endocrinology, Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Fernando Guerrero-Pérez
- Department of Endocrinology, Hospital de Bellvitge (L'Hospitalet de Llobregat), Barcelona, Spain
| | - Almudena Vicente
- Department of Endocrinology, Hospital Virgen de la Salud, Toledo, Spain
| | - Rocío Villar-Taibo
- Department of Endocrinology, Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Fernando Cordido
- Department of Endocrinology, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
- Facultad de Ciencias de la Salud, Universidad de A Coruña, A Coruña, Spain
| | - Miguel Paja
- Department of Endocrinology, Hospital Universitario de Basurto, Bilbao, Spain
| | - Mariela Glerean
- Department of Endocrinology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Department of Endocrinology, Hospital Sant Pau, Department of Medicine/Endocrinology, IIB-Sant Pau, Research Center for Pituitary Diseases, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Elena Dios Fuentes
- Department of Endocrinology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Concepción Blanco
- Department of Endocrinology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | | | - Tomás Martín
- Department of Endocrinology, Hospital Universitario Virgen de la Macarena, Sevilla, Spain
| | - Susan M Webb
- Department of Endocrinology, Hospital Sant Pau, Department of Medicine/Endocrinology, IIB-Sant Pau, Research Center for Pituitary Diseases, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ignacio Bernabéu
- Department of Endocrinology, Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Carles Villabona
- Department of Endocrinology, Hospital de Bellvitge (L'Hospitalet de Llobregat), Barcelona, Spain
| | - Alfonso Soto-Moreno
- Department of Endocrinology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Sonia Gaztambide
- Department of Endocrinology, Hospital Universitario Cruces, Biocruces Bizkaia, EndoERN, Cruces Barakaldo.Bizkaia, Barakaldo, Spain
- UPV-EHU, CIBERDEM, CIBERER, Barakaldo, Spain
| | - Juan J Díez
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana (IDIPHISA), Madrid, Spain
- Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
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25
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Nuijts MA, Veldhuis N, Stegeman I, van Santen HM, Porro GL, Imhof SM, Schouten–van Meeteren AYN. Visual functions in children with craniopharyngioma at diagnosis: A systematic review. PLoS One 2020; 15:e0240016. [PMID: 33002047 PMCID: PMC7529266 DOI: 10.1371/journal.pone.0240016] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/18/2020] [Indexed: 02/06/2023] Open
Abstract
Childhood craniopharyngioma is a rare and slow growing brain tumour, often located in the sellar and suprasellar region. It commonly manifests with visual impairment, increased intracranial pressure and hypothalamic and/or pituitary deficiencies. Visual impairment in childhood adversely affects a child’s daily functioning and quality of life. We systematically reviewed the literature to provide an extensive overview of the visual function in children with craniopharyngioma at diagnosis in order to estimate the diversity, magnitude and relevance of the problem of visual impairment. Of the 543 potentially relevant articles, 84 studies met our inclusion criteria. Visual impairment at diagnosis was reported in 1041 of 2071 children (50.3%), decreased visual acuity was reported in 546 of 1321 children (41.3%) and visual field defects were reported in 426 of 1111 children (38.3%). Other ophthalmological findings described were fundoscopic (32.5%) and orthoptic abnormalities (12.5%). Variations in ophthalmological testing methods and ophthalmological definitions precluded a meta-analysis. The results of this review confirm the importance of ophthalmological examination in children with craniopharyngioma at diagnosis in order to detect visual impairment and provide adequate support. Future studies should focus on long-term visual follow-up of childhood craniopharyngioma in response to different treatment strategies to provide insight in risks and ways to prevent further loss of vision.
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Affiliation(s)
- Myrthe A. Nuijts
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- * E-mail:
| | - Nienke Veldhuis
- Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
| | - Inge Stegeman
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hanneke M. van Santen
- Department of Pediatric Endocrinology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Giorgio L. Porro
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Saskia M. Imhof
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht, The Netherlands
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26
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Abstract
Energy homeostasis, appetite, and satiety are modulated by a complex neuroendocrine system regulated by the hypothalamus. Dysregulation of this system resulting in hypothalamic obesity (HO) is caused by brain tumors, neurosurgery, and/or cranial irradiation. Craniopharyngioma (CP) is a paradigmatic disease with regard to the development of HO. Initial hypothalamic involvement of CP and/or treatment-related damage to hypothalamic-pituitary axes result in HO. Attempts to control HO with lifestyle interventions have not been satisfactory. No generally accepted pharmacologic or bariatric therapy for HO in CP has been effective in randomized controlled trials. Accordingly, prevention of HO is recommended.
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Affiliation(s)
- Hermann L Müller
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children's Hospital, Klinikum Oldenburg AöR, Rahel-Straus-Strasse 10, Oldenburg 26133, Germany.
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27
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Snyder MH, Marino AC, Shepard MJ, Amoakohene P, Berry DM, Mukherjee S, Mattos JL, Jane JA. Neurocysticercosis Presenting as an Isolated Suprasellar Lesion. World Neurosurg 2020; 141:352-356. [PMID: 32522639 DOI: 10.1016/j.wneu.2020.05.212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although extraparenchymal neurocysticercosis (NCC) is well established, presentation in the suprasellar space is rare. When presenting in the suprasellar space, the imaging characteristics may mimic more common lesions including craniopharyngioma and Rathke cleft cyst depending on the life cycle of the parasite. Although antiparasitic medical therapy may be effective for viable NCC, it is not routinely employed for calcified NCC. CASE DESCRIPTION This report presents a 39-year-old male patient who presented with profound visual decline secondary to a partially calcified suprasellar NCC. Suprasellar NCC was presumed based on specific radiologic findings, which are discussed. Medical therapy was not offered because of the proximity to the optic chiasm and the partial calcification of the lesion leading to the presumption that the mass was nonviable. The patient underwent successful endoscopic endonasal resection of the suprasellar NCC and experienced significant improvement in vision. Despite the calcification, pathological evaluation revealed that a portion remained viable. CONCLUSIONS Regardless of the life cycle stage, endonasal resection offers a minimally invasive approach for suprasellar NCC; treatment can be tailored to the patient's presentation and stage of infection.
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Affiliation(s)
- M Harrison Snyder
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Alexandria C Marino
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Matthew J Shepard
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Peggy Amoakohene
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Debra M Berry
- Division of Neuropathology, Department of Pathology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Sugoto Mukherjee
- Division of Neuroradiology, Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jose L Mattos
- Division of Rhinology and Endoscopic Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - John A Jane
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.
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28
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Abstract
Craniopharyngioma (CP) is a rare embryonic malformation of the sellar/parasellar region with a low histological grade. Clinical manifestations are related to hypothalamic/pituitary deficiencies, visual impairment, and increased intracranial pressure. Recent insight into the molecular pathogenesis of CP opens new perspectives on targeted therapy in papillary CP harboring BRAF-V600E mutations. Further research to elucidate pathogenic mechanisms and hopefully prevent hypothalamic involvement of CP is warranted. If the tumor is favorably localized, the therapy of choice is complete resection, with care taken to preserve the optical and hypothalamic functions. In patients with unfavorable tumor localization (i.e., hypothalamic involvement), the recommended therapy is a limited hypothalamus-sparing surgical strategy followed by local irradiation. Surgical treatment strategies should be based on a multidisciplinary approach involving experienced teams. Centralizing the treatment of CP in experienced "centers of excellence" and multicenter-based networks for reference assessments should be considered to assure a high standard of treatment quality. CP recurrence and progression are frequent. Irradiation has proven effective in reducing recurrences and progression. Proton beam therapy, available in a wider range in the near future, will help to avoid radio-oncological side effects. Anatomical involvement and/or surgical lesions of posterior hypothalamic areas can result in serious sequelae that compromise quality of life (QoL), such as hypothalamic obesity and psychopathological symptoms. Novel insights into neuropsychological sequelae after CP occurrence should be the basis for the development of therapeutic neuropsychological interventions. CP should be managed as a frequently chronic disease, providing ongoing care of pediatric and adult patients' clinical and QoL consequences by experienced multidisciplinary teams.
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Affiliation(s)
- Hermann L Müller
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children's Hospital, Klinikum Oldenburg AöR, Oldenburg, Germany,
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29
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Abstract
Craniopharyngiomas (CP) are rare brain tumors managed primarily with surgery and radiotherapy. There are 2 phenotypes of CP, i.e., one with a rather good outcome without hypothalamic damage and another with hypothalamic damage. With hypothalamic damage, progressive disease with recurrent operations and additional cranial radiotherapy often result in hypothalamic obesity, an affected psychosocial life, and cognitive dysfunction. The morbidity and mortality are increased for particularly cerebrovascular diseases. Preoperative hypothalamic involvement to predict hypothalamic damage is important for decision making for hypothalamus-sparing surgery. Also a postoperative hypothalamic damage evaluation with the use of hypothalamus volume measurement can predict hypothalamic obesity, which is important for early treatment options. The morbidity of CP includes cognitive dysfunction with attention deficits and impaired episodic memory and processing speed. Again patients with hypothalamic damage are more affected. Treatment options of hypothalamic obesity in the chronic phase are scarce and not convincingly successful. The most optimal situation is to try to hinder or stop the evolution of hypothalamic obesity. Prevention of hypothalamic damage is recommended, with special regard to hypothalamus-sparing therapeutic approaches that respect the integrity of essential nuclei located in both the medial and the posterior hypothalamic areas.
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Affiliation(s)
- Eva-Marie Erfurth
- Department of Endocrinology, Skåne University Hospital, Lund, Sweden,
- Clinical Sciences, Lund University, Lund, Sweden,
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Mende KC, Kellner T, Petersenn S, Honegger J, Evangelista-Zamora R, Droste M, Stalla G, Deutschbein T, Wang Y, Moskopp D, Knappe U, Schilbach K, Flitsch J. Clinical Situation, Therapy, and Follow-Up of Adult Craniopharyngioma. J Clin Endocrinol Metab 2020; 105:5582673. [PMID: 31589293 DOI: 10.1210/clinem/dgz043] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 09/20/2019] [Indexed: 12/21/2022]
Abstract
CONTEXT Craniopharyngioma is a rare neoplastic entity of the central nervous system. Childhood-onset craniopharyngioma is the subject of frequent research whereas the information on adult-onset craniopharyngioma is scarce. OBJECTIVE The objective of this study was to examine the level of daily impairment in adult patients suffering from craniopharyngioma. DESIGN Noninterventional patient registry indexed as PV4842 with the local ethics committee. SETTING The study is set in a hospitalized and ambulatory setting. PATIENTS 148 patients with adult-onset craniopharyngioma were recruited from 8 centers, 22 prospectively and 126 retrospectively. Mean follow-up was 31 months. INTERVENTIONS No interventions performed. MAIN OUTCOME MEASURES Complications, symptoms, body mass index (BMI), and quality of life (QoL; EORTC QLQ C30 and BN20) were recorded preoperatively and at follow-up. The hypotheses tested were generated after data collection. RESULTS Complications were more frequent after transcranial than transsphenoidal approaches (31 % vs. 11%; P < 0.01). Preoperative obesity was present in 0% papillary and in 38% of all adamantinomatous craniopharyngiomas (P = 0.05), and diabetes insipidus was more frequent for papillary craniopharyngioma (36.8% vs. 16,7%; P < 0.05). Hormone deficits at follow-up were reduced in 16.9%, equal in 31.4%, and increased in 63.6% (P < 0.001). BMI increased from 28.7 ± 7.4 kg/m2 before surgery to 30.2 ± 7.4 kg/m2 at follow-up (P < 0.001). In QoL, a decrease of future uncertainty (62.5 vs. 36.8; P = 0.02) and visual disorders (38.9 vs. 12.0; P = 0.01) were observed in the prospective collective after surgery. CONCLUSIONS Adult craniopharyngioma is associated with a complex sociological and psychological burden and hypothalamic dysfunction, warranting further investigation and emphasizing the need for a wider treatment approach.
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Affiliation(s)
| | - Teresa Kellner
- Department of Neurosurgery, Hamburg University Medical Center, Hamburg, Germany
| | - Stephan Petersenn
- ENDOC Praxis für Endokrinologie, Andrologie und medikamentöse Tumortherapie, Hamburg, Germany
| | - Juergen Honegger
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
| | | | | | | | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, Würzburg, Germany
| | - Yawen Wang
- Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Dag Moskopp
- Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Ulrich Knappe
- Department of Neurosurgery, Johannes Wesling Klinikum Minden, Ruhr University Bochum, Minden, Germany
| | - Katharina Schilbach
- Ludwig-Maximilians-University of Munich, Department of Internal Medicine IV, Munich, Germany
| | - Joerg Flitsch
- Department of Neurosurgery, Hamburg University Medical Center, Hamburg, Germany
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Abstract
Craniopharyngiomas are rare malformational tumours of low histological malignancy arising along the craniopharyngeal duct. The two histological subtypes, adamantinomatous craniopharyngioma (ACP) and papillary craniopharyngioma (PCP), differ in genesis and age distribution. ACPs are diagnosed with a bimodal peak of incidence (5-15 years and 45-60 years), whereas PCPs are restricted to adults mainly in the fifth and sixth decades of life. ACPs are driven by somatic mutations in CTNNB1 (encoding β-catenin) that affect β-catenin stability and are predominantly cystic in appearance. PCPs frequently harbour somatic BRAFV600E mutations and are typically solid tumours. Clinical manifestations due to increased intracranial pressure, visual impairment and endocrine deficiencies should prompt imaging investigations, preferentially MRI. Treatment comprises neurosurgery and radiotherapy; intracystic chemotherapy is used in monocystic ACP. Although long-term survival is high, quality of life and neuropsychological function are frequently impaired due to the close anatomical proximity to the optic chiasm, hypothalamus and pituitary gland. Indeed, hypothalamic involvement and treatment-related hypothalamic lesions frequently result in hypothalamic obesity, physical fatigue and psychosocial deficits. Given the rarity of these tumours, efforts to optimize infrastructure and international collaboration should be research priorities.
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Affiliation(s)
- Hermann L Müller
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children's Hospital, Klinikum Oldenburg AöR, Oldenburg, Germany.
| | - Thomas E Merchant
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Juan-Pedro Martinez-Barbera
- Developmental Biology and Cancer Programme, Birth Defects Research Centre, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Stephanie Puget
- Service de Neurochirurgie, Hôpital Necker-Enfants Malades, Sorbonne Paris Cité, Paris, France
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Apps JR, Hutchinson JC, Shelmerdine S, Virasami A, Winter E, Jacques TS, Martinez-Barbera JP, Arthurs O, Czech T. Learning from cases: Analysis of two cases of craniopharyngioma from the 19 th to the 21 st centuries. F1000Res 2019; 8:1544. [PMID: 32047602 PMCID: PMC6993819 DOI: 10.12688/f1000research.19626.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2019] [Indexed: 11/20/2022] Open
Abstract
This manuscript describes the study of two cases of craniopharyngioma, which have been examined repeatedly over three separate centuries. This includes analysis by Josef Engel in 1839, who sought to uncover the physiological role of the pituitary gland; Jacob Erdheim in 1904, who initially described the disease we now call craniopharyngioma, and recent high resolution MRI and micro-CT imaging and attempted DNA analyses of the tumours. The cases highlight how, rightly or wrongly, our interpretation of data is shaped by the technologies, methodologies and prevailing theories of a given time.
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Affiliation(s)
- John R. Apps
- UCL Great Ormond Street Institute of Child Health, UCL, London, UK
- Cancer Research UK Clinical Trials Unit, University of Birmingham, UK, Birmingham, UK, UK
| | - J. Ciaran Hutchinson
- UCL Great Ormond Street Institute of Child Health, UCL, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Susan Shelmerdine
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Alex Virasami
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Thomas S. Jacques
- UCL Great Ormond Street Institute of Child Health, UCL, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Owen Arthurs
- UCL Great Ormond Street Institute of Child Health, UCL, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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33
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Schildermans J. [Psychosis and behavioural problems as first symptoms of brain tumour?]. Tijdschr Psychiatr 2019; 61:53-56. [PMID: 30640407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
A craniopharyngioma is a rare, slow-growing tumour in the pituitary gland. Brain tumours usually present with obvious neurological or other physical symptoms, whereas psychiatric symptoms as primary signs are rare. The presented case, in which psychosis and behavioural problems predominated, concerned a 42-year-old patient. Although the tumour was very large when diagnosed, there were no prior neurological signs or signs in the blood sample. Final imaging and histology confirmed the diagnosis of a craniopharyngioma. This case indicates the importance of being sufficiently alert as a psychiatrist when patients are admitted.
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Bishokarma S, Shrestha S, Ranabhat K, Koirala S, Shrestha D, Panth R, Gongal DN. Outcome of Surgical Resection of Craniopharyngioma:Single Center 12 Years' Experience. Kathmandu Univ Med J (KUMJ) 2018; 16:328-332. [PMID: 31729348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Background Craniopharyngiomas (CPs) are rare epithelial tumors arising from the Rathke's pouch remnant located along the path of the craniopharyngeal duct accounting for 1.2-4% of all primary intracranial brain tumors, the primary treatment of which is surgery. Objective Whether radical surgical resection or partial resection followed by radiotherapy is a topic of debate. We presented our 12 years single center experience on surgical resection of craniopharyngioma. Method This was a descriptive cross-sectional study conducted among forty-five patients who underwent transcranial resection of craniopharyngioma during a period of 12 years. Data were collected from medical record archives. Glassgow outcome score (GOS), electrolyte imbalance and visual complications were assessed as outcome measure. GOS > 3 was considered favorable while score ≤ 3 was considered unfavorable. Recurrence of tumors were analyzed. Result Out of 45 patients, 28 patients were male with male to female ration of 1.64. Mean age was 32.22±16.42 years. Supra-sellar craniopharyngioma were the most common location. Gross total resection was accomplished in 32 patients (71.1%) while subtotal resection among 13 patients (28.9%). Post-operative Diabetes Insipidus was developed among 35 patients (77.7%). Adamantinomatous craniopharyngioma was the most common histopathological type. Postoperative MRI with contrast was repeated to ascertain the completeness of resection. All patient with subtotal resection received radiotherapy. Follow up period ranged from 3 months to 8 years with mean of 4.2 years. Favorable outcome (GOS>3) was seen among 41 patients while unfavorable among 4 patients. Recurrence seen among 4 patients (8.9%). Overall mortality was 4 (8.8%). Conclusion Gross total excision of craniopharyngioma has a favorable outcome with acceptable morbidity.
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Affiliation(s)
- S Bishokarma
- Department of Neurosurgery, Upendra Devkota Memorial National Institute of Neurological and Allied Sciences, Bansbari, Kathmandu, Nepal
| | - S Shrestha
- Department of Neurosurgery, Upendra Devkota Memorial National Institute of Neurological and Allied Sciences, Bansbari, Kathmandu, Nepal
| | - K Ranabhat
- Department of Radiology, Upendra Devkota Memorial National Institute of Neurological and Allied Sciences, Bansbari, Kathmandu, Nepal
| | - S Koirala
- Department of Neurosurgery, Upendra Devkota Memorial National Institute of Neurological and Allied Sciences, Bansbari, Kathmandu, Nepal
| | - D Shrestha
- Department of Neurosurgery, Upendra Devkota Memorial National Institute of Neurological and Allied Sciences, Bansbari, Kathmandu, Nepal
| | - R Panth
- Department of Pathology, Upendra Devkota Memorial National Institute of Neurological and Allied Sciences, Bansbari, Kathmandu, Nepal
| | - D N Gongal
- Department of Neurosurgery, Upendra Devkota Memorial National Institute of Neurological and Allied Sciences, Bansbari, Kathmandu, Nepal
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Müller HL, Reichel J, Boekhoff S, Warmuth-Metz M, Eveslage M, Peng J, Flitsch J. Low concordance between surgical and radiological assessment of degree of resection and treatment-related hypothalamic damage: results of KRANIOPHARYNGEOM 2007. Pituitary 2018; 21:371-378. [PMID: 29589225 DOI: 10.1007/s11102-018-0883-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Assessment of presurgical hypothalamic involvement (psHI) and treatment-related hypothalamic damage (trHD) is relevant for the decision on risk-adapted treatment and rehabilitation strategies in craniopharyngioma. PATIENTS AND METHODS 129 surgical reports of childhood-onset craniopharyngioma patients recruited 2007-2014 in KRANIOPHARYNGEOM 2007 were analyzed. Data on psHI were available based on surgeon's (63%), reference neuroradiologist's (95%), and local radiologist's (23%) assessment. The surgical degree of resection (DoR) was assessed by neurosurgeon (95%), reference neuroradiologist (73%), and local radiologist (61%). TrHD was assessed by neurosurgeon (33%), by reference neuroradiologist (95%), and by local radiologist (2%). Neurosurgical center size was categorized based on patient load. RESULTS Surgical assessments on psHI (n = 78), DoR (n = 89) and trHD (n = 42) as documented in surgical reports could be compared with the assessment of respective parameters by reference neuroradiologist. Differences with regard to DoR (p = 0.0001) and trHD (p < 0.0001) were detectable between surgeon's and reference neuroradiologist's assessment, whereas psHI was assessed similarly. Concordance for DoR and trHD was observed in 48 and 62%, respectively. Surgeons estimated a higher rate of complete resections and a lower rate of trHD. Neuroradiological reference assessment of trHD had higher predictive value for hypothalamic sequelae then surgical assessment. Observed differences were not related to neurosurgical center size. CONCLUSIONS Observed differences between surgical and neuroradiological estimation of risk factors in craniopharyngioma support the necessity of neuroradiological reference review to assure standards of quality. This could be established by central internet-based neuroradiological review in KRANIOPHARYNGEOM 2007. Standardization of surgical reports including specific assessment of tumor/damage location is recommended.
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Affiliation(s)
- Hermann L Müller
- Department of Pediatrics and Pediatric Hematology/Oncology, Klinikum Oldenburg AöR, Medical Campus University Oldenburg, 26133, Oldenburg, Germany.
| | - Julia Reichel
- Department of Pediatrics and Pediatric Hematology/Oncology, Klinikum Oldenburg AöR, Medical Campus University Oldenburg, 26133, Oldenburg, Germany
| | - Svenja Boekhoff
- Department of Pediatrics and Pediatric Hematology/Oncology, Klinikum Oldenburg AöR, Medical Campus University Oldenburg, 26133, Oldenburg, Germany
| | | | - Maria Eveslage
- Institute of Biostatistics and Clinical Research, University of Münster, 48149, Munster, Germany
| | - Junxiang Peng
- Department of Pediatrics and Pediatric Hematology/Oncology, Klinikum Oldenburg AöR, Medical Campus University Oldenburg, 26133, Oldenburg, Germany
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Jörg Flitsch
- Department of Neurosurgery, University Hospital Hamburg-Eppendorf (UKE), 20246, Hamburg, Germany
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Pascual JM, Prieto R, Rosdolsky M, Strauss S, Castro-Dufourny I, Hofecker V, Winter E, Carrasco R, Ulrich W. Cystic tumors of the pituitary infundibulum: seminal autopsy specimens (1899 to 1904) that allowed clinical-pathological craniopharyngioma characterization. Pituitary 2018; 21:393-405. [PMID: 29680871 DOI: 10.1007/s11102-018-0889-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
A heterogeneous group of epithelial cystic tumors developed at the infundibulum and the third ventricle disconcerted pathologists at the dawn of the twentieth century. Very little was known at that time about the physiological role played by the pituitary gland, and there was almost complete ignorance regarding the function of the hypothalamus. Acromegaly, or enlargement of acral body parts, described in 1886 by Pierre Marie, was the only disease linked to primary hypertrophies of the pituitary gland, known as "pituitary strumas". A growing number of young patients manifesting an unexplained combination of physical and mental symptoms, including absent or delayed sexual maturation, progressive obesity, abnormal somnolence, and dementia-like changes in behavior were reported to present large solid-cystic tumors which characteristically expanded within the infundibulum and third ventricle, above an anatomically intact pituitary gland. Between 1899 and 1904, five seminal autopsy studies from different countries thoroughly described the anatomical relationships and histological features of this newly recognized type of infundibular tumors. These cases were instrumental in fostering the systematic investigation of similar lesions by the Austrian pathologist Jakob Erdheim (1874-1937), who in 1904 was able to classify these infundibulo-tuberal cysts under the common category of hypophyseal duct tumors. The pioneering American neurosurgeon Harvey Cushing (1869-1939) unsuccessfully attempted to surgically remove one of these cysts, for the first time in history, in 1902. The term "craniopharyngioma", chosen by Cushing in 1929 to designate these lesions, would eventually prevail over Erdheim's more accurate denomination, which linked their origin to squamous cell remnants derived from the embryological structures that give rise to the pituitary gland. This paper presents a comprehensive, renewed account of the five clinical-pathological reports which laid the groundwork for the proper clinical diagnosis, topographic conceptualization and pathological categorization of craniopharyngiomas.
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Affiliation(s)
- José M Pascual
- Department of Neurosurgery, La Princesa University Hospital, C/Diego de León 62, 28006, Madrid, Spain.
| | - Ruth Prieto
- Department of Neurosurgery, Puerta de Hierro University Hospital, Madrid, Spain
| | | | - Sewan Strauss
- Department of Pediatrics, Hospital Dahme-Spreewald, Königs Wusterhausen, Germany
| | | | - Verena Hofecker
- Pathologisch-anatomische Sammlung im Narrenturm-NHM, Vienna, Austria
| | - Eduard Winter
- Pathologisch-anatomische Sammlung im Narrenturm-NHM, Vienna, Austria
| | - Rodrigo Carrasco
- Department of Neurosurgery, Ramón y Cajal University Hospital, Madrid, Spain
| | - Walter Ulrich
- Department of Pathology and Clinical Bacteriology, Jakob Erdheim Institute, Vienna, Austria
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Belotti F, Lupi I, Cosottini M, Ambrosi C, Gasparotti R, Bogazzi F, Fontanella MM, Doglietto F. Persisting Embryonal Infundibular Recess (PEIR): Two Case Reports and Systematic Literature Review. J Clin Endocrinol Metab 2018; 103:2424-2429. [PMID: 29788483 DOI: 10.1210/jc.2018-00437] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 04/27/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT The persisting embryonal infundibular recess (PEIR) is a rare anomaly of the floor of the third ventricle with a debated pathogenesis. It can be a cause of misdiagnosis in the case of cystic lesions of the sellar and suprasellar area. OBJECTIVE To describe two recently evaluated cases and provide a systematic literature review. EVIDENCE ACQUISITION AND CASE DESCRIPTIONS PEIR has been previously reported in six adult patients. Because in some cases it was associated with hydrocephalus and/or empty sella, a possible role of altered intracranial pressure in PEIR formation has been postulated. We evaluated two female patients, aged 34 and 50 years, referred to the Pituitary Surgery Clinic of the University of Brescia with the diagnosis of a sellar cyst and craniopharyngioma, respectively. Endocrine screening and visual field testing were normal. No signs of hydrocephalus or empty sella, as well as other indirect signs of intracranial hypertension, were visible on MRI scans. After a multidisciplinary reevaluation, diagnosis of PEIR was made in both cases. Both patients are followed but have not developed any disturbance related to the PEIR in the following 18 months. CONCLUSIONS PEIR is a rare condition, probably unrecognized and the result of dysembriogenesis, which should be included in the differential diagnosis of cystic sellar lesions. Imaging features (funnel pituitary stalk and cyst in the sella) appear pathognomonic. A normal endocrine evaluation might help in the diagnosis and warrants conservative treatment.
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Affiliation(s)
- Francesco Belotti
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Isabella Lupi
- Endocrinology, Department of Clinical and Experimental Medicine, University Hospital, Pisa, Italy
| | - Mirco Cosottini
- Neuroradiology, Department of Translational Research and New Technologies in Medicine and Surgery, University Hospital, Pisa, Italy
| | - Claudia Ambrosi
- Neuroradiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Roberto Gasparotti
- Neuroradiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Fausto Bogazzi
- Endocrinology, Department of Clinical and Experimental Medicine, University Hospital, Pisa, Italy
| | - Marco M Fontanella
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Francesco Doglietto
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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Ni W, Shi X. Interventions for the Treatment of Craniopharyngioma-Related Hypothalamic Obesity: A Systematic Review. World Neurosurg 2018; 118:e59-e71. [PMID: 29945001 DOI: 10.1016/j.wneu.2018.06.121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 06/12/2018] [Accepted: 06/14/2018] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Craniopharyngiomas (CPs) and their treatment are associated with hypothalamic damage that causes hypothalamic obesity (HO) in 30%-70% of cases. Thus, there is ongoing research regarding tangible solutions for HO, because these patients have unrelenting resistance to basic weight-loss interventions. This review aims to summarize the interventions that are used to treat CP-related HO (CP-HO), including pharmacotherapy and bariatric surgery. METHODS The Cochrane Library, EMBASE, and PubMed databases were searched up to June 2017 for relevant reports. Two reviewers conducted independent evaluations of the studies identified. RESULTS Eighteen articles were included in the systematic review, with 3 reports describing pharmacotherapy in randomized controlled trials and 15 reports describing bariatric surgery. Although several studies described effective interventions for treating CP-HO, the evidence base was limited by its low quality and our inability to perform a meta-analysis, which was related to a lack of adequate or integrated data. CONCLUSIONS Octreotide appears to be a preferred treatment for patients with CP-HO, based on limited data. Gastric bypass surgery may also be suitable for select patients with CP-HO, based on a review of various procedures in this setting. Microsurgical preservation of the hypothalamic structures is mandatory to decrease CP-HO-related morbidity and mortality. Further studies with adequate analytical power and sufficient follow-up are needed to identify effective strategies for CP-HO treatment.
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Affiliation(s)
- Weimin Ni
- Department of Neurosurgery, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Xiang'en Shi
- Department of Neurosurgery, Fu Xing Hospital, Capital Medical University, Beijing, China.
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Qi ST. [The status and prospects of craniopharyngioma]. Zhonghua Yi Xue Za Zhi 2017; 97:1281-1282. [PMID: 28482426 DOI: 10.3760/cma.j.issn.0376-2491.2017.17.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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40
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Abstract
Childhood-onset craniopharyngiomas are rare embryonic tumours of low-grade histological malignancy. Novel insights into the molecular pathogenesis of human adamantinomatous craniopharyngioma have started to unveil the possibility of testing novel treatments targeting pathogenic pathways. Hypothalamic involvement and/or treatment-related lesions result in impaired physical and social functionality and in severe neuroendocrine sequelae. Quality of survival in patients with craniopharyngioma with hypothalamic involvement is impaired by severe obesity, physical fatigue and non-optimal psychosocial development. Patients with craniopharyngioma involving hypothalamic structures have reduced 20-year overall survival, but overall and progression-free survival are not related to the degree of surgical resection. Irradiation is effective in the prevention of tumour progression and recurrence. For favourably localized craniopharyngiomas, the preferred treatment of choice is to attempt complete resection with preservation of visual, hypothalamic and pituitary function. For unfavourably localized tumours in close proximity to optic and/or hypothalamic structures, a radical neurosurgical strategy attempting complete resection is not recommended owing to potential severe sequelae. As expertise has been shown to have an impact on post-treatment morbidity, medical societies should establish criteria for adequate professional expertise for the treatment of craniopharyngioma. On the basis of these criteria, health authorities should organize the certification of centres of excellence that are authorized to treat and care for patients with this chronic disease.
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Affiliation(s)
- Hermann L Müller
- Department of Pediatrics and Pediatric Hematology and Oncology, Klinikum Oldenburg AöR, Medical Campus University Oldenburg, Rahel-Straus-Strasse 10, 26133 Oldenburg, Germany
| | - Thomas E Merchant
- Division of Radiation Oncology, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee 38105-3678, USA
| | - Stephanie Puget
- Service de Neurochirurgie, Hôpital Necker-Enfants Malades, Sorbonne Paris Cité, 149 Rue de Sèvres, 75015 Paris, France
| | - Juan-Pedro Martinez-Barbera
- Developmental Biology and Cancer Programme, Birth Defects Research Centre, University College London (UCL) Great Ormond Street Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK
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Nagata T, Nakayama H, Uchida K, Uetsuka K, Yasoshima A, Yasunaga S, Masuda K, Tsujimoto H, Kuwajima E, Nishimura R, Sasaki N, Doi K. Two Cases of Feline Malignant Craniopharyngioma. Vet Pathol 2016; 42:663-5. [PMID: 16145213 DOI: 10.1354/vp.42-5-663] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Tumors at the cranial base in 2 cats (a 9 1/2-year-old, castrated male Chinchilla and a 7-year-old, castrated male American shorthair) were diagnosed as malignant craniopharyngioma. The tumor lesion was histopathologically divided into four parts: 1) a small acinus part, in which relatively large cells with a pale cytoplasm composed small acini; 2) a duct part, in which small cuboidal cells composed ducts; 3) a cyst part, in which there were large cysts lined with flat cells; and 4) a pavement part, in which large multiangular-shaped cells proliferated in a pavement pattern. The epithelial cells of some parts were positive for keratin by immunohistochemistry. Histopathologic findings of the present feline cases were identical to those of malignant craniopharyngioma in other animal species.
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Affiliation(s)
- T Nagata
- Department of Veterinary Pathology, Graduate School of Agricultural and Life Sciences, 1-1-1 Yayoi, Bunkyoku, Tokyo 113-8657, Japan
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Abstract
Papillary craniopharyngioma (PCP) is an intracranial tumor that results in high levels of morbidity. We recently demonstrated that the vast majority of these tumors harbor the oncogenic BRAF V600E mutation. The pathologic diagnosis of PCP can now be confirmed using mutation specific immunohistochemistry and targeted genetic testing. Treatment with targeted agents is now also a possibility in select situations. We recently reported a patient with a multiply recurrent PCP in whom targeting both BRAF and MEK resulted in a dramatic therapeutic response with a marked anti-tumor immune response. This work shows that activation of the MAPK pathway is the likely principal oncogenic driver of these tumors. We will now investigate the efficacy of this approach in a multicenter phase II clinical trial. Post-treatment resection samples will be monitored for the emergence of resistance mechanisms. Further advances in the non-invasive diagnosis of PCP by radiologic criteria and by cell-free DNA testing could someday allow neo-adjuvant therapy for this disease in select patient populations.
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Affiliation(s)
- Priscilla K Brastianos
- Division of Neuro-OncologyMassachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USADepartment of Cancer BiologyDana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts 02215, USADepartment of PathologyBrigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, 77 Avenue Louis Pasteur, Boston, Massachusetts 02115, USADepartment of PathologyBoston Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Sandro Santagata
- Division of Neuro-OncologyMassachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USADepartment of Cancer BiologyDana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts 02215, USADepartment of PathologyBrigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, 77 Avenue Louis Pasteur, Boston, Massachusetts 02115, USADepartment of PathologyBoston Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA Division of Neuro-OncologyMassachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USADepartment of Cancer BiologyDana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts 02215, USADepartment of PathologyBrigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, 77 Avenue Louis Pasteur, Boston, Massachusetts 02115, USADepartment of PathologyBoston Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA Division of Neuro-OncologyMassachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USADepartment of Cancer BiologyDana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts 02215, USADepartment of PathologyBrigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, 77 Avenue Louis Pasteur, Boston, Massachusetts 02115, USADepartment of PathologyBoston Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Pena AH, Chaudhry A, Seidman RJ, Peyster R, Bangiyev L. Ectopic craniopharyngioma of the fourth ventricle in a patient with Gardner syndrome. Clin Imaging 2016; 40:232-6. [PMID: 26995577 DOI: 10.1016/j.clinimag.2015.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 11/06/2015] [Accepted: 11/13/2015] [Indexed: 11/18/2022]
Abstract
Ectopic craniopharyngioma is uncommon and a craniopharyngioma confined purely within the fourth ventricle is extremely rare. We report a craniopharyngioma of the fourth ventricle in a 20-year-old man with Gardner syndrome. Imaging characteristics of craniopharyngiomas and fourth ventricle lesions are discussed with a review of the literature regarding the pathogenesis of craniopharyngiomas and the possible association with Gardner syndrome.
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Affiliation(s)
| | | | | | - Robert Peyster
- Department of Radiology, SUNY at Stony Brook, Stony Brook, NY.
| | - Lev Bangiyev
- Department of Radiology, SUNY at Stony Brook, Stony Brook, NY.
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Scagliotti V, Avagliano L, Gualtieri A, Graziola F, Doi P, Chalker J, Righini A, Korbonits M, Bulfamante G, Jacques TS, Massa V, Gaston-Massuet C. Histopathology and molecular characterisation of intrauterine-diagnosed congenital craniopharyngioma. Pituitary 2016; 19:50-6. [PMID: 26350256 DOI: 10.1007/s11102-015-0682-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE Adamantinomatous craniopharyngiomas (aCPs) are complex epithelial neoplasms that arise from the progenitors of the pituitary gland. Although benign, these tumours can be locally aggressive invading vital neighbouring structures such as the hypothalamus, the cranial and optic nerves. Congenital forms of aCPs diagnosed during foetal development are very rare. The purpose of this article is to present with a histopathological and molecular characterisation of congenital craniopharyngioma. METHODS Here we report a case of in utero diagnosed aCP, detected at 21 weeks of gestation by ultrasound, visualised by MRI at 22 weeks and histologically diagnosed at 23 weeks. We provide with histopathological characterisation of rare form of congenital aCPs. RESULTS Detailed examination of the tumour reveals the classical histological hallmarks of aCPs with the presence of stellate reticulum, palisading epithelium, wet keratin and calcification deposits. The tumour demonstrated complete absence of all pituitary hormones and the absence of the neuroendocrine marker, synaptophysin. Immunohistochemistry against β-catenin revealed occasional cells with nuclear-β-catenin localisation and the presence of pituitary progenitors positive for SOX9 and SOX2. Targeted Sanger sequencing revealed no genetic variants in oncogenes CTNNB1 and BRAF, previously associated with CP. CONCLUSIONS In this article, we provide with in-depth molecular and histological characterisation of in utero aCP due to an unknown driving mutation that could represent a sub-cohort of congenital aCPs.
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Affiliation(s)
- Valeria Scagliotti
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK.
| | - Laura Avagliano
- Department of Health Sciences, Università degli Studi di Milano, Via A. Di Rudini, 8, 20142, Milan, Italy.
| | - Angelica Gualtieri
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK.
| | - Federica Graziola
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK.
| | - Patrizia Doi
- Department of Health Sciences, Università degli Studi di Milano, Via A. Di Rudini, 8, 20142, Milan, Italy.
| | - Jane Chalker
- Haematology, Cellular and Molecular Diagnostic Service, Camelia Botnar Laboratories, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK.
| | - Andrea Righini
- Radiology and Neuroradiology Department, Children's Hospital V. Buzzi, 20142, Milan, Italy.
| | - Marta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK.
| | - Gaetano Bulfamante
- Department of Health Sciences, Università degli Studi di Milano, Via A. Di Rudini, 8, 20142, Milan, Italy.
| | - Thomas S Jacques
- Developmental Biology and Cancer Programme, UCL Institute of Child Health, University College London, London, UK.
- Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust, 30 Guilford Street, London, WC1N 1EH, UK.
| | - Valentina Massa
- Department of Health Sciences, Università degli Studi di Milano, Via A. Di Rudini, 8, 20142, Milan, Italy.
| | - Carles Gaston-Massuet
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK.
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Mortini P, Gagliardi F, Bailo M, Spina A, Parlangeli A, Falini A, Losa M. Magnetic resonance imaging as predictor of functional outcome in craniopharyngiomas. Endocrine 2016; 51:148-62. [PMID: 26179178 DOI: 10.1007/s12020-015-0683-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 07/06/2015] [Indexed: 10/23/2022]
Abstract
Quality of life of craniopharyngioma patients can be severely impaired by derangement of hypothalamic function. A classification, taking into account preoperative hypothalamic damage, evaluated by magnetic resonance imaging (MRI), and correlating it with postoperative weight change is still missing in the literature. The aim of our study is to identify objective radiological criteria as preoperative prognostic factors for hypothalamic damage. Pre- and post-operative MRI and clinical data of 47 patients, treated at our Institution for craniopharyngioma, were retrospectively analyzed, based on radiological variables, identified as prognostic factor for hypothalamic involvement. Main factors associated with postoperative obesity were hypothalamic hyperintensity in T2-weighted/FLAIR imaging (p < 0.033), mammillary body involvement according to Müller classification (p < 0.020), unidentifiable pituitary stalk (p < 0.001), dislocated chiasm (p < 0.038), either not visible infundibular recess (p < 0.019) or unrecognizable supra-optic recess (p < 0.004), and retrochiasmatic tumor extension (p < 0.019). Accordingly, postoperative hypothalamic syndrome was associated with peritumoral edema in T2-weighted/FLAIR images (p < 0.003), unidentifiable hypothalamus (p < 0.024), hypothalamic compression (p < 0.006), fornix displacement (p < 0.032), and unrecognizable supra-optic recess (p < 0.031). Ultimately, variables identified as predictive factors of postoperative hypothalamic syndrome were the degree of hypothalamic involvement according to the classification described by Sainte-Rose and Puget (p < 0.002; grade 0 vs 2 p < 0.001), Van Gompel (p < 0.002; grade 0 vs 1, p < 0.027; and grade 0 vs 2, p < 0.002), and Muller (p < 0.006; grade 0 vs 1, p < 0.05; and grade 0 vs 2, p < 0.004). The identification of these predictive factors will help to define and score the preoperative hypothalamic involvement in craniopharyngioma patients.
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Affiliation(s)
- Pietro Mortini
- Department of Neurosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Filippo Gagliardi
- Department of Neurosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.
| | - Michele Bailo
- Department of Neurosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Alfio Spina
- Department of Neurosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Andrea Parlangeli
- Department of Neurosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Andrea Falini
- Department of Neuroradiology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Marco Losa
- Department of Neurosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
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Marucci G, de Biase D, Zoli M, Faustini-Fustini M, Bacci A, Pasquini E, Visani M, Mazzatenta D, Frank G, Tallini G. Targeted BRAF and CTNNB1 next-generation sequencing allows proper classification of nonadenomatous lesions of the sellar region in samples with limiting amounts of lesional cells. Pituitary 2015; 18:905-11. [PMID: 26156055 DOI: 10.1007/s11102-015-0669-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To assess the role of high sensitivity next-generation sequencing (NGS) of CTNNB1 for the diagnosis of adamantinomatous craniopharyngiomas (aCPs) and of BRAF for that of papillary CPs (pCPs) in routinely processed surgical samples of non-adenomatous sellar lesions. METHODS Forty-five cases of patients operated for non-adenomatous masses of the sellar region between 2004 and 2014 were retrieved from the files of the Anatomic Pathology unit of the Bellaria Hospital in Bologna, Italy. BRAF and CTNNB1 mutation status was analyzed by NGS in samples smaller than 1 cm(3) and histological re-evaluation was performed on all cases. RESULTS CTNNB1 mutation analysis showed a sensitivity of 86.7 % and a specificity of 96.2 % for the diagnosis of aCPs. The specificity increased to 100 % considering that in one case, initially classified as a non-CP lesion (xanthogranuloma), the identification of a CTNNB1 S47R lead to histological re-evaluation and reclassification of the lesion as aCP. BRAF mutation analysis had a sensitivity of 76.9 % and a specificity of 96.4 % for the diagnosis of pCPs. The specificity increased to 100 % considering that in one case, initially classified as a Rathke cyst, the identification of BRAF V600E lead to histological re-evaluation and reclassification of the lesion as pCP. CONCLUSIONS This study confirms the diagnostic relevance of the molecular alterations recently identified in aCPs and pCPs and shows how the identification of BRAF and CTNNB1 mutations can be instrumental for the proper classification of samples that contain limiting amounts of diagnostic lesional tissue.
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Affiliation(s)
- Gianluca Marucci
- Department of Biomedical and NeuroMotor Sciences (DiBiNeM), Anatomic Pathology, Bellaria Hospital, University of Bologna, Bologna, Italy.
| | - Dario de Biase
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, Anatomic Pathology, Bellaria Hospital, University of Bologna, Bologna, Italy
| | - Matteo Zoli
- Center of Surgery for Pituitary Tumors and Endoscopic Skull Base Surgery, Bologna, Italy
| | | | - Antonella Bacci
- Department of Neuroradiology, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | | | - Michela Visani
- Department of Pharmacy and Biotechnology (FaBiT), University of Bologna, Molecular Biology Unit, Bellaria Hospital, Bologna, Italy
| | - Diego Mazzatenta
- Center of Surgery for Pituitary Tumors and Endoscopic Skull Base Surgery, Bologna, Italy
| | - Giorgio Frank
- Center of Surgery for Pituitary Tumors and Endoscopic Skull Base Surgery, Bologna, Italy
| | - Giovanni Tallini
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, Anatomic Pathology, Bellaria Hospital, University of Bologna, Bologna, Italy
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Hoffmann A, Boekhoff S, Gebhardt U, Sterkenburg AS, Daubenbüchel AMM, Eveslage M, Müller HL. History before diagnosis in childhood craniopharyngioma: associations with initial presentation and long-term prognosis. Eur J Endocrinol 2015; 173:853-62. [PMID: 26392473 DOI: 10.1530/eje-15-0709] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 09/21/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Childhood craniopharyngiomas (CP) are often diagnosed after a long duration of history (DOH). Tumor size, hypothalamic involvement (HI), and obesity are associated with reduced overall survival (OS) and functional capacity (FC). The effect of DOH and specific symptoms in history on presentation at initial diagnosis and long-term prognosis are unknown. DESIGN Retrospective analysis of patients' records and prospective longitudinal follow-up. METHODS Histories of 411 CP patients recruited in HIT Endo, KRANIOPHARYNGEOM 2000 were retrospectively evaluated for DOH, symptoms, and characteristics. The effect of specific manifestations and DOH on clinical presentation and tumor characteristics at time of initial CP diagnosis and long-term outcome were analyzed. Main outcome measures were 10-year OS and progression-free survival (PFS), FC, and BMI during longitudinal follow-up. RESULTS Median DOH was 6 months (range: 0.1-108 months) and correlated with age at diagnosis. Tumor size, HI, degree of resection, and BMI at diagnosis were not related to DOH. In multivariate analysis adjusted for age at diagnosis, only hydrocephalus was found to have a relevant influence on DOH. Visual and neurological deficits were associated with larger initial tumor size and impaired 10-year OS. Weight gain and growth failure were observed with longest DOH. PFS and FC were not related to any specific symptom. Endocrine deficits at diagnosis were associated with long DOH. CONCLUSIONS CP is frequently diagnosed after long DOH, especially in older children. However, DOH was not associated with tumor size, HI, survival, or FC. Visual and neurological deficits necessitate rapid diagnostic workup.
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Affiliation(s)
- Anika Hoffmann
- Department of PediatricsKlinikum Oldenburg, Medical Campus University Oldenburg, Rahel-Straus-Strasse 10, 26133 Oldenburg, GermanyUniversity of GroningenGroningen, The NetherlandsInstitute of Biostatistics and Clinical ResearchUniversity of Münster, Münster, Germany
| | - Svenja Boekhoff
- Department of PediatricsKlinikum Oldenburg, Medical Campus University Oldenburg, Rahel-Straus-Strasse 10, 26133 Oldenburg, GermanyUniversity of GroningenGroningen, The NetherlandsInstitute of Biostatistics and Clinical ResearchUniversity of Münster, Münster, Germany
| | - Ursel Gebhardt
- Department of PediatricsKlinikum Oldenburg, Medical Campus University Oldenburg, Rahel-Straus-Strasse 10, 26133 Oldenburg, GermanyUniversity of GroningenGroningen, The NetherlandsInstitute of Biostatistics and Clinical ResearchUniversity of Münster, Münster, Germany
| | - Anthe S Sterkenburg
- Department of PediatricsKlinikum Oldenburg, Medical Campus University Oldenburg, Rahel-Straus-Strasse 10, 26133 Oldenburg, GermanyUniversity of GroningenGroningen, The NetherlandsInstitute of Biostatistics and Clinical ResearchUniversity of Münster, Münster, Germany Department of PediatricsKlinikum Oldenburg, Medical Campus University Oldenburg, Rahel-Straus-Strasse 10, 26133 Oldenburg, GermanyUniversity of GroningenGroningen, The NetherlandsInstitute of Biostatistics and Clinical ResearchUniversity of Münster, Münster, Germany
| | - Anna M M Daubenbüchel
- Department of PediatricsKlinikum Oldenburg, Medical Campus University Oldenburg, Rahel-Straus-Strasse 10, 26133 Oldenburg, GermanyUniversity of GroningenGroningen, The NetherlandsInstitute of Biostatistics and Clinical ResearchUniversity of Münster, Münster, Germany Department of PediatricsKlinikum Oldenburg, Medical Campus University Oldenburg, Rahel-Straus-Strasse 10, 26133 Oldenburg, GermanyUniversity of GroningenGroningen, The NetherlandsInstitute of Biostatistics and Clinical ResearchUniversity of Münster, Münster, Germany
| | - Maria Eveslage
- Department of PediatricsKlinikum Oldenburg, Medical Campus University Oldenburg, Rahel-Straus-Strasse 10, 26133 Oldenburg, GermanyUniversity of GroningenGroningen, The NetherlandsInstitute of Biostatistics and Clinical ResearchUniversity of Münster, Münster, Germany
| | - Hermann L Müller
- Department of PediatricsKlinikum Oldenburg, Medical Campus University Oldenburg, Rahel-Straus-Strasse 10, 26133 Oldenburg, GermanyUniversity of GroningenGroningen, The NetherlandsInstitute of Biostatistics and Clinical ResearchUniversity of Münster, Münster, Germany
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Abstract
The birth of clinical neuroendocrinology can be dated to the year 1900, when the French neurologist Joseph Babinski (1857-1932) described a particular syndrome of adiposity and sexual infantilism in an adolescent with a craniopharyngioma expanding at the base of the brain. This condition of adipose-genital dystrophy, also known as Babinski-Fröhlich syndrome, represented the first clinical evidence that the brain controlled endocrine functions. Adipose-genital dystrophy forms part of infundibulo-tuberal syndrome, which groups the endocrine, metabolic and behavioral disturbances caused by lesions involving the upper neurohypophysis (median eminence) and the adjacent basal hypothalamus (tuber cinereum). This syndrome was originally described by the French neuropsychiatrists Henri Claude (1869-1946) and Jean Lhermitte (1877-1959) in 1917, also in a patient with a craniopharyngioma. This type of tumor involves specifically the infundibulo-tuberal region of the hypothalamus, providing a clinical model to conceptualize the separation of hypophyseal and hypothalamic functions. The French School of Neurology analyzed and reported the symptoms associated with dysfunction of the basal hypothalamus by craniopharyngiomas and other types of tumors, influencing significantly the development of clinical neuroendocrinology. Experimental lesions performed in the tuber cinereum by the French physiologists Jean Camus (1872-1924) and Gustave Roussy (1874-1948) demonstrated unmistakably the anatomical origin of infundibulo-tuberal syndrome in the basal hypothalamus. This article reviews the original findings on infundibulo-tuberal syndrome reported by the French School of Neurology in the first decades of the twentieth century and the great influence this school had on modern conceptions of hypothalamic control over endocrine functions and behavior.
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Affiliation(s)
- Inés Castro-Dufourny
- Department of Endocrinology, Sureste University Hospital, C/Ronda del Sur 10, Arganda del Rey, 28500, Madrid, Spain.
| | - Rodrigo Carrasco
- Department of Neurosurgery, Ramón y Cajal University Hospital, Madrid, Spain
| | - Ruth Prieto
- Department of Neurosurgery, Puerta de Hierro University Hospital, Madrid, Spain
| | - José M Pascual
- Department of Neurosurgery, La Princesa University Hospital, Madrid, Spain
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Nogueira MC, Berbel Júnior AS, Koenigkam-Santos M, Moreira AC, Nonino CB, de Castro M. Nutritional and endocrinologic evaluation of patients with craniopharyngioma. Clin Nutr ESPEN 2015; 10:e213-e218. [PMID: 28531465 DOI: 10.1016/j.clnesp.2015.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 06/12/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND & AIMS Lesions of hypothalamus or adjacent brain structures by the craniopharyngioma (CP) and/or its treatment, as well as changes in orexigenic and anorexigenic hormones, are possible pathogenic factors for the obesity observed in CP patients. This study assessed anthropometric measurements, food intake, and biochemical markers of CP patients. METHODS Weight, height, skinfold thicknesses, circumferences, body composition, food intake evaluation, basal glucose, lipids, insulin, ghrelin, PYY, and HOMA-IR calculation were obtained from CP children (n = 10, 4F, aged 12 ± 4.2yr) and CP adults (n = 27,13F aged 42 ± 13 yr) and from 32 gender and age matched controls. RESULTS Overweight/obesity was observed in 51.4% of the patients at the diagnosis and increased to 86.5% at the time of the study. Obesity was more frequent in patients with grade 2 hypothalamic involvement. Most anthropometric measurements were similar in patients and controls. Caloric intake was lower in CP adults, without difference between children. Lipid intake was higher in CP patients. Carbohydrate and protein intakes were lower in CP children, with no difference between adult groups. There were no differences in micronutrients intake as well as in insulin and PYY levels, and HOMA-IR between patients and controls. HDL-c was lower in CP adults and ghrelin higher in CP children. CONCLUSIONS There is a high rate of overweight/obesity in CP patients at the diagnosis and throughout the follow-up period. Obesity was associated with degree of hypothalamic involvement but not with caloric intake. Obesity and a lipid rich diet may have contributed to the dyslipidemia observed in CP patients.
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Affiliation(s)
- Mônica Cristina Nogueira
- Department of Internal Medicine, Ribeirao Preto Medical School - University of São Paulo, Ribeirão Preto, SP, Brazil.
| | - Alfredo Sérgio Berbel Júnior
- Department of Internal Medicine, Ribeirao Preto Medical School - University of São Paulo, Ribeirão Preto, SP, Brazil.
| | - Marcel Koenigkam-Santos
- Department of Internal Medicine, Ribeirao Preto Medical School - University of São Paulo, Ribeirão Preto, SP, Brazil.
| | - Ayrton Custódio Moreira
- Department of Internal Medicine, Ribeirao Preto Medical School - University of São Paulo, Ribeirão Preto, SP, Brazil.
| | - Carla Barbosa Nonino
- Department of Internal Medicine, Ribeirao Preto Medical School - University of São Paulo, Ribeirão Preto, SP, Brazil.
| | - Margaret de Castro
- Department of Internal Medicine, Ribeirao Preto Medical School - University of São Paulo, Ribeirão Preto, SP, Brazil.
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