The efficacy of radiotherapy for craniopharyngioma

Remote recurrence of craniopharyngioma in the epidural space. Case report

The case is reported of a 28-year-old man with "ectopic" craniopharyngioma recurring in the epidural space 21 years after the original tumor was resected. Previously described cases of similar remote recurrences as well as some features of the biological behavior of craniopharyngioma are discussed. The rarity of this postoperative complication is addressed.

Radiotherapy for the treatment of recurrent craniopharyngioma

Twenty-five patients with craniopharyngioma received radiotherapy at the time of recurrence. The 10-year progression free survival and survival from the time of recurrence were 72% and 77% respectively. Nineteen patients underwent surgery prior to radiotherapy (6 partial excision, 4 decompression and 9 cyst aspiration). The extent of resection at the time of recurrence did not influence the outcome. Apart from pituitary failure there was no serious morbidity associated with this approach. The results of radiotherapy at recurrence are similar to those of conservative surgery and radiotherapy at the time of presentation. It suggests that radiotherapy remains an effective treatment modality at the time of recurrence of craniopharyngioma and it may therefore be delayed in situations where immediate radiation is not advisable. However, the high recurrence rate in incompletely excised craniopharyngioma, together with the potential risk of additional morbidity and mortality from undiagnosed progressive tumour and salvage surgery, would argue for a policy of radiotherapy as part of the initial treatment of incompletely excised craniopharyngioma.

Microsurgical management of craniopharyngiomas

A retrospective analysis of 34 patients who underwent microsurgical therapy for craniopharyngioma from 1975 to 1989, a period when CT imaging was routinely used, is presented. Mean follow-up was 6.4 years with no patients lost to follow-up. Those who underwent subtotal resection with adjuvant radiation had a significantly better recurrence-free interval compared with those who either underwent total or subtotal surgical resection only (p < 0.05 and p < 0.025). Among patients treated with surgery alone, the total resection group had a recurrence rate of 20% and those with a subtotal resection 60%. Those with subtotal resection and radiation had a 12% rate of recurrence. Endocrine and visual deficits were common after surgery. Based on this review, our results suggest that with a policy of attempted total resection where possible, subtotal removal along with adjuvant radiation, in cases where total resection was deemed unsafe, may be more effective than aggressive total resection alone as the initial management of craniopharyngioma.

Pediatric craniopharyngiomas: long term results of combined treatment with surgery and radiation

From 1961 to 1981, 19 pediatric patients with craniopharyngiomas were treated with external beam radiation post surgery. Twelve underwent primary treatment while seven were treated for recurrence. Median follow-up is 21 years (range 8-28 years) with an overall 20-year survival of 62%. Twenty-six percent (5/19) developed disease recurrence following radiation. Of the multiple patient and treatment parameters analyzed, only initial disease status (i.e., primary vs recurrence), surgical extent, radiation dose, and treatment prior to routine use of CT scans (1961-1974) appeared to have major influence on patient outcome. The 20-year survival for those treated for primary disease was 78% versus 25% for those treated for recurrence. Fifty percent (3/6) of patients receiving tumor doses of < or = 5400 cGy developed recurrences versus 15% (2/13) in those receiving > 5400 cGy. Four of the five recurrences occurred in patients treated during the pre-CT era. Long term effects of treatment were analyzed. Surgical morbidity correlated strongly with extent of surgery. All patients who underwent total resection developed surgical sequelae. Radiation morbidity correlated strongly with radiation dose. The incidence of vascular or neurologic complications attributable to radiation were minimal, occurring in only two patients. Both received doses higher than that given with modern therapy. Long-term results from this series are better than those reported with surgery alone. Use of modern surgical and radiation equipment/technique along with CT/MRI imaging should yield improved treatment results both in terms of lower recurrence and lower toxicity rates.

Aggressive surgical management of craniopharyngiomas in children

The cases of 50 patients with craniopharyngioma operated on at The Hospital for Sick Children in Toronto between January, 1975, and December, 1989, are reviewed. All patients were under 18 years of age (mean 9.39 years). Headaches, endocrine deficiencies, and visual deficits were the most common symptoms on admission. Forty-five patients underwent what was considered by the surgeon to be total excision of their tumor, and five had subtotal excision. Tumors recurred in 17 patients (mean time of recurrence 32.6 months after surgery). One patient died in the postoperative period and three have been lost to follow-up study. Of the remaining 46 patients, 28 are leading a normal or nearly normal life, although all are receiving endocrine replacement and some have required help to overcome mild deficits in memory or visual acuity. Twelve patients are able to function reasonably well and attend school despite being hampered by intellectual or visual deficits or problems with weight control; four have a significant handicap, and two have died.

Craniopharyngiomas in children. Long-term effects of conservative surgical procedures combined with radiation therapy

Thirty-seven patients with craniopharyngioma were treated at Children's Hospital, Boston, between 1972 and 1981, the mean follow-up period now being 10.5 years. Twenty of these patients are old enough to have finished high school and have been queried about their college or job activity. None of the four patients who had undergone radical excision of their tumor and who had reached the age of finishing high school was able to work independently. Among the 16 patients who reached this age and who were treated by more conservative operations and irradiation or irradiation alone, job performance or college attendance varied considerably, indicating that psychosocial impairment occurred in this group, but suggesting that the risk was less. The rate of tumor recurrence or of failure to respond to treatment was 57% (four of a total of seven survivors) following radical surgery and 7% (two of 27 survivors) after conservative operations and irradiation. The overall mortality rate was 8%; the causes of the three deaths were: "hypothalamic crisis" 1 year after radical resection; progressive tumor growth despite two attempts at resection and irradiation; and a brain-stem glioma in the field of irradiation 8 years after treatment.

Nasopharyngeal craniopharyngioma. Case report and literature review

Craniopharyngioma is an intracranial tumor that occurs rarely in the infrasellar region. Eight patients with craniopharyngioma located within the nasopharynx have been reported previously. These cases originated in the nasopharynx and involved the sella turcica (6), the sphenoid sinus (1), and the vomer (1). Craniopharyngioma usually originates intracranially. When there is no evidence of sellar involvement, the tumor most likely arises along the path of the craniopharyngeal duct. According to the neurosurgical literature, the optimal treatment consists of total surgical excision. Incomplete tumor removal is supplemented by adjunctive radiotherapy, which has been shown to significantly increase the survival rate. A patient with craniopharyngioma of the nasopharynx and paranasal sinuses who presented with nasal obstruction is reported. Radiographic studies were employed for tumor evaluation, and biopsy was done to establish the histopathologic diagnosis. Treatment included a combination of surgical excision and irradiation.

Megavoltage external beam irradiation of craniopharyngiomas: analysis of tumor control and morbidity

From 1971 to 1985, 21 patients received megavoltage external beam radiation therapy at the University of Pittsburgh for control of craniopharyngioma. Minimum tumor doses prescribed to the 95% isodose volume ranged between 51.3 to 70.0 Gy. Median total dose was 60.00 Gy and median dose per fraction was 1.83 Gy. Three deaths occurred from intercurrent disease and no deaths from tumor progression. Actuarial overall survival was 89% and 82% at 5 and 10 years. Actuarial local control was 95% at 5 and 10 years. Radiation related complications included one patient with optic neuropathy, one with brain necrosis, and one that developed optic neuropathy followed by brain necrosis. The high dose group of patients who received a NSD or Neuret equivalent of greater than 60 Gy at 1.8 Gy per fraction had a significantly greater risk of radiation complications (p = .024). The actuarial risk at 5 years for optic neuropathy was 30% and brain necrosis was 12.5% in the high dose group. Tumor control in the high dose group was not shown to be significantly better. Any possible benefit in tumor control in treating patients with craniopharyngioma with doses above 60 Gy at 1.8 Gy per fraction appears to be offset by the increased risk of radiation injury.

The treatment and long-term prognosis of children with intracranial tumors: a study of 610 cases, 1950-1981

Six hundred and ten children aged under 16 years with intracranial tumors were referred for radiotherapy between 1950 and 1981: 579 were new cases and 31 had recurrent disease after primary treatment elsewhere. Radiotherapy was completed in 93% of all cases. The actuarial survival rate for all new cases was 53% at 5 years, 46% at 10 years, 40% at 20 years, and 39% at 30 years. The oldest children (10-15 years) had the best survival and the youngest (0-2 years) had the worst survival. Children treated with megavoltage x-ray equipment (1970 to 1981) had a significantly greater survival than those treated with orthovoltage X rays (1950-1969). Overall, a direct correlation was found between survival and maximum radiotherapy dose. Children having a total excision of the tumor prior to radiotherapy showed a greater survival than those treated by a subtotal or partial tumor removal. Children treated by radiotherapy alone had a survival comparable to those treated by sub-total excision and radiotherapy. There is a striking difference in survival expectation depending on initial functional category (I to III). The overall survival rates of 428 children completing treatment for glioma were 49% at 5 years, 43% at 10 years, and 40% at 15 years. The results according to certain specific tumor sites within the cerebral hemispheres are reported. Age is an important prognostic factor in low grade and also high grade astrocytomas, children having longer survivals than adults. Sub-total or partial excision of craniopharyngiomas combined with radical radiotherapy appears to give the best long-term results. Of 73 new cases, the 5-, 10-, and and 15-year survival rates were 92%, 84%, and 79%. Recurrent craniopharyngiomas treated by surgery alone can be salvaged by further conservative surgery and radical radiotherapy. Optic gliomas are slow growing low grade astrocytomas. Survival rates at 5, 10, and 15 years for 20 children with mostly chiasmal lesions were 89%, 89%, and 78%, respectively. In 73 children with brain stem tumors, 17% remained alive for up to 15 years. The risk of CNS seeding from intracranial ependymomas depends on site of origin and grade of malignancy, with 50% incidence occurring in cases with high grade lesions situated in the posterior fossa. Survivals at 5, 10, and 15 years in 51 children were 51%, 40%, and 31%. Adjuvant chemotherapy improves survival.(ABSTRACT TRUNCATED AT 400 WORDS)

Surgery of large retrochiasmatic craniopharyngiomas in children

From 1981 to 1988, 24 patients with craniopharyngiomas were operated at the Neurosurgical Clinic of the City Hospital of Hannover. Eleven patients were females and 13 males. The median age was 39 years. Ten patients were 20 years of age or younger at the time of surgery. Among these there were four patients who had large (more than 3 cm in greatest diameter), prevalently retrochiasmatic tumors. They represent 40% of the patients up to 20 years of age. Their age ranged from 8 to 17 years; they were all females. Two patients presented with increased intracranial pressure secondary to hydrocephalus, one patient with decreased vision, and one patient presented with seizures. One patient had been previously operated twice elsewhere. A preoperative shunting procedure was necessary in two patients (in one it was bilateral). All patients were preoperatively evaluated with enhanced and nonenhanced computerized tomography (CT) and with angiography. The major tumor diameter was 4 cm or more in three patients and between 3 and 4 cm in one patient. All tumors were prevalently retrochiasmatic. Three tumors extended to the level of the middle clivus. The tumor was approached subfrontally in two patients and subfrontotemporally in two patients. There was no operative mortality. No patient was neurologically worse postoperatively. All patients required hormonal replacement. Adjuvant therapy was not given. All four patients are clinically and CT recurrence free 5 and 20 months and 3 and 4 years after the surgery.

Visual outcome in cystic craniopharyngiomas treated with intracavitary phosphorus-32

Seven patients with cystic craniopharyngiomas were treated with stereotactic instillation of radioactive phosphorus-32 (32P). Five patients had been previously treated with various combinations of surgery and external beam irradiation, whereas two had the 32P instillation at a primary therapy. Visual acuity improved in 13 eyes and remained stable in 1. Visual fields normalized in three patients, improved in two, and remained stable in two. Two patients received single treatments with 32P, whereas five required multiple instillations for recurrent cyst expansion.

The role of radiation therapy in the management of childhood craniopharyngioma

Between 1965 and 1986, 31 children were treated for craniopharyngioma at the Children's Hospital of Philadelphia. Total removal was attempted in all patients. Some patients received radiation therapy following subtotal removal. Of the patients whose first resection was subtotal, five received radiation and seven did not. Four of the 5 patients who were radiated (80%) are stable (median 89 months, range 42-155 months) and one recurred at 42 months, failed salvage with total removal, and subsequently died of disease. Of the seven who were not irradiated, all had recurrences (median 12 months, range 3-192 months) and one died of disease. Nineteen patients initially had total removal and none received adjuvant radiation. One patient died postoperatively. Of the 18 remaining patients, 6 had recurrences (median 24 months, range 7-100 months) and 12 (66%) are stable (median 42 months, range 9-133 months). One of these stable patients died of endocrine complications 24 months after initial surgery. Fourteen of the 31 patients recurred. Two died with recurrence and one required no further treatment. Eleven had second resections following initial surgical removal. Seven of these 11 went on to receive radiation and four did not. All seven who were radiated are stable (median 33 months, range 1-228 months); whereas 1 of the 4 who were not radiated recurred again at 18 months. This patient had a third resection followed by radiation therapy and is now stable at 20 months. After initial surgery (and before radiation, when given) 26 of 31 patients had panhypopituitarism, 4 had partial deficits, and 1 was normal. Severe diencephalic syndrome, loss of visual acuity, and intellectual deficits were no more frequent in patients treated with total removal, subtotal removal, and in patients who received radiation. We conclude that radiation has an important role following subtotal removal and for salvage treatment after initial surgery. Aggressive attempt at total removal does result in prolonged progression-free survival in some patients. Extensive resections may result in significant mortality and endocrine morbidity. This review suggests that subtotal removal and radiation results in outcomes at least as favorable as treatment with total removal alone.

Management of primary or recurring grossly cystic craniopharyngiomas by means of draining systems. Topic review and 6 case reports

In primary or relapsing grossly cystic craniopharyngiomas most of the problems related to the neoplastic mass may be, even if temporarily, improved by reducing volume of the cyst. A major surgical approach is unjustified when the aim is only to empty the cyst contents. Drainage of the cyst cavity by means of derivative techniques may be as effective and less invasive; in combined management plans that such tumours often require, they are, therefore, useful complementary procedures that can achieve long-lasting relief of symptoms, provided that the cyst is unilocular. Technical features and indications for such methods, with special regard to the techniques of sump drainage and of tube ventriculocystostomy, are discussed on the basis of the few reported series and of 6 personal cases. Usually only palliative aims are achieved, waiting for more definitive treatment; in a few selected cases, however, they may be quite effective.

Postradiation astrocytoma. Report of two cases

The authors describe two cases of malignant astrocytomas associated with previous radiation therapy in childhood for intracranial germinoma and craniopharyngioma. In both patients, there was no recurrence at the primary tumor site. Because of a geometric coincidence between the tumor location and the radiation field, radiotherapy was strongly implicated as a cause of these two astrocytomas.

Craniopharyngioma surgery in children: endocrine and visual outcome

Twenty-two children with craniopharyngioma were operated on in our Department of Neurosurgery from 1970 to 1981. Removal was total in 11 patients. There was one surgical death, but no recurrences in this group. Only partial removal could be performed in 10 children, followed by stereotactic radiotherapy in one. Recurrences have occurred in 4 of these children and 2 of them have died. In 1 child a biopsy was performed, followed by insertion of a shunt and stereotactic radiotherapy. Nine years after treatment there have still been no recurrences. Visual acuity was unchanged after the procedure in 17/21 survivors, improved in 1, and deteriorated in 3. The visual fields remained unchanged in 11, improved in 3, and deteriorated in 7. The visual fields and visual acuity were normal postoperatively in 5 patients. Hypopituitarism was more extensive after the procedure. We recommended an attempt at total removal whenever possible.

Stereotaxic intracavitary irradiation for cystic craniopharyngiomas

Stereotaxic intracavitary irradiation with instillation of phosphorus-32 (32P) colloidal chromic phosphate was performed in nine patients with cystic craniopharyngiomas. Serial neurological, ophthalmological, neuroendocrinological, and radiological examinations were performed before and after treatment. Dosimetry was determined based on a computerized tomography (CT) estimation of tumor volume, and was calculated to provide a tumoricidal dose (200 to 300 Gy) to the cyst wall. The follow-up period ranged from 14 to 45 months (mean 27 months). After treatment, all nine patients showed improvement of symptoms and radiological evidence of cyst regression. Because of an expanding solid component producing recurrent symptoms, one patient required a craniotomy 14 months after isotope instillation. Three of five patients with impaired visual acuity before surgery had significant improvement in acuity after treatment. Preoperative visual field defects in eight patients improved in four after 32P therapy. Of seven patients with preoperative endocrine abnormalities, one individual showed almost complete normalization and another had improvement in endocrine function. Patients who exhibited residual neuroendocrine function before isotope instillation developed no significant deterioration in endocrine status during the follow-up period. The findings suggest that stereotaxic intracavitary irradiation is a safe and effective treatment which should be considered as the initial surgery for cystic craniopharyngiomas.

Craniopharyngioma in an elderly patient

Craniopharyngioma, a tumor most commonly diagnosed in the young, may occur at any age. The oldest patient known to have histologic documentation of a craniopharyngioma, an 82.5-year-old woman, presented with visual field changes, panhypopituitarism, and mental status changes. This diagnosis should be considered in such patients, because craniopharyngioma is a potentially curable tumor by either surgery or radiation therapy.

Surgical management of craniopharyngiomas. A review of 74 cases

A series of 74 patients with craniopharyngiomas were treated during a 15-year period. Of the 74 patients, 40 were males and 34 were females, with a mean age of 27 years (range 3 to 65 years). Twenty-eight patients (38%) were less than 18 years of age. Remission was defined as clinical improvement with stable ophthalmological and neurological status, radiological evidence of a decrease in tumor size, and either a continued decrease or a stable tumor size on follow-up radiological evaluations. A fair result was considered remission with new neurological deficits related to surgical intervention. All other results were considered a failure. The mean follow-up period in this study was 4 years, with 100% of the patients monitored. In children, the most common presentation was that of growth failure (93%). In adults, sexual dysfunction was the most common presentation, with 88% of males presenting with impotence or marked decrease in sexual drive, and 82% of females presenting with primary or secondary amenorrhea, often associated with galactorrhea. Considering the pediatric and adult populations together, the most common presenting symptom was visual dysfunction, with 71% of patients presenting in this manner. Fifty percent of patients presented with severe headache. The most frequent preoperative finding was a visual field defect, with 72% of patients so affected; 42% of patients had preoperative hypothyroidism and 24% had hypoadrenalism. Diabetes insipidus was present preoperatively in 23%. Hydrocephalus was uncommon, being present in only 15%. A subfrontal craniotomy was used in 47% of patients, a transsphenoidal approach in 39%, a subtemporal approach in 11%, a transcallosal approach in 5%, and a suboccipital craniectomy in 2%. Multiple procedures were required in 15% of patients in order to provide significant relief of compressive symptomatology. The results of therapy indicate that total tumor removal was deemed to have been achieved in only seven patients, six of whom have had no recurrence. However, 91% of patients are in remission, one had a fair result, and two died as a direct result of surgical intervention. One patient died from uncontrolled disease, and three patients died from unrelated causes. The results of this study indicate that radical subtotal removal followed by radiotherapy is an acceptable treatment for craniopharyngioma.

Head circumference, brain weight, and tumor burden

The failure to diagnose an ependymoma at an appropriately early age led to an incomplete excision and a tumor burden too great for radiotherapy to control. The development of normative curves for brain weight correlated with head circumference allowed for the estimates of the extremes of possible growth rates of the tumor. The importance of early diagnosis and combined surgical and radiotherapies is emphasized since ependymomas are locally recurrent but curable by x-irradiation (and host macrophages?) if the tumor burden is small.

Interstitial irradiation of skull base tumours

The rationale for interstitial irradiation of tumours in and around the skull base is reviewed, and the experience accumulated with pituitary adenomas, meningiomas, and chordomas is summarized. Intracystic irradiation for craniopharyngiomas is also reviewed.