Craniopharyngioma in adults and children: a study of 122 surgical cases

[Making the differential diagnosis between pituitary apoplexy and craniopharyngioma]

Pituitary apoplexy is characterized by an abrupt neurological deteriorating condition associated with rapid expansion of the pituitary gland, caused by ischemic necrosis and hemorrhage. Craniopharyngioma may be difficult to distinguish from pituitary apoplexy. In this study, we discuss a case of pituitary apoplexy in a 19-year-old male patient. In our patient, the tumor was confused with a craniopharyngioma because of the suprasellar extension of the tumor on magnetic resonance (MR) images and the hyperintensity in T1-weighted images, the young age of the patient, and the gradually progressive onset of the symptoms. In conclusion, even without a known history of pituitary adenoma or an abrupt onset of the clinical symptoms, the diagnosis of pituitary apoplexy should be considered in a patient with a suprasellar mass hyperintensity in T1-weighted MR images, which may mimic craniopharyngioma.

'Do no harm': management of craniopharyngioma

Craniopharyngioma management is challenging. Although histology is benign, the tumour can be clinically aggressive with local invasion and frequent recurrences. Extensive morbidity may be present at diagnosis and furthermore, occurs as a consequence of neurosurgery and radiotherapy. Hypothalamic symptoms can have a devastating effect on quality of life and may reduce life expectancy. This case highlights both the challenge of managing hyperphagia and morbid obesity and the importance of initial treatment preserving existing hypothalamic function and the need to avoid tumour recurrence and further surgery. A 11-year old boy presented with hydrocephalus secondary to a craniopharyngioma (he had visual failure and hypopituitarism but few hypothalamic symptoms). He underwent radical resection followed by radiotherapy. Following this treatment, he developed psychological and behavioural problems and hyperphagia. Weight gain in the first year (an increase from +1.4 to +3.7 s.d.) resulted in poor mobility and a fall which caused a slipped femoral epiphysis. In the next year, there was a 6-month period of unexpected weight loss (+4.2 to +3.8 s.d.) that culminated in emergency treatment for diabetic ketoacidosis secondary to severe insulin resistance. He developed a left hemiplegia, and a subsequent cerebral angiogram identified multiple stenoses of the Circle of Willis with a Moyamoya appearance secondary to radiotherapy. Weight gain has continued (+3.8 to +5.5 s.d.) so that bariatric surgery is a management option.

Surgical management of giant craniopharyngiomas

INTRODUCTION

Multimodal treatment in the management of giant craniopharyngiomas (>4 cm in diameter) is necessary to obtain optimal results, and includes conservative or palliative treatment and "aggressive" removal. The significance of a new treatment algorithm including direct surgical resection with the intent to avoid radiation therapy and regrowth will be discussed here.

MATERIALS AND METHODS

Between January 1996 and January 2005 16 patients were diagnosed with giant craniopharyngiomas. Two of them underwent only cyst aspiration because of their advanced age and/or lack of improvement of neuropsychological deficits. One patient underwent transsphenoidal operation and in the remaining 13 transcranial surgery was performed. Four additional patients underwent surgery for recurrence. The prospective protocol included pre- and post-operative dynamic endocrine tests, high field 1.5 T MRI and ophthalmological as well as neuropsychological examinations.

RESULTS

In resectable tumours, the rate of total removal was ten out of 12 with two recurrences. In the remaining two patients with recurrences this intention was abandoned because of a firm tumour or a deteriorating neuropsychological status prior to the scheduled additional operation. There was no mortality and the morbidity rate was 6.3%. Visual function improved in 11, was unchanged in one and deteriorated in two patients. Secretion of different adenohypophyseal hormones deteriorated after tumour resection in one to three patients, and new diabetes insipidus occurred in six patients. There was no permanent deterioration of neuropsychological function.

CONCLUSION

Special reference is given to direct resection of tumours at an optimal timing within this management. If hypothalamic disturbances are absent or improving due to pre-treatment (medical therapy, symptomatic surgery), giant craniopharyngiomas can be surgically removed in more than two of three patients with low morbidity and only moderate deterioration of endocrine function. The latter has to be accepted when curative surgery is intended, but even then, recurrences cannot be prevented. Contraindication for curative surgery is persisting hypothalamic damage necessitating conservative treatment modalities.

Measurement of optic nerve blood flow during dissection of parasellar tumors

The authors describe direct measurement of optic nerve blood flow (ONBF) and examine the application of such monitoring to detecting optic nerve ischemia during parasellar tumor surgery. Prospective evaluation was performed for 26 patients requiring surgery for parasellar tumors. Ophthalmologic examination was performed pre- and postoperatively. ONBF was measured using laser Doppler flowmetry before tumor dissection (initial ONBF) and after tumor removal (final ONBF). The waveform was analyzed using a data acquisition system. Initial ONBF could be measured in 16 patients (22 nerves; 8.9 +/- 0.9 ml/100 g/min). Final ONBF could be determined in all 26 patients (42 nerves; 10.8 +/- 0.7 ml/100 g/min). In the 22 nerves with initial measurements, final ONBF (11.3 +/- 0.6 ml/100 g/min) was significantly increased (p < 0.01). In six patients whose optic canal was unroofed, ONBF did not change immediately; nonetheless, an increase was prominent in the final phase (p < 0.05). In another six patients, a small vessel adjacent to the optic nerve was temporarily occluded. ONBF was demonstrably reduced in three patients and recovered quickly after reperfusion. Intraoperative ONBF measurement may be useful as real-time monitoring for prediction and prevention of intraoperative optic nerve ischemia.

The petrosal approach for the resection of retrochiasmatic craniopharyngiomas

THE PETROSAL (PRESIGMOID transtentorial) approach has been advocated for resecting retrochiasmatic craniopharyngiomas. The projection of the surgical corridor, posterior to anterior and inferior upward, is particularly valuable in dissecting the upper pole of the tumor, which projects high into the third ventricle. This approach allows direct visualization for dissecting the hypothalamus and the pituitary stalk, and maintaining their blood supply and functional integrity. With a web site video presentation, we demonstrate the operative nuances of the approach to these tumors. We recommend this approach for patients with large and giant retrochiasmatic craniopharyngiomas.

Outcomes following endoscopic, expanded endonasal resection of suprasellar craniopharyngiomas: a case series

Object

Craniopharyngiomas are challenging tumors that most frequently occur in the sellar or suprasellar regions. Microscopic transsphenoidal resections with various extensions and variations have been performed with good results. The addition of the endoscope as well as the further expansion of the standard and extended transsphenoidal approaches has not been well evaluated for the treatment of this pathological entity.

Methods

The authors performed a retrospective review of all patients who underwent a purely endoscopic, expanded endonasal approach (EEA) for the resection of craniopharyngiomas at their institution between June 1999 and February 2006. Endocrine and ophthalmological outcomes, extent of resection, and complications were evaluated.

Results

Sixteen patients underwent endoscopic EEA for the resection of craniopharyngiomas. Five patients (31%) presented with recurrent disease. Complete resection was planned in 11 of the 16 patients. Three elderly patients with vision loss underwent planned debulking, 1 patient with vision loss and a moderate-sized tumor had express wishes for debulking, and 1 patient had a separate, third ventricular nodule that was not resected. Of those in whom complete resection was planned, 91% underwent near-total (2/11) or gross-total (8/11) resection. No patient who underwent gross-total resection suffered a recurrence. The mean follow-up period was 34 months. Of the 14 patients who presented with vision loss, 93% had improvement or complete recovery and 1 patient's condition remained stable. No patient experienced visual worsening. Eighteen percent of patients (without preexisting hypopituitarism) developed panhypopituitarism and 8% developed permanent diabetes insipidus. There were no cases of new obesity. The postoperative cere-brospinal fluid leak rate was 58%. All leaks were resolved, and there were no cases of bacterial meningitis. There was 1 vascular injury (posterior cerebral artery perforator branch) resulting in the only new neurological deficit. No patient died.

Conclusions

Endoscopic EEA for the resection of craniopharyngiomas provides acceptable results and holds the potential to improve outcomes.

Endoscopic endonasal pituitary transposition for a transdorsum sellae approach to the interpeduncular cistern

OBJECTIVE

The interpeduncular cistern, including the retroinfundibular area, is one of the most challenging regions to approach surgically. The pituitary gland and the infundibulum guard the region when an endonasal route is undertaken. Superior transposition of the pituitary gland and infundibulum is described as a functional means to access this complex region through a fully endoscopic, completely transnasal route.

METHODS

Ten consecutive patients in whom a pituitary transposition was performed during an expanded endonasal approach at the University of Pittsburgh Medical Center for resection of retroinfundibular lesions were reviewed. The series consisted of seven men and three women with a mean age of 44.4 years. Pathology consisted of four craniopharyngiomas, four chordomas, and two petroclival meningiomas.

RESULTS

Five patients (50%) underwent total resection of the tumor, three patients (30%) underwent near total resection ( > 95% removal), and two patients (20%) had partial resection of petroclival meningiomas with the goal of optic apparatus decompression. All four patients with visual deficits recovered their vision completely. There was no neurological deterioration. Eight patients had normal pituitary function preoperatively, seven of whom (87.5%) had confirmed function preservation postoperatively, with one of these patients experiencing transient diabetes insipidus. The remaining patient with a hypothalamic craniopharyngioma underwent complete resection with obligatory panhypopituitarism and diabetes insipidus.

CONCLUSION

Endoscopic endonasal transposition of the pituitary gland and its stalk can provide a valuable corridor to the retroinfundibular space and interpeduncular cistern with pituitary function preservation in the majority of patients. This approach should only be pursued once significant experience with endoscopic endonasal approaches has been acquired.

Radiation therapy and CyberKnife radiosurgery in the management of craniopharyngiomas

OBJECT

Many benign intracranial tumors are amenable to radiotherapy treatment including meningiomas, schwannomas, pituitary tumors, and craniopharyngiomas. The authors present their experience in the treatment of craniopharyngiomas in 16 patients using frameless CyberKnife stereotactic radiosurgery (SRS). The authors discuss the role of radiation therapy in the management of these tumors, and more specifically, the role of CyberKnife SRS.

METHODS

Sixteen patients were treated for residual or recurrent craniopharyngioma between 2000 and 2007 with CyberKnife SRS at Stanford University Medical Center. All patients underwent magnetic resonance imaging and visual and neuroendocrine evaluations before and at regular intervals after SRS. A multisession treatment regimen and a nonisocentric treatment plan for each patient were used with a mean marginal dose of 21.6 Gy and a mean maximal dose of 29.9 Gy.

RESULTS

There were adequate clinical data to assess outcomes in 11 of 16 patients. Evaluation of patients between 13 and 71 years of age (mean 34.5 years) with a mean follow-up period of 15.4 months revealed no deterioration in visual or neuroendocrine function. Tumor shrinkage was achieved in 7 of these 11 patients, and tumor control in another 3. One patient had cystic enlargement of the residual tumor.

CONCLUSIONS

The authors' early experience with the application of CyberKnife SRS to residual or recurrent craniopharyngiomas has been positive; control or shrinkage of the tumor was achieved in 91% of patients, with no visual or neuroendocrine complications. Longer-term follow-up with a larger group of patients is required to fully evaluate the safety and effectiveness of this treatment modality.

Neuropsychological functioning following craniopharyngioma removal

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

Craniopharyngiomas

Craniopharyngiomas are epithelial tumors arising along the path of the craniopharyngeal duct and presenting with a variety of manifestations. Their optimal management remains a subject of debate. Currently, surgical excision followed by external beam irradiation is the main treatment option. Craniopharyngiomas are associated with significant long-term morbidity and mortality rates.

Craniopharyngiomas in children: recurrence, reoperation and outcome

INTRODUCTION

Craniopharyngioma bears a high rate of recurrence and morbidity in childhood. Although the outcome after recurrence and reoperation is an important parameter for the long-term evaluation of craniopharyngioma, it is poorly documented in literature.

MATERIALS AND METHODS

We studied children reoperated for recurrent craniopharyngioma in our institution since the advent of computed tomography (CT) scanner. Reoperation for tumor resection was decided whenever the recurrence was solid, with the aim total resection if possible and reasonable. Stereotactic techniques were used in case of cystic recurrence, and external irradiation was used only in case of recurrent tumor not amenable to surgery.

RESULTS

From September 1981 to January 2007, we performed one or more reoperations in 20 children presenting with recurrent craniopharyngiomas. The total number of reoperations was 29: resection was total in 12 cases, near-total in 8 cases, partial in 8 cases, and undocumented in 1. In addition, stereotactic procedures were performed in 11 cases, and 5 patients underwent external irradiation.

DISCUSSION

No patient died after surgery or because of tumor progression; one patient died abruptly of an undiagnosed cause during external irradiation. The event-free survival after reoperation was 49.9% at 5 years and 40.0% at 10 years. At last control, after a mean follow-up of 70.4 months after the last surgery, nine patients were tumor-free and ten had stable disease.

CONCLUSION

Reoperation for recurrent craniopharyngioma is an efficient method for tumor control and should be proposed whenever the recurrent tumor is solid. Morbidity results above all from tumor aggressiveness, rather than from surgical damage.

Craniopharyngioma surgery

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

The role of the endoscope in the transsphenoidal management of cystic lesions of the sellar region

Cystic mass lesions within the sella turcica are common, and they include cystic pituitary adenomas, craniopharyngiomas, Rathke's cleft cysts, arachnoid cysts, and other entities. Until recently, such lesions were typically removed by a microsurgical transsphenoidal route. Given the increased use of the endoscope in transsphenoidal surgery, we evaluated the potential benefits of this tool in the treatment of such lesions. Between January 1997 and March 2005, 76 consecutive patients with sellar-suprasellar cystic lesions treated in three Neurosurgical Divisions underwent transsphenoidal removal in which the endoscope was used at least during the sellar step of the procedure (endoscope-assisted or fully endoscopic). The series consisted of 26 pituitary macroadenomas, 20 Rathke's cleft cysts, 18 craniopharyngiomas, 10 arachnoid cysts, one craniopharyngioma associated with an adrenocorticotropic hormone-secreting adenoma, and one chordoid glioma. Rigid 4-mm endoscopes (0 degrees , 30 degrees , and/or 45 degrees ) were used, and the advantages and limits of the endoscope during the sellar step of the procedure were recorded. Endoscopic exploration after lesion evacuation was generally easier and of greatest efficacy when the residual cystic cavity was larger as opposed to smaller. The use of angled endoscopes was optimal in larger residual cavities. Early descent of the suprasellar cistern, bleeding inside the residual cyst cavity, and a small sella were the most common causes preventing thorough exploration of the residual cavity after its evacuation. In no cases did the endoscope cause injury during the sellar cavity exploration. Endoscopic exploration of the sellar cavity during transsphenoidal surgery offers both general and specific advantages in the treatment of a variety of different cystic sellar lesions. Its routine use during transsphenoidal surgery for such lesions is recommended to achieve maximal and safe tumor removal.

[Craniopharyngiomas]

Craniopharyngiomas are rare benign epithelial tumors, arising from the pituitary stalk or gland and developing in the sellar and suprasellar region, affecting both adults and children. Incidence is 0.5 to 2 new cases per million inhabitants. Clinical features essentially include visual disturbances, endocrine deficiencies, and neurological signs. Initial signs are often visual loss and increased intracranial pressure in children, growth and pubertal delay in teenagers, visual disturbances or cognitive impairment in adults. Diagnosis is made on MRI and CT scan, demonstrating a sellar or suprasellar tumor, heterogeneous, with frequent calcifications. Craniopharyngiomas can be classified depending on their locations from the sella, the diaphragma sellae, and upon their origins from the pituitary stalk or the infundibulum. They can also be classified depending on the location from the optic chiasm and the third ventricle. This classification allows surgical series comparison, which is of importance since developments and extensions of the tumor can explain surgical difficulties. The management of this lesion is still controversial. Because it is an extra-cerebral benign lesion, the ideal goal of treatment should be complete tumor removal with improvement of altered visual functions, minimal deterioration of endocrine function, and no neuropsychological impairment. But the situation of the tumor, its relationship with third ventricle, hypothalamus, optic tract, vascular structures make its removal often difficult. However, great progresses have been realized in surgical treatment, resulting in a dramatic improvement of the prognosis of craniopharyngiomas. Nowadays, one can expect total removal in 60 to 70% of patients, subtotal removal in 20 to 30%, and partial removal in 10%. When total removal is impossible, radiotherapy may reduce the risk of a poor evolution. Recurrences are a problem in 15% of patients with total removal, 35% in subtotal removal, 70% in partial removal. If radiotherapy has not been performed as first treatment, it is efficient in 80% of recurrences. Long term follow up is necessary in these patients, due to medical management of endocrine, visual and psychological problems, and risk of late recurrence. With close involvement in this management, most of patients may enjoy a good outcome, 80% being able to return to normal active life.

Devenir à long-terme des craniopharyngiomes de l'adulte

There is few published series dealing on the long-term outcome of the adult-onset craniopharyngiomas. We report the long term clinical, tomodensitometric and MRI data outcome of 35 (23 woman and 12 men) consecutive adult-onset cured for craniopharyngiomas between 1983 and 2002, and followed-up in Rennes University Hospital. The operation was performed via frontopterional approach in 59% and transphenoïdal approach in 41% of cases. Their age at the time of diagnosis was 44.7+/-15.1 years (21-74). The average postoperation follow-up was 7.4+/-7.0 years (0.1-19.1). Recurrence of tumour occurred in 8 patients (25.8%) and a tumor progression in 1 case. The delay of recurrence after initial surgery was 4.1+/-1.3 years (1.4-6.3). Two patients had 5 and 6 years treatment by growth hormone (GH), without tumor recurrence. The observed increase of weight after the surgical cure of craniopharyngiomas concerned 22 patients (63%). The average weight gain was 17.5+/-14.7 kg (1.5-58). In 7 cases (20%) neuropsychological disorders were noted, of which 2 with lost of professional activity. Three patients died. In conclusion the craniopharyngiomas recurrence is frequent and can appear in very prolonged deadlines after the initial surgery.

Craniopharyngioma

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

Angiogenesis and cell proliferation in human craniopharyngioma xenografts in nude mice

OBJECT

Craniopharyngioma is one of the most common congenital tumors of the sellar and suprasellar regions and accounts for between 4 and 6% of all intracranial tumors. Its oncogenesis and biological behavior have not been well studied, and neither a cell line nor an animal model have been established. To better understand the tumor and improve its clinical management, the authors investigated the angiogenesis and cellular proliferation in subcutaneous craniopharyngioma xenografts obtained by implanting human tumor cells into athymic nude mice.

METHODS

Human craniopharyngioma cells obtained from surgical specimens were subcutaneously implanted into BALB/c-nu/nu nude mice to establish a preliminary animal model of a transplanted tumor. Immunohistochemical staining with streptavidin-peroxidase complex was used to identify the cell phenotype and to evaluate the angiogenesis and proliferation in the xenografts. Expression of cytokeratin, minichromosome maintenance deficient 6 (MCM6) protein, and endothelial cell marker CD34 on the xenograft sections were assayed quantitatively by computer-assisted microscopy. Twenty-seven surviving subcutaneous xenografts were obtained in 15 nude mice. The total implantation success rate was 28.12% (adamantine epithelioma [AE], 37.50%; squamous papillary tumor [SPT], 18.75%). Formation of capillaries and cell proliferation were observed in all of these xenografts. Microvessel density and degree of MCM6 immunostaining were positively correlated in the surviving grafts (r = 0.410, p < 0.05), but there was no significant difference in these variables between the AE and SPT groups (p > 0.05).

CONCLUSIONS

A preliminary animal model of human craniopharyngioma was established in the nude mouse by heterotopic implantation. Surviving xenografts maintained their vascularization and proliferation activities until harvesting at 12 weeks.

Pituitary adenoma, craniopharyngioma, and Rathke cleft cyst involving both intrasellar and suprasellar regions: differentiation using MRI

AIMS

To determine the differential magnetic resonance imaging (MRI) features of pituitary adenoma, craniopharyngioma, and Rathke cleft cyst involving both intrasellar and suprasellar regions.

MATERIALS AND METHODS

The MRI images of 64 patients with pituitary adenoma (n=38), craniopharyngioma (n=13), or Rathke cleft cyst (n=13) were retrospectively reviewed by three neuroradiologists. The following characteristics were evaluated: shape, volume, extent, component characteristics, signal intensities of solid portions on T2-weighted images, signal intensities of cystic portions on T1-weighted images, and enhancement patterns of solid portions and cyst walls of tumours. Fisher's exact test applied with Bonferroni correction was used for multiple comparison. A flowchart for differential diagnosis was constructed based on statistical analysis of the results.

RESULTS

A snowman shape, solid characteristics, and homogeneous enhancement of the solid portion were more common in pituitary adenomas (p<0.017). A superiorly lobulated shape, third ventricle compression by superior tumour extension, mixed solid and cystic characteristics, and reticular enhancement of the solid portion were more common in craniopharyngiomas (p<0.017). Finally, an ovoid shape, a small tumour volume, cystic characteristics, and no or thin cyst wall enhancement were more common in Rathke cleft cysts (p<0.017). The flowchart yielded diagnostic accuracies as follows: 92.1% in pituitary adenoma; 92.3% in craniopharyngioma; 92.3% in Rathke cleft cyst; and 92.2% overall.

CONCLUSION

A combination of MRI findings is helpful in the differential diagnosis of the three tumours involving both intrasellar and suprasellar regions.

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

OBJECT

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

METHODS

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

CONCLUSIONS

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

The petrosal approach for the total removal of giant retrochiasmatic craniopharyngiomas in children

OBJECT

The surgical removal of retrochiasmatic craniopharyngiomas, particularly those of giant size, remains a formidable challenge. The posterior petrosal (or presigmoid transtentorial) approach provides wide, direct exposure of these tumors, which allows safe neurovascular dissection and facilitates their total removal.

METHODS

Two patients, one 7-year-old girl and one 4-year-old girl, harboring giant retrochiasmatic craniopharyngiomas underwent total resection via the posterior petrosal approach. Both patients had good outcomes, and no evidence of recurrence was noted in either patient after 3 years of follow up. The surgical technique used in these patients is described. The trajectory of the petrosal approach is posterior-to-anterior and inferior upward. This is particularly valuable for dissecting the upper portion of the tumor, which projects high into the third ventricle. Using this approach, the surgeon can achieve direct visualization for dissection of the hypothalamus and pituitary stalk, while maintaining the blood supply to these structures and preserving their functional integrity. The small and poorly aerated mastoid sinus in children does not contraindicate the use or diminish the advantages of the petrosal approach.

CONCLUSIONS

The authors recommend this approach for patients with large or giant retrochiasmatic craniopharyngiomas.

Fractionated stereotactic conformal radiotherapy following conservative surgery in the control of craniopharyngiomas

PURPOSE

To describe the technique and results of stereotactically guided conformal radiotherapy (SCRT) in patients with craniopharyngioma after conservative surgery.

METHODS AND MATERIALS

Thirty-nine patients with craniopharyngioma aged 3-68 years (median age 18 years) were treated with SCRT between June 1994 and January 2003. All patients were referred for radiotherapy after undergoing one or more surgical procedures. Treatment was delivered in 30-33 daily fractions over 6-6.5 weeks to a total dose of 50 Gy using 6 MV photons. Outcome was assessed prospectively.

RESULTS

At a median follow-up of 40 months (range 3-88 months) the 3- and 5-year progression-free survival (PFS) was 97% and 92%, and 3- and 5-year survival 100%. Two patients required further debulking surgery for progressive disease 8 and 41 months after radiotherapy. Twelve patients (30%) had acute clinical deterioration due to cystic enlargement of craniopharyngioma following SCRT and required cyst aspiration. One patient with severe visual impairment prior to radiotherapy had visual deterioration following SCRT. Seven out of 10 patients with a normal pituitary function before SCRT had no endocrine deficits following treatment.

CONCLUSION

SCRT as a high-precision technique of localized RT is suitable for the treatment of incompletely excised craniopharyngioma. The local control, toxicity and survival outcomes are comparable to results reported following conventional external beam RT. Longer follow-up is required to assess long-term efficacy and toxicity, particularly in terms of potential reduction in treatment related late toxicity.

Craniopharyngiomas in children

BACKGROUND

The modern era of pediatric craniopharyngioma treatment includes multiple modalities including microsurgical resection, irradiation, brachytherapy or chemotherapy. No clear consensus as to the best therapeutic approach has yet been established. The aim of this study was to describe the techniques and strategies for the treatment of pediatric craniopharyngiomas in light of a literature review with particular attention to the incidence of adverse postoperative effects.

METHODS

Twenty-seven pediatric patients (median age 9.0 years) who were surgically treated for craniopharyngiomas were evaluated. We reviewed the recent literature for clinical features of craniopharyngiomas in children, including the present cases.

RESULTS

The overall rate of radiographically complete resection of our cases was 92.6%. In the literature we reviewed, the rate of gross total resection was 33-91% (average 57.8%). According to the literature, recurrence rates range from zero to 52.8% (average 16.1%) in the gross total resection group, 51.1% in the subtotal resection without radiation therapy group, and 33.5% in the subtotal resection with radiation therapy group. In six of our most recent cases, for whom we have complete outcome analysis, radiographically complete resection is 100% with only one recurrence so far over 4 years.

CONCLUSIONS

For patients in whom early postoperative MRI reveals complete craniopharyngioma removal, a very low rate of recurrence is anticipated. In the authors' experience, radiographically total excision of even large craniopharyngiomas can be safely achieved by one or a combination of several advanced microsurgical techniques, sometimes by a staged strategy. Major morbidities can be avoided, although moderate morbidities occur and require management.

Nuclear β-Catenin Accumulation as Reliable Marker for the Differentiation Between Cystic Craniopharyngiomas and Rathke Cleft Cysts: A Clinico-Pathologic Approach

Clinical and histopathologic differentiation of cystic lesions from the sellar region, that is, craniopharyngiomas (CPs) and Rathke cleft cysts (RCCs), is challenging and has paramount importance with respect to variable clinical manifestation and adapted surgical treatment strategies in both entities. Here, we retrospectively evaluated clinico-pathologic findings in 81 patients presenting with a cystic tumor located in the sellar region. All patients underwent transsphenoidal or transcranial resections. Microscopic inspection of surgical specimens identified CP in 51 patients, and RCC in 30 patients. Amongst the panel of immunohistochemical marker proteins used for histopathologic analysis, nuclear accumulation of beta-catenin was detectable only in CP. On the basis of the histopathologic and immunohistochemical analysis, clinical presentation (sex, age, ophthalmologic, and endocrinologic deficits), imaging (tumor location, size, and calcification), as well as a description of cyst contents obtained during operation were retrospectively evaluated. In purely cystic CPs, an isointense signal was more frequent in T1-weighted magnetic resonance images and calcification of the tumor capsule in computed tomography scans. In addition, the size of RCC was smaller and this tumor entity was more often located within the sella. Aberrant (nuclear) immunohistochemical staining for beta-catenin appeared, however, as most reliable factor for the differentiation between purely cystic CPs and RCCs, whereas tumor location, tumor size, and calcification of the tumor capsule were less consistent parameters. The data are compatible with distinct pathogenic pathways associated with these related histopathologic entities.

Craniopharyngiomas: an update

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

Clinico-pathological and immunohistochemical characteristics associated to recurrence/regrowth of craniopharyngiomas

BACKGROUND

Craniopharyngioma is a rare, benign epithelial brain tumor of the suprasellar region with a high rate of recurrence. Clinical and histopathological features that might be predictors of recurrence/regrowth have not been clearly delineated.

METHODS

We compared recurrence/regrowth of the tumors with the clinico-pathological characteristics, vascular density, cell proliferation index, and immunohistochemical profile (cytokeratins, epithelial membrane antigen [EMA], carcinoembrionary antigen [CEA], and laminin) of 47 patients with craniopharyngioma followed for more than 5 years.

RESULTS

Tumors were adamantinomatous in 42 cases (89%) and papillary squamous in 5 cases (11%). Immunoreactivity for cytokeratin 8/18/19 was positive in 64%; cytokeratin 5 in 42%; laminin 8 in 62%; and CEA in 21%. The cell proliferation index and vascular density were greater in adamantinomatous than in papillary tumors (22+/-6 versus 17+/-3, p=0.05; and 21+/-3 versus 17+/-3, p=0.037, respectively); they were neither related to recurrence nor to regrowth. No significant differences were found between adamantinomatous and papillary tumors regarding the presence of cytokeratin, laminin, CEA or glial fibrillary acidic protein (GFAP). Recurrence rate at 5 years was 59%. No relation was found between recurrence and adjuvant radiotherapy (AR). Residual tumor after surgery, whorl-like arrays (p=0.04) and immunoreactivity for p53 (p=0.022) were significantly related to recurrence/regrowth.

CONCLUSIONS

Residual tumor after surgery, immunoreactivity to p53 and presence of whorl-like arrays are associated to recurrence/regrowth of craniopharyngioma.

Craniopharyngiomas

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

GH replacement does not increase the risk of recurrence in patients with craniopharyngioma

BACKGROUND

A significant number of patients with craniopharyngioma are GH deficient. The safety of GH replacement in these subjects has not been established.

OBJECTIVE

To assess the effect of GH replacement upon recurrence in patients with craniopharyngioma.

PATIENTS AND METHODS

All the patients with craniopharyngioma followed-up at the Departments of Endocrinology or Paediatrics in Oxford and treated or not with GH were studied retrospectively. These were recruited from the databases of the departments consisting of subjects diagnosed between January 1964 and July 2005. The impact of GH replacement upon recurrence was evaluated after adjusting for possible confounding factors.

RESULTS

Forty-one subjects received GH replacement. Nine of them did not have follow-up imaging during GH therapy and were not included in the statistical analyses. The remaining 32 (22 males/10 females) received GH for a mean period of 6.3 +/- 4.6 years (median 5.1, range 0.8-22); 21 started during childhood (13 of them continued after the achievement of final height with an adult dose) and 11 during adult life. The mean duration of their follow-up (from surgery until last assessment) was 10.8 +/- 9.2 years (range 1.9-40). Fifty-three subjects had not received GH therapy (30 men/23 women). The mean duration of their follow-up (from surgery until last assessment) was 8.3 +/- 8.8 years (range 0.5-36). During the observation period, 4 patients treated with GH and 22 non-GH treated ones developed tumour recurrence. After adjusting for sex, age at tumour diagnosis and type of tumour therapy (gross total removal, partial removal, surgery + irradiation), GH treatment was not a significant independent predictor of recurrence (P = 0.06; hazard ratio = 0.309). Similar results were obtained when the impact of GH replacement was assessed according to its duration (P = 0.18; hazard ratio = 0.991/month of treatment). None of the nine patients with insufficient imaging data for inclusion in the statistical analyses [5 men/4 women, 3 treated with GH during childhood/6 during adult life, mean duration of GH therapy 2.9 +/- 2.4 years (median 1.8, range 0.4-7)] showed clinical features suggestive of recurrence during the period of GH replacement. CONCLUSION Based on the data of the craniopharyngiomas database in Oxford, there is no evidence that GH replacement is associated with an increased risk of tumour recurrence.

Recurrence in craniopharyngiomas: Analysis of clinical and histological features

The aim of this study was to investigate the recurrence patterns and significance of various clinical and histological features as predictors of recurrence in craniopharyngiomas. A series of 234 craniopharyngiomas (156 males, 78 females; age range 1.6-65 years) was reviewed. The mean follow-up period was 18.53 months (range 1-120 months). Peri-operative mortality was 7.4% and tumor recurrence was observed in 26 patients (20.3%). Of the patients with recurrence, one had total tumor excision (recurrence-free survival (RFS) 14 months), four had near-total excision (mean RFS 18.2 months) and 21 had subtotal tumor excision (RFS for symptomatic recurrence 7.1 months). Histologically, an adamantinous pattern was seen in 81.4% of cases and a papillary pattern was seen in 18.6%. Brain tissue was included in 67 cases and brain invasion was noted in 44 (all were of adamantinous histology). No correlation was noted between histopathological subtyping or brain invasion and recurrence. The significant clinical factors predictive of recurrence included the extent of resection, tumor size greater than 4 cm and cystic tumors.

Advances in the treatment of pediatric brain tumors

Brain tumors are a heterogeneous group of neoplasms with different origins, pathobiologies, treatments and prognoses. The collective contributions from the fields of neuro-oncology, neurosurgery, radiation oncology, neurology, neuropathology, neuroradiology and molecular biology have all led to significant advances in the treatment of certain brain tumors. Ideas from these fields, under the cooperative umbrella of clinical cancer trial consortia, have been tested in large-scale studies. As a result, patient survivals have increased markedly for these tumor types. Unfortunately, there are certain brain tumors in childhood, such as the diffuse intrinsic pontine glioma and atypical teratoid rhabdoid tumor, for which survival advantages have not been found. This review will discuss the current and possible future therapies of the most common pediatric brain tumors and highlight some of the novel imaging modalities that are used pre- and intraoperatively.

Role of Radiation Therapy and Radiosurgery in the Management of Craniopharyngiomas

The variable clinical presentation, relation to vital anatomic structures, and complications associated with treatment contribute to the controversies that surround the management of craniopharyngiomas. Although the results with radiation therapy and radiosurgery have been equal to or better than those obtained with aggressive surgery, considerable debate exists regarding the role of surgery alone versus limited surgery followed by radiation therapy. Based on current data, one may consider using surgery for discrete tumors that do not involve the hypothalamus and for which gross total resection would result in minimal cognitive side effects. For tumors that clearly involve the hypothalamus and associated suprasellar structures, subtotal resection followed by radiation therapy tailored for the residual disease seems to offer the best long-term control rates with acceptable morbidity.

"Conservative" surgical approach and early postoperative radiotherapy in a patient with a huge cystic craniopharyngioma

OBJECTIVE

The treatment of huge craniopharyngiomas represents a therapeutic challenge for neurosurgeons. Some authors prefer to run the high risks of total removal at primary surgery, while others do not despise subtotal removal in accordance with a multidisciplinary treatment.

METHODS

We report the case of a 17-year-old girl who underwent subtotal removal (tumour remnant with maximum diameter of 2.5 cm) of a huge cystic craniopharyngioma by frontotemporal approach, followed by early external fractionated radiotherapy by linear accelerator. Serial magnetic resonance imaging during a follow-up period of 5 years showed a progressive marked reduction of the tumour remnant, accompanied by a complete recovery of visual deficits and an almost complete regression of diencephalic disturbances.

CONCLUSIONS

Subtotal removal followed by early fractionated radiotherapy can be an effective treatment for huge craniopharyngiomas. Such a multidisciplinary treatment may favour tumour control and assure a satisfactory quality of life as well.

Craniopharyngioma

Craniopharyngiomas are benign tumors of the parasellar region. These tumors may be cystic, solid, or combinations of the two. They have a bimodal age distribution and no apparent gender predilection. Patients may present with endocrinopathy or symptoms related to mass effect from the growing tumor. Patients require a multidisciplinary approach during their diagnostic evaluation and subsequent to initiating therapy. Endocrinopathy should be recognized and treated with appropriate hormonal replacement. Surgery is the first-line therapy for most patients. The specific surgical approach must be tailored to the specific clinical situation and depends on the patient age, endocrine status, and the geometry and consistency of the tumor. Whereas most solid tumors will require craniotomy or transsphenoidal surgery, some cystic tumors may be adequately managed with intracavitary therapies. Subtotally resected or residual tumors often require adjuvant radiation therapy or radiosurgery. Long-term multidisciplinary follow-up is necessary for all patients.

Recurrence in pediatric craniopharyngiomas: analysis of clinical and histological features

OBJECTIVE

The purpose of this study was to investigate the recurrence pattern and significance of various clinical and histological features as predictors of recurrence in pediatric craniopharyngiomas.

METHODS

A series of 116 pediatric craniopharyngiomas (68 boys and 48 girls; age range, 1.6-18 years) was reviewed. Mean follow-up period was 18.53 months. Tumors recurred in 15 patients within 96 months [mean recurrence-free survival (RFS), 12.67 months]. Of the recurrence cases, 2 had complete (mean RFS, 16 months) and 13 had subtotal tumor excision (mean RFS, 9.03 months). Histologically, an adamantinous pattern was seen in 95% of cases, whereas a papillary pattern was noted in 5%. Brain tissue was included in 41 cases. In 32 of 41 cases, brain invasion was noted, and all were of adamantinous histology. No correlation was noted of histopathological subtyping or brain invasion with recurrence.

CONCLUSIONS

The significant clinical factors associated with recurrence included extent of resection, tumor size >4 cm, and cystic tumors.

Pituitary radiotherapy: current controversies

External beam radiotherapy has been used extensively in the management of patients with pituitary disease. However, in view of advances in the techniques of radiotherapy planning and administration, neurosurgery and pharmacological manipulation of the pituitary, there are a growing number of questions and controversies surrounding the current and future use of pituitary radiotherapy in the management of pituitary disease.

Craniopharyngiomas in children: surgical experience at Children's Memorial Hospital

OBJECTIVES

Craniopharyngioma during childhood poses difficulty in management because of the high incidence of surgical complications and treatment failure. In order to identify less detrimental and more effective treatment, a personal series of craniopharyngioma was reviewed in regard to various clinical factors, patient factors (age and sex), tumor factors (location and extension, relationship with chiasm, and hydrocephalus), and therapeutic modes [extent of resection and radiation therapy (RT)].

MATERIALS AND METHODS

Fifty-four childhood craniopharyngiomas treated from 1984 to 2003 were reviewed. Preoperative neuroimaging studies were classified depending upon tumor location and extension. In this series of 54 patients, 43 had total tumor resection and 11 had subtotal resection. Of the total resection group, ten showed evidence of residual tumor on postoperative neuroimaging studies. Following the initial resection, 46 did not have RT whereas 8 with subtotal resection received RT.

RESULTS

There were no surgical deaths. Postoperative complications included pseudoaneurysm in 1, hemiparesis in 3, severe obesity in 5, panhypopituitarism in 50, and worsening of visual function in 7. During follow-up ranging from 12 months to 21 years, 24 patients had recurrence. Of the 33 patients with radiographic total resection, 9 (27.3%) had recurrence. Among the patients with total resection but radiographic residual and those with subtotal resection, the craniopharyngioma recurred in 90% and 100%, respectively. Three (37.5%) of eight patients with subtotal resection with RT had recurrence. Overall recurrence-free survival was 62% at 5 years and 49% at 10 years. The sex and age, location and extension of the tumor, nature of the optic chiasm, and hydrocephalus did not influence survival with statistical significance. However, the extent of surgical resection and use of RT showed significant differences for survival. Patients with total resection had a recurrence-free survival rate of 83% and 70% at 5 and 10 years, respectively. Patients with subtotal resection with RT had 71% at 5 years and 36% at 10 years. Patients who had subtotal resection or radiographically residual tumor without RT had a recurrence-free survival rate of only 9%. Among 22 patients whose recurrent tumor was treated with RT, a second recurrence-free survival rate was 90% at 5 years.

CONCLUSION

Total resection provided the best outcome. However, recurrence rates and surgical complications remained high following radical tumor resection. RT was effective for recurrent tumors and should be considered being the primary treatment for recurrences or difficult tumors, which are not amenable to total resections.

Craniopharyngioma in children: Marseille experience

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Craniopharyngiomas in children: Turkey experience

OBJECTIVES

Craniopharyngiomas are the most frequently encountered suprasellar tumors in children. Although they have a benign histology, total resection without morbidity is very difficult.

METHODS

We aimed to review the results of pediatric craniopharyngioma patients treated in eight institutions in Turkey. There were 51 boys and 36 girls, ranging in age from 20 months to 18 years (mean 10.2 years). The most frequent symptom was headache, followed by visual disturbances. Hydrocephalus was seen most frequently in tumors greater than 4 cm in size (P=0.002). Hydrocephalus was associated with the decreased gross total resection (P=0.043). The recurrence (28%) was significantly higher in patients with subtotal and partial tumor removal (P=0.010). Bad outcome was significantly associated with tumor dimension (P=0.039); the greater the tumor dimension, the worse the outcome. Outcome was significantly better in patients older than 10 years (P=0.032). Gender, tumor type and location, presence of hydrocephalus and calcification, histological type of craniopharyngioma, and surgical approach did not have a significant effect on the outcome.

CONCLUSIONS

The treatment should be individualized and a multidisciplinary approach should be used. The goal of surgery should be gross total removal without mortality and with acceptable morbidity.

Long-term results of the surgical treatment of craniopharyngioma: the experience at the Policlinico Gemelli, Catholic University, Rome

BACKGROUND

Craniopharyngioma (CP) is the most common intracranial non-glial tumour observed in pediatric age. Although histologically benign and amenable to surgical treatment, its location and relation with vital nervous and vascular structures makes the feasibility of a radical resection difficult even in the microneurosurgery era. Beside the difficulties experienced when performing tumour resection, post-operative complications, such as endocrinological imbalance, represent another point that makes CP total excision a challenge. In order to avoid such complications, some authors have suggested to renounce to radical resection and to rely on post-operative radiation therapy to minimise the risk of residual tumour progression.

METHODS

We report our experience with 52 children and adolescents operated on for CP at the Department of Pediatrics, Section of Pediatric Neurosurgery, Catholic University Medical School, Rome, between January 1985 and December 2002. The study included 14 children <5 years old (five less than 2 years of age), 25 between 6 and 10 years old, and 13 more than 10 years old. The most common presenting signs were related to endocrinological imbalance (35 cases), increased intracranial pressure (32 cases), and to a lesser extent, visual compromise (17 cases). Concerning location, CP was intrasellar in three cases; sellar/suprasellar with prominent prechiasmatic growth in 24 cases; retrochiasmatic/3rd ventricular in 14 cases, and giant (with an extension into the middle and/or posterior cranial fossae) in 11 cases. The tumour was managed by means of a single surgical approach in 47 cases and with a two-stage operation in the remaining five cases. In 11 cases of intrasellar or intra/suprasellar midline location, the first surgical approach was done through the transsphenoidal route (which represented the first step of a staged operation in five instances); in the remaining 41 patients, craniotomy was the first surgical procedure. Radical tumour resection was achieved in 40 cases, subtotal (only small tumour remnants adherent to the carotid arteries, 3rd ventricle floor or visual pathways) in nine, and only partial in the remaining three cases

RESULTS

Histology demonstrated the adamantinous variant in all cases. Two surgical deaths were recorded in this series (both following a transsphenoidal approach): one secondary to uncontrollable intra-operative bleeding from the carotid artery, and the other to fulminating bacterial meningoencephalitis. Morbidity included endocrinological disturbances, namely hypopituitarism and diabetes insipidus, in more than 80% of cases, worsening of pre-operative visual deficit in six cases, and transitory neurological deficits in five cases. One late death was recorded 2 years after surgery, secondary to electrolytic imbalance although favoured by a major head trauma with subacute subdural haematoma. Nine recurrences occurred 1-8 years after surgery (three true recurrences, and six re-growths of incompletely resected tumours) that required re-operation. Twelve patients underwent radiotherapy, six after an initially incomplete tumour resection and six following relapse. One patient presented with a malignant thalamic glioma 8 years after radiotherapy. At long-term follow-up, all survivors showed good clinical condition, even though approximately 60% relied on hormone replacement, and some patients presented obesity. Diabetes insipidus has subsided in about 80% of the cases; visual deficits improved or remained stable, whereas post-operative neurological deficits subsided in all but one patient.

CONCLUSION

In our experience, radical resection of CP represented the first and almost unique treatment modality. Although not insignificant, post-operative mortality and morbidity do not seem to represent a major contraindication in attempting a radical tumour resection whenever possible. On the other hand, extensive hypothalamic involvement should suggest a less aggressive attitude.

Surgical management of the recurrence and regrowth of craniopharyngiomas

Object. The authors performed a retrospective analysis of a consecutive series of craniopharyngiomas and their recurrences, which were managed with surgery alone.

Methods. In the past 20 years, 37 consecutive patients with craniopharyngiomas underwent surgery without adjuvant radiotherapy. During that period there was a consistent strategy that surgical management was the first choice of treatment whenever possible.

Of these 37 patients, 11 experienced tumor recurrence (29.7%) during the mean follow-up period of 11.1 years. Of these 11 patients, seven experienced recurrence after neuroimaging-confirmed total removal, and four patients experienced recurrence after partial or incomplete removal. In these 11 patients, surgical removal was performed 17 times. Using a proper surgical approach (mainly a basal interhemispheric approach) and meticulous microsurgical techniques, total removal of the recurrent tumor was achieved in nine surgeries (52.9). The mortality and morbidity rates associated with these 17 surgeries were 0% and 9.1%, respectively. In most cases, visual function was preserved or improved and intellectual performance was also preserved.

Conclusions. Recurrence of craniopharyngioma can be safely managed by using meticulous contemporary microsurgical techniques without additional radiotherapy. The role of surgery and adjuvant radiotherapy for craniopharyngiomas may vary in the future, depending on innovations in treatment and technology. Nevertheless, surgery can be still a major therapeutic option in the management of recurrent craniopharyngiomas.

Individualized treatment of craniopharyngioma in children: ways and means

BACKGROUND

Medium- and long-term prognosis of craniopharyngioma is overwhelmed by the risks of hypothalamic and visual impairment. This problem has been underestimated for a long time because the major concern for the neurosurgeon was the risk of recurrences, their best prevention being thought to be complete tumour resection. Today, we know that radical surgery not only is not an absolute guarantee against recurrences but also can cause hypothalamic and visual complications.

METHODS

The authors suggest that instead of complete removal, the first choice treatment should be, when possible, a less aggressive, multistaged and personalized treatment. In this perspective they focus on other therapeutic methods: endocavity treatment of cysts with rhenium-186, triconformational radiotherapy, radiosurgery, and widespread use of the trans-sphenoidal approach.

CONCLUSIONS

These simple methods should reduce the risks of visual aggravation and metabolic syndrome.

Functional capacity and body mass index in patients with sellar masses--cross-sectional study on 403 patients diagnosed during childhood and adolescence

RATIONALE

We analyzed the impact of tumour localization and histology on functional capacity (FC) and body mass index (BMI) in children with sellar masses.

METHODS

FC was evaluated using the ability scale Fertigkeitenskala Münster-Heidelberg in 403 children and adolescents with sellar masses (276 craniopharyngioma, 14 germinoma, 21 optic/chiasmatic glioma, 40 hypothalamic glioma, 13 cysts of Rathke's cleft and 39 other sellar masses). Besides tumour localization, the influence of gender, irradiation and age at diagnosis and at evaluation on FC and BMI was analyzed. General linear models with explanatory influential variables were built.

RESULTS

In multivariate analysis, only age at diagnosis (p<0.001) and hypothalamic involvement (p=0.005) had relevant impact on FC. The second model showed BMI at diagnosis (p<0,001), hypothalamic involvement (p<0.001) and craniopharyngioma (p=0,004) to influence BMI at the latest evaluation.

CONCLUSION

We conclude that hypothalamic involvement and young age at diagnosis had major impact on FC and BMI and should be considered as risk factors for impaired rehabilitation.

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

OBJECT

The authors report on a cohort of patients with craniopharyngioma treated principally through transnasal (TN) resection and followed up for a minimum of 5 years. More specifically, they evaluate the role of the TN approach in the management of craniopharyngioma.

METHODS

Between 1984 and 1994, 68 patients underwent TN resection of craniopharyngiomas at the University of Southern California. The tumor was at least partially cystic in 88% of cases. Four tumors were purely intrasellar, 53 had intra- and suprasellar components, and 11 were exclusively suprasellar. During the same period, 18 patients underwent transcranial (TC) resection of purely suprasellar craniopharyngiomas. Long-term neurological, visual, and endocrine outcomes were reviewed for all patients. In 61 (90%) of 68 patients in the TN group, total resection was achieved, according to 3-month postoperative magnetic resonance images, although four patients suffered a recurrence. Three (43%) of the seven tumors that had been partially resected were enlarged on serial imaging. Fifty-four (87%) of 62 patients with preoperative visual loss experienced improvement in one or both eyes, but two patients (3%) with exclusively suprasellar tumors experienced postoperative visual worsening in one or both eyes. New instances of postoperative endocrinopathy (that is, not present preoperatively) occurred as follows: hypogonadism (eight of 22 cases), growth hormone (GH) deficiency (four of 18 cases), hypothyroidism (11 of 49 cases), hypocortisolemia (nine of 52 cases), and diabetes insipidus (DI; four of 61 cases). One case each of hypocortisolemia and hypothyroidism resolved after surgery. Hyperphagia occurred in 27 (40%) of 68 patients. One patient had short-term memory loss. Postoperative complications included one case of cerebrospinal fluid leak. Among the 18 patients in the TC group, 11 had complete resections. In one case (9%) the tumors recurred. Three (43%) of the seven subtotally resected tumors grew during the follow-up interval. Vision improved in 11 (61%) of 18 cases and worsened in three (17%) as a result of surgery. New instances of postoperative endocrinopathy occurred as follows: hypogonadism (one of six cases), GH deficiency (four of seven cases), hypothyroidism (11 of 14 cases), hypocortisolemia (eight of 15 cases), and DI (nine of 16 cases). No instance of preoperative endocrinopathy was corrected through TC surgery. Four patients (22%) exhibited short-term memory loss and 11 (61%) had hyperphagia after surgery. When compared with those in the TC group, patients in the TN group had shorter hospital stays.

CONCLUSIONS

Use of the TN approach can render good outcomes in properly selected patients with craniopharyngioma, particularly when the tumor is cystic. Even in mostly suprasellar cases, an extended TN approach can afford complete resection. Note that endocrine function often worsens after surgery and that postoperative obesity can be a significant problem.

Monitoring the Expression Profiles of Integrins and Adhesion/Growth-regulatory Galectins in Adamantinomatous Craniopharyngiomas: Their Ability to Regulate Tumor Adhesiveness to Surrounding Tissue and Their Contribution to Prognosis

OBJECTIVE

The purpose of this study was to identify biological markers that may be involved in the adhesiveness of craniopharyngiomas to optical chiasms and/or pituitary stalks.

METHODS

We determined the complete pattern of integrin expression in three craniopharyngiomas by means of a complementary deoxyribonucleic acid microarray. We quantitatively determined the levels of immunohistochemical expression of the different integrins in a series of 37 cases and the pattern of immunohistochemical expression of 10 extracellular matrix components (acting as integrin ligands) in 7 optical chiasms and 11 pituitary stalks. We also quantitatively (computer-assisted microscopy) determined the levels of immunohistochemical expression of galectin-1, -3, -4, -7, and -8 in 50 adamantinomatous craniopharyngiomas.

RESULTS

The present study shows that at both the ribonucleic acid and protein levels, adamantinomatous craniopharyngiomas express the alpha2, alpha6, alpha(v), beta1, beta5, and beta8 integrin subunits, whereas optical chiasms and pituitary stalks express vitronectin, thrombospondin, and various forms of collagens.

CONCLUSION

Our data suggest that at least part of the adhesiveness of craniopharyngiomas to the surrounding tissue, such as optical chiasms and pituitary stalks, could be explained by the interactions between alpha(2beta1) integrin expressed by craniopharyngiomas and collagens on the one hand, and vitronectin expressed by the surrounding tissue on the other hand. In addition, a Cox regression analysis has revealed that the levels of galectin-4 contribute significant information toward the delay in recurrence independently of surgical status.

Craniopharyngiomas in children and adults: systematic analysis of 121 cases with long-term follow-up

BACKGROUND

Craniopharyngiomas account for 2-5% of all primary intracranial tumours. Despite their benign histological appearance, they are often associated with an unfavourable prognosis and their optimal treatment remains controversial.

AIM

To analyse the natural history and treatment outcome of children and adults presenting to the Departments of Paediatrics and Endocrinology with craniopharyngioma between 1964 and 2003.

PATIENTS AND METHODS

The records of 121 patients (age range 2.5-83 years, 42 aged < 16 and 79 aged > or = 16) were identified. The mean follow-up period since presentation was 103 months (8.6 years) (range 0.3-468 months). Sixteen patients underwent gross total removal (A), 3 gross total removal + radiotherapy (B), 51 partial removal (C), 33 partial removal + radiotherapy (D), 6 cyst evacuation alone (E) and 3 cyst evacuation + radiotherapy (F). The clinical, imaging and endocrinological data at presentation and during follow-up were analysed.

RESULTS

Headache and visual field defects were the most common presenting clinical features (64% and 55%, respectively). Ninety-four per cent of the tumours had an extrasellar component and 23% of them were associated with hydrocephalus. There was a significant difference in the recurrence-free survival rates between groups A-D [at 10 years: 100% (A), 100% (B), 38% (C) and 77% (D), P < 0.01], which persisted even when analysing patients operated after 1980. The median time of first recurrence was 2.5 years (range 0.5-36). The peri-operative mortality of the patients who had any type of neurosurgical intervention due to recurrence was higher than that observed after primary surgery (24%vs. 1.8%) (P < 0.01). The rate of re-accumulation of the cyst fluid was 58% during the first year in patients of group E, whereas none of the subjects of group F experienced such an event during their follow-up period. There was no reversal of pre-existing pituitary hormone deficits after any surgical intervention. The probabilities of GH, FSH/LH, ACTH, TSH deficiency and diabetes insipidus at the 10-year follow-up were 88%, 90%, 86%, 80% and 65%, respectively. After excluding the non-tumour-related deaths, the 10-year survival rate following presentation was 90%. Patients with recurrence had a significantly lower probability for survival compared with those without it (at 10 years: 70%vs. 99%, P < 0.01). At the 10-year follow-up the probability of the presence of major visual field defects was 48%, hyperphagia/obesity 39%, epilepsy 12% and hemi-/monoparesis 11%. In this large series no substantial differences in the outcome of tumours diagnosed during childhood or adult life were found.

CONCLUSIONS

Craniopharyngiomas remain tumours associated with significant morbidity. Gross total removal provides favourable results in terms of recurrences. If this cannot be achieved safely, adjuvant radiotherapy is beneficial in preventing tumour re-growth. Childhood- and adult-onset lesions generally behave similarly.