Ultrastructure of a craniopharyngioma

Two Cases of Feline Malignant Craniopharyngioma

Tumors at the cranial base in 2 cats (a 9 1/2-year-old, castrated male Chinchilla and a 7-year-old, castrated male American shorthair) were diagnosed as malignant craniopharyngioma. The tumor lesion was histopathologically divided into four parts: 1) a small acinus part, in which relatively large cells with a pale cytoplasm composed small acini; 2) a duct part, in which small cuboidal cells composed ducts; 3) a cyst part, in which there were large cysts lined with flat cells; and 4) a pavement part, in which large multiangular-shaped cells proliferated in a pavement pattern. The epithelial cells of some parts were positive for keratin by immunohistochemistry. Histopathologic findings of the present feline cases were identical to those of malignant craniopharyngioma in other animal species.

Ghost cells in pilomatrixoma, craniopharyngioma, and calcifying cystic odontogenic tumor: histological, immunohistochemical, and ultrastructural study

BACKGROUND

Pilomatrixoma, craniopharyngioma, and calcifying cystic odontogenic tumor are the main entities presenting ghost cells as an important histological feature, in spite their quite different clinical presentation; it seems that they share a common pathway in the formation of these cells. The aim of this study is to examine and compare the characteristics of ghost and other cells that form these lesions.

METHODS

Forty-three cases including 21 pilomatrixomas, 14 craniopharyngiomas, and eight calcifying cystic odontogenic tumors were evaluated by immunohistochemistry for cytokeratins, CD138, β-catenin, D2-40, Glut-1, FAS, CD10 and also by scanning electron microscopy.

RESULTS

The CKs, CD138, β-catenin, Glut-1, FAS, and CD10 were more often expressed by transitional cells of craniopharyngioma and calcifying cystic odontogenic tumor, compared with pilomatrixoma. Basaloid cells of pilomatrixoma showed strong positivity for CD138 and CD10. Differences on expression pattern were identified in transitional and basal cells, as ghost cells were negative for most antibodies used, except by low expression for cytokeratins. By scanning electron microscopy, the morphology of ghost cells were similar in their fibrillar cytoplasm, but their pattern varied from sheets in pilomatrixoma to small clusters in craniopharyngioma and calcifying cystic odontogenic tumor.

CONCLUSIONS

Mechanisms involved in formation of ghost cells are unknown, but probably they follow different pathways as protein expression in the basal/transitional cells was not uniform in the three tumors studied.

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.

Nuclear beta-catenin accumulation associates with epithelial morphogenesis in craniopharyngiomas

Activation of the Wnt/wingless signalling cascade is a key mechanism in developmental morphogenesis, whereas aberrant nuclear accumulation of beta-catenin in adult tissues seems to be associated with neoplastic transformation and tumour progression. Adamantinomatous craniopharyngiomas carry activating mutations in exon 3 of the beta-catenin gene, which results in a distinct pattern of nuclear beta-catenin accumulation in up to 95% of respective tumour specimens. To better characterise the impact of nuclear beta-catenin aggregation in these neoplasms, we systematically examined epithelial differentiation and cell cycle-associated molecules in accumulating compared to non-accumulating tumour cell clusters using a cohort of 65 adamantinomatous craniopharyngiomas. Monoclonal antibodies directed against cytokeratins 5/6 (CK5/6) were utilised to differentiate squamous from simple epithelium, the latter being identified by immunoreactivity for cytokeratins 8 and 18 (CK8/CK18). Intriguingly, nuclear beta-catenin accumulation in whorl-like tumour cell clusters was always associated with a distinct CK8 and CK18 immunoreactivity, whereas surrounding non-accumulating tumour cells showed exclusively squamous differentiation indicated by CK5/6 expression. In addition, a low proliferation activity combined with an increased expression of p21(WAF1/CIP1), a key control protein of the cell cycle, was observed in beta-catenin accumulating cells. Our data support an impact of nuclear beta-catenin on different cytoarchitectural and epithelial differentiation patterns in adamantinomatous 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

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.

Frontobasal interhemispheric trans-lamina terminalis approach for suprasellar lesions

The frontobasal interhemispheric approach for suprasellar tumors currently incorporates technological advancements and refinements in patient selection, operative technique, and postoperative care. This technique is a valid choice for the removal of suprasellar lesions with extension into the third ventricle without major sequelae related to the surgical approach. The method described here reflects the combination of the frontal interhemispheric and trans-lamina terminalis approaches.

Benign cysts in the central nervous system: Neuropathological observations of the cyst walls

A diverse variety of benign cysts exist in the CNS. Advances in diagnostic radiology have facilitated diagnoses and surgical intervention in many patients with CNS cysts. However, a fundamental understanding of the pathological features of these lesions is clinically vital. From an etiological point of view, the cysts can be divided into two groups. The first includes lesions that arise from within the CNS and may be static structures such as cavities arising from infarcts and other destructive processes while other lesions such as arachnoid cysts, ependymal cysts, cystic hemangioblastoma, cystic cerebellar astrocytoma and infectious processes, are progressive. The second group of cysts arise from the intrusion of non-nervous system tissue into the neuroaxis and are usually midline. They are frequently expanding congenital lesions although some become symptomatic only in adults. Examples include teratomas, dermoid cysts, epidermoid cysts, craniopharyngiomas, Rathke's cleft cysts, and other epithelial cysts presumably derived from the upper respiratory or intestinal tract. Chick embryos exposed to lead have been used as a model of cyst formation.

Different keratin profiles in craniopharyngioma subtypes and ameloblastomas

Craniopharyngiomas are generally considered to arise from the remnants of Rathke's pouch or a misplaced enamel organ. We tried to refine these hypotheses, comparing the subtypes of craniopharyngioma with Rathke's cleft cyst, a known Rathke's pouch derivative, and with ameloblastoma, an enamel organ derivative. Nineteen craniopharyngiomas (14 adamantinomatous and 5 papillary type tumors) and 17 ameloblastomas were immunostained for cytokeratin (CK) 7, CK 8, CK 14, and human hair keratin (HHK). All cases of adamantinomatous craniopharyngioma were CK 7+/CK 8+/CK 14+. Two cases (40%) of papillary craniopharyngioma were CK 7+/CK 8+/CK 14+, whereas the remaining three cases (60%) were CK 7+/CK 8-/CK 14+. Fifteen cases (88%) of ameloblastoma were CK 7-/CK 8+/CK 14+. Only the shadow cells present in adamantinomatous craniopharyngiomas were positive for HHK, which may indicate their follicular differentiation. In Rathke's cleft cyst, ciliated cuboidal cells were CK 7+/CK 8+/CK 14- and metaplastic squamous cells were CK 7+/CK 8/CK 14+. These findings suggest that both subtypes of craniopharyngioma may differ from ameloblastoma in histogenesis, although cytokeratin expression patterns may change during tumor development. Adamantinomatous craniopharyngioma may be related to a heterotopic ectodermal tissue which can differentiate into hair follicles, while papillary craniopharyngioma may arise from Rathke's cleft cyst.

Initial clinical results of stereotactic radiotherapy for the treatment of craniopharyngiomas

The efficacy and toxicity of stereotactic radiotherapy (SRT) for the treatment of craniopharyngioma has been retrospectively evaluated in 16 patients. The median tumor diameter was 2.8 cm (range 1.5-6.1) and the median tumor volume was 7.7 cc (range 0.7-62.8). SRT was delivered to a single isocenter using a dedicated 6 MV linear accelerator to patients immobilized with a relocatable stereotactic head frame. The three-year actuarial overall survival was 93% and the rate of survival free of any imaging evidence of progressive disease was 75%. The three-year actuarial survival rates free of solid tumor growth or cyst enlargement were 94% and 81% respectively. Our results suggest that SRT is a safe and effective treatment approach for patients with craniopharyngioma. Long-term follow-up is required to determine whether the normal tissue-sparing inherent with SRT results in reduction of the neurocognitive effects of conventional radiotherapy for craniopharyngioma. SRT can be delivered to craniopharyngioma that may be difficult to treat with stereotactic radiosurgery due to proximity of the optic chiasm. Further clinical experience is necessary to determine the clinical utility of beam shaping in the setting of SRT.

Fine structure of ossification in craniopharyngiomas

Three cases of adamantinomatous craniopharyngiomas were examined by light and electron microscopy and special attention was paid to the formation of ossified tissue. The tumors were composed of neoplastic epithelial cells with keratinized cell nests and fibrous connective tissue. Keratinized cell masses sometimes directly contacted fibrous connective tissue. In these border areas, multipotential mesenchymal cells in the latter may have differentiated into osteoblasts. Ultrastructurally, these osteoblastic mesenchymal cells were surrounded by amorphous ground matrix and collagen fibrils. Membrane-bound vesicles were occasionally seen among the spaces between the collagen fibrils. These vesicles were presumably derived from osteoblastic mesenchymal cells and were morphologically similar to matrix vesicles. Precipitation of hydroxyapatite crystals in these vesicles was considered to be the initial stage of ossification. Further mineralization of adjacent collagen fibrils resulted in the formation of small bone trabeculae. Then apositional growth of ossified tissue occurred in the surrounding keratinized cell masses.

A histopathological study of craniopharyngioma with special reference to its stroma and surrounding tissue

The numerous pathology reports on craniopharyngioma describe the classical features of squamous epithelium and keratin. Relatively little attention has been paid to its stroma and the surrounding tissue. We focused our observation on these two areas in a retrospective study of craniopharyngiomas in 36 operative cases and 5 autopsy cases. The tumor interdigitated with the brain and pituitary gland. At the interface, the brain was markedly gliotic with Rosenthal fibers simulating pilocytic astrocytoma. The tumor stroma had reactive changes and commonly showed cyst formation and calcification.

Craniopharyngioma: improving outcome by early recognition and treatment of acute complications

PURPOSE

To assess the frequency, mode of presentation, treatment, and outcome of acute complications in patients with craniopharyngioma around the time of radiotherapy.

METHODS AND MATERIALS

A review was made of 188 patients with craniopharyngioma treated with conservative surgery and external beam radiotherapy at the Royal Marsden Hospital between 1950 and 1992.

RESULTS

Twenty six (14%) (95% confidence interval: 9-19%) patients with craniopharyngioma developed acute deterioration immediately before, during and 2 months after radiotherapy with visual deterioration (19 patients), hydrocephalus (7 patients), and global deficit (7 patients). Cystic enlargement with or without hydrocephalus was the most common cause of deterioration. No patient or disease characteristics were predictive of deterioration on univariate or multivariate analysis. Eighteen patients had surgical intervention at the time of deterioration and survived the immediate period. Six of seven patients who did not have surgical intervention died. All patients who survived the postcomplication period completed the full course of external beam radiotherapy. The 10-year progression-free survival of 162 patients without deterioration was 86%, and of 18 patients with acute deterioration who recovered after surgery, 77%.

CONCLUSION

Patients with craniopharyngioma develop acute deterioration around the time of radiotherapy owing to cystic enlargement and/or hydrocephalus which does not represent tumor progression. Early recognition and appropriate surgical treatment followed by conventional full-dose radiotherapy are associated with good long-term outcome.

Craniopharyngiomas: a clinicopathological analysis of factors predictive of recurrence and functional outcome

Pathological and clinical data from 56 patients operated on for craniopharyngioma since 1981 were analyzed to determine the utility of dividing patients with this tumor into distinct clinical groups based on recognized pathological type and to determine the prognostic import of brain invasion. Of the tumors in the 30 adult patients, 66% were adamantinomatous, 28% were squamous papillary, and the remainder were mixed. However, of the tumors in the 26 children, 96% were adamantinomatous and none were pure squamous papillary (P < 0.01). Forty-six percent of the children compared with 17% of the adults had brain invasion (P < 0.01). Brain invasion was present in 37% of the adamantinomatous but in only 13% of the squamous papillary tumors. Seventy-seven percent of the children underwent gross total resection (GTR) compared with 27% of the adults (P < 0.01). Sixty-three percent of the squamous papillary tumors underwent GTR compared with 54% of the adamantinomatous and mixed tumors. Follow-up ranged from 7 to 187 months (mean, 49 mo). After subtotal resection, with or without radiation therapy, 58% of the tumors recurred compared with 17% recurrence after GTR (P < 0.01), with a mean time to recurrence of 34 months. In both tumor histological types, subtotal resection was associated with a higher rate of tumor recurrence compared with gross total resection. Among the subtotally resected craniopharyngiomas, 2 of the 3 (67%) squamous papillary and 11 of the 21 (52%) adamantinomatous and mixed tumors recurred. In contrast, among the totally resected tumors, none of the 5 squamous papillary and only 5 of the 25 (20%) adamantinomatous and mixed tumors recurred. There were no significant differences in Karnofsky performance status score, mortality rate, or visual and endocrine outcomes when comparing patients based on histological tumor type. When controlling for age and extent of resection, we found that brain invasion had no significant effect on recurrence rate in totally resected tumors. Based on the limited number of patients in this series, we conclude as follows. 1) Contrary to previous reports, squamous papillary craniopharyngiomas, like adamantinomatous tumors, may recur when subtotally resected. 2) For both tumor variants, the most significant factor associated with craniopharyngioma recurrence is the extent of surgical resection rather than histopathological subtype. 3) Contrary to prior hypotheses, brain invasion in totally resected tumors does not predict higher recurrence. 4) GTR is associated with a significantly lower recurrence rate and can be achieved without sacrificing functional outcome.

Ossified adamantinous type craniopharyngiomas. A series of 13 patients

Thirteen patients admitted to hospital mainly with visual disturbances (100%), retarded growth (39%) and diabetes insipidus (23%) were all diagnosed as ossified adamantinous craniopharyngioma. Tumour size was found to be large in all patients. Localization displayed a heterogenous dissemination; 8% intra-suprasellar, 69% suprasellar-extraventricular, 15% extra-intraventricular, and 8% in the suprasellar region extending bilaterally to the frontal and temporal lobes. During the early postoperative period, four patients died with hypothalamic deterioration. Three patients underwent a second operation in view of recurrence, and one died from an infection. Thus, the postoperative survival rate was 62%. All the patients who survived continued to have visual disturbances, but only one deteriorated. Five patients exhibited diabetes insipidus during the postoperative period, among them 4 after surgical intervention and 5 patients displayed panhypothyroidism, three of them after surgery. Consequently, it is confirmed by the present review that craniopharyngiomas still offer a potential dilemma in their management. Difficulties caused by adhesion or invasion of ossified craniopharyngiomas and thus the increase in morbidity and mortality during surgical intervention and in the postoperative period are discussed.

Long-term results of pediatric and adult craniopharyngiomas treated with combined surgery and radiation

From 1958 to 1982, 58 patients with craniopharyngioma were treated with external beam radiation, 56 post surgery. Nineteen were pediatric (< 16 years) and 39 were adult. Forty patients underwent primary treatment while 18 (7 pediatric and 11 adult) were treated for recurrence. Median follow-up is 17 years. Tumor dose and 'maximum dose' (i.e. dose to smallest isodose > 1 cm) were recorded. The mean tumor and maximum dose for pediatric patients was 5588 and 5870 cGy vs. 6243 and 6542 cGy, respectively for adults. The actuarial 5- and 10-year survivals for pediatric patients were 84% and 72%, respectively and were significantly better than the 54% and 51% for adults (p = 0.01). However, overall disease recurrence rates were 26% (5/19) for pediatric patients and 18% (7/39) for adults. Of the multiple patient and treatment parameters analyzed, initial disease type (i.e. primary vs. recurrence) in pediatric patients, surgical extent, tumor dose, maximum dose, age of adults and use of pretreatment CT evaluation appeared to impact on patient outcome. Pediatric patients treated for primary disease showed improved survival over those treated for recurrence. The same was not observed in adults and appeared to be due to treatment toxicity. Surgical morbidity correlated with extent of surgery. All patients who underwent total resection developed surgical sequelae. Forty-four percent (4/9) of patients receiving tumor doses of < or = 5400 cGy developed recurrences vs. 16% (8/49) in those receiving > 5400 cGy. Nine of the 12 recurrences were in patients who did not undergo pretreatment CT evaluation.(ABSTRACT TRUNCATED AT 250 WORDS)

Craniopharyngioma--a long-term results following limited surgery and radiotherapy

Between 1950 and 1986 173 patients with craniopharyngioma were treated at the Royal Marsden Hospital with external beam radiotherapy either alone or following surgery. Four patients had complete tumour excision, 21 subtotal and 78 partial resection, 14 had biopsy alone, 34 aspiration alone and 22 had no surgery directed at tumour eradication. Seventy-seven (45%) were children (aged < 16 years). The 10 and 20 year progression-free survival (PFS) rates were 83% and 79%. There were no independent prognostic factors for PFS. The 10 and 20 year survival rates were 77% and 66% at a median follow-up of 12 years. After adjustment for mortality in the normal population, age and technique of radiotherapy (which corresponded with era of treatment) were significant independent prognostic factors for survival. The risk of death (corrected for mortality from natural causes and controlling for radiotherapy technique) for age groups 16-39 and > or = 40 was 0.58 and 0.40 respectively, relative to a risk of 1.0 for the age group < 16 years. Survival and PFS were not influenced by the extent of surgical excision. Visual field defect improved after radiotherapy in 36% of patients (38/106) and visual acuity in 30% (27/91). No patient developed radiation optic neuropathy. We conclude that limited surgery and radiotherapy achieve excellent long-term tumour control and survival with low morbidity.

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.

Neurological and behavioral sequelae following different approaches to craniopharyngioma. Long-term follow-up review and therapeutic guidelines

The criteria by which the operative approaches to craniopharyngioma are chosen are still controversial. The authors performed a retrospective analysis in 32 patients with craniopharyngioma who were surgically treated. Results of neurological and psychological tests administered during the follow-up period were correlated with the surgical approach. On the basis of these preliminary data and a maximum follow-up period of 10 years, the authors conclude that the subfrontal approach to the craniopharyngioma and partial removal of its solid part appears to be associated with a lower morbidity rate and minor frontal lobe disorders.

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.

Benign cystic lesions in the central nervous system. Light and electron microscopic observations of cyst walls

A wide variety of benign cystic lesions is known to occur in both adults and children. Recent advances in diagnostic radiology have facilitated meaningful surgical intervention in most instances. It is convenient to classify these cysts into two groups. The first group includes those that arise from defects wholly within the central nervous system. Among these are certain static lesions such as cystic cavities arising from infarcts and other destructive lesions. Some of these are observed to communicate with the subarachnoid space or ventricle. The progressive lesions in this group include arachnoid cysts, ependymal cysts, cystic hemangioblastoma, cystic cerebellar astrocytoma, and certain infectious processes. The second group is constituted by cysts resulting from the intrusion of non-nervous tissue into the neuroaxis, usually in the midline. These are expanding congenital lesions, although some become symptomatic only in the adult. Among these are teratomas, dermoid cysts, epidermoid cysts, craniopharyngiomas, Rathke's cleft cysts, and other epithelial cysts apparently derived from the upper respiratory or the intestinal tract. Colloid cysts of the III ventricle are usually considered to be neuroectodermal in origin, but certain features suggest an endodermal origin.

The origin of ciliated cell cysts of the anterior pituitary. An experimental study in the rat

Rats were decapitated and the heads were stored at 4 degrees C for 24 h. The anterior pituitaries were then removed and incubated for 5 days. On the 1st, 3rd and 5th days of incubation, explants were studied by electron microscopy and immunohistochemistry using antiserum against S-100 protein. In the explant many granulated cells underwent necrosis; folliculo-stellate (FS) cells formed many cyst-like structures (CLSs) and became squamous epithelioid cells (CLS-forming cells). After incubation for 5 days the explants were isotransplanted under the renal capsules of male rats in order to observe morphological changes in the CLSs. Immediately after transplantation, the CLSs were encircled by a basement membrane, but from the 8th to 14th day, ciliation occurred in CLS-forming cells and "ciliated cell cysts" were formed. The ciliated cells were immunostained with antiserum against S-100 protein. The present study suggests that FS cells are related to CLS formation and have the potential to trans-differentiate to ciliated cells.

Ciliated craniopharyngioma

A tumor of Rathke's cleft origin was studied, which showed some histologic features consistent with craniopharyngioma, but also had ciliated and mucin-containing cells more commonly observed in Rathke's cleft cysts. The combination of features provides further evidence that craniopharyngiomas and Rathke's cleft cysts have a common embryonic origin.

The efficacy of radiotherapy for craniopharyngioma

A series of 125 patients who underwent surgery for craniopharyngiomas was evaluated to assess the efficacy of radiation therapy: 45 patients had received radiotherapy and 80 had not. These patients included all operative survivors (excluding cases with total tumor removal) treated during the 30 years from 1950 to 1979. Median survival time of the irradiated group was greater than 10 years, whereas it was 3.12 years for the nonirradiated (or control) group. The 5- and 10-year survival rates were 88.9% and 76.0% for the irradiated group, and 34.9% and 27.1% for the control group, respectively. Overall comparison, using the Lee-Desu statistical method, revealed that there was a very high statistical significance (at the level of p less than 0.0001) in the difference between the survival times of the irradiated and control groups. The influence of the following factors on the effectiveness of radiotherapy was analyzed: age of the patient at the first operation, sex, date of surgery, the extent of tumor removal, the size of the tumor, the composition of the tumor (cystic or solid), whether the tumor was calcified or not, the histological subtype of the tumor, the presence of intracranial hypertension, the grade of visual failure, and the presence or absence of diabetes insipidus, altered mentation, and adiposogenital syndrome. The results indicated that, when total removal of the tumor is impossible, radiotherapy should be administered.

The histologic similarity between craniopharyngioma and odontogenic lesions: a reappraisal

The histologic similarities between the craniopharyngioma and the ameloblastoma are well recognized and supported by their common embryologic origin from oral ectoderm. Differences in these lesions include a greater tendency for craniopharyngiomas to be cystic and form ghost cells and calcifications. The keratinizing and calcifying odontogenic cyst (KCOC), a lesion that features proliferating ameloblastic epithelium, ghost keratin, calcification, and cyst formation, may more precisely mimic the craniopharyngioma. The histologic features of twenty-seven craniopharyngiomas were studied. Twenty cases resembled KCOC microscopically. Two examples duplicated the histologic features of infiltrative ameloblastoma, while five showed characteristics of both lesions. This study shows that the range of histologic features in craniopharyngioma includes and spans both odontogenic lesions but more often simulates KCOC. The results suggest that the KCOC and the ameloblastoma may be closely related developmentally.

Microsurgery of the hypothalamus with special reference to craniopharyngioma

After a short survey of microanatomy, microtopography, neurophysiology and neuropathophysiology of the hypothalamus the surgical approaches to the hypothalamus with special reference to the craniopharyngiomas are described in detail. Based on 100 personal cases (1954-1979) the special procedure, depending on the site and extent of the tumour and its involvement of the hypothalamus, is discussed. Primary radical excision (19 cases) with a mortality rate of 10.5% seems to be the method of choice, as late mortality recurrences and secondary operations are frequent after non-radical procedures. Modern microsurgical technique promises to achieve primary radical excision more frequently and with less risk.

Radioisotope therapy of cystic craniopharyngomas

Eighteen patients suffering from cystic craniopharyngeoma were treated with intracavitary irradiation. The beta-emitting radioisotope 90y (2.25 MeV) was instilled into the cyst following stereotactic puncture of the space-occupying lesion. The surgical approach was planned using angiograms and reconstructed transmission computer tomography (TCT) coronal and saggital sections. Therapy was devised to deliver 20,000 rad to the cyst's wall. Eleven patients received follow-up TCT examinations after four months. Eight of 11 patients had a significant volume decrease in the craniopharyngeoma cyst. In two patients, the cystic volume remained unchanged; one had progression of disease. It is concluded that the intracavitary treatment of cystic craniopharyngeoma will result in a reduction of the size of the space-occupying lesion.

Successful surgical treatment of an odontogenic ossified craniopharyngioma. Case report

A large, highly ossified craniopharyngioma was diagnosed and surgically treated in a 2-year-old girl. About 20 teeth were macroscopically identified in the operative specimen, some of them totally developed, complete with crown and root. Pathological study established the diagnosis of craniopharyngioma with formation of teeth. Only five cases have been reported previously, and only one patient survived the operation. The patient is alive 3 years after surgical treatment. Radiotherapy was not used.

Scanning and transmission electron microscopy of a craniopharyngioma: x-ray microanalytical study of the intratumoral mineralized deposits

This paper discusses the value of scanning electron microscopy (SEM) and x-ray microanalysis in the classification of craniopharyngiomas. This neoplasm shows epithelial nest, cords of cuboid cells, foci of squamous metaplasia, and microcystic degeneration. SEM reveals that the epithelial cysts are lined with elongated cells that possess numerous microvilli and blebs and that some cysts are lined with polyhedral cells. The microvilli are interpreted as characteristic of the fast growing craniopharyngiomas. A microanalytical study of the calcified areas reveals the presence of magnesium, phosphorus, and calcium.

Craniopharyngiomas: a critical approach to treatment

The authors have conducted a retrospective statistical study in a series of 45 patients with craniopharyngiomas in order to assess the value of different therapeutic approaches. All the patients included in the study were placed in three groups according to their method of treatment: 1) total excision; 2) subtotal excision; and 3) surgery followed by a course of radiotherapy (RT). Symptomatic recurrence was used to define failure of treatment. Of the patients subjected to total excision, 30% experienced recurrence after a mean time of 2 years. Tumors recurred in 71% of those treated by subtotal excision, with a mean time of 2.6 years. Of patients receiving RT in addition to surgery, only 6% had recurrence, after a mean time of 1 year. The authors conclude that the elective treatment for craniopharyngiomas is controlled subtotal surgery plus RT. Total excision should be attempted only if there is a negligible danger of mortality.

Immunohistochemical localization of keratin in craniopharyngiomas and squamous cell nests of the human pituitary

To identify keratin, the immunoperoxidase technique was performed on 41 nontumourous pituitaries, 14 pituitary adenomas composed of different cell types and 15 craniopharyngiomas. No keratin was demonstrated in adenohypophysial cells, neurohypophysis or hypophysial vessels, however, it was occasionally identified in the pairs intermedia within cells lining cystic structures. Crooke's hyaline material and all pituitary adenomas were negative for keratin. The epithelial portions of craniopharyngiomas exhibited positive keratin immunostaining, as did squamous cell nests, which are frequently found in hypophysial stalk. Immunostaining for keratin can effectively be used in the differential diagnosis of pituitary tumours and may prove valuable in the investigation of histogenesis and embryology.

Calcium deposition in human pituitary adenomas studied by histology, electron microscopy, electron diffraction and X-ray spectrometry

The incidence and morphogenesis of calcification were investigated by histology, electron microscopy, electron diffraction and X-ray spectrometry in 312 surgically removed human pituitary adenomas. By light microscopy the incidence of calcification was 9%. The calcium deposits were evident in several adenoma types, but were most frequent and extensive in prolactin-producing adenomas. Histologically calcium deposits represented amorphous precipitates and psammoma bodies staining with hematoxylin, the von Kossa technique and alizarin red. By electron microscopy, calcified deposits were noted in the cytoplasm of adenoma cells and extracellular space. Electron diffraction and X-ray spectrometry of intracellular precipitates as well as psammoma bodies showed the presence of phosphate, calcium and organically bound sulphur with a ratio of 3.5:5:2, indicating that they contained calcium hydroxyapatite. Present findings provide evidence that mitochondria with microcrystal deposition of calcium represent the primary sites of calcification.

Morphological, biochemical, ultrastructural, tissue culture and clinical observations of typical and aggressive craniopharyngiomas

Craniopharyngiomas are tumors of the suprasellar area, which are often cystic, encapsulated and slow-growing. Certain of these tumors can behave in an aggressive manner and either invade surrounding structures or recur. In order to determine characteristics which may aid in distinguishing typical from atypical lesions, a study of biopsy and tissue culture specimens from 25 human craniopharyngiomas was undertaken. Tissue culture observations reveal two distinct cell populations. Typical lesions grew in culture in an orderly epithelial pattern and had desmosome-tonofibril aggregates and smooth surface topography demonstrable by electron microscopy. In the atypical tumors the cell growth was irregular, with mitotic activity, cholesterol crystals and features characteristic of neoplastic transformation, such as surface microvilli, an increase of cytoplasmic basophilia, size and number of nucleoli and retraction of cytoplasm. Correlation with the clinical status of the patients suggests that tumors of the four patients which exhibited atypical features in culture behaved more aggressively.

Further observation on the fine structure of a colloid cyst of the third ventricle

The fine structure of a surgically excised colloid cyst is described. The cyst was lined by ciliated and nonciliated columnar cells. The nonciliated cells contained secretory material and had a surface coating. In addition, a third type of smaller cell was seen wedged between the columnar cells and abutting on the basement membrane. These cells contained abundant free ribosomes and tonofilaments and displayed well developed desmosomes and half desmosomes. The cyst lining closely resembled the upper respiratory epithelium rather than neuroepithelium, thus supporting the contention that colloid cysts are derived from an endodermal source.