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Abstract
Craniopharyngiomas are rare malformational tumours of low histological malignancy arising along the craniopharyngeal duct. The two histological subtypes, adamantinomatous craniopharyngioma (ACP) and papillary craniopharyngioma (PCP), differ in genesis and age distribution. ACPs are diagnosed with a bimodal peak of incidence (5-15 years and 45-60 years), whereas PCPs are restricted to adults mainly in the fifth and sixth decades of life. ACPs are driven by somatic mutations in CTNNB1 (encoding β-catenin) that affect β-catenin stability and are predominantly cystic in appearance. PCPs frequently harbour somatic BRAFV600E mutations and are typically solid tumours. Clinical manifestations due to increased intracranial pressure, visual impairment and endocrine deficiencies should prompt imaging investigations, preferentially MRI. Treatment comprises neurosurgery and radiotherapy; intracystic chemotherapy is used in monocystic ACP. Although long-term survival is high, quality of life and neuropsychological function are frequently impaired due to the close anatomical proximity to the optic chiasm, hypothalamus and pituitary gland. Indeed, hypothalamic involvement and treatment-related hypothalamic lesions frequently result in hypothalamic obesity, physical fatigue and psychosocial deficits. Given the rarity of these tumours, efforts to optimize infrastructure and international collaboration should be research priorities.
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Affiliation(s)
- Hermann L Müller
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children's Hospital, Klinikum Oldenburg AöR, Oldenburg, Germany.
| | - Thomas E Merchant
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Juan-Pedro Martinez-Barbera
- Developmental Biology and Cancer Programme, Birth Defects Research Centre, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Stephanie Puget
- Service de Neurochirurgie, Hôpital Necker-Enfants Malades, Sorbonne Paris Cité, Paris, France
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2
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Apps JR, Carreno G, Gonzalez-Meljem JM, Haston S, Guiho R, Cooper JE, Manshaei S, Jani N, Hölsken A, Pettorini B, Beynon RJ, Simpson DM, Fraser HC, Hong Y, Hallang S, Stone TJ, Virasami A, Donson AM, Jones D, Aquilina K, Spoudeas H, Joshi AR, Grundy R, Storer LCD, Korbonits M, Hilton DA, Tossell K, Thavaraj S, Ungless MA, Gil J, Buslei R, Hankinson T, Hargrave D, Goding C, Andoniadou CL, Brogan P, Jacques TS, Williams HJ, Martinez-Barbera JP. Tumour compartment transcriptomics demonstrates the activation of inflammatory and odontogenic programmes in human adamantinomatous craniopharyngioma and identifies the MAPK/ERK pathway as a novel therapeutic target. Acta Neuropathol 2018. [PMID: 29541918 PMCID: PMC5904225 DOI: 10.1007/s00401-018-1830-2] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Adamantinomatous craniopharyngiomas (ACPs) are clinically challenging tumours, the majority of which have activating mutations in CTNNB1. They are histologically complex, showing cystic and solid components, the latter comprised of different morphological cell types (e.g. β-catenin-accumulating cluster cells and palisading epithelium), surrounded by a florid glial reaction with immune cells. Here, we have carried out RNA sequencing on 18 ACP samples and integrated these data with an existing ACP transcriptomic dataset. No studies so far have examined the patterns of gene expression within the different cellular compartments of the tumour. To achieve this goal, we have combined laser capture microdissection with computational analyses to reveal groups of genes that are associated with either epithelial tumour cells (clusters and palisading epithelium), glial tissue or immune infiltrate. We use these human ACP molecular signatures and RNA-Seq data from two ACP mouse models to reveal that cell clusters are molecularly analogous to the enamel knot, a critical signalling centre controlling normal tooth morphogenesis. Supporting this finding, we show that human cluster cells express high levels of several members of the FGF, TGFB and BMP families of secreted factors, which signal to neighbouring cells as evidenced by immunostaining against the phosphorylated proteins pERK1/2, pSMAD3 and pSMAD1/5/9 in both human and mouse ACP. We reveal that inhibiting the MAPK/ERK pathway with trametinib, a clinically approved MEK inhibitor, results in reduced proliferation and increased apoptosis in explant cultures of human and mouse ACP. Finally, we analyse a prominent molecular signature in the glial reactive tissue to characterise the inflammatory microenvironment and uncover the activation of inflammasomes in human ACP. We validate these results by immunostaining against immune cell markers, cytokine ELISA and proteome analysis in both solid tumour and cystic fluid from ACP patients. Our data support a new molecular paradigm for understanding ACP tumorigenesis as an aberrant mimic of natural tooth development and opens new therapeutic opportunities by revealing the activation of the MAPK/ERK and inflammasome pathways in human ACP.
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Affiliation(s)
- John R Apps
- Developmental Biology and Cancer Programme, Birth Defects Research Centre, UCL Great Ormond Street Institute of Child Health, University College London, London, UK.
- Histopathology Department, Great Ormond Street Hospital NHS Trust, London, UK.
| | - Gabriela Carreno
- Developmental Biology and Cancer Programme, Birth Defects Research Centre, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Jose Mario Gonzalez-Meljem
- Developmental Biology and Cancer Programme, Birth Defects Research Centre, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
- Basic Research Department, National Institute of Geriatrics, Mexico City, Mexico
| | - Scott Haston
- Developmental Biology and Cancer Programme, Birth Defects Research Centre, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Romain Guiho
- Developmental Biology and Cancer Programme, Birth Defects Research Centre, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Julie E Cooper
- Developmental Biology and Cancer Programme, Birth Defects Research Centre, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Saba Manshaei
- Developmental Biology and Cancer Programme, Birth Defects Research Centre, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Nital Jani
- Centre for Translational Omics-GOSgene, Genetics and Genomic Medicine Programme, UCL Institute of Child Health, University College London, London, UK
| | - Annett Hölsken
- Department of Neuropathology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | | | - Robert J Beynon
- Centre for Proteome Research, Institute of Integrative Biology, University of Liverpool, Liverpool, UK
| | - Deborah M Simpson
- Centre for Proteome Research, Institute of Integrative Biology, University of Liverpool, Liverpool, UK
| | - Helen C Fraser
- Developmental Biology and Cancer Programme, Birth Defects Research Centre, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Ying Hong
- Infection, Immunity and Inflammation Programme, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Shirleen Hallang
- Centre for Craniofacial and Regenerative Biology, King's College London, London, UK
| | - Thomas J Stone
- Developmental Biology and Cancer Programme, Birth Defects Research Centre, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
- Histopathology Department, Great Ormond Street Hospital NHS Trust, London, UK
| | - Alex Virasami
- Histopathology Department, Great Ormond Street Hospital NHS Trust, London, UK
| | - Andrew M Donson
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - David Jones
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Kristian Aquilina
- Neurosurgery Department, Great Ormond Street Hospital NHS Trust, London, UK
| | - Helen Spoudeas
- Endocrinology Department, Great Ormond Street Hospital NHS Trust, London, UK
| | - Abhijit R Joshi
- Laboratory Medicine, Royal Victoria Infirmary, Newcastle, UK
| | - Richard Grundy
- Children's Brain Tumour Research Centre, University of Nottingham, Nottingham, UK
| | - Lisa C D Storer
- Children's Brain Tumour Research Centre, University of Nottingham, Nottingham, UK
| | - Márta Korbonits
- William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University, London, UK
| | - David A Hilton
- Pathology Department, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Kyoko Tossell
- MRC London Institute of Medical Sciences, Imperial College London, London, UK
| | - Selvam Thavaraj
- Head and Neck Pathology, Dental Institute, King's College London, London, UK
| | - Mark A Ungless
- MRC London Institute of Medical Sciences, Imperial College London, London, UK
| | - Jesus Gil
- MRC London Institute of Medical Sciences, Imperial College London, London, UK
| | - Rolf Buslei
- Department of Neuropathology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
- Institute of Pathology, Klinikum Sozialstiftung Bamberg, Bamberg, Germany
| | - Todd Hankinson
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Darren Hargrave
- Haematology and Oncology Department, Great Ormond Street Hospital NHS Trust, London, UK
| | - Colin Goding
- Ludwig Institute for Cancer Research, Oxford University, Old Road Campus, Headington, Oxford, UK
| | - Cynthia L Andoniadou
- Centre for Craniofacial and Regenerative Biology, King's College London, Guy's Hospital, Floor 27 Tower Wing, London, UK
- Department of Internal Medicine III, Technische Universität Dresden, Fetscherstaße 74, 01307, Dresden, Germany
| | - Paul Brogan
- Infection, Immunity and Inflammation Programme, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
- Rheumatology Department, Great Ormond Street Hospital NHS Trust, London, UK
| | - Thomas S Jacques
- Developmental Biology and Cancer Programme, Birth Defects Research Centre, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
- Histopathology Department, Great Ormond Street Hospital NHS Trust, London, UK
| | - Hywel J Williams
- Centre for Translational Omics-GOSgene, Genetics and Genomic Medicine Programme, UCL Institute of Child Health, University College London, London, UK
| | - Juan Pedro Martinez-Barbera
- Developmental Biology and Cancer Programme, Birth Defects Research Centre, UCL Great Ormond Street Institute of Child Health, University College London, London, UK.
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Pascual JM, Prieto R. Harvey Cushing and pituitary Case Number 3 (Mary D.): the origin of this most baffling problem in neurosurgery. Neurosurg Focus 2017; 41:E6. [PMID: 27364259 DOI: 10.3171/2016.2.focus1592] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
From the very beginning of his career, Harvey Williams Cushing (1869-1939) harbored a deep interest in a complex group of neoplasms that usually developed at the infundibulum. These were initially known as "interpeduncular" or "suprasellar" cysts. Cushing introduced the term "craniopharyngioma" for these lesions, which he believed represented one of the most baffling problems faced by neurosurgeons. The patient who most influenced Cushing's thinking was a 16-year-old seamstress named "Mary D.," whom he attended in December 1901, exactly the same month that Alfred Fröhlich published his seminal article describing an adiposogenital syndrome in a young boy with a pituitary cyst. Both Cushing's and Fröhlich's patients showed similar symptoms caused by the same type of tumor. Notably, Cushing and Fröhlich had met one another and became good friends in Liverpool the summer before these events took place. Their fortunate relationship led Cushing to realize that Fröhlich's syndrome represented a state of hypopituitarism and provided a useful method of diagnosing interpeduncular cysts. It is noteworthy that Cushing's very first neurosurgical procedure on a pituitary tumor was performed in the case of Mary D.'s "interpeduncular cyst," on February 21, 1902. Cushing failed to remove this lesion, which was later found during the patient's autopsy. This case was documented as Pituitary Case Number 3 in Cushing's masterpiece, The Pituitary Body and Its Disorders, published in 1912. This tumor was considered "a teratoma"; however, multiple sources of evidence suggest that this lesion actually corresponded to an adamantinomatous craniopharyngioma. Unfortunately, the pathological specimens of this lesion were misplaced, and this prompted Cushing's decision to retain all specimens and documents of the cases he would operate on throughout his career. Accordingly, Mary D.'s case crystallized the genesis of the Cushing Brain Tumor Registry, one of Cushing's major legacies to neurosurgery. In this paper the authors analyze the case of Mary D. and the great influence it had on Cushing's conceptions of the pituitary gland and its afflictions, and on the history of pituitary surgery.
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Affiliation(s)
| | - Ruth Prieto
- Department of Neurosurgery, Puerta de Hierro University Hospital, Madrid, Spain
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Pascual JM, Rosdolsky M, Prieto R, Strauβ S, Winter E, Ulrich W. Jakob Erdheim (1874–1937): father of hypophyseal-duct tumors (craniopharyngiomas). Virchows Arch 2015; 467:459-69. [DOI: 10.1007/s00428-015-1798-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 05/07/2015] [Accepted: 06/04/2015] [Indexed: 11/28/2022]
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Prieto R, Pascual JM. Craniopharyngiomas with a mixed histological pattern: the missing link to the intriguing pathogenesis of adamantinomatous and squamous-papillary varieties? Neuropathology 2013; 33:682-6. [DOI: 10.1111/neup.12030] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Ruth Prieto
- Department of Neurosurgery; Virgen de La Salud Hospital; Toledo
| | - José M. Pascual
- Department of Neurosurgery; La Princesa University Hospital; Madrid Spain
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İnci MF, Özkan F, Bozkurt S, Demir CF. A rare presentation of craniopharyngioma: delayed puberty. BMJ Case Rep 2012. [PMID: 23195827 DOI: 10.1136/bcr-2012-007519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Craniopharyngiomas are the most frequently encountered suprasellar tumours in children. Owing to the slow growth rate of these tumours, they are often quite large before becoming symptomatic. They are more common among children and older adults (55-74 years). Depending upon the direction of growth and tumour size, craniopharyngiomas can affect the hypothalamus, pituitary stalk, optic nerves and chiasm and carotid arteries. Compression of these neural and vascular structures frequently precipitates endocrine disorders, visual loss and an increased intracranial pressure. Hypopituitarism leading to a delayed puberty is a rare presentation of craniopharyngioma. The diagnosis of craniopharyngioma is usually made with the classic radiological imaging features based on CT and MRI.
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Affiliation(s)
- Mehmet Fatih İnci
- Department of Radiology, Sütçü İmam University Medical School, Kahramanmaraş, Turkey.
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7
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Kikuchi K, Ito S, Inoue H, Gonz^|^aacute;lez-Alva P, Miyazaki Y, Sakashita H, Yoshino A, Katayama Y, Terui T, Ide F, Kusama K. Immunohistochemical expression of podoplanin in so-called hard ^|^alpha;-keratin-expressing tumors, including calcifying cystic odontogenic tumor, craniopharyngioma, and pilomatrixoma. J Oral Sci 2012; 54:165-75. [DOI: 10.2334/josnusd.54.165] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Deutsch H, Kothbauer K, Persky M, Epstein FJ, Jallo GI. Infrasellar craniopharyngiomas: case report and review of the literature. Skull Base 2011; 11:121-8. [PMID: 17167611 PMCID: PMC1656789 DOI: 10.1055/s-2001-14432] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Although craniopharyngiomas account for a large percentage of pediatric intracranial tumors, there is a bimodal age distribution. Most of these neoplasms are suprasellar or sellar in location. In this report we describe an unusual case of an infrasellar craniopharyngioma in a child. Only four previous cases of infrasellar craniopharyngiomas with no sellar involvement have been described. Infrasellar craniopharyngiomas are part of the continuum representing intracranial craniopharyngiomas and ameloblastomas of the jaw. A transnasal endoscopic biopsy was performed with a preliminary diagnosis of craniopharyngioma. The patient then underwent a radical resection of the infrasellar tumor via a subfrontal transbasal approach. This case illustrates a rare and unusual location for a craniopharyngioma. Craniopharyngiomas should be considered in the differential diagnosis of infrasellar neoplasms. Infrasellar craniopharyngiomas compromise part of the spectrum of tumors originating from enamel-forming neural crest cells.
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Muller C, Adroos N, Lockhat Z, Slavik T, Kruger H. Toothy craniopharyngioma: a literature review and case report of craniopharyngioma with extensive odontogenic differentiation and tooth formation. Childs Nerv Syst 2011; 27:323-6. [PMID: 20922394 DOI: 10.1007/s00381-010-1296-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Accepted: 09/23/2010] [Indexed: 10/19/2022]
Affiliation(s)
- Craig Muller
- University of Witwatersrand, Johannesburg, South Africa
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de Faria PR, Cardoso SV, Rocha A, Gomes DC, de Castro SC, Loyola AM. Intracranial compound odontome. J Craniomaxillofac Surg 2009; 37:376-9. [PMID: 19541495 DOI: 10.1016/j.jcms.2009.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Revised: 02/12/2009] [Accepted: 02/19/2009] [Indexed: 10/20/2022] Open
Abstract
An exceedingly rare case of an extragnathic odontome is described arising within the brain. A 10-year-old boy complained of progressive frontal headache for 5 years. Axial computerized tomography the head revealed a solid, calcified lesion with well-defined borders localized in the sellar and suprasellar region composed of multiple calcified structures resembling teeth. The diagnosis was compound odontome. Physical examination and blood analysis revealed hypopituitarism. The patient was submitted for radical tumour resection. He developed persistent diabetes insipidus, hypothyroidism and adrenal insufficiency for which appropriate replacement therapy has been necessary. This case demonstrates that an odontogenic lesion may arise in brain tissues due to the embryological relationship between primordial stomodeum and Rathke's pouch. Its development could be associated with endocrine disturbances.
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Affiliation(s)
- Paulo Rogério de Faria
- Departamento de Morfologia, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, Brazil
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Mutations in Exon 3 of the CTNNB1 Gene (β-Catenin Gene) in Cutaneous Adnexal Tumors. Am J Dermatopathol 2009; 31:248-55. [DOI: 10.1097/dad.0b013e318198922a] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Hölsken A, Kreutzer J, Hofmann BM, Hans V, Oppel F, Buchfelder M, Fahlbusch R, Blümcke I, Buslei R. Target gene activation of the Wnt signaling pathway in nuclear beta-catenin accumulating cells of adamantinomatous craniopharyngiomas. Brain Pathol 2008; 19:357-64. [PMID: 18540944 DOI: 10.1111/j.1750-3639.2008.00180.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Activating beta-catenin (CTNNB1) mutations can be identified in the majority of adamantinomatous craniopharyngiomas (adaCP), suggesting an aberrant Wnt signaling pathway in this histopathologically peculiar tumor entity. However, there is no proven evidence that nuclear translocation of beta-catenin is associated with CTNNB1 mutations and target gene activation. We performed a laser-microdissection-based study comparing beta-catenin accumulating vs. non-accumulating tumor cells. Mutational analysis and gene expression profiling using real-time polymerase chain reaction were conducted in adamantinomatous and papillary tumor specimens. Target gene activation, that is, over-expression of Axin2 could be detected in adaCP, especially in tumor cells with nuclear beta-catenin accumulation. In addition, increased expression of BMP4 was identified in the accumulating cell population, which supports the hypothesis of an oral ectodermal origin. Interestingly, accumulating and non-accumulating tumor cell populations carried CTNNB1 mutations within exon 3. We extended the analysis, therefore, towards genetic regions encoding for membrane linkage and active/passive nuclear transport mechanisms (exon 4 and exon 8-13), but could not detect any alteration. This is the first report demonstrating an association between nuclear beta-catenin accumulation and target gene activation in adaCP. The results confirm the Wnt signaling pathway as molecular basis of the distinct and challenging clinical and morphological phenotype of adaCP.
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Affiliation(s)
- Annett Hölsken
- Departments of Neuropathology Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
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Abstract
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.
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Affiliation(s)
- Niki Karavitaki
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology, and Metabolism, Old Road, Headington, Oxford, OX3 7LJ, United Kingdom
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Karavitaki N, Scheithauer BW, Watt J, Ansorge O, Moschopoulos M, Llaguno AV, Wass JAH. Collision lesions of the sella: co-existence of craniopharyngioma with gonadotroph adenoma and of Rathke's cleft cyst with corticotroph adenoma. Pituitary 2008; 11:317-23. [PMID: 17917812 DOI: 10.1007/s11102-007-0070-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Collision lesions of the sellar region are relatively uncommon. Most contributions include a pituitary adenoma or a cyst/cystic tumor, particularly a Rathke cleft cyst. The association of craniopharyngioma with an adenoma is particularly rare. Among reported cases, some have included secondary prolactin cell hyperplasia due to pituitary stalk section effect. Herein, we report two collision lesions, including a gonadotroph adenoma with adamantinomatous craniopharyngioma and a corticotroph adenoma with Rathke's cleft cyst. Clinicopathologic correlation and a review of the literature are undertaken.
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Affiliation(s)
- N Karavitaki
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
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15
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Rodriguez FJ, Scheithauer BW, Tsunoda S, Kovacs K, Vidal S, Piepgras DG. The Spectrum of Malignancy in Craniopharyngioma. Am J Surg Pathol 2007; 31:1020-8. [PMID: 17592268 DOI: 10.1097/pas.0b013e31802d8a96] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Craniopharyngiomas are low-grade epithelial neoplasms occurring almost exclusively in the sellar/suprasellar region. Histologic malignancy is extremely rare; the literature consists mostly of isolated case reports. Herein, we report 3 patients with craniopharyngiomas exhibiting histologic malignancy, 2 of which received radiation therapy before its appearance. Hematoxylin and eosin-stained slides and selected immunohistochemical stains were reviewed in all cases. Microvessel density analysis was performed in case 2. The patients included 2 men and 1 woman, age 14, 31, and 58 years at presentation, respectively. All patients expired 3 months to 9 years after first resection and 3 to 9 months after identification of histologic malignancy. The latter developed after multiple recurrences and radiation therapy in 2 cases, but seemed to arise de novo in 1 case resembling odontogenic ghost cell carcinoma and lacking any definite low-grade craniopharyngioma precursor. The malignant component of the other 2 cases resembled squamous cell carcinoma and low-grade myoepithelial carcinoma, respectively. The MIB-1 labeling index was markedly increased in the malignant component in comparison with the low-grade precursor. Malignant transformation in craniopharyngiomas, although rare, does exist. It assumes varied histologic appearances, usually after multiple recurrences and radiation therapy, and has a near uniformly fatal outcome. De novo malignancy in odontogenic tumors of the sella is even more unusual, but also has an ominous prognosis.
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Affiliation(s)
- Fausto J Rodriguez
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
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16
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Buslei R, Hölsken A, Hofmann B, Kreutzer J, Siebzehnrubl F, Hans V, Oppel F, Buchfelder M, Fahlbusch R, Blümcke I. Nuclear beta-catenin accumulation associates with epithelial morphogenesis in craniopharyngiomas. Acta Neuropathol 2007; 113:585-90. [PMID: 17221204 DOI: 10.1007/s00401-006-0184-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2006] [Revised: 11/10/2006] [Accepted: 12/01/2006] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Rolf Buslei
- Department of Neuropathology, Friedrich-Alexander University Erlangen-Nuremberg, Krankenhausstrasse 8-10, 91054 Erlangen, Germany.
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Abstract
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.
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Affiliation(s)
- Niki Karavitaki
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LJ, United Kingdom
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Sekine S, Takata T, Shibata T, Mori M, Morishita Y, Noguchi M, Uchida T, Kanai Y, Hirohashi S. Expression of enamel proteins and LEF1 in adamantinomatous craniopharyngioma: evidence for its odontogenic epithelial differentiation. Histopathology 2005; 45:573-9. [PMID: 15569047 DOI: 10.1111/j.1365-2559.2004.02029.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS Adamantinomatous craniopharyngioma (ACP) resembles histologically some odontogenic tumours, such as ameloblastoma and calcifying odontogenic cyst. However, there has been no evidence that ACP differentiates also functionally as odontogenic epithelium. The aim of this study was to gain evidence of odontogenic epithelial differentiation in ACP by means of immunohistochemistry. Among normal human tissues, enamel proteins are expressed exclusively in teeth, and lymphoid enhancer factor 1 (LEF1), in co-operation with beta-catenin, play an important role in tooth development. The expression of these proteins is therefore indicative of odontogenic epithelial differentiation. METHODS AND RESULTS The expression of enamel proteins and LEF1 was examined in 10 adamantinomatous and six papillary craniopharyngiomas. All the ACPs showed a variable degree of enamel protein expression, including amelogenin, enamelin and enamelysin, mainly in ghost cells. LEF1 was also heterogeneously expressed in ACPs; remarkably, its expression pattern was identical to that of nuclear beta-catenin accumulation. In contrast, none of the papillary craniopharyngiomas expressed enamel proteins or LEF1. CONCLUSIONS These results suggest that ACP consistently shows odontogenic epithelial differentiation. Since ACPs harbour beta-catenin mutation, the inappropriate activation of beta-catenin/LEF1 complex-dependent transcription may play a critical role in ACP tumorigenesis.
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Affiliation(s)
- S Sekine
- Pathology Division, National Cancer Center Research Institute, Tokyo, Japan
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19
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Tateyama H, Tada T, Okabe M, Takahashi E, Eimoto T. Different keratin profiles in craniopharyngioma subtypes and ameloblastomas. Pathol Res Pract 2002; 197:735-42. [PMID: 11770017 DOI: 10.1078/0344-0338-00152] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- H Tateyama
- Department of Pathology, Nagoya City University Medical School, Nagoya, Aichi, Japan.
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20
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Abstract
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.
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Affiliation(s)
- K Sato
- Department of Neurosurgery, Fukui Medical University, Japan
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21
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Gilcrease MZ, Delgado R, Albores-Saavedra J. Intrasellar adenoid cystic carcinoma and papillary mucinous adenocarcinoma: two previously undescribed primary neoplasms at this site. Ann Diagn Pathol 1999; 3:141-7. [PMID: 10359849 DOI: 10.1016/s1092-9134(99)80041-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Most carcinomas involving the sella turcica are metastases. We report two previously undescribed carcinomas that appear to be primary at this site. The first occurred in a 44-year-old woman who presented with hemianopsia. A mass was noted by computed tomography to occupy the sella turcica, from which it appeared to originate. Transphenoidal biopsy showed the tumor to be an adenoid cystic carcinoma with a typical cribriform pattern. The patient died shortly after a subsequent attempt at tumor resection. The second tumor arose in a 55-year-old man who presented with diplopia. Computed tomography showed a mass in the sella turcica that was presumed to be a pituitary adenoma. However, transphenoidal resection revealed a mucinous adenocarcinoma composed of small papillae and glands lined by columnar epithelium. The tumor cells exhibited varying degrees of stratification with prominent interspersed mucin vacuoles. Focal solid areas showed a component of signet ring-type cells. In contrast to the apparent aggressive behavior of the adenoid cystic carcinoma, the papillary mucinous adenocarcinoma appeared much less aggressive, as the second patient was alive and without evidence of disease 5 years later. Both tumors may be derived from epithelial rests within the pituitary gland, either minor salivary gland rests or Rathke's cleft remnants.
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Affiliation(s)
- M Z Gilcrease
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX 75235-9073, USA
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22
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Kasai H, Hirano A, Llena JF, Kawamoto K. A histopathological study of craniopharyngioma with special reference to its stroma and surrounding tissue. Brain Tumor Pathol 1998; 14:41-5. [PMID: 9384801 DOI: 10.1007/bf02478867] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- H Kasai
- Department of Neurosurgery, Kansai Medical University, Moriguchi, Japan
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23
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Hampton TA, Scheithauer BW, Rojiani AM, Kovacs K, Horvath E, Vogt P. Salivary gland-like tumors of the sellar region. Am J Surg Pathol 1997; 21:424-34. [PMID: 9130989 DOI: 10.1097/00000478-199704000-00008] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Herein we present a group of rare tumors of the sella region that have not been previously recognized. Although clinically and radiographically the tumors resemble nonfunctioning pituitary adenomas, their histologic, immunohistochemical, and ultrastructural features differ and indicate a salivary gland origin. The lesions cover a morphologic spectrum that includes cellular pleomorphic adenoma, monomorphic adenoma, oncocytoma, and low-grade adenocarcinoma of the salivary gland. All tumors except the oncocytoma were immunoreactive for cytokeratin and were negative for pituitary hormones and synaptophysin. Ultrastructural characteristics in the cases examined include hypodense stromal material, basal lamina, and tonofilament bundles. The single oncocytoma was packed with mitochondria and lacked membrane-bound secretory granules. DNA ploidy based on image analysis and MIB-1 labeling indices showed diversity within this group of tumors, with labeling indices ranging from 0.06% to 15%. The presumed origin of these rare neoplasms is from salivary gland rests related to the normal pituitary gland. Despite their varied morphology, such tumors are easily confused with pituitary adenoma. Although rare, tumors of salivary gland origin should be considered in the differential diagnosis of unusual adenohypophyseal tumors.
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Affiliation(s)
- T A Hampton
- Department of Pathology, University of Florida College of Medicine, Gainesville 32610-0275, USA
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24
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Abstract
BACKGROUND Ordinary craniopharyngiomas affecting sellar regions of children and preadolescents are composed of ameloblastomatous and/or squamous constituents. The authors encountered an autopsy case of a stillborn infant with a large craniopharyngioma with unusual manifestations. METHODS The craniopharyngioma was analyzed using detailed histologic and immunohistochemical techniques. RESULTS An autopsy revealed a large tumor arising from the pituitary gland with associated severe hydrocephalus. Histologically, the cells of the tumor showed features of ameloblastoma and organoid structures simulating tooth buds and adenohypophyseal primordia in the stage of organogenesis. Cells of the latter were shown to be immunoreactive for chromogranin A and six adenohypophyseal hormones. CONCLUSIONS Because embryology of the adenohypophysis and the teeth indicated that all of the epithelia in this tumor emerged during the normal development of the stomodeum, it was believed that an "embryonal form of craniopharyngioma" would characterize this organoid neoplasm best. The possible morphogenesis of craniopharyngioma is also discussed.
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Affiliation(s)
- H Yamada
- Department of Pathology and Oncology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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Weiner HL, Wisoff JH, Rosenberg ME, Kupersmith MJ, Cohen H, Zagzag D, Shiminski-Maher T, Flamm ES, Epstein FJ, Miller DC. Craniopharyngiomas: a clinicopathological analysis of factors predictive of recurrence and functional outcome. Neurosurgery 1994; 35:1001-10; discussion 1010-1. [PMID: 7885544 DOI: 10.1227/00006123-199412000-00001] [Citation(s) in RCA: 233] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
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.
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Affiliation(s)
- H L Weiner
- Department of Neurosurgery, New York University Medical Center, New York
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27
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Konovalov AN, Lichterman BL, Korshunov AG. Endo-suprasellar teratoma with teeth formation. Case report. Acta Neurochir (Wien) 1992; 118:181-4. [PMID: 1456104 DOI: 10.1007/bf01401306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A highly ossified teratoma was diagnosed and surgically treated in a 2-year old girl. More than 150 teeth were macroscopically identified during the operation. Pathological study established the diagnosis of mature teratoma with teeth formation. Only six analogous cases have been reported previously and only two patients survived the operation.
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Affiliation(s)
- A N Konovalov
- Department of Paediatric Neurosurgery, All-Russian Postgraduate Medical Institute, Moscow
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28
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Orlowski WA, Doyle JL, Salb R. Unique odontogenic tumor with dentinogenesis and features of unicystic plexiform ameloblastoma. ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY 1991; 72:91-4. [PMID: 1891249 DOI: 10.1016/0030-4220(91)90196-j] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A case of an atypical odontogenic tumor with features of unicystic plexiform ameloblastoma and odontoblastic differentiation with deposition of tubular dentin matrix is reported. The significance of dentinogenesis, amelogenesis, and calcification in odontogenic tumors is discussed.
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Affiliation(s)
- W A Orlowski
- Department of Oral Medicine and Pathology, New York University College of Dentistry, New York
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29
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Abstract
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.
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30
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Bernstein ML, Buchino JJ. The histologic similarity between craniopharyngioma and odontogenic lesions: a reappraisal. ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY 1983; 56:502-11. [PMID: 6196702 DOI: 10.1016/0030-4220(83)90098-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
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.
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Abstract
✓ The authors report the uncomplicated removal of an intrasellar epidermoid cyst that on presentation mimicked a pituitary adenoma. Current controversies regarding the differentiation of this cyst from other cystic lesions of the sellar region are reviewed.
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Alvarez-Garijo JA, Froufé A, Taboada D, Vila M. Successful surgical treatment of an odontogenic ossified craniopharyngioma. Case report. J Neurosurg 1981; 55:832-5. [PMID: 6796660 DOI: 10.3171/jns.1981.55.5.0832] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
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.
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34
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Thompson IL, Griffin TW, Parker RG, Blasko JC. Craniopharyngioma: the role of radiation therapy. Int J Radiat Oncol Biol Phys 1978; 4:1059-63. [PMID: 102623 DOI: 10.1016/0360-3016(78)90022-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Pullon PA, Child PL. An unusual dental variant of ovarian teratoma. Report of a case. ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY 1972; 34:800-5. [PMID: 4507446 DOI: 10.1016/0030-4220(72)90297-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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