Long-term follow-up of children with craniopharyngioma

Obesity in patients with craniopharyngioma in the South Asian region - A distinct phenotype

Background

Craniopharyngiomas are rare benign tumors located in the sellar and suprasellar region, with an incidence of 0.5-2 cases per million as reported in Western studies. Post-treatment, including surgery and/or radiotherapy, many patients develop significant obesity, primarily due to hypothalamic damage and associated complications such as hypopituitarism. In the South Asian population, genetic predisposition to obesity at lower BMIs, coupled with a carbohydrate-rich diet, may exacerbate obesity in craniopharyngioma patients, presenting a unique challenge.

Methods

This submission is a commentary based on a comprehensive literature review. The authors conducted the review using PubMed to focus on English-language articles covering hypothalamic obesity, craniopharyngioma and obesity in the South Asian population from 1939 to the present.

Results

The literature review revealed that 50-60 % of patients treated for craniopharyngioma develop obesity, predominantly linked to hypothalamic damage, although these data are mainly derived from Western studies. Hypopituitarism was frequently observed, further contributing to the obesity. Despite a caloric intake appropriate for the age and gender, these patients exhibited reduced physical activity as measured by wrist accelerometers. Patients with hypothalamic obesity due to craniopharyngioma are at risk for metabolic syndrome and cardiovascular morbidity. Additionally, visual impairment was common, leading to a decreased quality of life. The South Asian population, genetically predisposed to visceral obesity and a carbohydrate-rich diet, may display a distinct phenotype. Although multiple treatment modalities have been tried, there is no definite treatment modality available to counteract this condition at present.

Conclusion

South Asian phenotype of craniopharyngioma-related obesity is characterized by significant metabolic and hormonal dysregulation, influenced by both dietary and genetic factors. Nevertheless, there may be a lot to be still understood about this devastating, rapid, relentless hypothalamic obesity syndrome. Also, a higher morbidity rate within this population, underscores the need for further research to develop targeted interventions.

Predictive Factors for Pediatric Craniopharyngioma Recurrence: An Extensive Narrative Review

Despite being classified as benign tumors, craniopharyngiomas (CPs) are associated with significant morbidity and mortality due to their location, growth pattern, and tendency to recur. Two types can be identified depending on age distribution, morphology, and growth pattern, adamantinomatous and papillary. The adamantinomatous CP is one of the most frequently encountered central nervous system tumors in childhood. Our aim was to review the relevant literature to identify clinical, morphological, and immunohistochemical prognostic factors that have been implicated in childhood-onset CP recurrence. Lack of radical surgical removal of the primary tumor by an experienced neurosurgical team and radiotherapy after a subtotal excision has been proven to significantly increase the recurrence rate of CP. Other risk factors that have been consistently recognized in the literature include younger age at diagnosis (especially <5 years), larger tumor size at presentation, cystic appearance, difficult tumor location, and tight adherence to surrounding structures, as well as the histological presence of whorl-like arrays. In addition, several other risk factors have been studied, albeit with conflicting results, especially in the pediatric population. Identifying risk factors for CP recurrence is of utmost importance for the successful management of these patients in order to ultimately ensure the best prognosis.

Visual functions in children with craniopharyngioma at diagnosis: A systematic review

Childhood craniopharyngioma is a rare and slow growing brain tumour, often located in the sellar and suprasellar region. It commonly manifests with visual impairment, increased intracranial pressure and hypothalamic and/or pituitary deficiencies. Visual impairment in childhood adversely affects a child’s daily functioning and quality of life. We systematically reviewed the literature to provide an extensive overview of the visual function in children with craniopharyngioma at diagnosis in order to estimate the diversity, magnitude and relevance of the problem of visual impairment. Of the 543 potentially relevant articles, 84 studies met our inclusion criteria. Visual impairment at diagnosis was reported in 1041 of 2071 children (50.3%), decreased visual acuity was reported in 546 of 1321 children (41.3%) and visual field defects were reported in 426 of 1111 children (38.3%). Other ophthalmological findings described were fundoscopic (32.5%) and orthoptic abnormalities (12.5%). Variations in ophthalmological testing methods and ophthalmological definitions precluded a meta-analysis. The results of this review confirm the importance of ophthalmological examination in children with craniopharyngioma at diagnosis in order to detect visual impairment and provide adequate support. Future studies should focus on long-term visual follow-up of childhood craniopharyngioma in response to different treatment strategies to provide insight in risks and ways to prevent further loss of vision.

Outcomes following endoscopic endonasal resection of sellar and supresellar lesions in pediatric patients

PURPOSE

The endoscopic endonasal approach (EEA) is a credible surgical alternative for the resection of sellar and suprasellar lesions such as pituitary adenomas, craniopharyngiomas, and Rathke cleft cysts. However, its application to pediatric patients poses several unique challenges that have not yet been well evaluated. The authors evaluate the safety, efficacy, and outcomes associated with the use of the EEA for treatment of these pathologic entities in pediatric patients.

METHODS

Retrospective review of 30 patients between the ages of two and 24 who underwent endoscopic endonasal resection of sellar or suprasellar lesions between January 2010 and December 2015. Endocrinological and ophthalmological outcomes, as well as extent of resection and complications were all evaluated.

RESULTS

Gross total resection was achieved in eight of the nine pituitary adenomas, nine of the 12 craniopharyngiomas, and six of the nine Rathke cleft cysts. Of the 30 patients, 22 remained disease free at last follow-up. A total of six patients developed hypopituitarism and five developed diabetes insipidus. Eleven patients experienced improved vision, sixteen experienced no change, and one patient experienced visual worsening. Postoperative cerebrospinal fluid leak was seen in a single case and later resolved, vasospasm/stroke was experienced by 10% of patients, and new obesity was recorded in 10% of patients. There were no perioperative deaths.

CONCLUSIONS

Endoscopic endonasal resection is a safe and effective surgical alternative for the management of sellar and suprasellar pathologies in pediatric populations with excellent outcomes, minimal complications, and a low risk of morbidity.

Metabolic syndrome as cardiovascular risk factor in childhood cancer survivors

Over the past decades, survival rates of childhood cancer have increased considerably from 5 to 30% in the early seventies to current rates exceeding 80%. This is due to the development of effective chemotherapy, surgery, radiotherapy and stem cell transplantation, combined with an optimized stratification of therapy and better supportive care regimens. As a consequence, active surveillance strategies of late sequelae have been developed to improve the quality of survival. Several epidemiological studies have reported an increased incidence of (components of) metabolic syndrome (MetS) and cardiovascular disease in childhood cancer survivors (CCS). Growth hormone deficiency (GHD) after cranial radiotherapy (CRT) has been previously described as an important cause of MetS. New insights suggest a role for abdominal radiotherapy as a determinant for MetS as well. The role of other risk factors, such as specific chemotherapeutic agents, steroids, gonadal impairment, thyroid morbidity and genetics, warrants further investigation. This knowledge is important to define subgroups of CCS that are at risk to develop (subclinical) MetS features. These survivors might benefit from standard surveillance and early interventions, for example lifestyle and diet advice and medical treatment, thereby preventing the development of cardiovascular disease.

Association of pituitary stalk management with endocrine outcomes and recurrence in microsurgery of craniopharyngiomas: A meta-analysis

OBJECTIVE

A craniopharyngioma (CP) is a benign tumor commonly considered to originate from the pituitary stalk. However, it is still controversial as to whether the pituitary stalk should be maintained after microsurgery to resect the tumor despite its own physiological function of the pituitary stalk. In this study, meta-analysis was conducted to evaluate the influence of the pituitary stalk resection on endocrine function and tumor recurrence rate.

METHODS

The relevant publications were identified by searching databases including Pubmed, Embase, Medline, and Web of Science. The extracted data were used as the basis for the meta-analysis by the RevMan 5.2 software program.

RESULTS

Seven articles were selected, including 420 clinical cases. The meta-analysis showed that retaining the pituitary stalk might reduce the occurrence rate of diabetes insipidus (OR=0.21, 95%CI=0.10, 0.46, P=0.0001) and the risk of potential impairment of anterior pituitary function (OR=0.04, 95%CI=0.01, 0.13, P<0.0001). However, there was no significant relationship between craniopharyngioma recurrence and pituitary stalk treatment (i.e., preservation or resection) (OR=1.40, 95%CI=0.59, 3.34, P=0.45).

CONCLUSION

The maintenance of the pituitary stalk may reduce the alterations in endocrine function and the occurrence of diabetes insipidus. However, it is not likely to enhance the recurrence rate of craniopharyngiomas.

GLP-1 analogues as a new treatment option for hypothalamic obesity in adults: report of nine cases

BACKGROUND

Patients with hypothalamic pathology often develop morbid obesity, causing severe metabolic alterations resulting in increased morbidity and mortality. Glucagon-like peptide-1 (GLP-1) analogues improve glycaemic control in type 2 diabetic patients and cause weight loss in obese patients by yet unknown mechanisms. Here we tested whether GLP-1 analogues were also effective in the treatment of obesity and associated metabolic alterations in patients with hypothalamic disease.

METHODS

Nine patients (eight with type 2 diabetes mellitus) with moderate to severe hypothalamic obesity were treated with GLP-1 analogues for up to 51 months. Body weight, homeostasis model assessment - insulin resistance (HOMA-IR), HbA1c and lipids were assessed.

RESULTS

Eight patients experienced substantial weight loss (-13.1±5.1 kg (range -9 to -22)). Insulin resistance (HOMA-IR -3.2±3.5 (range -9.1 to 0.8)) and HbA1c values (-1.3±1.4% (range -4.5 to 0.0)) improved under treatment (24.3±18.9 months (range 6 to 51)). Five patients reported increased satiation in response to the treatment. Two of the eight patients complained about nausea and vomiting and one of them abandoned therapy because of sustained gastrointestinal discomfort after 6 months. One patient suffered from intolerable nausea and vomiting and discontinued treatment within 2 weeks.

CONCLUSION

GLP-1 analogues can cause substantial and sustained weight loss in obese patients with hypothalamic disease. This offers a new approach for medical treatment of moderate to severe hypothalamic obesity and associated metabolic alterations.

Predictive factors for craniopharyngioma recurrence: a systematic review and illustrative case report of a rapid recurrence

BACKGROUND

Recurrence of craniopharyngiomas (CPs) represents a frequent and unpredictable incident. Rapid tumor recurrence within a few months after surgery has been rarely reported. Nondefinitive predictive factors for rapid CP recurrence have been identified to date. We have systematically analyzed the tumor factors that presumably influence in CP recurrence.

METHODS

We present the histologic and immunohistochemical analysis of an infundibulo-tuberal CP that was operated twice within a 3-month interval due to rapid recurrence. We investigated the differential characteristics of the subgroup of CPs that recurred in large surgical series published in the literature, along with cases reporting rapid tumor recurrence after surgery.

RESULTS

Specimens of our patient showed an adamantinomatous CP with whorl-like arrays and thick peritumoral gliosis. Ki-67 labeling index in primary and recurrent samples was 20% and 15%, respectively. p53 labeling index was 18% and 15%, respectively. The thorough analysis of literature showed that presence of tumor remnants and missing radiotherapy treatment after subtotal removal are strong predictors of tumor recurrence. Third ventricle involvement, large tumor size, tight adherence to surrounding structures, and presence of whorl-like arrays might also foster recurrence. High Ki-67 levels, p53 expression, and an intense reactive gliosis might point to rapid tumor growth.

CONCLUSIONS

Reliable tumor markers that predict CP recurrence are still lacking. The CP features presumably related to a higher risk of its recurrence are thought to be a larger tumor size, a tight adherence to the hypothalamus, the presence of whorl-like arrays, and high Ki-67 and p53 levels.

Hypothalamic obesity after craniopharyngioma: mechanisms, diagnosis, and treatment

Obesity is a common complication after craniopharyngioma therapy, occurring in up to 75% of survivors. Its weight gain is unlike that of normal obesity, in that it occurs even with caloric restriction, and attempts at lifestyle modification are useless to prevent or treat the obesity. The pathogenesis of this condition involves the inability to transduce afferent hormonal signals of adiposity, in effect mimicking a state of CNS starvation. Efferent sympathetic activity drops, resulting in malaise and reduced energy expenditure, and vagal activity increases, resulting in increased insulin secretion and adipogenesis. Lifestyle intervention is essentially useless in this syndrome, termed "hypothalamic obesity." Pharmacologic treatment is also difficult, consisting of adrenergics to mimic sympathetic activity, or suppression of insulin secretion with octreotide, or both. Recently, bariatric surgery (Roux-en-Y gastric bypass, laparoscopic gastric banding, truncal vagotomy) have also been attempted with variable results. Early and intensive management is required to mitigate the obesity and its negative consequences.

Benefit of 1.5-T intraoperative MR imaging in the surgical treatment of craniopharyngiomas

BACKGROUND

As low-field magnetic resonance imaging (MRI) has very limited significance for intraoperative control of total tumor removal (TTR), we examined the influence of 1.5-T MRI, incorporating higher resolution into the intraoperative strategy of craniopharyngioma surgery.

METHODS

Surgery with intraoperative imaging was performed in 25 selected patients in whom tumor resection was anticipated to be difficult according to pre-operative findings.

RESULTS

Intraoperative MRI confirmed the intended extent of tumor removal in 15 patients (14 TTRs, one intended incomplete removal, while a second procedure was scheduled due to complex shape). Misinterpretation was false positive or negative in one patient each. The extent of removal was not achieved as expected in eight patients (expectation: seven TTRs, one incomplete removal). In three patients, the expected TTR was achieved by resuming surgery. In another case, that goal was accomplished by performing an unscheduled second procedure. In total, by using intraoperative imaging, the rate of TTR was increased by 16% (four patients), leading to 80% in the entire series. Compared with the literature, the rate of new ophthalmologic and endocrine deficits is acceptable; the rate of other surgical complication is slightly higher but not directly caused by intraoperative imaging.

CONCLUSION

Intraoperative 1.5-T MRI provides benefits because of good early prediction of TTR (sensitivity, positive predictive value: 93.8%; specificity, negative predictive value: 88.9%) and a low rate of false-positive results. Moreover, extended resection of remnants visualized is enabled and helps to increase the rate of TTR but does not exclude recurrence.

Obesity, metabolic syndrome, and insulin dynamics in children after craniopharyngioma surgery

INTRODUCTION

Children after craniopharyngioma surgery often develop rapid weight gain and hyperphagia. We investigate the metabolic syndrome features, risk factors, and the insulin dynamics in these patients.

MATERIALS AND METHODS

Standard oral glucose tolerance tests (OGTT) were performed in 12 subjects, aged 7.7-18.1 years, after surgical removal of craniopharyngioma and their healthy age-, sex-, body mass index-, and pubertal stage-matched controls. Blood samples were obtained for measurement of levels of plasma glucose, insulin, lipids, liver enzymes, baseline hormonal profiles with calculation of insulin secretion, and insulin sensitivity indices derived from OGTT.

RESULTS AND DISCUSSION

Nine of 12 subjects were severely obese. All patients exhibited significant weight gain after surgery. The waist to hip ratio was higher in subjects compared to controls (P = 0.023). Subjects had higher fasting triglycerides (P = 0.019) and lower HDL/total cholesterol ratio (P = 0.012). Five of 12 subjects met the criteria for the metabolic syndrome, compared with one of 12 in controls. One patient had prediabetes and another patient had overt type 2 diabetes. Six of 12 subjects had nonalcoholic steatohepatitis. No significant risk factors were found between each group of patients with and without the metabolic syndrome. There were no differences of insulin secretion and insulin sensitivity indices between craniopharyngioma and control subjects.

CONCLUSION

Children after craniopharyngioma surgery are at risk of rapid weight gain and the development of metabolic syndrome. Further studies to better understand the mechanism are required to design effective treatment and prevention.

Management of recurrent craniopharyngioma

Craniopharyngioma accounts for approximately 1.2% to 4.6% of all intracranial tumours. Their close proximity to vital structures such as the hypothalamic-pituitary axis and optic apparatus makes them one of the most challenging and controversial management dilemmas in neurosurgery. Recurrence following initial transcranial resection is reported as 9% to 51% at a median time of 26 months to 96 months. Treatment options for recurrent craniopharyngioma include repeat surgery, radiotherapy, radiosurgery and intracystic therapies. We present a series of 54 recurrent craniopharyngiomas treated at The Royal Melbourne Hospital between 1991 and 2008 and discuss the management options now available.

Endocrinologic, neurologic, and visual morbidity after treatment for craniopharyngioma

Craniopharyngiomas are locally aggressive tumors which typically are focused in the sellar and suprasellar region near a number of critical neural and vascular structures mediating endocrinologic, behavioral, and visual functions. The present study aims to summarize and compare the published literature regarding morbidity resulting from treatment of craniopharyngioma. We performed a comprehensive search of the published English language literature to identify studies publishing outcome data of patients undergoing surgery for craniopharyngioma. Comparisons of the rates of endocrine, vascular, neurological, and visual complications were performed using Pearson's chi-squared test, and covariates of interest were fitted into a multivariate logistic regression model. In our data set, 540 patients underwent surgical resection of their tumor. 138 patients received biopsy alone followed by some form of radiotherapy. Mean overall follow-up for all patients in these studies was 54 ± 1.8 months. The overall rate of new endocrinopathy for all patients undergoing surgical resection of their mass was 37% (95% CI = 33-41). Patients receiving GTR had over 2.5 times the rate of developing at least one endocrinopathy compared to patients receiving STR alone or STR + XRT (52 vs. 19 vs. 20%, χ(2) P < 0.00001). On multivariate analysis, GTR conferred a significant increase in the risk of endocrinopathy compared to STR + XRT (OR = 3.45, 95% CI = 2.05-5.81, P < 0.00001), after controlling for study size and the presence of significant hypothalamic involvement. There was a statistical trend towards worse visual outcomes in patients receiving XRT after STR compared to GTR or STR alone (GTR = 3.5% vs. STR 2.1% vs. STR + XRT 6.4%, P = 0.11). Given the difficulty in obtaining class 1 data regarding the treatment of this tumor, this study can serve as an estimate of expected outcomes for these patients, and guide decision making until these data are available.

Craniopharyngioma: a comparison of tumor control with various treatment strategies

OBJECT

Craniopharyngiomas have a propensity to recur after resection, potentially causing death through their aggressive local behavior in their critical site of origin. Recent data suggest that subtotal resection (STR) followed by adjuvant radiotherapy (XRT) may be an appealing substitute for gross-total resection (GTR), providing similar rates of tumor control without the morbidity associated with aggressive resection. Here, the authors summarize the published literature regarding rates of tumor control with various treatment modalities for craniopharyngiomas.

METHODS

The authors performed a comprehensive search of the English language literature to identify studies publishing outcome data on patients undergoing surgery for craniopharyngioma. Rates of progression-free survival (PFS) and overall survival (OS) were determined through Kaplan-Meier analysis.

RESULTS

There were 442 patients who underwent tumor resection. Among these patients, GTR was achieved in 256 cases (58%), STR in 101 cases (23%), and STR+XRT in 85 cases (19%). The 2- and 5-year PFS rates for the GTR group versus the STR+XRT group were 88 versus 91%, and 67 versus 69%, respectively. The 5- and 10-year OS rates for the GTR group versus the STR+XRT group were 98 versus 99%, and 98 versus 95%, respectively. There was no significant difference in PFS (log-rank test) or OS with GTR (log-rank test).

CONCLUSIONS

Given the relative rarity of craniopharyngioma, this study provides estimates of outcome for a variety of treatment combinations, as not all treatments are an option for all patients with these tumors.

Mortality in patients with pituitary disease

Pituitary disease is associated with increased mortality predominantly due to vascular disease. Control of cortisol secretion and GH hypersecretion (and cardiovascular risk factor reduction) is key in the reduction of mortality in patients with Cushing's disease and acromegaly, retrospectively. For patients with acromegaly, the role of IGF-I is less clear-cut. Confounding pituitary hormone deficiencies such as gonadotropins and particularly ACTH deficiency (with higher doses of hydrocortisone replacement) may have a detrimental effect on outcome in patients with pituitary disease. Pituitary radiotherapy is a further factor that has been associated with increased mortality (particularly cerebrovascular). Although standardized mortality ratios in pituitary disease are falling due to improved treatment, mortality for many conditions are still elevated above that of the general population, and therefore further measures are needed. Craniopharyngioma patients have a particularly increased risk of mortality as a result of the tumor itself and treatment to control tumor growth; this is a key area for future research in order to optimize the outcome for these patients.

Optimal treatment strategy for craniopharyngiomas based on long-term functional outcomes of recent and past treatment modalities

Although many authors have described treatment strategies for craniopharyngiomas, the optimal treatment of craniopharyngiomas remains controversial. This study aimed to define an adequate surgical strategy for craniopharyngiomas by reviewing the long-term functional performance of patients treated by current and past treatment modalities. Fifty-five patients with longer than 5 years of follow-up were selected for the present long-term study. The duration of follow-up ranged from 5.5 to 33 years (median, 14.8 years). There were 28 adult patients (14 males; median age, 44.4 years) and 27 children younger than 16 years of age (15 males; median age, 8.1 years). The patients were divided into the following treatment groups: single surgery (group A; n=14 multiple surgeries (group B; n=8), surgery or surgeries followed by radiotherapy (group C; n=23), surgery or surgeries (partial removal) followed by radiotherapy + additional treatments (multiple surgeries and/or re-irradiation; group D; n=10). In addition to the routine assessments of neurological, endocrine, and visual outcomes, the level of daily functioning was analyzed using the Karnofsky Performance Scale (KPS). Statistical analysis of relationship between KPS score and treatment mode demonstrated that group D had a significantly lower KPS score (F=5.82, p=0.0017). Furthermore, mortality, cognitive function, and visual function were significantly better in groups A, B, and C than in group D. Multiple regression analysis demonstrated that cognitive dysfunction, visual disturbance, and treatment mode were independent covariates that significantly affected postoperative KPS score. Adequate primary treatment for craniopharyngiomas is important to avoid subsequent multiple treatments. Craniopharyngiomas should be removed surgically as far as possible but without further deteriorating cognitive and visual functions, either as total resection or subtotal resection with a small remnant that is controllable by radiation therapy.

Prevalence and risk factors of radiation-induced growth hormone deficiency in childhood cancer survivors: a systematic review

BACKGROUND

Growth hormone deficiency (GHD) is usually the first and most frequent endocrine problem occurring after cranial radiotherapy (CRT). The aim of this systematic review was to evaluate the existing evidence of the prevalence and risk factors of radiation-induced GHD in childhood cancer survivors.

METHODS

MEDLINE, EMBASE and CENTRAL were searched for studies reporting on radiation-induced GHD in childhood cancer survivors. Information about study characteristics, prevalence and risk factors was abstracted and the quality of each study was assessed. A meta-regression analysis was performed.

RESULTS

The prevalence of radiation-induced GHD was estimated in 33 studies. Most studies had methodological limitations. The prevalence varied considerably between 0% and 90.9%. Selecting only the studies with adequate peak GH cut-off limits (<5 microg/L) resulted in 3 studies. In these studies the prevalence ranged from 29.0% to 39.1%, with a pooled prevalence of 35.6%. Higher CRT dose and longer follow-up time have been suggested to be the main risk factors of GHD by studies included in this review. The meta-regression analysis showed that the wide variation in the prevalence of GHD could be explained by differences in maximal CRT dose.

CONCLUSIONS

GHD is a frequent consequence after CRT in childhood cancer survivors. The prevalence of radiation-induced GHD ranged from 29.0% to 39.1% when selecting only studies with adequate peak GH cut-off limits. Higher CRT dose and longer follow-up time are the main risk factors. More well-designed studies are needed to accurately estimate the prevalence of GHD and to define the exact CRT threshold dose.

Slow-growing craniopharyngioma masquarading as early-onset eating disorder: two cases

BACKGROUND

Craniopharyngiomas are slow-growing tumors, which can either be asymptomatic or present themselves with visual, neuropsychiatric or endocrine disturbances. Eating disorders (EDs) are syndromes with unknown etiology, associated with multiple endocrine abnormalities. In pediatric cases the presentation of EDs may differ markedly from those of adults.

OBJECTIVE

We report on two pediatric patients with craniopharyngioma misinterpreted as ED.

METHOD

Available patient records, psychiatric examinations, neuro-radiographic imaging, and biochemical data were evaluated.

DISCUSSION

The reported cases illustrate the importance to consider slow-growing craniopharyngioma in ED. Especially in atypical ED, neuro-radiographic, ophthalmologic and endocrine examination should be carried out. Furthermore, structural hypothalamic lesions in these cases mimicking features of ED, suggesting the possibility of an as yet unidentified structural hypothalamic disorder to be implicated in the etiopathogeny of ED.

Craniopharyngiomas in children

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Origin of craniopharyngiomas: implication on the growth pattern

BACKGROUND

The surgical management of craniopharyngiomas has been among the most challenging neurosurgical procedures because of their complex topographical relationship with surrounding structures and high recurrence rate after subtotal resection. Craniopharyngiomas have been classified only by their location to determine an appropriate surgical approach without due regard to other factors that could affect the surgical results, such as the extent of adhesion to surrounding structures or the nature of the tumor.

METHODS

We describe the role of the diaphragm sellae on the growth patterns of craniopharyngiomas from surgical experiences and pathological evidences, suggesting the classification of craniopharyngiomas into three categories by the level of origin and the competence of the diaphragm sellae: a tumor of subdiaphragmatic origin with competent diaphragm sellae, subdiaphragmatic with incompetent diaphragm sellae, and supradiaphragmatic.

DISCUSSION

Tumors in each category have shown peculiar topographical relationship with the optic chiasm, third ventricle, and also adhesion extents. The nature of the tumor itself, e.g., the composition of cystic and solid parts, may bring additional minor variations to the topographical features of a craniopharyngioma, but will maintain the major characteristics determined by its level of origin and competence of the diaphragm sellae.

CONCLUSION

This classification scheme, which considers the origin level, is clinically relevant and useful because optimal surgical approaches could be designed by considering multiple factors affecting surgical procedure and outcome, including the expected extent of adhesion and preferred sites of recurrence, as well as the topographical location of the tumor. In subdiaphragmatic tumors, which correspond to intrasellar and prechiasmatic tumors, a transsphenoidal approach could be reasonably attempted even with considerable suprasellar extensions because they tend to adhere to the intrasellar structures, and the superior surface of the tumor may be easily separated from the brain structures by pulling. Supradiaphragmatic tumors, however, may need a wider surgical approach that can provide direct vision of the tumor because of possible extensive adhesion.

Endocrine and neuroanatomic features associated with weight gain and obesity in adult patients with hypothalamic damage

PURPOSE

Obesity is a common consequence in patients with tumors of the hypothalamic region and of related treatment in children. Much less information is available on adult patients and long-term survivors. The aims of this study were to estimate the prevalence of obesity in adult patients with acquired structural hypothalamic damage and to define the characteristics of patients at greatest risk of obesity.

METHODS

A retrospective study was conducted of 52 patients (25 women; median age at diagnosis, 44 years; range, 17 to 78 years) with tumors involving the hypothalamic region. These included 22 craniopharyngiomas, 24 pituitary adenomas, and six other hypothalamic tumors. Changes in body mass index were determined, magnetic resonance imaging scans were scored by a radiologist for tumor size and the extent of involvement of the hypothalamus, and current hormone replacement therapy was recorded, to identify possible features associated with new or worsened obesity (defined as a body mass index > or =30 kg/m(2) at the latest follow-up, which had increased by at least 2 kg/m(2) since diagnosis of the tumor).

RESULTS

Serial body mass index data from diagnosis to the latest follow-up were available for 42 patients. After a median of 5 years (range, 1 to 19 years) of follow-up, most patients with hypothalamic damage were obese (52% [n = 22] vs. 24% [n = 10] at the time of diagnosis, P < 0.0001). In a multivariate model, use of desmopressin (odds ratio [OR] = 13; 95% confidence interval [CI]: 2.0 to 86; P = 0.007) and growth hormone replacement (OR = 7.6; 95% CI: 1.1 to 51; P = 0.04) were associated with new or worsened obesity during follow-up. No correlation was found between the initial size or location of the tumor and subsequent weight gain.

CONCLUSION

Obesity is highly prevalent in adult survivors of hypothalamic tumors. Use of desmopressin and growth hormone therapy, but not size or location of the tumor, were associated with weight gain and obesity following diagnosis. These findings may be helpful in identifying patients at increased risk of obesity, to whom earlier intervention could be offered.

Correlation between clinical characteristics and proliferative activity in patients with craniopharyngioma

OBJECTIVES

The aim of the study was to correlate the Ki-67 and cyclin A labelling index (LI) with clinical characteristics and risk of recurrence of craniopharyngiomas.

METHODS

47 consecutive patients were studied, 21 female and 26 male, aged 34.3 (2.8) years. Immunohistochemical analysis was performed on paraffin wax embedded material using monoclonal antibodies directed against the proliferation associated nuclear antigen Ki-67 and cyclin A.

RESULTS

The median Ki-67 LI was 8.6% (interquartile range, 4.4%-14.0%). Ki-67 LI was significantly higher in tumours with a heavy inflammatory reaction and diabetes insipidus at presentation, whereas other clinical and histological features were not associated with the proliferation index. There was a strong linear correlation between Ki-67 LI and cyclin A LI (r = 0.77; p<0.0001); therefore, cyclin A LI showed the same clinical and histological relations described for Ki-67 LI. Recurrence of craniopharyngioma occurred in 13 of 46 patients (28.3%). The median Ki-67 LI in the 13 recurrent craniopharyngiomas (9.0%) was not significantly different from that of non-recurring tumours (7.9%). Cyclin A LI was also not associated with the risk of relapse.

CONCLUSIONS

This study confirms the great variability of proliferative activity in craniopharyngiomas. Ki-67 and cyclin A LIs were associated with the presence of a heavy inflammatory reaction and diabetes insipidus, but did not correlate with the long term risk of tumour regrowth.

Autopsy findings of a craniopharyngioma with a natural course over 60 years

BACKGROUND

We report the histologic manifestations in an autopsy case of craniopharyngioma with an unusually long treatment-free course.

CASE DESCRIPTION

A 72-year-old woman with craniopharyngioma, in whom ateliosis due to the suprasellar tumor had been identified at the age of 10 years but had not been treated, was studied postmortem. She had not acquired secondary sex characteristics. At autopsy, a hard mass 2 cm in diameter was present in the suprasellar region and invaded the anterior floor of the third ventricle. Histologically, a large proportion of the mass was replaced by wet keratin, ossified tissue, dystrophic calcification, and fatty adipose tissue: these features indicate widespread degeneration of the tumor cells. Only a few residual cell nests of craniopharyngioma-composed of squamous cells lined with a single columnar cell layer-were observed at the peripheral portion of the mass. Conspicuous reactive astrocytosis with relatively high cellularity was evident in the brain tissue adjacent to the mass.

CONCLUSION

This case may represent a rare example of craniopharyngioma lacking spontaneous growth activity and consequently showing marked degeneration of the tumor cells.

Obesity and endocrine disease

Several endocrine abnormalities are reported in obesity. Some of these abnormalities are considered as causative factors for the development of obesity, whereas others are considered to be secondary effects of obesity and usually are restored after weight loss. Thyroid hormones usually are normal in obesity, with the exception of T3 which is elevated. Prolactin is normal but prolactin response to different stimuli is blunted. GH is low and GH response to stimuli is blunted. IGF-I levels are normal or elevated. Cortisol, ACTH, and urine free cortisol levels are usually normal; however, a hyperresponsiveness of the HPA axis with increased cortisol and ACTH response to stimulatory tests is observed in centrally obese individuals. Total testosterone and SHBG levels are low, but free testosterone levels are usually normal in obese men. LH and FSH levels usually are normal and estrogens are elevated. Norepinephrine levels are elevated, whereas epinephrine levels are low or normal. Aldosterone levels are elevated but renin activity is usually normal. Parathyroid hormone levels are elevated with normal serum calcium levels and increased urine calcium levels. Monogenic mutations that result in severe obesity have been described in several individuals. Also, several endocrine diseases have obesity as one their clinical manifestations. Hypothyroidism, Cushing's syndrome, GH and testosterone deficiency, polycystic ovarian syndrome, insulinoma, hypothalamic lesions, and genetic syndromes often present with obesity. In most of these conditions, appropriate treatment of the primary disease results in weight loss. In addition, the fat cell has been found to be an endocrine organ that produces several peptides that are bioactive and participate in the regulation of adipocyte function.

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

OBJECT

This work is devoted to a 25-year retrospective study of 122 cases of craniopharyngiomas in adults and children treated and followed by the same neurosurgeon (R.V.E.). In this homogeneous series, the aim was total microsurgical removal of the tumor, without postoperative radiotherapy.

METHODS

The operation was performed via a frontopterional approach in 112 cases and a transsphenoidal approach in 10 cases. The tumor removal was considered total in 59%, subtotal in 29%, and partial in 12%. The surgical mortality rate was 2.5%. Even when tumor removal was not complete, radiotherapy was not systematically administered; it was reserved for cases of recurrence. The authors have studied clinical signs, operative characteristics, and ophthalmological, endocrinological, and functional outcomes, as well as recurrence risk and long-term patient survival. The mean follow-up period was 7 years. The functional results in these patients were excellent in 85%, good in 9%, fair in 5% (usually because of ophthalmological sequelae), and poor in 1%. Tumors recurred in 29 patients, but the salvage treatment, by operation or radiotherapy, was successful in 83%. The actuarial patient survival rate was 92% after 5 years and 85% after 10 years.

CONCLUSIONS

These results compared favorably with the data reported in the literature, suggesting that radical surgery of craniopharyngiomas allows good outcome in terms of survival, full recovery, and quality of life for both adults and children.

Use of somatostatin receptor ligands in obesity and diabetic complications

Somatostatin (SMS) is a potent inhibitory molecule. It inhibits both exocrine and endocrine secretory functions of the pancreas, suppresses growth hormone secretion and reduces the level of insulin-like growth factor-1. Long-acting somatostatin analogues were currently investigated for potential clinical benefits in two settings: (a) control of hyperinsulinaemia in obesity and (b) control of an excess of pro-angiogenic factors in diabetes-associated retinal complications. In two randomized, controlled trials the long-acting somatostatin analogue octreotide retarded progression of the microvascular complications in pre-proliferative and advanced stages of diabetic retinopathy. Inhibition of the early phase of insulin secretion by use of octreotide in patients with hypothalamic obesity resulted in weight loss and improved quality of life. Efficacy of octreotide correlated to residual beta-cell activity prior to the treatment. Obesity and diabetes mellitus are the most common chronic metabolic disorders in the world. The use of somatostatin analogues addressing the various hormonal imbalances of these disorders may provide a novel concept for their pharmacological treatment.

Leptin acts as a growth factor on the chondrocytes of skeletal growth centers

Childhood obesity frequently is associated with an increase in height velocity and acceleration of epiphyseal growth plate maturation despite low levels of serum growth hormone (GH). In addition, obesity is associated with higher circulating levels of leptin, a 16-kDa protein that is secreted from the adipocytes. In this study, we evaluated the direct effect of leptin on the chondrocyte population of the skeletal growth centers in the mouse mandibular condyle, a model of endochondral ossification. We found that chondrocytes in the growth centers contain specific binding sites for leptin. Leptin, at a concentration of 0.5-1.0 microg/ml, stimulated in a dose-dependent manner the width of the chondroprogenitor zone (up to 64%), whereas higher concentrations had an inhibitory effect. Leptin induction of both proliferation and differentiation activities in the mandibular condyle was confirmed by our findings of an increase in bromodeoxyuridine (BrdU) incorporation into DNA and in (acidic) Alcian blue (AB) staining of the cartilaginous matrix. Leptin also increased the abundance of the insulin-like growth factor (IGF) I receptor and IGF-I receptor messenger RNA (mRNA) within the chondrocytes and the progenitor cell population. Our results indicate that leptin acts as a skeletal growth factor with a direct peripheral effect on skeletal growth centers. Some of its effects on the growing bone may be mediated by the IGF system via regulation of IGF-I receptor expression. We speculate that the high circulating levels of leptin in obese children might contribute to their growth.

Growth patterns of craniopharyngioma in children: role of the diaphragm sellae and its surgical implication

BACKGROUND

Most craniopharyngiomas can be classified as either "prechiasmatic" or "retrochiasmatic" according to their growth patterns. The purpose of our study was to investigate the factors determining these growth patterns.

METHODS

The radiological, operative, and pathological findings of 25 consecutive cases were reviewed.

RESULTS

In cases with prechiasmatic growth (n = 14), most tumors were easily separated from the undersurface of the third ventricular floor with the exception of a small area at the top of the tumor where tumor-glial interfaces occurred. Pathological examination of the tough tumor surface demonstrated well-organized collagen tissue, which is compatible with diaphragm sellae. All tumors of this type had intrasellar components, suggesting a subdiaphragmatic origin for this tumor type. On the other hand, tumors with retrochiasmatic growth (n = 11) demonstrated a prefixed chiasm, and most of the surface excluding areas exposed to ventricular cerebrospinal fluid showed tumor-glial interfaces. With the exception of three, all tumors of this type lacked intrasellar components, and the diaphragm sellae was depressed and free of tumor, suggestive of a supradiaphragmatic infundibular origin of the tumor.

CONCLUSION

Growth pattern is closely correlated to the origin of the tumor, whether it is above or below the diaphragm sellae. In craniopharyngiomas with prechiasmatic growth, the major portion of the tumor could be resected by traction. These tumors are candidates for the transsphenoidal approach if the sphenoid sinus is pneumatized. Tumors with retrochiasmatic growth, which are not covered by diaphragm sellae and contact brain tissue directly, are easily torn by traction and the tumor-glial interface should be carefully dissected under direct vision.

The neuroendocrinology of obesity

The regulation of energy balance is enormously complex, with numerous genetic, hormonal, neural/behavioral, and societal influences. Although the current epidemic of obesity has its underpinnings in the changes in culture during the last half century, the role of the neuroendocrine system in the genesis of obesity is physiologically and therapeutically unavoidable. Increased understanding of this system has suggested organic etiologies (and therapies) for some rare and not-so-rare forms of obesity. With so many inputs, it is not implausible that dysfunction of other parts of this feedback system will be found to explain other forms of obesity in the future. Fortunately or unfortunately, diet and exercise remain the mainstays of obesity therapy. Most diet-exercise programs result in an acute 11-kg weight loss in adults; the question is whether it can be sustained without significant long-term behavior modification. In the European Sibutramine Trial of Obesity Reduction and Maintenance (STORM), 42% of treated patients dropped out; of those remaining, 77% of subjects lost more than 5% of initial body weight, but only 43% of these individuals maintained greater than 80% of this loss over 2 years. Could there be an organic component in persons who do not respond? Obesity pharmacotherapies sometimes have beneficial acute effects, but these effects are impermanent; discontinuation tends to result in a rebound weight gain, suggesting that the etiology of the obesity is still present. A useful guiding principle is that patients who do not respond to diet and exercise should undergo an initial medical evaluation, including assessments of birth weight, past medical history, weight history, family history, diet, exercise, and fasting insulin and thyroid levels. As the nosology of obesity improves, diagnostic efficiency and therapeutic success should increase, leading to a decrease in associated morbidity, mortality, and socioeconomic ramifications.

The neuroendocrinology of childhood obesity

The regulation of energy balance is enormously complex, with numerous genetic, hormonal, neural and behavioral, and societal influences. Although the current epidemic of obesity clearly has its underpinnings in the changes in culture during the past half-century (see other articles in this issue), the role of the neuroendocrine system in the genesis of obesity, as described in this article, is physiologically and therapeutically unavoidable. An understanding of this system has suggested organic causes (and therapies) for some rare and not-so-rare forms of obesity. With so many inputs, it is not far-fetched to assume that dysfunction of other parts of this feedback system will be found to explain other forms of obesity in the future. What does this mean for obese children entering the pediatrician's office? Fortunately or unfortunately, diet and exercise are the mainstays of obesity therapy for children and adults. Most diet-exercise programs result in an acute 11-kg weight loss in adults; the question is whether it can be sustained without significant long-term behavioral modification. For instance, the European Sibutramine Trial of Obesity Reduction and Maintenance trial showed that 42% of treated subjects drop out; of those remaining, 77% of subjects lost more than 5% of initial body weight, but only 43% of those maintained more than 80% of this over 2 years. Could there be an organic component in those who do not respond? Of course, obesity pharmacotherapies sometimes have beneficial acute effects, but these drugs work for only as long as they are consumed; discontinuation tends to result in a "rebound" weight gain, suggesting that the cause of the obesity is still present. Furthermore, in 2001, there are no obesity drugs approved for children. A useful guiding principle is that children deserve at the minimum an initial medical evaluation, including birth weight, medical history, family history, dietary evaluation, and exercise assessment. Perhaps the most important feature that can distinguish "organic" from "behavioral" weight gain in childhood is the age of the "adiposity rebound." The Centers for Disease Control and Prevention now supplies BMI charts for boys and girls at www.cdc.gov/growthcharts. Plotting of the BMI versus age allows pediatricians to determine the age at which the BMI starts to increase (mean, 5.5 years). The earlier the adiposity rebound, the more likely the child will be obese as an adult, and the more likely that an organic cause can be determined. In such patients, thyroid levels and fasting insulin and leptin levels should be measured. An initial attempt at diet and exercise is essential; patients who do not respond with BMI stabilization should be investigated for a more ominous cause of their obesity. As the nosology of obesity improves, pediatricians will be able to increase the diagnostic efficiency and therapeutic success of this unfortunate, debilitating, and expensive epidemic.

A study of the growth-promoting and metabolic effects of growth hormone (GH) in a patient with the "growth without GH" syndrome

The paradox of normal or even excessive growth despite a proven lack of GH is a well-known but still unexplained phenomenon that has been described in some patients following resection of a craniopharyngioma or other suprasellar tumours. However, the consequences of GH deficiency on other metabolic aspects of GH action in this syndrome have not been adequately investigated. The aim of this study was to examine whether a dissociation might exist between the growth-promoting and metabolic effects of GH. We studied a 7.1 year old boy who, after removal of a suprasellar craniopharyngioma, developed panhypopituitarism with mild hyperprolactinaemia. Despite the presence of severe GH deficiency associated with persistently low IGF-I and IGFBP-3 levels, the patient grew spontaneously at an accelerated rate for a prepubertal boy, achieving a height velocity of 9.0 cm during the first and 8.5 cm during the second post-operative year. However, other metabolic parameters of GH activity were adversely affected by the lack of GH. The maximum tubular reabsorption rate for phosphate over glomerular filtration rate ratio (2.8) was persistently low and normalized during a 4 day course of hGH administration (4.2) together with the normalization of IGF-I (from 34 microg/l to 294 microg/l), suggesting that GH-dependent renal phosphate handling is impaired in this syndrome. In addition, bone age was delayed by 1.7 years consistently with delayed skeletal maturation, whereas skinfold thickness and the waist to hip ratio were increased in comparison with normative data, suggesting increased adipose tissue mass with central fat distribution, a phenotype characteristic of GH deficiency. In conclusion, our case study suggests that, in the "growth without GH" syndrome, the excessive growth is independent of GH and dissociated from other GH-dependent metabolic effects, which are decreased.

Endocrine sequelae of childhood craniopharyngioma

The endocrine sequelae of 62 children with craniopharyngioma were studied retrospectively. These patients were followed for a median duration of 3 years (range 1 to 10 years). Eighteen patients had a long-term follow-up for more than 5 years (range 5 to 10 years). Complete surgical resection was achieved in 30 patients and 32 patients had residual tumor. Twenty-five patients had recurrence or progression of the residual tumor and were treated with radiotherapy. Presenting complaints suggestive of endocrinopathy were infrequent. The most common presenting symptoms were headache, nausea and vomiting, followed by growth failure. Pre-operatively, growth hormone deficiency was the most commonly encountered pituitary hormonal deficiency; however postoperatively, most children had diabetes insipidus. Multiple pituitary hormonal deficiencies were more frequently observed in children treated with extensive radical surgery than in those treated with conservative surgery and radiotherapy. The endocrine morbidity associated with craniopharyngioma and its different management modalities remains high; however, it is manageable with appropriate hormonal replacement therapy.

Long-term outcomes for surgically resected craniopharyngiomas

OBJECTIVE

This retrospective study critically analyzed the long-term functional outcomes and tumor recurrence rates for surgically treated craniopharyngiomas.

METHODS

This study used an outcome classification system that included functioning vision, independent versus dependent living, Karnofsky Performance Scale scores, academic levels, work status, and psychological status. Tumor recurrence rates were analyzed with respect to the extent of surgical resection and adjunctive radiotherapy.

RESULTS

For 121 patients, with a mean follow-up period of 10 years, the overall "good outcome" rate was 60.3%. Factors associated with poor outcomes included lethargy at presentation, visual deterioration, papilledema, tumor calcification, hydrocephalus, and tumor adhesiveness at surgery. Gross total resection was associated with good outcomes (P = 0.017) and decreased risk of recurrence (P = 0.024). Subtotal resection was associated with increased risk of tumor recurrence (P = 0.0235). The highest risk of recurrence was in the subtotal resection/no radiation group (P = 0.0001). There were no differences in outcomes or recurrence rates between pediatric and adult patients. There were also no differences in outcomes or recurrence rates between papillary and adamantinous tumors. Approximately one-third of patients exhibited morbid obesity, and permanent diabetes insipidus was observed for 25 patients.

CONCLUSION

A rigorous evaluation of outcomes for tumors such as craniopharyngiomas must consider not only the extent of resection, as judged by postoperative imaging, but also the long-term physical, intellectual, and psychological functioning of the patients.

Hypothalamic obesity caused by cranial insult in children: altered glucose and insulin dynamics and reversal by a somatostatin agonist

OBJECTIVE

Hypothalamic obesity is a rare sequela of cranial insult, for which pathogenesis and treatment remain obscure. In rodents ventromedial hypothalamic damage causes hyperphagia, obesity, hyperinsulinism, and insulin resistance. Reduction of insulin secretion in humans may attenuate weight gain.

METHODS

Eight children with intractable obesity after therapy for leukemia or brain tumors underwent oral glucose tolerance testing (OGTT) with simultaneous insulin levels before and after treatment with octreotide for 6 months.

RESULTS

In comparison with a 6-month pre-study observation period, patients exhibited weight loss (+6.0 +/- 0.7 kg vs -4.8 +/- 1.8 kg; P =.04) and decrease in body mass index (+2.1 +/- 0.3 kg/m(2) vs -2.0 +/- 0.7 kg/m(2); P =.0001). Recall calorie count decreased during the 6 months of treatment (P =. 015). OGTT demonstrated biochemical glucose intolerance in 5 of 8 patients initially and in 2 of 7 at study end, whereas insulin response was decreased (281 +/- 47 microU/mL vs 114 +/- 35 microU/mL; P =.04). Percent weight change correlated with changes in insulin response (r = 0.72, P =.012) and changes in plasma leptin r = 0.76, P =.0004).

CONCLUSIONS

Patients with hypothalamic obesity demonstrate excessive insulin secretion. Octreotide administration promoted weight loss, which correlated with reduction in insulin secretion on OGTT and with reduction in leptin levels. Pre-study biochemical glucose tolerance improved in several patients while they were receiving octreotide. These results suggest that normalization of insulin secretion may be an effective therapeutic strategy in this syndrome.

Health status in 52 long-term survivors of pediatric brain tumors

The percentage of children who survive childhood brain tumors is increasing. A number have neurological and other sequelae which impact on the quality of their survival. We reviewed long-term survivors using a standardized health status instrument. The mothers of 52 survivors of brain tumors were surveyed. Eight different aspects (attributes) of health status were scored. The first 6 of these attributes were scored in a health status index (HSI) developed at McMaster University. Subgroup analysis was performed. Limitation in the quality of life was found in one of the 8 attributes in all but 2 of the subjects. The health status index (HSI) score using the first 6 attributes of this survey had a median of 0.73 (range 0.16-1.00). This score is lower than that found in previously surveyed survivors of leukemia or other childhood cancers. Examination of age at diagnosis, extent of surgery, sex and therapeutic modalities used showed no correlation with HSI score. Those with supratentorial astrocytomas had a lower HSI score (0.65) than those with infratentorial astrocytomas (0.85) (p = 0.05). Children with craniopharyngiomas had a poor score (0.64). This survey shows that the survivors of brain tumors have an appreciable burden of morbidity. Most have deficits in health status that affect many areas of their lives. Apart from site of the primary tumor, there was little correlation between subgroups studied and health status. The health status of children who survive brain tumors is lower than that of survivors of other childhood malignancies.

Transnasal surgery for infradiaphragmatic craniopharyngiomas in pediatric patients

OBJECTIVE

Transnasal surgery has been performed in only a small number of cases of pediatric craniopharyngiomas, and its efficacy is still a matter of debate.

METHODS

We analyzed the results of transnasal surgery performed in 11 pediatric patients (6 male and 5 female patients) with infradiaphragmatic craniopharyngiomas who were younger than 15 years at the time of surgery (age range, 7.7-14.9 yr) and who were treated between 1985 and 1996, when more refined diagnostic and surgical techniques were available. Two of the patients had undergone primary surgery elsewhere. The transnasal approach was chosen because of sellar enlargement and the presence of an infradiaphragmatic tumor. The duration of the clinical follow-up period was at least 1 year.

RESULTS

Five patients required drilling of incompletely pneumatized sphenoid sinuses to reach the sella, but in no cases were the anatomic differences related to patient age or size thought to be a limiting factor in the transnasal procedure. The normal pituitary gland was incised to expose a dorsally located tumor in each of eight patients (72.7%). This surgical procedure has never provoked any major functional damage to the anterior pituitary gland. Complete tumor resection was achieved in three patients (27.3%) and subtotal removal in eight (72.7%). Twenty-two (95.7%) of 23 normal functions were preserved after subtotal tumor removal. In contrast, only one of four normal functions was maintained after complete tumor resection. Persistent diabetes insipidus occurred after total tumor resection in one patient. Tumor regrowth occurred in two patients. No tumor recurrence was observed during the follow-up period.

CONCLUSION

Based on the present findings, transnasal surgery seems to be indicated for most infradiaphragmatic craniopharyngiomas occurring in pediatric patients. Transnasal surgery is as safe to perform in pediatric patients as it is in adult patients. The concept of subtotal tumor removal with preservation of pituitary function, avoiding damage to hypothalamic structures and excessive cerebrospinal fluid leakage, seems to be justified in pediatric patients.

Health status in 52 long-term survivors of pediatric brain tumors

The percentage of children who survive childhood brain tumors is increasing. A number have neurological and other sequelae which impact on the quality of their survival. We reviewed long-term survivors using a standardized health status instrument. The mothers of 52 survivors of brain tumors were surveyed. Eight different aspects (attributes) of health status were scored. The first 6 of these attributes were scored in a health status index (HSI) developed at McMaster University. Subgroup analysis was performed. Limitation in the quality of life was found in one of the 8 attributes in all but 2 of the subjects. The health status index (HSI) score using the first 6 attributes of this survey had a median of 0.73 (range 0.16-1.00). This score is lower than that found in previously surveyed survivors of leukemia or other childhood cancers. Examination of age at diagnosis, extent of surgery, sex and therapeutic modalities used showed no correlation with HSI score. Those with supratentorial astrocytomas had a lower HSI score (0.65) than those with infratentorial astrocytomas (0.85) (p = 0.05). Children with craniopharyngiomas had a poor score (0.64). This survey shows that the survivors of brain tumors have an appreciable burden of morbidity. Most have deficits in health status that affect many areas of their lives. Apart from site of the primary tumor, there was little correlation between subgroups studied and health status. The health status of children who survive brain tumors is lower than that of survivors of other childhood malignancies.

Effect of growth hormone treatment in children with craniopharyngioma with reference to the KIGS (Kabi International Growth Study) database

In children with craniopharyngioma, poor growth commonly precedes diagnosis, but is observed less frequently than neurological or visual symptoms. A deficiency of growth hormone (GH) is common before, and almost universal after, treatment of the tumour, and is usually treated with GH. However, a minority of these children with GH deficiency (GHD) grow well without GH replacement therapy but exhibit other metabolic effects of GHD that are correctable by GH treatment. This article provides a review of studies in 422 children with craniopharyngioma whose details have been entered into the database of KIGS, the Kabi International Growth Study. The response to GH during the first year of therapy was similar to that seen in children with idiopathic GHD (IGHD). Leg length was relatively greater than sitting height and this disproportion was maintained during treatment. Adiposity increased in some children receiving GH treatment. At the end of GH treatment in 82 patients, there was a median gain in height SD score of 1.51, with evidence of residual growth potential still remaining in the majority. Tumour recurrence occurred in 13.5% of the total group of patients with craniopharyngioma within KIGS, at a median of 3.9 years from diagnosis and 2.3 years from the start of GH therapy. Tumour recurrence was not associated with an impairment in height achieved, but there was a tendency towards greater adiposity in patients in whom recurrence occurred. Adverse events during GH treatment were more frequent in children with craniopharyngioma than in those with IGHD, and headache was commonly reported. The results of these studies suggest that GH treatment is recommended for the treatment of children with craniopharyngioma on the grounds of improved growth velocity, adult height and other GH-dependent metabolic functions, and of the good safety profile of GH in these patients.

The growth without growth hormone syndrome

The phenomenon of growth without GH has been recognized for over a quarter of a century in various physiologic or near-physiologic situations, including the fetal state and obesity, and in various obviously pathologic states, including postsurgical resection of suprasellar/hypothalamic tumors, most notably craniopharyngiomas, and in acromegaloidism. The mechanism or mechanisms responsible for this fascinating clinical syndrome are unknown. The available data implicate, at least in some of these subjects, a role for hypothalamic injury leading to obesity and insulin resistance which, in turn, leads to elevated circulating concentrations of insulin to which the body retains mitogenic sensitivity. Alternatively, in other subjects with this syndrome, evidence exists to support the presence of a circulating as yet incompletely characterized potent growth-promoting factor which appears in the serum. Further studies of this syndrome should help to enhance our knowledge of the mechanisms governing both normal and abnormal human growth.

Growth and endocrine sequelae of craniopharyngioma

The growth and endocrine sequelae of 75 children (33 girls and 42 boys) with craniopharyngioma, treated from 1973 to 1994, were studied by retrospective review and by follow up assessment in 66 survivors, with a mean time from initial surgery of 6.7 years (range 1.5 to 19.8 years). Although infrequently complained of, 71% of patients had symptoms to suggest an endocrinopathy at diagnosis. After surgery, multiple endocrinopathies were almost universal, such that 75% of children had panhypopituitarism at follow up. Hypoadrenal crises in association with intercurrent illness contributed significantly to morbidity and mortality, as did the metabolic consequences of concomitant antidiuretic hormone (ADH) insufficiency and absent thirst. Final height in 25 patients was significantly below genetic target height, particularly in the girls, with loss of height potential occurring during the pubertal years. The endocrine morbidity associated with craniopharyngioma and its treatment remains high but manageable with appropriate hormone replacement. However, the combination of ADH insufficiency and an impaired sense of thirst following aggressive surgery and severe hypothalamic injury remains one of the most complex management problems.

Gamma knife surgery for craniopharyngioma

We present our results of Gamma Knife surgery for craniopharyngioma in nine patients. The current status of surgery, radiation therapy, intracavitary instillation of radionucleides and Gamma Knife surgery in the management of craniopharyngiomas is discussed.

Prolactinoma associated with transient growth hormone deficiency but persistent growth retardation

A 14.8 year old boy was evaluated for galactorrhea of two months duration and growth deceleration for greater than three years. He was 3.7 standard deviations (SD) below the mean for age in height and euthyroid with uncompromised vision, bilateral galactorrhea, and pubertal arrest. MRI demonstrated a 10 x 8 mm left pituitary mass. Bone age was 11.5 years. Serum prolactin (PRL) decreased by more than 85% after 5 weeks of treatment with bromocriptine (Br). After five months, the prolactinoma (PRLoma) measured 5 x 4 mm. Hypothalamic-pituitary function indicated growth hormone (GH) deficiency and hypogonadotropic hypogonadism as assessed by ITT-TRH-GnRH-clonidine. After nine months of Br, despite return of adequate gonadotropin and GH secretion as assessed by repeat ITT-TRH-GnRH-clonidine, pooled 12 hour nocturnal spontaneous GH secretion, and clinical progression of puberty, there was no linear "catch-up growth" (growth rate = 4.4 cm/yr and height 4.2 SD below the mean for age). Growth rate increased following supplemental GH administration without untoward effect. We conclude that there may be discordance/lag between reduction in secretion and size of PRLomas and growth despite resolution of other anterior pituitary dysfunction. Other possibilities are discussed.

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.