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Park HJ, Kim JW, Cho BK, Wang KC, Phi JH, Park SH, Lee YA, Shin CH, Kim YH, Kim SK. Comparison of the Transcranial Approach and Transsphenoidal Approach Based on the Anatomical Location of Origin in Pediatric Craniopharyngiomas. World Neurosurg 2024; 189:e519-e532. [PMID: 38914136 DOI: 10.1016/j.wneu.2024.06.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Various clinical classifications of craniopharyngiomas (CRPs) have been proposed to suggest optimal surgical planning. We aimed to evaluate the clinical outcomes of pediatric CRPs and the clinical significance of anatomical classification in relation to the diaphragm sellae. METHODS A retrospective review was conducted on patients below 18 years of age who underwent surgery for CRPs from July 1998 to August 2022. The patients were divided into transcranial approach (TCA), and transsphenoidal approach (TSA) groups, which included microscopic TSA and endoscopic endonasal approach (EEA) groups. EEA has been adopted at our institute since 2011. CRPs were classified by their origin and relationship with the diaphragm sellae. RESULTS A total of 132 pediatric CRP patients were included in this study, 117 of whom underwent surgery for primary CRP and 15 for recurrent CRP. Among them, 89 (67.4%) underwent TCA, 9 (6.8%) had microscopic TSA, and 34 (25.8%) had EEA. In subdiaphragmatic CRPs with competent diaphragm sellae, TSA tended to yield better outcomes than TCA did in terms of stalk preservation and ophthalmologic outcomes. After the introduction of EEA, the proportion of supradiaphragmatic CRPs treated via the TSA increased from 0% to 50% (P<0.001). Gross total resection (HR=0.194; 95% CI=0.102-0.367, P<0.001) and adjuvant therapy (HR=0.208; 95% CI=0.048-0.897, P=0.035) were found to be positive prognostic factors for long-term tumor control. CONCLUSIONS Over time, with the adoption of EEA at our institute, the impact of anatomical classification on the surgical approach has decreased. Nevertheless, an individualized surgical approach should be employed to improve long-term outcomes and minimize complications for pediatric CRPs.
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Affiliation(s)
- Hyun Joo Park
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Joo Whan Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Byung-Kyu Cho
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyu-Chang Wang
- Neuro-Oncology Clinic, National Cancer Center, Goyang, Republic of Korea
| | - Ji Hoon Phi
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sung-Hye Park
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Choong Ho Shin
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yong Hwy Kim
- Pituitary Center, Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung-Ki Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Colliander R, Sharma S, Shlobin NA, Fernandez LG, LoPresti MA, Lam S, DeCuypere M. Visual outcomes after treatment of craniopharyngioma in children: A systematic review. Childs Nerv Syst 2024; 40:1641-1659. [PMID: 38416204 DOI: 10.1007/s00381-024-06328-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/19/2024] [Indexed: 02/29/2024]
Abstract
OBJECTIVE Craniopharyngiomas (CP) are rare brain tumors that often result in visual impairment due to their proximity to the optic pathway. The optimal management approach to preserve visual function in these patients remains controversial. We sought to investigate visual outcomes of children with craniopharyngiomas based on treatment modality. METHODS A systematic review was performed according to PRISMA guidelines. PubMed, Embase, and Scopus databases were searched in December 2022 for relevant articles. Articles were screened by title/abstract for relevance, then by full-text. Relevant demographic, intervention, and outcome data were extracted from included studies. RESULTS A total of 59 studies were included, representing 2655 patients. The overall visual status (OVS) of patients receiving surgery alone was improved in 27.6% of reported outcomes, unchanged in 50.3%, and deteriorated in 22.1%. The OVS for patients receiving radiation alone was improved in 21.1%, unchanged in 42.1%, and deteriorated in 36.8%. Patients receiving surgery plus adjuvant radiotherapy had OVS improvement in 27.4%, unchanged in 63.2%, and deteriorated in 9.4%. Of those receiving intracystic bleomycin, 23.1% had improvement in OVS, 46.2% remained unchanged, and 30.8% deteriorated. Of patients receiving interferon-α, 34.8% improved, 54.5% remained unchanged, and 10.6% deteriorated. CONCLUSION OVS most frequently remained unchanged regardless of intervention. The greatest improvement in OVS was seen in those receiving interferon-α or surgery alone. The greatest OVS deterioration was noted with radiation alone. Future standardized, randomized, large-scale studies with focused assessment of ophthalmologic findings are key to further understanding the impact different interventions have on visual outcomes in these children.
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Affiliation(s)
- Reid Colliander
- Division of Pediatric Neurosurgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Shelly Sharma
- Division of Pediatric Neurosurgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Nathan A Shlobin
- Division of Pediatric Neurosurgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Luis G Fernandez
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Chicago, IL, 60611, USA
| | - Melissa A LoPresti
- Division of Pediatric Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Sandi Lam
- Division of Pediatric Neurosurgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Chicago, IL, 60611, USA
- Malnati Brain Tumor Institute of the Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - Michael DeCuypere
- Division of Pediatric Neurosurgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA.
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Chicago, IL, 60611, USA.
- Malnati Brain Tumor Institute of the Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA.
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Cinalli MA, Malineni S, Spennato P, Nayak SS, Cinalli G, Deopujari C. Neuroendoscopy: intraventricular and skull base tumor resection in children. Childs Nerv Syst 2023; 39:2737-2756. [PMID: 37589762 DOI: 10.1007/s00381-023-06110-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 07/28/2023] [Indexed: 08/18/2023]
Abstract
During the last 30 years, the neurosurgeons have witnessed a revolution in the practice of interventricular surgery. The advent of neuroendoscopy at the end of the 1980s has allowed a minimally invasive management of a very large series of pathologies in pediatric neurosurgery ranging from hydrocephalus to arachnoid cyst to intraventricular tumors. The progresses in the management of hydrocephalus, intracranial cyst, and the fluid filled collection nevertheless has been more rapid and radical due to the simpler equipment that is necessary to perform this kind of surgery. The intraventricular tumors instead have been addressed in a slower way, and for many years, the only endoscopic procedure that was allowed on interventricular tumors was a biopsy associated with the management of hydrocephalus. Only very small tumors have been considered operable for complete removal during many years due to the limitations of the neuroendoscopic equipment and to the small calibers of the working channel. More recently, the advent of new devices and new surgical techniques are offering new perspectives on the possibility of intraventricular tumor surgery in children. In this review, we describe the historical perspective of the learning curve of intraventricular tumor surgery under neuroendoscopic control and try to offer a view of the future perspective in the removal of larger intraventricular tumors, analyzing the main indications for intraventricular endoscopic tumor surgery. We offer as well an historical perspective of the evolution of skull base surgery and endonasal transsphenoidal approach for skull-based tumors in children. This kind of surgery that has acquired widespread acceptance for many pathologies in adult age has diffused more slowly in pediatric neurosurgery due to the anatomical limitation observed in these age range. Also in this field, the slow evolution of the technique and of the technology available to neurosurgeons has allowed a very significant expansion of indication for the minimally invasive removal of skull base tumors in children.
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Affiliation(s)
| | - Suhas Malineni
- Department of Neurosurgery, Bombay Hospital, Mumbai, India
| | - Pietro Spennato
- Pediatric Neurosurgery Unit, Department of Pediatric Neurosciences, Santobono-Pausilipon Children's Hospital (AORN), Via Mario Fiore N. 6, 80129, Naples, Italy
| | | | - Giuseppe Cinalli
- Pediatric Neurosurgery Unit, Department of Pediatric Neurosciences, Santobono-Pausilipon Children's Hospital (AORN), Via Mario Fiore N. 6, 80129, Naples, Italy.
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Pang JC, Chung DD, Wang J, Abiri A, Lien BV, Himstead AS, Ovakimyan A, Kim MG, Hsu FPK, Kuan EC. Characteristics and Outcomes in Pediatric Versus Adult Craniopharyngiomas: A Systematic Review and Meta-Analysis. Neurosurgery 2023; 92:1112-1129. [PMID: 36639856 DOI: 10.1227/neu.0000000000002346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 11/05/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Craniopharyngiomas account for 1.2% to 4.6% of all intracranial tumors. Although age at presentation is distributed bimodally, with a pediatric peak occurring between 5 and 15 years and an adult peak between 50 and 70 years, presentation, treatment, and outcome differences between these two craniopharyngioma populations have not been thoroughly characterized. OBJECTIVE To compare treatments and outcomes between adult and pediatric craniopharyngiomas. METHODS This is a systematic review and meta-analysis. Web of Science, MEDLINE, and Scopus databases were searched for primary studies reporting postoperative complications, functional outcomes, recurrence, and overall survival in patients with craniopharyngioma undergoing surgery. RESULTS The search yielded 1,202 unique articles, of which 106 (n=4,202 patients) met criteria for qualitative synthesis and 23 (n=735 patients) met criteria for meta-analysis. Compared with adult, pediatric craniopharyngiomas were less likely to present with visual defects (odds ratio [OR] 0.54, 95% CI 0.36-0.80) or cognitive impairment (OR 0.29, 95% CI 0.12-0.71) and more likely with headaches (OR 2.08, 95% CI 1.16-3.73). Children presented with significantly larger tumors compared with adults (standardized mean difference 0.68, 95% CI 0.38-0.97). Comparing functional outcomes, pediatric patients sustained higher rates of permanent diabetes insipidus (OR 1.70, 95% CI 1.13-2.56), obesity (OR 3.15, 95% CI 1.19-8.31), and cranial nerve and/or neurological defects (OR 4.87, 95% CI 1.78-13.31) than adults. No significant differences were found in rates of postoperative cerebrospinal fluid leak, overall or progression-free survival, or recurrence. CONCLUSION Adult and pediatric craniopharyngiomas seem to have fundamental differences in clinical presentation and functional outcomes. These patients frequently require multimodality treatment and are best managed with a multidisciplinary team and an individualized approach.
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Affiliation(s)
- Jonathan C Pang
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Dean D Chung
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Jenny Wang
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Arash Abiri
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Brian V Lien
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA
| | - Alexander S Himstead
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA
| | - Andrew Ovakimyan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Michael G Kim
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA
| | - Frank P K Hsu
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA
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Neurosurgical Treatment and Outcome of Pediatric Skull Base Lesions: A Case Series and Review of the Literature. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020216. [PMID: 36832345 PMCID: PMC9954611 DOI: 10.3390/children10020216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Pediatric skull base lesions occur rarely and are of various etiologies. Traditionally, open craniotomy has been the treatment of choice; however, nowadays, endoscopic approaches are increasingly applied. In this retrospective case series, we describe our experience in treating pediatric skull base lesions and provide a systematic overview of the literature on the treatment and outcome of pediatric skull base lesions. METHODS We conducted a retrospective data collection of all pediatric patients (<18 years) treated for a skull base lesion at the Division of Pediatric Neurosurgery, University Children's Hospital Basel, Switzerland, between 2015 and 2021. Descriptive statistics and a systematic review of the available literature were additionally conducted. RESULTS We included 17 patients with a mean age of 8.92 (±5.76) years and nine males (52.9%). The most common entity was sellar pathologies (n = 8 47.1%), with craniopharyngioma being the most common pathology (n = 4, 23.5%). Endoscopic approaches, either endonasal transsphenoidal or transventricular, were used in nine (52.9%) cases. Six patients (35.3%) suffered from transient postoperative complications, while in none of the patients these were permanent. Of the nine (52.9%) patients with preoperative deficits, two (11.8%) showed complete recovery and one (5.9%) partial recovery after surgery. After screening 363 articles, we included 16 studies with a total of 807 patients for the systematic review. The most common pathology reported in the literature confirmed our finding of craniopharyngioma (n = 142, 18.0%). The mean PFS amongst all the studies included was 37.73 (95% CI [36.2, 39.2]) months, and the overall weighted complication rate was 40% (95% CI [0.28 to 0.53] with a permanent complication rate of 15% (95% CI [0.08 to 0.27]. Only one study reported an overall survival of their cohort of 68% at five years. CONCLUSION This study highlights the rarity and heterogeneity of skull base lesions in the pediatric population. While these pathologies are often benign, achieving GTR is challenging due to the deep localization of the lesions and eloquent adjacent structures, leading to high complication rates. Therefore, skull base lesions in children require an experienced multidisciplinary team to provide optimal care.
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Palmieri D, Champagne PO, Valappil B, McDowell MM, Gardner PA, Snyderman CH. Risk Factors in a Pediatric Population for Postoperative Intracranial Infection Following Endoscopic Endonasal Skull Base Surgery and the Role of Antibiotic Prophylaxis. Am J Rhinol Allergy 2022; 37:13-18. [PMID: 36050937 DOI: 10.1177/19458924221123113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Endoscopic endonasal skull base surgery (EESBS) is performed through a non-sterile corridor. Intracranial infection rates in a pediatric population have not been extensively studied and the exact effect of antibiotic prophylaxis on rates of infection after EESBS in pediatric patients remains unclear. OBJECTIVE The purpose of our study is to investigate risk factors for postoperative intracranial infection during EESBS in a pediatric population and help elucidate the role of antibiotic prophylaxis. METHODS We conducted a retrospective chart review of 99 consecutive patients under the age of 18 who underwent EESBS at our institution from 2013 to 2021. Centers for Disease Control and Prevention/National Healthcare Safety Network criteria for diagnosis of meningitis were used to identify postoperative intracranial infections. RESULTS The average age was 12.3 years (range 1.6-18) with 66 male patients and 33 female patients. 49 patients had an intraoperative cerebrospinal fluid (CSF) leak, of which 4 had a postoperative CSF leak. We identified 3 postoperative intracranial infections (3%), which were all meningitis cases. The infection rate was 6% (3/49) among those with intraoperative CSF leaks. All patients with meningitis had a postoperative CSF leak. All infections were transclival approaches (2 chordoma and 1 neurenteric cyst). CONCLUSION This investigation represents one of the largest pediatric endoscopic skull base surgery cohorts. EESBS is safe to perform in pediatric populations, but transclival approaches and postoperative CSF leaks are risk factors for postoperative meningitis.
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Affiliation(s)
- Daniel Palmieri
- 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Pierre-Olivier Champagne
- Department of Neurological Surgery, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Benita Valappil
- Department of Otolaryngology, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael M McDowell
- Department of Neurological Surgery, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Paul A Gardner
- Department of Neurological Surgery, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Carl H Snyderman
- Department of Otolaryngology, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Yang J, Kim YH, Phi JH, Kim SK, Wang KC. Complications of Endoscopic Skull Base Surgery for Sellar and Parasellar Tumors in Pediatric Population; Neurosurgical Perspectives. Front Oncol 2022; 12:769576. [PMID: 35692769 PMCID: PMC9186047 DOI: 10.3389/fonc.2022.769576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 04/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background Advances in surgical techniques based on in-depth anatomical knowledge of the skull base have broadened the indications for endoscopic skull base surgery (ESS) with the advantage of wide and direct surgical exposure while minimizing invasiveness. However, the low incidence of the indicated diseases and narrow surgical corridors in children have limited the popularization of ESS. In addition, surgical complications and preventive interventions are not yet well known. Therefore, we retrospectively investigated the complications and prevention methods of ESS in children with a comprehensive review. Methods We retrospectively analyzed the medical records of pediatric patients who underwent ESS for sellar and parasellar tumors at Seoul National University Children's Hospital from July 2010 to December 2020. Visual and endocrine status, extent of resection, complications, and recurrences were investigated depending on the pathology of the tumor. In addition, a comprehensive literature review regarding the complications of pediatric ESS was performed. Results A total of 98 patients were enrolled. The median age of the patients was 12 years, and 52 patients were male. Preoperative visual disturbance was found in 53 patients, anterior pituitary function deficit in 69, and diabetes insipidus in 32. Gross total resection was attempted in 67 patients and achieved in 62 (93%). Biopsy and cyst fenestration were the goals of surgery in 26 patients, and all were achieved as planned. Regarding outcomes, visual disturbance worsened in two patients (2%), endocrine status was aggravated in 34 (35%) patients, and new-onset diabetes insipidus occurred in 27 (41%) patients. The overall surgical complication rate (other than aggravation of visual or endocrine status) was 17%. Postoperative meningitis (12%) was the most common complication, followed by cerebrospinal fluid leakage (2%), vasospasm, hemorrhage and infarction. By pathological diagnosis, craniopharyngioma had the highest complication rate of 29%. All but one patient with postoperative hemorrhage showed no permanent deficits. Conclusion ESS in children is feasible and relatively safe. More attention and different postoperative management protocols are required in children to avoid complications, especially in craniopharyngiomas. However, the complications can be mostly managed conservatively without permanent neurologic deficits.
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Affiliation(s)
- Jeyul Yang
- Neuro-Oncology Clinic, National Cancer Center, Goyang, South Korea
| | - Yong Hwy Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Ji Hoon Phi
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
- Division of Pediatric Neurosurgery, Seoul National University Children’s Hospital, Seoul, South Korea
| | - Seung-Ki Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
- Division of Pediatric Neurosurgery, Seoul National University Children’s Hospital, Seoul, South Korea
| | - Kyu-Chang Wang
- Neuro-Oncology Clinic, National Cancer Center, Goyang, South Korea
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Kelly AP, Greenfield JP, Dobri GA, Schwartz TH. Pediatric pituitary adenomas are more aggressive, more likely to be hormone producing and are more difficult to cure than adult pituitary adenomas: case series and systematic literature review. Childs Nerv Syst 2022; 38:729-738. [PMID: 35048170 DOI: 10.1007/s00381-022-05445-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/06/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Pediatric pituitary adenomas (pPAs) are uncommon. Thus, their presentation and outcomes after treatment are less well-understood than those of pituitary adenomas in adulthood (aPAs). METHODS A retrospective chart review was conducted for all patients who underwent endoscopic endonasal transsphenoidal surgery (EETS) for pPA at NewYork-Presbyterian Hospital/Weill Cornell Medicine (NYP/WCM) from 2005-2020. Eleven patients were identified, and information pertaining to age, sex, adenoma characteristics, procedural details, and outcomes was reviewed. A systematic review of the literature was also performed to compare outcomes of EETS versus microscopic endonasal transsphenoidal surgery (METS) for pPA. RESULTS From 2005-2020, 11 patients underwent EETS for pPA at NYP/WCM. Mean age at operation was 14.9 ± 2.7 years, and 5 patients (45.5%) were male. 10 adenomas (90.9%) were hormone-producing. Of the functional adenomas, 8 (80.0%) were PRL-secreting and 2 (20.0%) were GH-secreting. Maximum adenoma diameter (MAD) ranged from 1.2-5.1 cm, with a median of 1.55 cm. Cavernous sinus invasion (CSI) occurred in 2 patients with macroprolactinoma. Gross total resection (GTR) was achieved in 10 (90.9%). Biochemical remission occurred in 5/10 (50.0%). Post-operative complications were documented in 8 cases (72.7%) and included diabetes insipidus, hypopituitarism, sinusitis, weight gain, cerebrospinal fluid leak, meningitis, and hydrocephalus. Systematic literature review of 105 microscopic and 175 endoscopic cases revealed high frequency of hormone-producing tumors (83.6%) and similar rates of GTR (82.4% vs 85.1%) and biochemical cure (75.8% vs 64.3%). CONCLUSIONS pPAs are more likely to be hormone producing and may be more aggressive and difficult to cure than aPAs. EETS is an effective treatment, although complication rates may be higher than in adult populations.
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Affiliation(s)
- Alexander P Kelly
- Weill Cornell Medical College, Weill Cornell Medicine, New York, NY, USA
| | - Jeffrey P Greenfield
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY, USA
| | - Georgiana A Dobri
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY, USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY, USA.
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Rennert RC, Brandel MG, Steinberg JA, Nation J, Couldwell WT, Fukushima T, Day JD, Khalessi AA, Levy ML. Maturation of the sella turcica and parasellar region: Surgical relevance for anterior skull base approaches in pediatric patients. Clin Neurol Neurosurg 2022; 215:107168. [PMID: 35247690 DOI: 10.1016/j.clineuro.2022.107168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/13/2022] [Accepted: 02/02/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Traditional and extended transnasal transsphenoidal approaches provide direct access to a variety of anterior skull base pathologies. Despite increased utilization of transnasal approaches in children, anatomic studies on pediatric skull base maturation are limited. We herein perform a surgically relevant morphometric analysis of the sella and parasellar regions during pediatric maturation. METHODS Measurements of sellar length (SL), sellar depth (SDp), sellar diameter (SDm), interclinoid distance (ID), intercavernous distance (ICD), and the presence of sphenoid sinus pneumatization (SSP), and sphenoid sinus type (SST) were made on thin-cut CT scans from 60 patients (evenly grouped by ages 0-3, 4-7, 8-11 12-15, 16-18, and >18 years) for analysis. Data were analyzed by sex and age groups using t-tests and linear regression. RESULTS Sella and parasellar parameters did not differ by sex. SL steadily increased from 8.5 ± 1.2 mm to 11.5 ± 1.6 mm throughout development. SDp and SDm increased from 6.0 ± 0.9 mm to 9.3 ± 1.4 mm and 9.0 ± 1.6 mm to 14.4 ± 1.8 mm during maturation, with significant interval growth from ages 16-18 to adult (p < 0.01). ID displayed significant growth from ages 0-3 to 4-7 (18.0 ± 2.4 mm to 20.7 ± 1.9 mm; p = 0.002) and ICD from ages 0-3 to 8-11 (12.0 ± 1.8 mm to 13.5 ± 2.1 mm; p < 0.001), without further significant interval growth. SSP was not seen in patients < 3, but was 100% by ages 8-11. SSTs progressed from conchal/presellar (60% at ages 4-7) to sellar/postsellar (80% at adulthood). CONCLUSION The sella and parasellar regions have varied growth patterns with development. Knowledge of the expected maturation of key anterior skull base structures may augment surgical planning in younger patients.
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Affiliation(s)
- Robert C Rennert
- Department of Neurological Surgery, University of California, San Diego, La Jolla, CA, United States
| | - Michael G Brandel
- Department of Neurological Surgery, University of California, San Diego, La Jolla, CA, United States
| | - Jeffrey A Steinberg
- Department of Neurological Surgery, University of California, San Diego, La Jolla, CA, United States
| | - Javan Nation
- Department of Head and Neck Surgery, University California San Diego, San Diego, CA, United States
| | - William T Couldwell
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, United States
| | | | - John D Day
- Department of Neurosurgery, University of Arkansas, Little Rock, AR, United States
| | - Alexander A Khalessi
- Department of Neurological Surgery, University of California, San Diego, La Jolla, CA, United States
| | - Michael L Levy
- Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, CA, United States.
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Wu D, Xu L, Xie S, Sun F, Xie M, Wang P, Xiao S. Extended Neuroendoscopic Endonasal Approach for Resection of Craniopharyngioma in Children. Front Neurol 2022; 13:771236. [PMID: 35173672 PMCID: PMC8841857 DOI: 10.3389/fneur.2022.771236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 01/03/2022] [Indexed: 11/29/2022] Open
Abstract
Objective To explore the surgical approach and technique of neuroendoscopic endonasal resection of pediatric craniopharyngiomas and to further evaluate its safety and effect in children. Methods The clinical data of 8 children with craniopharyngiomas who were surgically treated by neuroendoscopy through an extended endonasal approach in our center from 2018 to 2021 were retrospectively analyzed. The related surgical approach and technique were evaluated to improve the surgical results and further reduce the surgical complications when removing craniopharyngioma in children. Results All 8 patients achieved a gross-total resection of the tumor under neuroendoscopy. Postoperatively, 2 cases of transient hyperthermia and 4 cases of transient hyper- and/or hyponatremia occurred within the first 2 weeks, all of which were quickly controlled. Seven patients had symptoms of diabetes insipidus to varying degrees after the operation, and 4 of them improved within 1–3 months after surgery, but 3 cases still needed oral pituitrin. There were no cases of coma or death, leakage of cerebrospinal fluid, or severe electrolyte imbalance after surgery. During the postoperative follow-up of 3 months to 2 years, no tumor recurrence was found. Among the 7 patients who suffered postoperative neuroendocrine deficiencies, 3 patients were found to be temporary during the follow-up, but 4 patients still required hormone replacement therapy. Particularly, postoperative visual deterioration and olfactory defect that occurred in patients were all improved during follow-up periods. In addition, 4 cases of obesity were noted at the last follow-up. Conclusions Extended neuroendoscopic endonasal resection of craniopharyngiomas may be used as a safe and effective approach for children. Due to the poor pneumatization of the sphenoid sinus and worse compliance of treatment in children, surgical techniques of exposing the sellar region, removing the tumor, and reconstructing the skull base, as well as postoperative management of patients was proposed. However, due to the limited surgical cases in the study, the surgical safety and effects of the extended neuroendoscopic endonasal approach for children with craniopharyngiomas need to be further studied in the future.
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Affiliation(s)
- Danyang Wu
- Department of Neurosurgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Ling Xu
- Department of Neurosurgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Sungel Xie
- Department of Neurosurgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Feiji Sun
- Department of Neurosurgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Mingxiang Xie
- Department of Neurosurgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Graduate School, Zunyi Medical University, Zunyi, China
| | - Pei Wang
- Department of Neurosurgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Shunwu Xiao
- Department of Neurosurgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Graduate School, Zunyi Medical University, Zunyi, China
- *Correspondence: Shunwu Xiao ; orcid.org/0000-0002-3690-4963
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Ballestero MFM, de Souza SNF, Pacheco Neto RC, Gondim GGP, Valera ET, Dos Reis MBF, Colli BO, de Oliveira RS. Pediatric Skull Base Tumors: A Management Challenge. J Pediatr Neurosci 2021; 16:35-43. [PMID: 34316306 PMCID: PMC8276951 DOI: 10.4103/jpn.jpn_56_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/29/2020] [Accepted: 08/17/2020] [Indexed: 12/29/2022] Open
Abstract
Context Skull base tumors are varied in children and are particularly challenging to pediatric neurosurgeons, with few papers in the literature describing the evolution, complications, and outcome. The authors evaluated long-term outcomes in children submitted to skull base tumor surgery and performed a literature review. Aims The aim of this study was to analyze surgical results, complications, and outcomes, on comparison with previous publications. Materials and Methods A retrospective analysis of children undergoing surgery at a single institution between 2000 and 2018 for lesions of the cranial base was carried out. In addition, a literature review was carried out describing a total of 115 children operated on for skull base tumors. Statistical Analysis Chi-squared and Fisher's exact tests were performed to compare the distribution of categorical variables and a nonparametric Mann-Whitney U test was used to perform intergroup comparisons of continuous variables. Results Seventeen children ranging in age from 8 months to 17 years (mean, 10.9 years) underwent skull base approaches. Tumor types included schwannoma, meningioma, chondroid chordoma, mature teratoma, epidermoid cyst, hemangiopericytoma, rhabdomyosarcoma, myofibroblastic inflammatory tumor, fibromyxoid sarcoma, Crooke's cell adenoma, ossifying fibroma, osteoblastoma, nasopharyngeal angiofibroma and Ewing's sarcoma. Gross total resection was achieved in 6 patients (35.3%), 12 patients (70.6%) had benign histology, and 5 patients (29.4%) had a malignant tumor. Transient postoperative cerebrospinal fluid leak affected only one patient. Thirteen children (76.4%) had a residual neurological deficit at last follow-up evaluation. Three (17.6%) surviving patients received adjuvant therapy. The rate of recurrence or lesion progression was 17.6%. Conclusions Skull base tumors in children present a therapeutic challenge because of their unique pathological composition and can lead to considerable morbidity and mortality in pediatric age.
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Affiliation(s)
- Matheus F M Ballestero
- Department of Medicine, Federal University of São Carlos, São Carlos, Brazil.,Division of Neurosurgery, Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Stephanie N F de Souza
- Division of Neurosurgery, Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Romilto C Pacheco Neto
- Division of Neurosurgery, Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Guilherme G P Gondim
- Division of Neurosurgery, Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Elvis T Valera
- Division of Pediatric Neuroncology, Department of Pediatrics, Ribeirão Preto Medical School, University of Sao Paulo, São Carlos, Brazil
| | - Maristella B F Dos Reis
- Division of Pediatric Neuroncology, Department of Pediatrics, Ribeirão Preto Medical School, University of Sao Paulo, São Carlos, Brazil
| | - Benedicto O Colli
- Division of Neurosurgery, Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Ricardo S de Oliveira
- Division of Neurosurgery, Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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Javadpour M, Amoo M, Crimmins D, Caird J, Daly P, Pears J, Owens C, Capra M, Cody D. Endoscopic extended transsphenoidal surgery for newly diagnosed paediatric craniopharyngiomas. Childs Nerv Syst 2021; 37:1547-1561. [PMID: 33665678 DOI: 10.1007/s00381-021-05108-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 03/01/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE Endoscopic extended transsphenoidal surgery (EETSS) has gained popularity for treatment of craniopharyngiomas. The aim of this study is to assess the outcome of endoscopic extended transsphenoidal surgery (EETSS) for newly diagnosed paediatric craniopharyngiomas. METHODS Patient details were obtained from a prospective database of all endoscopic transnasal operations performed by a single surgeon. Outcomes including visual function, pituitary function, body mass index (BMI), postoperative neurological deficit, extent of resection and recurrence on follow-up were obtained. Obesity was defined as BMI percentile of equal to or greater than 95%. RESULTS Between January 2011 and January 2020, 15 of 16 children (5-18 years old) with newly diagnosed craniopharyngiomas underwent EETSS. Four patients had a conchal-type sphenoid sinus. Gross total resection (GTR) was achieved in 4 patients and near total resection (NTR) in 5 patients. The remaining 6 had subtotal resection (STR). Postoperative radiotherapy was used in 6 patients (4 with STR, 2 with NTR). There were no postoperative deaths, strokes or CSF leaks. Normalisation of visual fields (VF) occurred in 9/13 patients with preoperative VF defects. One patient developed a new visual field defect. During a median follow-up period of 74 (8-104) months, 2 patients have required further surgery for tumour progression following initial STR, where a tumour remnant was left in situ to preserve the pituitary stalk. 6/11 patients developed new anterior pituitary dysfunction as a result of surgery and 9/12 developed new diabetes insipidus (DI). At the time of last follow-up, 14/15 children had anterior panhypopituitarism, 13/15 had DI and 1 patient developed new onset obesity. Two patients, who were obese preoperatively, were no longer obese at last follow-up. CONCLUSIONS EETSS can be performed as the first option in the majority of children with newly diagnosed craniopharyngioma, despite factors such as small nose, non-pneumatised sphenoid sinus, small sella or purely suprasellar tumour location. Preservation of the pituitary stalk at the expense of leaving residual tumour may not be in the best interests of the patient.
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Affiliation(s)
- Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.
- Trinity College Dublin, Dublin, Ireland.
- Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Michael Amoo
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Darach Crimmins
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - John Caird
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Patricia Daly
- Trinity College Dublin, Dublin, Ireland
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - Jane Pears
- Departments of Paediatric Oncology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Cormac Owens
- Departments of Paediatric Oncology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Michael Capra
- Departments of Paediatric Oncology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Declan Cody
- Departments of Paediatric Endocrinology, Children's Health Ireland at Crumlin, Dublin, Ireland
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London NR, Rangel GG, Walz PC. The expanded endonasal approach in pediatric skull base surgery: A review. Laryngoscope Investig Otolaryngol 2020; 5:313-325. [PMID: 32337363 PMCID: PMC7178460 DOI: 10.1002/lio2.369] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 01/31/2020] [Accepted: 02/17/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Surgery of the pediatric skull base has multiple unique challenges and has seen recent rapid advances. The objective of this review is to assess key issues in pediatric skull base surgery (SBS), including anatomic limitations, surgical approaches, reconstruction techniques, postoperative care, complications, and outcomes. DATA SOURCES PubMed literature review. REVIEW METHODS A review of the literature was conducted to assess the challenges, recent advances, and reported outcomes in pediatric SBS. RESULTS The pediatric skull base presents multiple anatomic challenges, including variable patterns of pneumatization, narrow piriform aperture width, and narrow intercarotid distance at the level of the cavernous sinus but not the superior clivus. These issues may be particularly challenging in patients less than 2 years of age. Endoscopic endonasal approaches in the sagittal and coronal plane have been applied to the pediatric skull base while open approaches may still be necessary in the setting of extensive intracranial or orbital disease, as well as disease lateral to critical neurovascular structures. While the nasoseptal flap was initially called into question for pediatric cases, it has been shown through multiple reports to be a feasible and robust reconstructive option. Complications and outcomes often depend upon the pathology. In children, response to noxious stimuli, ability to avoid Valsalva, and adherence to nasal precautions is variable. The use of lumbar drains is more common in pediatric than adult patients. CONCLUSION While the pediatric skull base presents unique challenges, outcomes data support that endoscopic endonasal approaches are a pertinent surgical technique in appropriately selected patients. LEVEL OF EVIDENCE 3a.
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Affiliation(s)
- Nyall R. London
- Otolaryngology‐Head and Neck SurgeryThe Ohio State UniversityColumbusOhioUSA
- Otolaryngology‐Head and Neck SurgeryJohns Hopkins School of MedicineBaltimoreMarylandUSA
- National Institute on Deafness and Other Communication DisordersNIHBethesdaMarylandUSA
| | - Gustavo G. Rangel
- Otolaryngology‐Head and Neck SurgeryThe Ohio State UniversityColumbusOhioUSA
- Pediatric Otolaryngology‐Head and Neck SurgeryNationwide Children's HospitalColumbusOhioUSA
| | - Patrick C. Walz
- Otolaryngology‐Head and Neck SurgeryThe Ohio State UniversityColumbusOhioUSA
- Pediatric Otolaryngology‐Head and Neck SurgeryNationwide Children's HospitalColumbusOhioUSA
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14
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Lee JA, Cooper RL, Nguyen SA, Schlosser RJ, Gudis DA. Endonasal Endoscopic Surgery for Pediatric Sellar and Suprasellar Lesions: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2020; 163:284-292. [PMID: 32204653 DOI: 10.1177/0194599820913637] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The advent of endonasal endoscopic skull base surgery (ESBS) has redefined the management of pediatric sellar and suprasellar lesions. To date, the outcomes of these procedures have not been systematically reviewed. This study performed a systematic review with meta-analysis of surgical outcomes for pediatric patients undergoing ESBS for sellar and suprasellar lesions. DATA SOURCES PubMed (National Library of Medicine, National Institutes of Health), Scopus (Elsevier), and Cochrane Library (Wiley). REVIEW METHODS Articles reporting on pediatric patients undergoing ESBS for craniopharyngiomas, pituitary adenomas, and Rathke's cleft cysts were reviewed. The primary outcome was postoperative cerebrospinal fluid (CSF) leak. Secondary outcomes included endocrine, visual, and other complications. RESULTS Twenty-five articles reporting on 554 patients were included. Overall postoperative CSF leak rate was 8.6%, with tumor-specific rates of 10.6% in craniopharyngiomas, 6.5% in pituitary adenomas, and 7.2% in Rathke's cleft cysts (P > .05). Older studies demonstrate higher postoperative CSF leak rates as compared with more recent studies (12.5% vs 6.1%, P = .0082). Younger children (8.9-12.6 years old) experienced a higher rate of postoperative CSF leaks as compared with older children (13.0-16.6 years old; 12.9% vs 4.9%, P = .0016). Additional postoperative complications included diabetes insipidus (26.7%), hypopituitarism (46.6%), visual deficits (2.6%), meningitis (3.4%), and weight gain (3.4%). CONCLUSION ESBS for pediatric sellar and suprasellar lesions is overall an effective management approach with an increasingly favorable risk-benefit profile. Younger children may be more susceptible to postoperative CSF leak as compared with older pediatric patients. Tumor type does not appear to be an independent risk factor for postoperative CSF leak in this population.
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Affiliation(s)
- Joshua A Lee
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Rebecca L Cooper
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Rodney J Schlosser
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David A Gudis
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Irving Medical Center, New York, New York, USA
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