An endoscopic endonasal approach to craniopharyngioma via the infrachiasmatic corridor: a single center experience of 84 patients

Infrasellar Nasopharyngeal Craniopharyngiomas: An Individual Participant Data Meta-Analysis and Review of the Literature

BACKGROUND

Craniopharyngiomas are benign tumors of the anterior skull base arising from epithelial remnants of Rathke pouch. They mainly occur in the suprasellar space, can be incredibly debilitating, and remain difficult to resect as they frequently involve critical neurovascular structures. Although it is embryologically possible for craniopharyngiomas to arise extracranially along the entire migrational path of Rathke pouch, these remain exceedingly rare, especially among adults, and can be mistaken for nasopharyngeal cancer. As such, minimal data exist evaluating the management and outcomes of such lesions. We evaluated our institutional experience with purely infrasellar nasopharyngeal craniopharyngiomas and obtained individual patient data reported in the contemporary literature to better characterize the demographics, presentation, surgical management, and long-term outcomes of these lesions.

METHODS

A systematic review of the literature was performed to identify previously published cases of purely infrasellar nasopharyngeal craniopharyngioma in 3 electronic databases: MEDLINE (PubMed), Embase, and Scopus. Search terms were "infrasellar craniopharyngioma" and "nasopharyngeal craniopharyngioma."

RESULTS

We identified 25 cases, in which 72% of patients presented with symptoms of nasal obstruction, epistaxis, or headache. An endoscopic approach was performed in 40% of cases; 83.3% of all patients had gross total resection, with 60% having no recurrence at a median follow-up of 13 months. No postoperative complications were reported. Tumor location involving the cavernous sinus was associated with incomplete resection (100%) compared with tumors not involving the cavernous sinus (87%) (P = 0.033).

CONCLUSIONS

While uncommon, infrasellar nasopharyngeal craniopharyngiomas appear to have better perioperative and long-term surgical outcomes than their suprasellar counterparts.

Extended endoscopic endonasal approach to the chiasmatic cistern: An anatomical study of the arachnoid

This paper studied the arachnoid of the chiasmatic cistern (CC) and the methods for increasing the exposure of the CC from an endoscopic perspective. Eight anatomical specimens with vascular injection were used for endoscopic endonasal dissection. The anatomical characteristics of the CC were studied and documented, and anatomical measurements were collected. The CC is an unpaired five-walled arachnoid cistern located between the optic nerve, optic chiasm, and the diaphragma sellae. The average exposed area of the CC before the anterior intercavernous sinus (AICS) was transected was 66.67 ± 33.76 mm2 . After the AICS was transected and the pituitary gland (PG) was mobilized, the average exposed area of the CC was 95.90 ± 45.48 mm2 . The CC has five walls and a complex neurovascular structure. It is located in a critical anatomical position. The transection of the AICS and mobilization of the PG or the selective sacrifice of the descending branch of the superior hypophyseal artery can improve the operative field.

Factors predicting outcomes of endoscopic endonasal approach in craniopharyngioma patients

Objectives

Endoscopic endonasal approach (EEA) is commonly used for resection of craniopharyngioma (CP). Treatment outcomes of EEA for CP were related to numerous factors; however, they have been evaluated in few studies. The objective of this study is to investigate factors associated with the outcomes of CP following this operation.

Materials and Methods

The records of patients with CP, who underwent EEA at our institution from January 2014 to June 2022, were retrospectively reviewed. Surgical outcomes, including the extent of resection, visual recovery, and endocrinological outcomes, were reported. Clinical and radiographic factors were analyzed for their associations with treatment outcomes using logistic regression analyzes.

Results

This study cohort consisted of 28 patients with CP. Gross total resection (GTR) was achieved in 12 patients (43%). Post-operative visual status improved, stabilized, and deteriorated in 89%, 6%, and 6% of the patients, respectively. There were no patients recovered from pre-operative pituitary dysfunctions, while post-operative hypoadrenalism, hypothyroidism, and hypogonadism were found in 9 (36%), 11 (42%), and 4 (22%) patients, respectively. Post-operative permanent diabetic insipidus was found in 13 patients (50%). Greater suprasellar extension of the tumor was associated with a lower rate of GTR (P = 0.011). Diabetes mellitus (DM) was associated with poor visual recovery (P = 0.022). Larger tumor size and Puget grade 2 were associated with postoperative hypoadrenalism (P = 0.01 and 0.023, respectively). In addition, Puget grade 2 was associated with post-operative hypothyroidism (P = 0.017).

Conclusion

For EEA in CP, the extent of resection could be determined by suprasellar extension of the tumor. DM was a poor predicting factor for visual recovery, while larger tumors and Puget grade 2 had a higher risk of post-operative hypopituitarism.

Advances in the treatment of Adamantinomatous craniopharyngioma: How to balance tumor control and quality of life in the current environment: a narrative review

Adamantinomatous craniopharyngioma (ACP) presents a significant challenge to neurosurgeons despite its benign histology due to its aggressive behavior and unique growth patterns. This narrative review explores the evolving landscape of ACP treatments and their efficacy, highlighting the continuous development in therapeutic approaches in recent years. Traditionally, complete resection was the primary treatment for ACP, but surgical -related morbidity have led to a shift. The invasive nature of the finger-like protrusions in the histological structure results in a higher recurrence rate for ACP compared to papillary craniopharyngioma (PCP), even after complete macroscopic resection. Given this, combining subtotal resection with adjuvant radiotherapy has shown potential for achieving similar tumor control rates and potentially positive endocrine effects. Simultaneously, adjuvant treatments (such as radiotherapy, intracystic treatment, and catheter implantation) following limited surgery offer alternative approaches for sustained disease control while minimizing morbidity and alleviating clinical symptoms. Additionally, advances in understanding the molecular pathways of ACP have paved the way for targeted drugs, showing promise for therapy. There is a diversity of treatment models for ACP, and determining the optimal approach remains a subject of ongoing debate in the present context. In order to achieve a good-term quality of life (QOL), the main goal of the cyst disappearance or reduction of surgical treatment is still the main. Additionally, there should be a greater emphasis on personalized treatment at this particular stage and the consideration of ACP as a potentially chronic neurosurgical condition. This review navigates the evolving landscape of ACP therapies, fostering ongoing discussions in this complex field.

Feasibility of transsphenoidal approach for hypothalamic biopsy based on a radiological evaluation of subchiasmatic corridor dimension

BACKGROUND

Surgical access to hypothalamic pathologies can be challenging. Recent case series demonstrate that the transsphenoidal approach to the hypothalamus can be safe and effective, however, may not be feasible in all patients. This study aims to investigate the feasibility of the endonasal transsphenoidal suprasellar subchiasmatic (ETSS) approach to the hypothalamus through a radiological evaluation of the subchiasmatic corridor dimension in an adult population.

METHODS

A retrospective review of magnetic resonance imaging of the brain was performed on 164 consecutive adult patients at our institution, of which 100 patients were deemed eligible for inclusion. Measurements were obtained at the two narrowest points along the subchiasmatic corridor: the subchiamastic window, which is the face of the subchiasmatic corridor and the midpoint window, which is located in the middle of the subchiasmatic corridor. Based on defined parameters, including the subchasmiatic window width (SW), subchiasmatic window height (SH), midpoint window width (MW), and midpoint window height (MH), patients were dichotomised into groups: patients with subchiasmatic corridor measurements any dimension of less than 3 mm, or patients with dimensions greater than or equal to 3 mm.

RESULTS

A total of 72 (72%) of the study population had dimensions of equal to or greater than 3 mm throughout the entirety of the subchiasmatic corridor, making hypothalamic biopsy feasible through the ETSS route for these patients.

CONCLUSION

Based on a radiological evaluation of the subchiasmatic corridor dimension in an Australian adult population, the majority of the population are suitable to undergo an endonasal transsphenoidal suprasellar subchiasmatic biopsy of the hypothalamus.

Comparing Surgical Approaches for Craniopharyngioma Resection Among Adults and Children: A Meta-analysis and Systematic Review

BACKGROUND

Craniopharyngioma treatment often necessitates surgical resection. Conventional approaches, such as transcranial and transsphenoidal approaches, are predominantly used. However, a recently adopted supraorbital approach may be more efficacious. Thus, this meta-analysis and systematic review aimed to compare the efficacy of the transcranial, transsphenoidal, and supraorbital approaches for resection and treatment of craniopharyngiomas.

METHODS

This study was performed following PRISMA guidelines. Analyses were performed according to study design: (1) analyses for studies comparing several surgical approaches; and (2) analyses of all included studies. Random effects meta-analysis models were used to pool odds ratios among studies comparing several approaches. Similarly, categorical meta-regression models were used to examine the effect of surgical approach as a covariate of outcome data for all studies. Statistics were performed using Comprehensive Meta-Analysis software (CMA 3.3, Biostat, Englewood, NJ) (significance set at P < 0.05).

RESULTS

Patients were well-matched for age, sex, and preoperative comorbidities between groups stratified by surgical approach. Analyses including 22 studies that compared several approaches demonstrated that the transsphenoidal group had a greater occurrence of postoperative visual improvement (P < 0.0001), lesser occurrence of visual deterioration (P < 0.0001), and lower tumor recurrence rate (P = 0.015) compared with the transcranial group. Only 2 studies compared the supraorbital approach to another approach, limiting analyses. Analyses including all studies demonstrated that the supraorbital group did not differ to either the transcranial or transsphenoidal group for any examined variables.

CONCLUSIONS

The present study suggests that the transsphenoidal approach is associated with improved clinical outcomes for craniopharyngioma resection. There are limited data regarding the supraorbital approach, warranting future investigation.

Endoscopic transnasal surgery in optic pathway gliomas located in the chiasma-hypothalamic region: case series of ten patients in a single-center experience and endoscopic literature review

OBJECTIVE

Optic pathway gliomas (OPGs) constitute approximately 3-5% of childhood intracranial tumors. In this study, the authors presented their experience of using the endoscopic endonasal approach to treat patients with OPG located in the chiasma-hypothalamic region and aimed to use the infrachiasmatic corridor in the endoscopic endonasal approach as an alternative to the transcranial approach in the surgical necessity of OPGs.

METHODS

We retrospectively analyzed the data of ten patients diagnosed with OPG histopathologically among 3757 cases who underwent endoscopic endonasal surgery between August 1997 and March 2021 at Kocaeli University Faculty of Medicine Pituitary Research Center and Department of Neurosurgery. Mean follow-up period 48.5 months. During the postoperative follow-up period, 3 of these 10 patients underwent reoperation due to tumor recurrence. Combined (endoscopic endonasal approach + transcranial approach) approach was applied to 2 patients in the same session. Surgical and clinical outcomes were evaluated in detail.

RESULTS

Ten patients with a mean patient age of 20.6 ± 11.4 were included in this study. The most common complaint was visual impairment. After surgery, improvement in visual impairment was observed in five patients. No increase in postoperative visual impairment was observed in any of the patients. Postoperative panhypopituitarism was not observed in any of the patients. STR resection was performed in 5 patients and NTR resection in 5 patients. No additional treatment was required during follow-up in 4 of 5 patients who underwent NTR. A total of 6 patients received postoperative radiotherapy treatment.

CONCLUSIONS

In gliomas located in the chiasma-hypothalamic region, appropriate patient selection and endoscopic endonasal surgical treatment may contribute to the elimination of symptoms due to the mass effect of the tumor. It may also contribute to keeping the disease under control with targeted adjuvant therapies by clarifying the pathological diagnosis of the lesion.

Endoscopic endonasal surgical anatomy through the prechiasmatic sulcus: the key window to suprachiasmatic and infrachiasmatic corridors

BACKGROUND

Classically, the transtuberculum and transplanum approaches have been utilized to reach the suprachiasmatic and infrachiasmatic corridors. The aim of this study was to provide a better understanding of the key endoscopic endonasal anatomy of the suprachiasmatic and infrachiasmatic corridors provided through selective removal of the prechiasmatic sulcus (SRPS).

METHOD

A SRPS was performed in 16 sides of 8 alcohol-fixed head specimens. Twenty anatomical measurements were collected on the suprachiasmatic and infrachiasmatic corridors. The transplanum and transtuberculum approaches were also performed.

RESULTS

In the suprachiasmatic corridor, the SRPS exposed the anterior communicating artery (AComm) and the post-communicating segment of the anterior cerebral arteries in all the cases, while the pre-communicating segment of the anterior cerebral arteries, recurrent arteries of Heubner, and fronto-orbital arteries were visualized in 75% (12/16), 31% (5/16), and 69% (11/16) of cases, respectively. In the infrachiasmatic corridor, the ophthalmic segment of the internal carotid artery and superior hypophyseal arteries were always visible through the SRPS. The mean width and height of the prechiasmatic sulcus were 13.2 mm and 9.6 mm, respectively. The mean distances from the midpoint of the AComm to the anterior margin of the optic chiasm (OCh) was 5.3 mm. The mean width of the infrachiasmatic corridor was 12.3 mm at the level of the proximal margin of the ophthalmic segment of the internal carotid artery. The mean distances from the posterior superior limit of the pituitary stalk to the basilar tip and oculomotor nerve were 9.7 mm and 12.3 mm, respectively.

CONCLUSIONS

The SRPS provides access to the main neurovascular and cisternal surgical landmarks of the suprachiasmatic and infrachiasmatic corridors. This anatomical area constitutes the key part of the approach to the suprasellar area. To afford adequate surgical maneuverability, the transplanum or transtuberculum approaches are usually a necessary extension.

Operative nuances and surgical limits of the endoscopic approach to clival chordomas and chondrosarcomas: A single-center experience of 72 patients

OBJECTIVE

Gross total resection (GTR) is the mainstay therapy for chordomas and chondrosarcomas to have the best prognosis. The aims of this study were to specify the limits of EEA, emphasize the need for additional combined approaches for tumors beyond these limitations for high resection rates, discuss the prognostic factors and operative nuances that affect GTR, and present the causes and characteristics of early and late recurrences.

METHODS

We retrospectively analyzed the endoscopic endonasal surgeries in the Pituitary Research Center and Neurosurgery Department of the Kocaeli University Faculty of Medicine, Turkey between January 2004 and December 2019. We retrospectively reviewed the medical data, radiological images, and surgical videos of patients, and 72 patients with chordoma and chondrosarcoma were included in the study.

RESULTS

Based on pathology reports, 72 patients (seven pediatric) were identified, to whom 91 endoscopic operations were performed. We determined the surgical limitations for each clival segment as superior, middle, and inferior. Then, we divided these into three subgroups according to whether the tumor shows dural invasion (extradural chordoma, large extradural - minimal intradural component, and minimal extradural - large intradural component). The tumors of 19 (26.4%), 25 (26.4%), and nine (12.5%) patients originated from the superior, middle, and inferior clivus, respectively. Nineteen (26.4%) patients had panclival involvement. GTR was performed in 47 (65.3%) the patients. The GTR rate in patients with panclival tumors was 47.3% (9/19). The experience, lateralization, dural involvement, and origin of the clivus affecting GTR were analyzed. Extradural - intradural extensions were verified as negative predictor factors for GTR, whereas tumors located in the superior (OR: 16.710, p=0.030) and middle (OR: 11.154, p=0.023) segments were positive predictive factors for GTR.

CONCLUSION

An increasing experience in endoscopic surgery significantly increases the GTR rates by widening the surgical limitations. Due to dense bone infiltration and adhesion to critical neurovascular structures, recurrence rates are high despite performing GTR. Although surgery and adjuvant treatments improve the 5-year survival of patients, the mortality rates remain high. Therefore, surgery of these tumors should be performed by experienced centers. In addition to surgical and adjuvant therapies, targeted molecular and translational biological therapies are also needed for chordomas and chondrosarcomas in the future.