Outcome and mid-term prognosis after maximum and radical removal of craniopharyngiomas with the priority to the extended transsphenoidal approach--a single center experience

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.

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.

Predictors of the Spontaneous Resolution of Central Diabetes Insipidus Following Endoscopic Endonasal Surgery for Craniopharyngioma

OBJECTIVE

Central diabetes insipidus (CDI) is the most common complication of endoscopic endonasal surgery (EES) for craniopharyngioma. However, some cases of CDI could spontaneously resolve during the follow-up period. Hence, this study aimed to determine the predictive factors for the spontaneous resolution of CDI.

METHODS

Data of patients with CDI who underwent EES for craniopharyngioma between February 2009 and June 2021 were retrospectively reviewed. All patients were divided into 2 groups based on the resolution of CDI during follow-up: the recovery and no recovery groups. The baseline characteristic, surgical, and follow-up results of patients were compared.

RESULTS

We identified 84 patients with CDI (35 in the recovery group and 49 in the no recovery group). A direct comparison showed that retaining the pituitary stalk (57.1% vs. 14.3%, P = 0.000) and no-hypothalamic injury (HI) (68.6% vs. 20.4%, P = 0.000) were more common in the recovery group, whereas hydrocephalus at diagnosis (8.6% vs. 46.9%, P = 0.000) was significantly more common in the no recovery group. Subsequently, we found through univariate and multivariate analysis that the spontaneous resolution of CDI was associated with hydrocephalus at diagnosis (yes vs. no: odds ratio [OR], 0.198; P = 0.045), pituitary stalk injury (retaining vs. sectioning: OR, 7.055; P = 0.004), and the Hong et al HI pattern (mild-HI vs. no-HI: OR, 0.183; P = 0.038; unilateral-HI vs. no-HI: OR, 0.147; P = 0.017; bilateral-HI vs. no-HI: OR, 0.154; P = 0.044).

CONCLUSIONS

Hydrocephalus at diagnosis, pituitary stalk injury, and the Hong et al HI pattern might be predictors of the spontaneous resolution of CDI following EES for craniopharyngioma.

Relationship between postoperative hypothalamic injury and water and sodium disturbance in patients with craniopharyngioma: A retrospective study of 178 cases

OBJECTIVE

To investigate the relationship between postoperative hypothalamo-hypophyseal injury (HHI) and postoperative water and sodium disturbances in patients with craniopharyngioma.

METHODS

The medical records, radiological data, and laboratory results of 178 patients (44 children and 134 adults) who underwent microsurgery for craniopharyngioma in a single center were reviewed. Postoperative HHI was assessed using magnetic resonance imaging. Structural defects of the hypothalamo-hypophyseal system (pituitary, pituitary stalk, floor and lateral wall of the third ventricle) were assessed in four standard T1-weighted images. The defect of each structure was assigned 1 score (0.5 for the unilateral injury of the third ventricle wall), and a HHI score was calculated.

RESULTS

The number of patients with HHI scores of 0-1, 2, 2.5-3, and >3 was 35, 49, 61, and 33, respectively. Diabetes insipidus (DI) worsened in 56 (31.5%) patients with preoperative DI, while 119 (66.9%) patients were diagnosed with new-onset DI. Hypernatremia and hyponatremia developed in 127 (71.3%) and 128 (71.9%) patients after surgery, respectively. Syndrome of inappropriate antidiuresis occurred in 97(54.5%) patients. During hospitalization, hypernatremia recurred in 33 (18.5%) patients and in 54 (35.7%) during follow-up, of which 18 (11.9%) were severe. DI persisted in 140 (78.7%) patients before discharge. No relationship was found between the HHI score and incidence of early DI, hyponatremia, syndrome of inappropriate diuretic hormone, or prolonged DI. Compared with patients with a score of 0-1, those with scores =2.5-3 (OR = 5.289, 95% CI:1.098-25.477, P = 0.038) and >3 (OR = 10.815, 95% CI:2.148-54.457, P = 0.004) had higher risk of developing recurrent hypernatremia. Patients with a score >3 had higher risk of developing severe hypernatremia during hospitalization (OR = 15.487, 95% CI:1.852-129.539, P = 0.011) and at follow-up (OR = 28.637, 95% CI:3.060-267.981, P = 0.003).

CONCLUSIONS

The neuroimaging scoring scale is a simple tool to semi-quantify HHI after surgery. Recurrent and severe hypernatremia should be considered in patients with a high HHI score (>2.5). An HHI score >3 is a potential predictor of adipsic DI development. Preventive efforts should be implemented in the perioperative period to reduce the incidence of potentially catastrophic complications.

Single-Layer Fascia Patchwork Closure for the Extended Endoscopic Transsphenoidal Transtuberculum Transplanum Approach: Deep Suturing Technique and Preliminary Results

OBJECTIVE

To describe a single-layer fascia patchwork closure (FPWC) without nasoseptal flap (NSF) and compare postoperative cerebrospinal fluid (CSF) leakage between FPWC using NSF and single-layer FPWC without NSF for the extended endoscopic transsphenoidal transtuberculum transplanum approach.

METHODS

Forty-five cases of suprasellar tumor in 42 patients were treated with extended endoscopic transsphenoidal removal, resulting in extensive, high-flow CSF leakage. Following the intradural procedure for treatment of various suprasellar tumors, fascia lata was inlaid subdurally on the cranial base defect and patch-sutured around its entire circumference under endoscope visualization, using an average of 17 stitches. Septal bone or hydroxyapatite plate was used for the hard support material against pulsatile intracranial pressure. NSF was added in the earlier 17 cases. Closure was completed without NSF in the more recent 28 cases when the Valsalva maneuver confirmed watertight closure. Two recent cases required NSF after Valsalva maneuver and were included in the FPWC + NSF group.

RESULTS

Postoperative CSF leakage did not occur in the FPWC + NSF group but occurred in 2 patients in the single-layer FPWC group (7.1%) (P = 0.52). There was no significant difference in CSF leakage between single-layer FPWC and FPWC + NSF. The mean suturing time for FPWC was 85.8 minutes, and the shortest was 39 minutes in a recent case (mean, 17 stitches; n = 35, video analysis).

CONCLUSIONS

Single-layer FPWC may be a viable technical option for effective skull base reconstruction after the extended endoscopic transsphenoidal transtuberculum transplanum approach.

Heterogeneity of Growth Hormone Receptor Expression in Craniopharyngioma-Implications for Surgical Strategy

BACKGROUND

Recent molecular investigations for craniopharyngiomas have investigated possible predictive biologic markers. Growth hormone receptor (GHR) is thought to be involved in tumor aggressiveness, and high expression of GHR is associated with shorter duration of postoperative stable disease.

CASE DESCRIPTION

A 27-year-old man with a large suprasellar tumor underwent an inexplicable clinical course. Transsphenoidal surgery achieved gross total removal of the tumor. Histologic diagnosis was adamantinomatous craniopharyngioma, and immunohistochemistry revealed very low GHR expression. He was discharged with multiple hormonal supplements except for growth hormone. Recurrence was detected 18 months later, and removal of the second tumor was performed with coagulation of the superior surface of the remaining pituitary gland. Growth hormone supplementation was started in the postoperative period, and he returned to work. However, a further recurrence was detected. Head magnetic resonance imaging showed almost the same pattern of tumor recurrence as preoperative imaging of the second surgery, and simultaneous removal of the tumor and the normal pituitary gland was performed. Reevaluation of histology revealed no morphologic differences between the first and the third surgical specimens, but immunohistochemical staining for GHR showed diffuse high expression in the third specimen. The difference was thought to reflect the heterogeneity of GHR, and appearance of histologic hot spots greatly affected the postoperative prognosis.

CONCLUSIONS

Extensive removal of the possible tumor bed may be necessary for patients requiring growth hormone supplementation even after gross total removal of craniopharyngioma.

Precision Medicine for Primary Central Nervous System Tumors: Are We There Yet?

In recent years, technologic advances have increased tremendously our understanding of the molecular characteristics and genetic drivers of a variety of brain tumors. These discoveries have led to paradigm shifts in the treatment of these tumor entities and may therefore have a considerable impact on the outcome of affected patients in the near future. Here, we provide a broad overview of recently discovered clinically actionable mutations that have been identified in three different primary brain tumors: gliomas, meningiomas, and craniopharyngiomas. We furthermore highlight the diagnostic and therapeutic implications of these findings and summarize recently published and ongoing trials.

Preoperative Assessment of Craniopharyngioma Adherence: Magnetic Resonance Imaging Findings Correlated with the Severity of Tumor Attachment to the Hypothalamus

BACKGROUND AND OBJECTIVE

Craniopharyngioma (CP) adherence represents a heterogeneous pathologic feature that critically influences the potentially safe and radical resection. The aim of this study was to define the magnetic resonance imaging (MRI) predictors of CP adherence severity.

METHODS

This study retrospectively investigated a cohort of 200 surgically treated CPs with their corresponding preoperative conventional MRI scans. MRI findings related to the distortions of anatomic structures along the sella turcica-third ventricle axis caused by CPs, in addition to the tumor's shape and calcifications, were analyzed and correlated with the definitive type of CP adherence observed during the surgical procedures.

RESULTS

CP adherence is defined by 3 components, as follows: 1) the specific structures attached to the tumor, 2) the adhesion's extent, and 3) its strength. Combination of these 3 components determines 5 hierarchical levels of adherence severity with gradually increasing surgical risk of hypothalamic injury. Multivariate analysis identified 4 radiologic variables that allowed a correct overall prediction of the levels of CP adherence severity in 81.5% of cases: 1) the position of the hypothalamus in relation to the tumor-the most discriminant factor; 2) the type of pituitary stalk distortion; 3) the tumor shape; and 4) the presence of calcifications. A binary logistic regression model including the first 3 radiologic variables correctly identified the CPs showing the highest level of adherence severity (severe/critical) in almost 90% of cases.

CONCLUSIONS

A position of the hypothalamus around the middle portion of the tumor, an amputated or infiltrated appearance of the pituitary stalk, and the elliptical shape of the tumor are reliable predictors of strong and extensive CP adhesions to the hypothalamus.

New outlook on the diagnosis, treatment and follow-up of childhood-onset craniopharyngioma

Childhood-onset craniopharyngiomas are rare embryonic tumours of low-grade histological malignancy. Novel insights into the molecular pathogenesis of human adamantinomatous craniopharyngioma have started to unveil the possibility of testing novel treatments targeting pathogenic pathways. Hypothalamic involvement and/or treatment-related lesions result in impaired physical and social functionality and in severe neuroendocrine sequelae. Quality of survival in patients with craniopharyngioma with hypothalamic involvement is impaired by severe obesity, physical fatigue and non-optimal psychosocial development. Patients with craniopharyngioma involving hypothalamic structures have reduced 20-year overall survival, but overall and progression-free survival are not related to the degree of surgical resection. Irradiation is effective in the prevention of tumour progression and recurrence. For favourably localized craniopharyngiomas, the preferred treatment of choice is to attempt complete resection with preservation of visual, hypothalamic and pituitary function. For unfavourably localized tumours in close proximity to optic and/or hypothalamic structures, a radical neurosurgical strategy attempting complete resection is not recommended owing to potential severe sequelae. As expertise has been shown to have an impact on post-treatment morbidity, medical societies should establish criteria for adequate professional expertise for the treatment of craniopharyngioma. On the basis of these criteria, health authorities should organize the certification of centres of excellence that are authorized to treat and care for patients with this chronic disease.

Risk-adapted, long-term management in childhood-onset craniopharyngioma

PURPOSE

This report is a review of findings on the diagnosis, treatment, clinical course, follow-up, and prognosis of craniopharyngioma patients with special regard to clinical trials and long-term management.

METHODS

Literature search on Pubmed for paper published after 1994.

RESULTS

Craniopharyngiomas are rare, embryonic malformations of the sellar/parasellar region with low histological grade. Clinical manifestations are related to increased intracranial pressure, visual impairment, and hypothalamic/pituitary deficiencies. If the tumor is favorably localized, therapy of choice is complete resection, with care taken to preserve hypothalamic and optic functions. In patients with unfavorable tumor location (i.e. involvement of hypothalamic areas), recommended therapy is limited hypothalamus-sparing surgical strategy followed by irradiation. Irradiation has proven effective in treatment of recurrences and progression. Surgical lesions and/or anatomical involvement of posterior hypothalamic areas can result in serious sequelae, mainly hypothalamic syndrome.

CONCLUSIONS

It is crucial that craniopharyngioma be managed as a frequently chronic disease, providing ongoing care of pediatric and adult patients' by experienced multidisciplinary teams in the context of multicenter trials.

ENDOCRINE TUMORS: BRAF V600E mutations in papillary craniopharyngioma

Papillary craniopharyngioma (PCP) is an intracranial tumor that results in high levels of morbidity. We recently demonstrated that the vast majority of these tumors harbor the oncogenic BRAF V600E mutation. The pathologic diagnosis of PCP can now be confirmed using mutation specific immunohistochemistry and targeted genetic testing. Treatment with targeted agents is now also a possibility in select situations. We recently reported a patient with a multiply recurrent PCP in whom targeting both BRAF and MEK resulted in a dramatic therapeutic response with a marked anti-tumor immune response. This work shows that activation of the MAPK pathway is the likely principal oncogenic driver of these tumors. We will now investigate the efficacy of this approach in a multicenter phase II clinical trial. Post-treatment resection samples will be monitored for the emergence of resistance mechanisms. Further advances in the non-invasive diagnosis of PCP by radiologic criteria and by cell-free DNA testing could someday allow neo-adjuvant therapy for this disease in select patient populations.

Craniopharyngioma and hypothalamic injury: latest insights into consequent eating disorders and obesity

PURPOSE OF REVIEW

Hypothalamic alterations, pathological or treatment induced, have major impact on prognosis in craniopharyngioma patients mainly because of consequent hypothalamic obesity. Recent insight in molecular genetics, treatment strategies, risk factors and outcomes associated with hypothalamic obesity provide novel therapeutic perspectives. This review includes relevant publications since 2013.

RECENT FINDINGS

Recent findings confirm that alterations in posterior hypothalamic areas because of tumour location and/or treatment-related injuries are associated with severe hypothalamic obesity, reduced overall survival and impaired quality of life in long-term survivors of childhood-onset craniopharyngioma. However, eating disorders are observed because of hypothalamic obesity without clear disease-specific patterns. Treatment options for hypothalamic obesity are very limited. Treatment with invasive, nonreversible bariatric methods such as Roux-en-Y gastric bypass is most efficient in weight reduction, but controversial in the paediatric population because of medical, ethical, and legal considerations. Accordingly, treatment in craniopharyngioma should focus on prevention of (further) hypothalamic injury. Presurgical imaging for grading of hypothalamic involvement should be the basis for hypothalamus-sparing strategies conducted by experienced multidisciplinary teams.

SUMMARY

Until a nonsurgical therapeutic option for hypothalamic obesity for paediatric patients is found, prevention of hypothalamic injury should be the preferred treatment strategy, conducted exclusively by experienced multidisciplinary teams.

Prognostic factors of craniopharyngioma with special reference to autocrine/paracrine signaling: underestimated implication of growth hormone receptor

BACKGROUND

Craniopharyngioma is a slow-growing tumor classified as benign, but tight adhesion and significant local infiltration to the vital structures are common. In spite of improvement of modern microsurgery techniques and precise anatomical understanding not few cases of this tumor recur, and long-term tumor control and maintenance of quality of life are sometimes difficult. However, very little is known about the effects of the molecular characters of craniopharyngioma on the prognosis.

METHODS

Ninety eight cases of craniopharyngioma surgically treated at the Department of Neurosurgery, Tohoku University Hospital and Kohnan Hospital from April 1996 to May 2014, 45 males and 53 females aged from 2 to 80 years (mean, 40.84 years) were retrospectively reviewed, and postoperative outcomes and the possible involvement of the autocrine/paracrine mechanism were investigated. The patients were followed up at intervals of 6 months to assess tumor recurrence, and clinical outcomes were correlated with the findings of immunohistochemical examinations used growth hormone receptor (GHR) and downstream hormones. The follow-up period ranged from 3 to 209 months.

RESULTS

Hormone expression was examined in 88 patients, of which 46 specimens (52.3 %) showed high expression of GHR. The GHR high expression group had a significantly shorter duration of postoperative stable disease compared with the low expression group (logrank test, p = 0.007). Simultaneous high expression of growth hormone (GH) and GHR was found in 33 specimens (37.5 %), and the high expression group had a significantly shorter duration of postoperative stable disease compared with the low expression group (logrank test, p = 0.011). No other hormones showed statistically significant differences in outcomes.

CONCLUSIONS

High expression of GHR is associated with shorter duration of postoperative stable disease in patients with craniopharyngioma. If the surgical specimens were craniopharyngiomas with high GHR expression, GH supplementation would be introduced quite prudently.