The role of the endoscopic endonasal route in the management of craniopharyngiomas

The role of endoscopic endonasal salvage surgery in recurrent or residual craniopharyngioma after a transcranial approach: a systematic review

BACKGROUND

The management of craniopharyngiomas is challenging due to their high rate of recurrence following resection. Excision of recurrent tumors poses further surgical challenges due to loss of arachnoidal planes and adherence to anatomical structures. The endoscopic endonasal approach (EEA) offers a favorable alternative to transcranial approaches for primary craniopharyngiomas. However, the safety and efficacy of EEA for recurrent tumors, specifically after a prior transcranial approach, needs further investigation.

METHODS

We performed a systematic review using PubMed to develop a database of cases of recurrent craniopharyngiomas previously treated with a transcranial approach.

RESULTS

Fifteen articles were included in this review with a total of 75 cases. There were 50 males and 25 females with a mean age of 38 years (range 2-80). One prior transcranial surgery was done in 80.0% of cases, while 8.0% had two and 12.0% had more than two prior surgeries. Radiotherapy after transcranial resection was given in 18 cases (24.0%). Following EEA, vision improved in 60.0% of cases, and vision worsened in 8.6% of the cases. Of cases, 64.4% had pre-existing anterior hypopituitarism, and 43.8% had diabetes insipidus prior to EEA. New anterior hypopituitarism and diabetes insipidus developed in 24.6% and 21.9% of cases, respectively following EEA. Gross total resection (GTR) was achieved in 64.0%, subtotal resection in 32.0%, and partial resection in 4.0% revision EEA cases. GTR rate was higher in cases with no prior radiotherapy compared to cases with prior radiotherapy (72.0% vs 39.0%, p = 0.0372). The recurrence rate was 17.5% overall but was significantly lower at 10.0% following GTR (p = 0.0019). The average follow-up length was 41.2 months (range, 1-182 months).

CONCLUSION

The EEA can be utilized for resection of recurrent or residual craniopharyngiomas previously managed by a transcranial approach.

Extended endoscopic transsphenoidal approach for suprasellar craniopharyngiomas

BACKGROUND

Craniopharyngiomas are benign sellar lesions. Surgical excision of craniopharyngiomas is difficult because of the surrounding important neurovascular structures. The choice of surgery depends on the histological type, location, hormonal status, and size of the craniopharyngioma, surrounding neurovascular structures, and invasion of the brain parenchyma.

METHODS

We describe the resection of an adamantinomatous craniopharyngioma using an extended endoscopic endonasal approach and discuss the relevant surgical anatomy, indications, limitations, and possible complications.

CONCLUSIONS

The extended endoscopic endonasal approach allows successful removal of the craniopharyngioma and poses little risk to surrounding neurovascular structures.

Endoscopic versus Nonendoscopic Surgery for Resection of Craniopharyngiomas

OBJECTIVE

While surgery is a critical treatment option for craniopharyngiomas, the optimal surgical approach remains under debate. Herein, we studied a large cohort of craniopharyngioma patients to identify predictors of endoscopic surgery (ES) and to compare survival outcomes between patients undergoing ES versus nonendoscopic surgery (NES).

METHODS

The National Cancer Database was queried for patients receiving definitive surgical treatment in 2010-2016. Cox proportional hazards and propensity score-adjusted Kaplan-Meier analyses assessed mortality risk and overall survival, respectively. Predictors of surgical approach were evaluated via logistic regression.

RESULTS

Of 1721 patients, 508 (29.5%) underwent ES, 877 (50.9%) were female, and the average age was 41.8 ± 21.3 years. Matched ES and NES cohorts exhibited 5-year overall survival rates of 88.0% and 79.8%, respectively (P = 0.004). ES was associated with reduced mortality (Hazard Ratio = 0.634; 95% confidence interval [CI], 0.439-0.914; P = 0.015). Patients treated at academic facilities (Odds Ratio [OR] = 2.095; 95% CI, 1.529-2.904; P < 0.001) or diagnosed recently (OR = 1.132; 95% CI, 1.058-1.211; P < 0.001) were more likely to undergo ES, while those with tumor sizes >3 cm (OR = 0.604; 95% CI, 0.451-0.804; P < 0.001) or receiving adjuvant radiotherapy (OR = 0.641; 95% CI, 0.454-0.894; P = 0.010) were more likely to receive NES. Surgical inpatient stays were significantly shorter with ES compared to NES (8.0 vs. 10.5 days, P < 0.001). On linear regression, ES usage increased by 82.4% and NES usage decreased by 23.4% between 2010 and 2016 (R² = 0.575, P = 0.031).

CONCLUSIONS

ES of craniopharyngioma was associated with reduced mortality and shorter inpatient stays compared to NES. Factors including tumor size, extent of resection, facility type, and year of diagnosis may predict receiving ES. There is a trend towards increased usage of ES for surgical management of craniopharyngiomas.

Extended endoscopic endonasal approach for resecting anterior intrinsic third ventricular craniopharyngioma

Background

The surgical treatment of the extended endoscopic endonasal approach (EEEA) is a safe and effective treatment for suprasellar craniopharyngiomas. However, due to damage to the hypothalamus and third ventricle floor (TVF), EEEA is generally regarded as unsuitable in treating intrinsic third ventricle craniopharyngioma (ITVC) that is entirely within the third ventricle. Until now, there have been only a small number of reports using EEEA to treat TVC via a supra-infrachiasmatic approach. Given that the translamina terminalis (TLT) corridor was used in the transcranial subfrontal approach, EEEA via a suprachiasmatic approach may be feasible and practical to treat ITVC. In the current study, we accumulated experience applying the suprachiasmatic translamina terminalis (STLT) corridor for anterior treatment of ITVC.

Methods

From March 2016 to December 2020, 14 patients with ITVC in our center were analyzed retrospectively. All patients underwent surgery by EEEA via an STLT corridor. The multilayer reconstruction technique was adopted to achieve skull base reconstruction. Data concerning the patient’s tumor resection, vision, hypophyseal hormone, and complications were collected.

Results

Gross-total resection was achieved in 13 (92.8%) of14 patients, with achievement of near-total (90%) resection in the remaining 1 patient. Nine cases (64.3%) were papillary craniopharyngiomas, and the other 5 cases were adamantinomatous subtypes. Postoperatively, 3 patients with pituitary insufficiency received hormone replacement therapy. No permanent diabetes insipidus or hypothalamic obesity was found. All pairs showed significant improvement or stability in vision except 1 patient who encountered visual deterioration. No other neurological deficit occurred postoperatively. Observation results for the exudation of nasal tissue and the length of hospitalization were satisfactory. After a mean follow-up period of 26.2 months, tumor recurrence was not observed.

Conclusion

TLT is a minimally invasive corridor used in EEEA for treating anterior ITVC without increasing risks of visual and hormonal deficits. The multilayered reconstruction technique we used is a safe and effective method for achieving watertight closure and avoiding cerebrospinal fluid leaks and infection. The endonasal approach via STLT provides a new, safe and efficacious operative strategy that should be considered a surgical alternative in treating ITVC.

Challenges, Learning Curve, and Safety of Endoscopic Endonasal Surgery of Sellar-Suprasellar Lesions in a Community Hospital

BACKGROUND AND OBJECTIVE

Endoscopic endonasal surgery (EES) for the management of sellar, suprasellar, and anterior skull base lesions is gaining popularity. Our aim was to analyze and present the clinical outcomes of EES for the management of these lesions in a community hospital setting.

METHODS

We retrospectively reviewed the charts of 56 patients with sellar, suprasellar, and anterior skull base lesions who underwent EES between 2010 and 2018.

RESULTS

There was male predominance (53.6%) with a mean age of 54.9 ± 13.7 years. Lesions were 45 pituitary adenomas, 5 meningiomas, 3 metastatic, 1 craniopharyngioma, 1 Rathke cyst, and 1 mucocele. Gross total excision was achieved in 57.1%, subtotal excision occurred in 37.5%, and decompression and biopsy were achieved in 5.4% patients. Postoperative vision normalized or improved in 27 patients (86.1%) and was stable in 4 patients (13.9%). Recovery of a preexisting hormonal deficit occurred in 13 (23.2%) patients, and a new hormonal deficit occurred in 9 patients (16.1%). The mean hospital stay was 6.1 ± 4.9 days. Postoperative complications included cerebrospinal fluid leak in 8 patients (14.3%). Four patients (7.1%) had meningitis. Diabetes insipidus was present in 19 patients (33.9%), and postoperative intracranial hematoma requiring evacuation was necessary in 2 patients (3.6%). The mean follow-up duration was 47.5 ± 25.8 months. Lesion progression or recurrence requiring redo surgery occurred in 5 patients (8.9%). Regarding the learning curve, the postoperative cerebrospinal fluid leak, meningitis, new hormonal deficits, and diabetes insipidus decreased in the second half of the patients.

CONCLUSIONS

EES provides an effective and safe surgical option with low morbidity and mortality for the treatment of sellar, suprasellar, and anterior skull base lesions in a community hospital setting.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Surgical management of craniopharyngiomas in adult patients: a systematic review and consensus statement on behalf of the EANS skull base section

BACKGROUND AND OBJECTIVE

Craniopharyngiomas are locally aggressive neuroepithelial tumors infiltrating nearby critical neurovascular structures. The majority of published surgical series deal with childhood-onset craniopharyngiomas, while the optimal surgical management for adult-onset tumors remains unclear. The aim of this paper is to summarize the main principles defining the surgical strategy for the management of craniopharyngiomas in adult patients through an extensive systematic literature review in order to formulate a series of recommendations.

MATERIAL AND METHODS

The MEDLINE database was systematically reviewed (January 1970-February 2019) to identify pertinent articles dealing with the surgical management of adult-onset craniopharyngiomas. A summary of literature evidence was proposed after discussion within the EANS skull base section.

RESULTS

The EANS task force formulated 13 recommendations and 4 suggestions. Treatment of these patients should be performed in tertiary referral centers. The endonasal approach is presently recommended for midline craniopharyngiomas because of the improved GTR and superior endocrinological and visual outcomes. The rate of CSF leak has strongly diminished with the use of the multilayer reconstruction technique. Transcranial approaches are recommended for tumors presenting lateral extensions or purely intraventricular. Independent of the technique, a maximal but hypothalamic-sparing resection should be performed to limit the occurrence of postoperative hypothalamic syndromes and metabolic complications. Similar principles should also be applied for tumor recurrences. Radiotherapy or intracystic agents are alternative treatments when no further surgery is possible. A multidisciplinary long-term follow-up is necessary.

Endoscopic Endonasal Transsphenoidal Surgery: History and Evolution

In previous decades, extensive and disfiguring transfacial and/or transcranial approaches were used to reach the sellar and parasellar areas. However, these surgical routes were burdened by severe complications and high mortality rates. Recently, the development of endoscopic endonasal techniques has revolutionized the surgical strategies for approaching the sella and adjacent areas and increased the development of transsphenoidal surgery. With these techniques, surgeons have been able to overcome the visual limitations of the open surgical approaches and access areas previously hidden from view. After the contributions of the Pittsburgh duo, Carrau and Jho, pioneers of pure endoscopic surgery, our school began to implement this technique, introducing technical innovations and variations, describing the anatomical details and defining new routes, and playing a key role in its widespread clinical application.

Preserve or sacrifice the stalk? Endocrinological outcomes, extent of resection, and recurrence rates following endoscopic endonasal resection of craniopharyngiomas

OBJECTIVE

Gross-total resection (GTR) of craniopharyngiomas (CPs) is potentially curative and is often the goal of surgery, but endocrinopathy generally results if the stalk is sacrificed. In some cases, GTR can be attempted while still preserving the stalk; however, stalk manipulation or devascularization may cause endocrinopathy and this strategy risks leaving behind small tumor remnants that can recur.

METHODS

A retrospective review of a prospective cohort of patients who underwent initial resection of CP using the endoscopic endonasal approach over a period of 12 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital, was performed. Postresection integrity of the stalk was retrospectively assessed using operative notes, videos, and postoperative MRI. Tumors were classified based on location into type I (sellar), type II (sellar-suprasellar), and type III (purely suprasellar). Pre- and postoperative endocrine function, tumor location, body mass index, rate of GTR, radiation therapy, and complications were reviewed.

RESULTS

A total of 54 patients who had undergone endoscopic endonasal procedures for first-time resection of CP were identified. The stalk was preserved in 33 (61%) and sacrificed in 21 (39%) patients. GTR was achieved in 24 patients (73%) with stalk preservation and 21 patients (100%) with stalk sacrifice (p = 0.007). Stalk-preservation surgery achieved GTR and maintained completely normal pituitary function in only 4 (12%) of 33 patients. Permanent postoperative diabetes insipidus was present in 16 patients (49%) with stalk preservation and in 20 patients (95%) following stalk sacrifice (p = 0.002). In the stalk-preservation group, rates of progression and radiation were higher with intentional subtotal resection or near-total resection compared to GTR (67% vs 0%, p < 0.001, and 100% vs 12.5%, p < 0.001, respectively). However, for the subgroup of patients in whom GTR was achieved, stalk preservation did not lead to significantly higher rates of recurrence (12.5%) compared with those in whom it was sacrificed (5%, p = 0.61), and stalk preservation prevented anterior pituitary insufficiency in 33% and diabetes insipidus in 50%.

CONCLUSIONS

While the decision to preserve the stalk reduces the rate of postoperative endocrinopathy by roughly 50%, nevertheless significant dysfunction of the anterior and posterior pituitary often ensues. The decision to preserve the stalk does not guarantee preserved endocrine function and comes with a higher risk of progression and need for adjuvant therapy. Nevertheless, to reduce postoperative endocrinopathy attempts should be made to preserve the stalk if GTR can be achieved.

Third Ventricular Tumors: A Comprehensive Literature Review

Third ventricle tumors are uncommon and account for 0.6 - 0.9% of all the brain tumors. Tumors of the third ventricle are classified into primary tumors, such as colloid cysts, choroid plexus papillomas, and ependymomas, or secondary tumors, such as craniopharyngiomas, optic nerve gliomas, pineal tumors, and meningiomas. Third ventricular tumors are uncommon, and their treatment involves significant morbidity and mortality. The colloid cyst has a better surgical outcome and many approaches are available to achieve a complete cure. Choroid plexus papilloma is also a common tumor documented with its treatment majorly based on surgical resection. In addition to multiple treatment options for craniopharyngiomas, surgery is the most preferred treatment option. Ependymomas also have few treatment options, with surgical resection adopted as the first line of treatment.

Endocrine and Metabolic Outcomes After Transcranial and Endoscopic Endonasal Approaches for Primary Resection of Craniopharyngiomas

OBJECTIVE

Craniopharyngiomas have traditionally been resected through the transcranial approaches (TCA). The endoscopic endonasal approach (EEA) has recently been developed as an alternative for surgeons, but controversy remains regarding which approach has better outcomes. We compared the endocrine and metabolic outcomes of TCA and EEA in patients who underwent primary resection of craniopharyngiomas.

METHODS

A retrospective analysis was conducted of patients with craniopharyngioma who were treated by the department of endocrinology and metabolism at our institution between 2011 and 2015.

RESULTS

Of 43 patients assessed, 26 underwent TCA and 17 underwent EEA. After surgery, 29.4% (5/17) of patients in the EEA group had normal anterior pituitary function, whereas none in the TCA group had complete anterior pituitary function. Higher prevalences of corticotropic deficiency (92.3% vs. 52.9%, P = 0.009), thyrotrophic deficiency (96.2% vs. 52.9%, P = 0.003), and hypogonadotropic hypogonadism (100% vs. 70.6%, P = 0.014) were found in the TCA group. The TCA group showed a trend toward having more patients with at least 3 anterior pituitary deficits (88.5% vs. 58.8%, P = 0.060). The mean body mass index at last follow-up tended to be lower in the EEA group (24.13 ± 3.16 kg/m² vs. 26.79 ± 4.5 kg/m², P = 0.079), and the preoperative body mass index was comparable between groups. Similar prevalences of overweight/obesity, hypertension, hyperglycemia, and metabolic syndrome were detected in the 2 groups. Moreover, no significant differences were observed in the rates of cerebrospinal fluid leakage and intracranial infection between the 2 groups.

CONCLUSIONS

EEA may provide the same gross total resection rate for craniopharyngioma as TCA while providing better protection of anterior pituitary function.

Endoscopic Endonasal Surgery for Subdiaphragmatic Type Craniopharyngiomas

Subdiaphragmatic type craniopharyngiomas are tumors that originate within the sella. They are divided into two types; those localized within an enlarged sella (intrasellar type) and those accompanying a suprasellar extension (suprasellar extended type). The clinicopathological features and the recent outcomes of endoscopic endonasal surgery were retrospectively reviewed in 32 patients, with 11 surgeries for recurrence. These tumors showed a preponderance in young patients (19 patients were younger than 18-year-old) and suprasellar extended type (25 cases), were mostly composed of a large cyst (96.9%) and were frequently adamantinomatous type (68.8%). Combined transcranial-endoscopic endonasal surgery was applied in three patients with extremely large tumors and significant frontal extension. Total tumor resection and stalk preservation were achieved in 26 and 17 patients, respectively. No complications developed after surgery apart from pituitary dysfunction and visual deterioration. 5 of 6 patients with subtotal tumor resection and 6 of 7 patients with no improvement or deterioration of visual function were in the recurrent cases. Although this type is basically an extraarachnoidal tumor, the suprasellar portion of the tumor showed adherence to important tissues in some patients with recurrence. Pituitary function remained normal in only one third of patients with stalk preservation. To avoid pituitary dysfunction after surgery, sharp excision of firm adherence to the stalk should be considered in some patients.

Defining the lateral limits of the endoscopic endonasal transtuberculum transplanum approach: anatomical study with pertinent quantitative analysis

OBJECTIVE

The extended endoscopic endonasal transtuberculum transplanum approach is currently used for the surgical treatment of selected midline anterior skull base lesions. Nevertheless, the possibility of accessing the lateral aspects of the planum sphenoidale could represent a limitation for such an approach. To the authors' knowledge, a clear definition of the eventual anatomical boundaries has not been delineated. Hence, the present study aimed to detail and quantify the maximum amount of bone removal over the planum sphenoidale required via the endonasal pathway to achieve the most lateral extension of such a corridor and to evaluate the relative surgical freedom.

METHODS

Six human cadaveric heads were dissected at the Laboratory of Surgical NeuroAnatomy of the University of Barcelona. The laboratory rehearsals were run as follows: 1) preliminary predissection CT scans, 2) the endoscopic endonasal transtuberculum transplanum approach (lateral limit: medial optocarotid recess) followed by postdissection CT scans, 3) maximum lateral extension of the transtuberculum transplanum approach followed by postdissection CT scans, and 4) bone removal and surgical freedom analysis (a nonpaired Student t-test). A conventional subfrontal bilateral approach was used to evaluate, from above, the bone removal from the planum sphenoidale and the lateral limit of the endonasal route.

RESULTS

The endoscopic endonasal transtuberculum transplanum approach was extended at its maximum lateral aspect in the lateral portion of the anterior skull base, removing the bone above the optic prominence, that is, the medial portion of the lesser sphenoid wing, including the anterior clinoid process. As expected, a greater bone removal volume was obtained compared with the approach when bone removal is limited to the medial optocarotid recess (average 533.45 vs 296.07 mm2; p < 0.01). The anteroposterior diameter was an average of 8.1 vs 15.78 mm, and the laterolateral diameter was an average of 18.77 vs 44.54 mm (p < 0.01). The neurovascular contents of this area were exposed up to the insular segment of the middle cerebral artery. The surgical freedom analysis revealed a possible increased lateral maneuverability of instruments inserted in the contralateral nostril compared with a midline target (average 384.11 vs 235.31 mm2; p < 0.05).

CONCLUSIONS

Bone removal from the medial aspect of the lesser sphenoid wing, including the anterior clinoid process, may increase the exposure and surgical freedom of the extended endoscopic endonasal transtuberculum transplanum approach over the lateral segment of the anterior skull base. Although this study represents a preliminary anatomical investigation, it could be useful to refine the indications and limitations of the endoscopic endonasal corridor for the surgical management of skull base lesions involving the lateral portion of the planum sphenoidale.

Is Low-Lying Optic Chiasm an Obstacle to an Endoscopic Endonasal Approach for Retrochiasmatic Craniopharyngiomas? (Korean Society of Endoscopic Neurosurgery -003)

OBJECTIVE

Despite advances in endoscopic techniques, retrochiasmatic craniopharyngiomas (CPs) are difficult to remove completely, because the low-lying optic chiasm often provides an obstacle to an endoscopic endonasal approach. This study aimed to identify the endoscopic surgical outcomes of the retrochiasmatic CP and resolve the issues related to low-lying optic chiasm.

METHODS

We reviewed 154 consecutive patients with CP who underwent endonasal endoscopic resection from February 2009 to April 2017 at 2 independent institutions. The topographic relationship of the tumor with the third ventricle, stalk, and optic chiasm and clinical outcomes were investigated.

RESULTS

Retrochiasmatic CPs were found in 142 of 154 patients (92.2%). The median follow-up time was 25 months. Gross total resection and near-total resection were achieved in 113 patients (79.6%) and 21 patients (13.8%), respectively. Postoperative cerebrospinal fluid leaks were found in 16 patients (11.3%). Low-lying and high-lying chiasms were found in 44 patients (31.0%) and 98 patients (69.0%), respectively. Low-lying chiasm did not affect clinical outcomes including the extent of resection. Patients with low-lying chiasm showed a marginal trend for postoperative visual deterioration. The ventricular growth pattern representing the origin of the tumor and previous surgery were significantly associated with the position of the optic chiasm (P = 0.007 and 0.001, respectively).

CONCLUSIONS

An endoscopic endonasal approach is an effective surgical approach for retrochiasmatic CP, even in tumors with low-lying chiasm. However, a thorough and careful dissection is necessary to prevent visual deterioration.

Supraorbital subfrontal trans-laminar endoscope-assisted approach for tumors of the posterior third ventricle

BACKGROUND

Different surgical approaches have been developed for dealing with third ventricle lesions, all aimed at obtaining a safe removal minimizing brain manipulation. The supraorbital subfrontal trans-lamina terminalis route, commonly employed only for the anterior third ventricle, could represent, in selected cases with endoscopic assistance, an alternative approach to posterior third ventricular lesions.

METHODS

Seven patients underwent a supraorbital subfrontal trans-laminar endoscope-assisted approach to posterior third ventricle tumors (two craniopharyngiomas, one papillary tumor of the pineal region, one pineocytoma, two neurocytomas, one glioblastoma). Moreover, a conventional third ventriculostomy was performed via the same trans-laminar approach in four cases.

RESULTS

Complete tumor removal was accomplished in four cases, subtotal removal in two cases, and a simple biopsy in one case. Adjuvant radiotherapy and/or chemotherapy was administered, if required, on the basis of the histologic diagnosis. No major complications occurred after surgery except for an intratumoral hemorrhage in a patient undergoing a biopsy for a glioblastoma, which simply delayed the beginning of adjuvant radiochemotherapy. No ventriculoperitoneal shunt placement was needed in these patients at the most recent clinical and radiologic session (average 39.57 months, range 13-85 months). Two illustrative cases are presented.

CONCLUSIONS

The supraorbital subfrontal trans-laminar endoscope-assisted approach may provide, in selected cases, an efficient and safe route for dealing with posterior third ventricular tumors.

Microscopic versus endoscopic approaches for craniopharyngiomas: choosing the optimal surgical corridor for maximizing extent of resection and complication avoidance using a personalized, tailored approach

Resection remains the mainstay of treatment for craniopharyngiomas with the goal of radical resection, if safely possible, to minimize the rate of recurrence. Endoscopic endonasal and microscopic transcranial surgical approaches have both become standard methods for the treatment for craniopharyngiomas. However, the approach selection paradigm for craniopharyngiomas is still a point of discussion. Choosing the optimal surgical approach can play a significant role in maximizing the extent of resection and surgical outcome while minimizing the risks of potential complications. Craniopharyngiomas can present with a variety of different sizes, locations, and tumor consistencies, and each individual tumor has distinct features that favor one specific approach over another. The authors review standard cranial base techniques applied to craniopharyngioma surgery, using both the endoscopic endonasal approach and traditional open microsurgical approaches, and analyze factors involved in approach selection. They discuss their philosophy of approach selection based on the location and extent of the tumor on preoperative imaging as well as the advantages and limitations of each surgical corridor, and they describe the operative nuances of each technique, using a personalized, tailored approach to the individual patient with illustrative cases and videos.

Sellar Lesions/Pathology

The sellar region is a tiny anatomic compartment in which many lesions and developmental diseases can be found. If pituitary adenomas represent most of the sellar mass, it is important to recognize other pathologic conditions before any surgical procedure, because the optimal treatment may differ considerably from one lesion to another. A careful clinical evaluation followed by neuroimaging studies and an endocrinologic and ophtalmologic workup will lead, in most cases, to a diagnosis with near certainty. This article provides an overview of sellar diseases with emphasis on their most useful characteristics for clinical practice.

Microsurgical removal of craniopharyngioma: endoscopic and transcranial techniques for complication avoidance

Craniopharyngioma remains a challenging entity for neurosurgeons because of its midline, deep seated location and intimate relationship with critical neurovascular structures. Although gross total resection is ideal, the need to reduce surgical morbidity and preserve quality of life has led to a number of neurosurgical approaches which have attained this goal. Here we discuss the commonly used approaches for surgical resection and highlight technical considerations to reduce the potential of complications. We also discuss the mutually exclusive underlying genetic lesions in different histopathological subtypes that will likely lead to future treatment options for these tumors.

Endoscopic Endonasal Surgery for Purely Intrathird Ventricle Craniopharyngioma

BACKGROUND

Extended endoscopic transsphenoidal surgery (EETS) is a safe and effective treatment for many suprasellar craniopharyngiomas, including those with third-ventricle involvement. Craniopharyngioma entirely within the third ventricle (purely intraventricular type), however, is generally regarded unsuitable for treatment with EETS.

CASE DESCRIPTION

Three patients underwent total removal of a purely intraventricular craniopharyngioma with inferior extension via EETS by direct incision of the bulging, stretched ventricular floor and fine dissection from the ventricular wall. In 2 patients with an anteriorly displaced chiasm, the space between the chiasm and pituitary stalk created a wide corridor to the ventricle, whereas in the third case, in which the infrachiasmal space was somewhat narrowed, partial sacrifice of the pituitary gland was necessary to obtain sufficient space. Despite preservation of the stalk in 2 patients, hypopituitarism and diabetes insipidus developed after surgery. There was no other complication including obesity.

CONCLUSIONS

Selected patients with purely intraventricular craniopharyngioma can be treated effectively and safely with EETS. Those with inferior extension in the interpeduncular fossa and anterior displacement of the chiasm may be suitable candidates.

Endoscopic transsphenoidal anterior petrosal approach for locally aggressive tumors involving the internal auditory canal, jugular fossa, and cavernous sinus

OBJECTIVE Reports about endoscopic endonasal surgery for skull base tumors involving the lateral part of petrous apex remain scarce. The authors present their experience with the endoscopic transsphenoidal anterior petrosal (ETAP) approach through the retrocarotid space for tumors involving the internal auditory canal, jugular fossa, and cavernous sinus. METHODS The authors performed the ETAP approach in 10 patients with 11 tumors (bilateral in 1 patient) that extensively occupied the lateral part of petrous apex, e.g., the internal auditory canal and jugular fossa. Eight patients presented with diplopia (unilateral abducens nerve palsy), 3 with tinnitus, and 1 with unilateral hearing loss with facial palsy. After wide anterior sphenoidotomy, the sellar floor, clival recess, and carotid prominence were verified. Tumors were approached via an anteromedial petrosectomy through the retrocarotid triangular space, defined by the cavernous and vertical segments of the internal carotid artery (ICA), the clivus, and the petrooccipital fissure. The surgical window was easily enlarged by drilling the petrous bone along the petrooccipital fissure. After exposure of the tumor and ICA, dissection and resection of the tumor were mainly performed under direct visualization with 30° and 70° endoscopes. RESULTS Gross-total resection was achieved in 8 patients (9 tumors). In a patient with invasive meningioma, the tumor was strongly adherent to the ICA, necessitating partial resection. Postoperatively, all 8 patients who had presented with abducens nerve palsy preoperatively showed improvement within 6 months. In the patient presenting with hearing loss and facial palsy, the facial palsy completely resolved within 3 months, but hearing loss remained. Regarding complications, 3 patients showed mild and transient abducens nerve palsy resolving within 2 weeks, 3 months, and 6 months. Postoperative CSF rhinorrhea requiring surgical repair was observed in 1 patient. No patient exhibited hearing deterioration, facial palsy, or symptoms of lower cranial nerve palsy after surgery. CONCLUSIONS The ETAP approach can offer a simple, less invasive option for invasive skull base tumors involving petrous regions, including the internal auditory canal, jugular fossa, and cavernous sinus. The ETAP approach can reach more extensive areas in the extradural regions around the petrous bone. The authors' results indicate that the transsphenoidal retrocarotid route is sufficient to approach the petrosal areas in select cases. Further expansion of the surgical field is not always necessary. However, experience with intradural lesions remains limited, and the extent of tumor resection largely depends on tumor characteristics. Application of the ETAP approach should thus be carefully determined in each patient, taking into consideration the size of the retrocarotid window and tumor characteristics.

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.

Neuroendoscopy Followed by Radiotherapy in Cystic Craniopharyngiomas--a Long-Term Follow-Up

BACKGROUND

Treatment of cystic craniopharyngiomas is often complicated because of adherence of craniopharyngiomas to adjacent brain structures. A strategy involving neuroendoscopic procedures followed by stereotactic radiotherapy is less invasive, avoiding brain damage. However, long-term follow-up of this strategy has not been investigated in depth.

METHODS

Cystic craniopharyngiomas in 9 patients were treated with neuroendoscopic cyst aspiration and fenestration, followed by fractionated stereotactic radiotherapy (FSRT). The neuroendoscopic procedure focused on widening of cyst fenestration and extensive irrigation of the cyst contents. FSRT was performed using 6 fixed beams, an 8-mm margin to cover the gross tumor volume with a 95% isodose line, and a target delivered dose of 50.4 Gy in 28 fractions.

RESULTS

The median follow-up period was 72.9 months. Tumor control was achieved in 8 of 9 patients (88.9%). Marked tumor volume reduction was obtained with the neuroendoscopic procedure alone (26.1%) at 6 months (20.4%), 1 year (11.0%), and 2 years (3.1%). One recurrent case showed multilobulated cysts, and a second surgery was required 1 year after the treatment. Clinical symptoms such as headache and visual disruption were rapidly alleviated after the neuroendoscopic procedure. No new visual disturbances, endocrinopathy, or hypothalamic dysfunction was observed during follow up.

CONCLUSIONS

Neuroendoscopic cyst aspiration and fenestration followed by FSRT is a less invasive, powerful strategy for treating adult cystic craniopharyngiomas.