1
|
Deng H, Lei T, Liu S, Hao W, Hu M, Xiang X, Ye L, Chen D, Li Y, Liu F. Proteomics study of primary and recurrent adamantinomatous craniopharyngiomas. Clin Proteomics 2024; 21:29. [PMID: 38594611 PMCID: PMC11003072 DOI: 10.1186/s12014-024-09479-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 04/02/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Adamantinomatous craniopharyngiomas (ACPs) are rare benign epithelial tumours with high recurrence and poor prognosis. Biological differences between recurrent and primary ACPs that may be associated with disease recurrence and treatment have yet to be evaluated at the proteomic level. In this study, we aimed to determine the proteomic profiles of paired recurrent and primary ACP, gain biological insight into ACP recurrence, and identify potential targets for ACP treatment. METHOD Patients with ACP (n = 15) or Rathke's cleft cyst (RCC; n = 7) who underwent surgery at Sanbo Brain Hospital, Capital Medical University, Beijing, China and received pathological confirmation of ACP or RCC were enrolled in this study. We conducted a proteomic analysis to investigate the characteristics of primary ACP, paired recurrent ACP, and RCC. Western blotting was used to validate our proteomic results and assess the expression of key tumour-associated proteins in recurrent and primary ACPs. Flow cytometry was performed to evaluate the exhaustion of tumour-infiltrating lymphocytes (TILs) in primary and recurrent ACP tissue samples. Immunohistochemical staining for CD3 and PD-L1 was conducted to determine differences in T-cell infiltration and the expression of immunosuppressive molecules between paired primary and recurrent ACP samples. RESULTS The bioinformatics analysis showed that proteins differentially expressed between recurrent and primary ACPs were significantly associated with extracellular matrix organisation and interleukin signalling. Cathepsin K, which was upregulated in recurrent ACP compared with that in primary ACP, may play a role in ACP recurrence. High infiltration of T cells and exhaustion of TILs were revealed by the flow cytometry analysis of ACP. CONCLUSIONS This study provides a preliminary description of the proteomic differences between primary ACP, recurrent ACP, and RCC. Our findings serve as a resource for craniopharyngioma researchers and may ultimately expand existing knowledge of recurrent ACP and benefit clinical practice.
Collapse
Affiliation(s)
- Haidong Deng
- Beijing Key Laboratory of New Drug Mechanisms and Pharmacological Evaluation Study, Department of Pharmacology, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100050, China
| | - Ting Lei
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China
| | - Siqi Liu
- Beijing Key Laboratory of New Drug Mechanisms and Pharmacological Evaluation Study, Department of Pharmacology, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100050, China
| | - Wenzhe Hao
- School of Basic Medical Sciences, Tianjin Medical University, Tianjin, 300070, China
| | - Mengqing Hu
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China
| | - Xin Xiang
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China
| | - Ling Ye
- Beijing Key Laboratory of New Drug Mechanisms and Pharmacological Evaluation Study, Department of Pharmacology, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100050, China
| | - Dongting Chen
- Beijing Key Laboratory of New Drug Mechanisms and Pharmacological Evaluation Study, Department of Pharmacology, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100050, China
| | - Yan Li
- Beijing Key Laboratory of New Drug Mechanisms and Pharmacological Evaluation Study, Department of Pharmacology, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100050, China.
| | - Fangjun Liu
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China.
| |
Collapse
|
2
|
Webb KL, Pruter WW, Hinkle ML, Walsh MT. Comparing Surgical Approaches for Craniopharyngioma Resection Among Adults and Children: A Meta-analysis and Systematic Review. World Neurosurg 2023; 175:e876-e896. [PMID: 37062335 DOI: 10.1016/j.wneu.2023.04.037] [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: 03/09/2023] [Accepted: 04/10/2023] [Indexed: 04/18/2023]
Abstract
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.
Collapse
Affiliation(s)
- Kevin L Webb
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Wyatt W Pruter
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mickayla L Hinkle
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael T Walsh
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| |
Collapse
|
3
|
Molecular biological features of cyst wall of adamantinomatous craniopharyngioma. Sci Rep 2023; 13:3049. [PMID: 36810626 PMCID: PMC9944325 DOI: 10.1038/s41598-023-29664-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 02/08/2023] [Indexed: 02/23/2023] Open
Abstract
The molecular biological differences between cyst walls and those in solid bodies are the foundation of the outcomes. In this study, the CTNNB1 mutations were confirmed by DNAsequencing; CTNNB1 expression levels were detected by PCR; the differences between solid bodies and cyst walls in proliferative capacity and tumor stem cell niches were assessed by immunohistochemistry; the effect of the residual cyst wall on recurrence was assessed by follow-up. Mutations in the CTNNB1 in the cyst wall and the solid body were identical in each case. No differences were found in the transcriptional level of CTNNB1 between the cyst walls and the solid bodies (P = 0.7619). The cyst wall showed a pathological structure similar to the solid body. Proliferative capacity of cyst walls was stronger than that of solid body (P = 0.0021), and β-catenin nuclear positive cells (cell clusters) in cyst walls were more than that in solid tumor (P = 0.0002). The retrospective 45 ACPs showed residual cyst wall was significantly associated with tumor recurrence or regrowth (P = 0.0176). Kaplan-Meier analysis showed there was a significant difference in the prognosis between GTR and STR (P < 0.0001).The cyst wall of ACP contained more tumor stem cell niches which could lead to the recurrence. According to the above-mentioned, a special attention to the management of the cyst wall should be paid.
Collapse
|
4
|
Liu J, Wang P, Tang C, Jiang HT, Zhang G, Wu N. Endoscopic endonasal transsphenoidal approach for craniopharyngioma: A case report. Exp Ther Med 2023; 25:114. [PMID: 36815971 PMCID: PMC9932652 DOI: 10.3892/etm.2023.11813] [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: 06/07/2022] [Accepted: 01/04/2023] [Indexed: 01/28/2023] Open
Abstract
Thanks to the rapid development and progress of endoscopic technology, the endoscopic endonasal transsphenoidal approach has become one of the best surgical methods for resection of sellar and suprasellar tumors. The craniopharyngioma is usually located in the sellar region or suprasellar region, which is suitable for resection through the endoscopic endonasal transsphenoidal approach. The present report describes 21 cases of craniopharyngioma treated by endoscopic endonasal transsphenoidal approach in the Department of Neurosurgery at the Chongqing General Hospital from February 2014 to September 2019. The characteristics of patients and tumors, including clinical symptoms, preoperative magnetic resonance imaging, intraoperative conditions, as well as postoperative and follow-up outcomes were evaluated. The main clinical symptoms were headache in 15 cases, visual deficiency in 13 cases and growth retardation in two cases. All 21 patients with craniopharyngioma underwent endoscopic endonasal transsphenoidal surgery. Of these, 20 patients achieved gross total resection and one case achieved subtotal resection. After surgery, headache symptoms improved in 11 patients without deterioration and the vision of 11 patients improved without deterioration. The primary postoperative complications were pituitary deficiency in eight cases and permanent diabetes insipidus in five cases. The patients were followed up from one to 52 months post-operation. There was no recurrence in all patients during the follow-up period. The endoscopic endonasal transsphenoidal approach is a safe and effective resection for craniopharyngioma. Moreover, the endoscopic endonasal trans-sphenoidal approach is one of the preferred surgical methods for treatment of sellar or suprasellar tumor.
Collapse
Affiliation(s)
- Jie Liu
- Department of Neurosurgery, Chongqing General Hospital, Liangjiang, Chongqing 401147, P.R. China
| | - Pan Wang
- Department of Neurosurgery, Chongqing General Hospital, Liangjiang, Chongqing 401147, P.R. China
| | - Chao Tang
- Department of Neurosurgery, Chongqing General Hospital, Liangjiang, Chongqing 401147, P.R. China
| | - Hao-Tian Jiang
- Department of Neurosurgery, Chongqing General Hospital, Liangjiang, Chongqing 401147, P.R. China
| | - Gang Zhang
- Department of Neurosurgery, Chongqing General Hospital, Liangjiang, Chongqing 401147, P.R. China
| | - Nan Wu
- Department of Neurosurgery, Chongqing General Hospital, Liangjiang, Chongqing 401147, P.R. China,Correspondence to: Dr Nan Wu, Department of Neurosurgery, Chongqing General Hospital, 118 Xingguang Avenue, Liangjiang, Chongqing 401147, P.R. China
| |
Collapse
|
5
|
Piloni M, Gagliardi F, Bailo M, Losa M, Boari N, Spina A, Mortini P. Craniopharyngioma in Pediatrics and Adults. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1405:299-329. [PMID: 37452943 DOI: 10.1007/978-3-031-23705-8_11] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Craniopharyngiomas are rare malignancies of dysembryogenic origin, involving the sellar and parasellar areas. These low-grade, epithelial tumors account for two main histological patterns (adamantinomatous craniopharyngioma and papillary craniopharyngioma), which differ in epidemiology, pathogenesis, and histomorphological appearance. Adamantinomatous craniopharyngiomas typically show a bimodal age distribution (5-15 years and 45-60 years), while papillary craniopharyngiomas are limited to adult patients, especially in the fifth and sixth decades of life. Recently, craniopharyngioma histological subtypes have been demonstrated to harbor distinct biomolecular signatures. Somatic mutations in CTNNB1 gene encoding β-catenin have been exclusively detected in adamantinomatous craniopharyngiomas, which predominantly manifest as cystic lesions, while papillary craniopharyngiomas are driven by BRAF V600E mutations in up to 95% of cases and are typically solid masses. Despite the benign histological nature (grade I according to the World Health Organization classification), craniopharyngiomas may heavily affect long-term survival and quality of life, due to their growth pattern in a critical region for the presence of eloquent neurovascular structures and possible neurological sequelae following their treatment. Clinical manifestations are mostly related to the involvement of hypothalamic-pituitary axis, optic pathways, ventricular system, and major blood vessels of the circle of Willis. Symptoms and signs referable to intracranial hypertension, visual disturbance, and endocrine deficiencies should promptly raise the clinical suspicion for sellar and suprasellar pathologies, advocating further neuroimaging investigations, especially brain MRI. The optimal therapeutic management of craniopharyngiomas is still a matter of debate. Over the last decades, the surgical strategy for craniopharyngiomas, especially in younger patients, has shifted from the aggressive attempt of radical resection to a more conservative and individualized approach via a planned subtotal resection followed by adjuvant radiotherapy, aimed at preserving functional outcomes and minimizing surgery-related morbidity. Whenever gross total removal is not safely feasible, adjuvant radiotherapy (RT) and stereotactic radiosurgery (SRS) have gained an increasingly important role to manage tumor residual or recurrence. The role of intracavitary therapies, including antineoplastic drugs or sealed radioactive sources, is predominantly limited to monocystic craniopharyngiomas as secondary therapeutic option. Novel findings in genetic profiling of craniopharyngiomas have unfold new scenarios in the development of targeted therapies based on brand-new biomolecular markers, advancing the hypothesis of introducing neoadjuvant chemotherapy regimens in order to reduce tumor burden prior to resection. Indeed, the rarity of these neoplasms requires a multispecialty approach involving an expert team of endocrinologists, neurosurgeons, neuro-ophthalmologists, neuroradiologists, radiotherapists, and neuro-oncologists, in order to pursue a significant impact on postoperative outcomes and long-term prognosis.
Collapse
Affiliation(s)
- Martina Piloni
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Filippo Gagliardi
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele Bailo
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Boari
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alfio Spina
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy.
| |
Collapse
|
6
|
Zhao C, Zhou Z, Zhang Y, Qi X, Wang X, Lin D, Liu H, Wang Y, Weng C, Chen J, Hu W, Liao L, Lin Z. Diagnosis and Management of Pediatric Papillary Craniopharyngiomas. World Neurosurg 2022; 165:e148-e158. [PMID: 35660482 DOI: 10.1016/j.wneu.2022.05.115] [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: 04/21/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Papillary craniopharyngioma (PCP) was previously believed to occur only in adults. Sporadic pediatric PCP (PPCP) confirmed by detection of BRAF V600E mutation has been reported since 2018, but is often misdiagnosed before being diagnosed definitively. We aimed to evaluate PPCP characteristics and propose diagnostic criteria for prompt diagnosis, seeking to reduce patient morbidity and mortality and reduce costs linked to misdiagnosis. METHODS This study included 5 patients with PPCPs whose data were retrieved retrospectively from among 1032 patients with craniopharyngiomas admitted to Sanbo Brain Hospital Management Group from March 2017 to May 2021. Patients' demographics, clinical presentation, tumor imaging characteristics, histopathologic results, surgical approaches, and postoperative outcomes were analyzed. RESULTS PPCP was misdiagnosed intraoperatively as sellar abscess (n = 4) or Rathke cleft cyst (n = 1). Preoperative magnetic resonance imaging showed that all tumors were under the saddle diaphragm, and the cyst wall was enhanced (n = 5). Computed tomography scans showed scattered high-density signs (n = 4). No recurrence was noted after complete resection. Postoperative hypothalamic dysfunction was mild. BRAF V600E mutation was confirmed in all cases by sequencing and immunohistochemistry. Immunohistochemistry showed granulation and inflammation and MPO, CD3, CD20, CD38, CD68, and CD163 were positively expressed. CONCLUSIONS Misdiagnosis of PPCP is responsible for failed surgical treatment. We propose that prompt diagnosis of PPCP can be achieved if preoperative magnetic resonance images show the tumor under saddle diaphragm with tumor wall enhancement and computed tomography scans show high-density signs scattered in the tumor, which leads to safe, effective tumor resection. Our proposed diagnosis and treatment strategy for PPCP reduces morbidity and mortality.
Collapse
Affiliation(s)
- Chuan Zhao
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Zhongqing Zhou
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Yongli Zhang
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Xueling Qi
- Department of Pathology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Xianlong Wang
- Department of Bioinformatics, School of Medical Technology and Engineering, Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian, China
| | - Da Lin
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Hongxing Liu
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, Ditan Hospital, Capital Medical University, Beijing, China
| | - Ye Wang
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, the Second Affiliated Hospital, Xiamen Medical College, Xiamen, Fujian, China
| | - Chaoqun Weng
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jintao Chen
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Wenxin Hu
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Lianming Liao
- Center of Laboratory Medicine, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Zhixiong Lin
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
7
|
Clarke L, Zyga O, Pineo-Cavanaugh PL, Jeng M, Fischbein NJ, Partap S, Katznelson L, Parker KJ. Socio-behavioral dysfunction in disorders of hypothalamic-pituitary involvement: The potential role of disease-induced oxytocin and vasopressin signaling deficits. Neurosci Biobehav Rev 2022; 140:104770. [PMID: 35803395 PMCID: PMC10999113 DOI: 10.1016/j.neubiorev.2022.104770] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 06/16/2022] [Accepted: 07/02/2022] [Indexed: 10/17/2022]
Abstract
Disorders involving hypothalamic and pituitary (HPIT) structures-including craniopharyngioma, Langerhans cell histiocytosis, and intracranial germ cell tumors-can disrupt brain and endocrine function. An area of emerging clinical concern in patients with these disorders is the co-occurring socio-behavioral dysfunction that persists after standard hormone replacement therapy. Although the two neuropeptides most implicated in mammalian social functioning (oxytocin and arginine vasopressin) are of hypothalamic origin, little is known about how disease-induced damage to HPIT structures may disrupt neuropeptide signaling and, in turn, impact patients' socio-behavioral functioning. Here we provide a clinical primer on disorders of HPIT involvement and a review of neuropeptide signaling and socio-behavioral functioning in relevant animal models and patient populations. This collective evidence suggests that neuropeptide signaling disruptions contribute to socio-behavioral deficits experienced by patients with disorders of HPIT involvement. A better understanding of the biological underpinnings of patients' socio-behavioral symptoms is now needed to enable the development of the first targeted pharmacological strategies by which to manage patients' socio-behavioral dysfunction.
Collapse
Affiliation(s)
- Lauren Clarke
- Department of Psychiatry and Behavioral Sciences, Stanford University, 1201 Welch Road, MSLS P-104, Stanford, CA 94305, USA
| | - Olena Zyga
- Department of Psychiatry and Behavioral Sciences, Stanford University, 1201 Welch Road, MSLS P-104, Stanford, CA 94305, USA
| | - Psalm L Pineo-Cavanaugh
- Department of Psychiatry and Behavioral Sciences, Stanford University, 1201 Welch Road, MSLS P-104, Stanford, CA 94305, USA
| | - Michael Jeng
- Department of Pediatrics (Hematology/Oncology Division), Stanford University, 1000 Welch Road, Suite 300, Palo Alto, CA 94304, USA
| | - Nancy J Fischbein
- Department of Radiology, Stanford University, 450 Quarry Rd, Suite 5659, Palo Alto, CA 94304, USA
| | - Sonia Partap
- Department of Neurology and Neurological Sciences (Child Neurology Division), Stanford University, 750 Welch Road, Suite 317, Palo Alto, CA 94304, USA
| | - Laurence Katznelson
- Departments of Neurosurgery and Medicine (Endocrinology Division), Stanford University, 875 Blake Wilbur Drive, Stanford, CA 94305, USA
| | - Karen J Parker
- Department of Psychiatry and Behavioral Sciences, Stanford University, 1201 Welch Road, MSLS P-104, Stanford, CA 94305, USA; Department of Comparative Medicine, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA.
| |
Collapse
|
8
|
Lin D, Zhao W, Yang J, Wang H, Zhang H. Integrative Analysis of Biomarkers and Mechanisms in Adamantinomatous Craniopharyngioma. Front Genet 2022; 13:830793. [PMID: 35432485 PMCID: PMC9006448 DOI: 10.3389/fgene.2022.830793] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/14/2022] [Indexed: 12/26/2022] Open
Abstract
Craniopharyngioma is a benign tumor, and the predominant treatment methods are surgical resection and radiotherapy. However, both treatments may lead to complex complications, seriously affecting patients’ survival rate and quality of life. Adamantinomatous craniopharyngioma (ACP), as one of the histological subtypes of craniopharyngioma, is associated with a high incidence and poor prognosis, and there is a gap in the targeted therapy of immune-related genes for ACP. In this study, two gene expression profiles of ACP, namely GSE68015 and GSE94349, were downloaded from the Gene Expression Omnibus (GEO) database. The differentially expressed genes (DEGs) were identified by the Limma package, and 271 differentially expressed immune-related genes (DEIRGs) were obtained from the Immport database. The gene ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and Gene Set Enrichment Analysis (GSEA) were performed for annotation, visualization, and integrated discovery. Five hub genes, including CXCL6, CXCL10, CXCL11, CXCL13, and SAA1, were screened out through protein-protein interaction (PPI) network interaction construction. Two diagnostic markers, namely S100A2 and SDC1 (both of which have the Area Under Curve value of 1), were screened by the machine learning algorithm. CIBERSORT analysis showed that M2 macrophages, activated NK cells, and gamma delta T cells had higher abundance in ACP infiltration, while CD8+ T cells, regulatory T cells, and Neutrophils had less abundance in ACP infiltration. The expression of gamma delta T cells was positively correlated with CXCL6, S100A2, SDC1, and SAA1, while CD8+ T cells expression was negatively correlated with CXCL6, S100A2, SDC1, and CXCL10. ACP with high CXCL6 showed remarkable drug sensitivity to Pentostatin and Wortmannin via CellMiner database analysis. Our results deepened the understanding of the molecular immune mechanism in ACP and provided potential biomarkers for the precisely targeted therapy for ACP.
Collapse
Affiliation(s)
- Da Lin
- Department of Neurosurgery, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Wenyue Zhao
- Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Jun Yang
- Department of Neurosurgery, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Hao Wang
- Department of Neurosurgery, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Hongbing Zhang
- Department of Neurosurgery, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- *Correspondence: Hongbing Zhang,
| |
Collapse
|
9
|
Du C, Leng Y, Zhou Q, Xiao JX, Yuan XR, Yuan J. Relationship between postoperative hypothalamic injury and water and sodium disturbance in patients with craniopharyngioma: A retrospective study of 178 cases. Front Endocrinol (Lausanne) 2022; 13:958295. [PMID: 36120435 PMCID: PMC9478176 DOI: 10.3389/fendo.2022.958295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/15/2022] [Indexed: 11/29/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Can Du
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Yueshuang Leng
- Radiological Intervention Center, Department of Radiology, Xiangya Hospital, Central South University, Changsha, China
| | - Quanwei Zhou
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Ju-Xiong Xiao
- Radiological Intervention Center, Department of Radiology, Xiangya Hospital, Central South University, Changsha, China
| | - Xian-Rui Yuan
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Department of Neurosurgery, The Institute of Skull Base Surgery and Neuro-oncology at Hunan, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Jian Yuan
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Department of Neurosurgery, The Institute of Skull Base Surgery and Neuro-oncology at Hunan, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Jian Yuan,
| |
Collapse
|
10
|
Prieto R, Barrios L, Pascual JM. Strictly third ventricle craniopharyngiomas: pathological verification, anatomo-clinical characterization and surgical results from a comprehensive overview of 245 cases. Neurosurg Rev 2021; 45:375-394. [PMID: 34448081 DOI: 10.1007/s10143-021-01615-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/29/2021] [Accepted: 07/22/2021] [Indexed: 11/29/2022]
Abstract
The strictly third ventricle craniopharyngioma topography (strictly 3V CP) defines the subgroup of lesions developed above an anatomically intact third ventricle floor (3VF). The true existence of this exceedingly rare topographical category is highly controversial owing to the presumed embryological CP origin from Rathke's pouch, a structure developmentally situated outside the neural tube. This study thoroughly analyzes the largest series of strictly 3V CPs ever collected. From 5346 CP reports published between 1887 and 2021, we selected 245 cases with reliable pathological, surgical, and/or neuroradiological verification of an intact 3VF beneath the tumor. This specific topography occurs predominantly in adult (92.6%), male (64.4%) patients presenting with headache (69.2%), and psychiatric disturbances (59.2%). Neuroradiological features defining strictly 3V CPs are a tumor-free chiasmatic cistern (95.9%), an entirely visible pituitary stalk (86.4%), and the hypothalamus positioned around the tumor's lower pole (92.6%). Most are squamous papillary (82%), showing low-risk severity adhesions to the hypothalamus (74.2%). The adamantinomatous variant, however, associates a higher risk of severe hypothalamic adhesion (p < .001). High-risk attachments are also associated with psychiatric symptoms (p = .013), which represented the major predictor for unfavorable prognoses (83.3% correctly predicted) among cases operated from 2006 onwards. CP recurrence is associated with infundibulo-tuberal symptoms (p = .036) and incomplete surgical removal (p = .02). The exclusive demographic, clinico-pathological and neuroradiological characteristics of strictly 3V CPs make them a separate, unique topographical category. Accurately distinguishing strictly 3V CPs preoperatively from those tumors replacing the infundibulum and/or tuber cinereum (infundibulo-tuberal or not strictly 3V CPs) is critical for proper, judicious surgical planning.
Collapse
Affiliation(s)
- Ruth Prieto
- Department of Neurosurgery, Puerta de Hierro University Hospital, Manuel de Falla 1, 28222, Majadahonda, Madrid, Spain.
| | - Laura Barrios
- Statistics Department, Computing Center, CSIC, Madrid, Spain
| | - José M Pascual
- Department of Neurosurgery, La Princesa University Hospital, Madrid, Spain
| |
Collapse
|
11
|
Lin D, Yang Y, Zhou Z. Natural pregnancy after gross total resection of a large craniopharyngioma with hypothalamic involvement: a case report. Acta Neurol Belg 2021; 122:1641-1644. [PMID: 34406611 DOI: 10.1007/s13760-021-01773-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/03/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Da Lin
- Department of Neurosurgery, Capital Medical University Sanbo Brain Hospital, Beijing, China
| | - Yang Yang
- Department of Neurosurgery, Capital Medical University Sanbo Brain Hospital, Beijing, China
| | - Zhongqing Zhou
- Department of Neurosurgery, Capital Medical University Sanbo Brain Hospital, Beijing, China.
| |
Collapse
|
12
|
Fan J, Liu Y, Pan J, Peng Y, Peng J, Bao Y, Nie J, Wang C, Qiu B, Qi S. Endoscopic endonasal versus transcranial surgery for primary resection of craniopharyngiomas based on a new QST classification system: a comparative series of 315 patients. J Neurosurg 2021; 135:1298-1309. [PMID: 33668037 DOI: 10.3171/2020.7.jns20257] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 07/08/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE An assessment of the transcranial approach (TCA) and the endoscopic endonasal approach (EEA) for craniopharyngiomas (CPs) according to tumor types has not been reported. The aim of this study was to evaluate both surgical approaches for different types of CPs. METHODS A retrospective review of primary resected CPs was performed. A QST classification system based on tumor origin was used to classify tumors into 3 types as follows: infrasellar/subdiaphragmatic CPs (Q-CPs), subarachnoidal CPs (S-CPs), and pars tuberalis CPs (T-CPs). Within each tumor type, patients were further arranged into two groups: those treated via the TCA and those treated via the EEA. Patient and tumor characteristics, surgical outcomes, and postoperative complications were obtained. All variables were statistically analyzed between surgical groups for each tumor type. RESULTS A total of 315 patients were included in this series, of whom 87 were identified with Q-CPs (49 treated via TCA and 38 via EEA); 56 with S-CPs (36 treated via TCA and 20 via EEA); and 172 with T-CPs (105 treated via TCA and 67 via EEA). Patient and tumor characteristics were equivalent between both surgical groups in each tumor type. The overall gross-total resection rate (90.5% TCA vs 91.2% EEA, p = 0.85) and recurrence rate (8.9% TCA vs 6.4% EEA, p = 0.35) were similar between surgical groups. The EEA group had a greater chance of visual improvement (61.6% vs 35.8%, p = 0.01) and a decreased risk of visual deterioration (1.6% vs 11.0%, p < 0.001). Of the patients with T-CPs, postoperative hypothalamic status was better in the TCA group than in the EEA group (p = 0.016). Postoperative CSF leaks and nasal complication rates occurred more frequently in the EEA group (12.0% vs 0.5%, and 9.6% vs 0.5%; both p < 0.001). For Q-CPs, EEA was associated with an increased gross-total resection rate (97.4% vs 85.7%, p = 0.017), decreased recurrence rate (2.6% vs 12.2%, p = 0.001), and lower new hypopituitarism rate (28.9% vs 57.1%, p = 0.008). The recurrence-free survival in patients with Q-CPs was also significantly different between surgical groups (log-rank test, p = 0.037). The EEA required longer surgical time for T-CPs (p = 0.01). CONCLUSIONS CPs could be effectively treated by radical surgery with favorable results. Both TCA and EEA have their advantages and limitations when used to manage different types of tumors. Individualized surgical strategies based on tumor growth patterns are mandatory to achieve optimal outcomes.
Collapse
|
13
|
Hu M, Shi X, Liu F, Sun Y, Qian H, Zhou Z, Shi X. Aggressive resection of craniopharyngioma achieved by drilling the tuberculum sellae/planum sphenoidale using a frontal basal interhemispheric approach: A review of 55 cases. J Clin Neurosci 2020; 83:13-20. [PMID: 33328148 DOI: 10.1016/j.jocn.2020.11.042] [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: 05/11/2020] [Revised: 09/17/2020] [Accepted: 11/23/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The frontal basal interhemispheric approach (FBIA) is preferable for resection of craniopharyngioma (CP), achieving desirable total resection rates in early reports of lesions located in the suprasellar region to the third ventricle. For tumours that have created a larger obstruction of the tuberculum sellae and planum sphenoidale, aggressive resection in the intrasellar region and medial wall of the cavernous sinus is not feasible compared to improving tumour visualization by drilling the tuberculum sellae and planum sphenoidale. In a report of drilling the sellar tuberculum and sphenoid planum, drilling allowed the direct visualization of tumours invading the intrasellar region and medial wall of the cavernous sinus. Reconstructing the opening of the sellar-sphenoid cavity is achieved by microsuturing a piece of the pericranium/dura around the dural edge of the defective dura of the open sphenoid sinus and sellar cavity to prevent cerebrospinal fluid (CSF) leakage. PATIENTS AND METHODS The FBIA with drilling of the tuberculum sellae and planum sphenoidale was performed to remove the tumours that invaded the intrasellar region and cavernous sinus in 55 patients from January 2014 to October 2019 at our institution. The pre- and postoperative pituitary hormone levels and vision were evaluated as effective standards after surgery and compared using paired t-tests. The different rates of CSF leakage between the packing and microsuture groups were compared by χ2 test, p < 0.05. RESULTS In all patients with a mean 37-month follow-up (range, 3-2 months), 43 (78.2%) patients returned to their normal life or school independently, 7 (12.7%) patients were able to perform normal activities with minor complaints or effort, and 4 (7.3%) patients could care for themselves or only required occasional assistance. One (1.8%) death occurred, attributed to CSF leak-related meningitis at 5 months after surgery. Postoperative CSF leakage occurred in eight (19.0%) of 42 patients with packed bone wax or pieces of muscle to the sphenoid sinus. Of 13 patients with a piece of the periosteum/dura microsutured around the defective dura of the sellar region and open sphenoid sinus, one (7.7%) of 13 patients experienced CSF leakage in the perioperative period. With statistical analysis, there was a potential risk for postoperative CSF leakage in the bone wax and muscle piece in the open sphenoid sinus, whereas microsuture manoeuvres were effective for avoiding the risk of postoperative CSF leakage (χ2 = 8.865, p < 0.005). The microsutures closed the open sphenoid sinus such that it was water-tight. Postoperative visual acuity and the visual field were not affected by the increased intrasellar exposure or the open sphenoid sinus achieved by drilling the tuberculum sellae and planum sphenoidale. CONCLUSION Tuberculum sellae/planum sphenoidale drilling via FBIA is feasible to enhance the direct visualization of CP resection, which expands the intrasellar region with a direct resection of recurrent tumours in the sellar cavity and adhering to the medial wall of the cavernous sinus. The potential risk of a CSF leakage seemed to be mitigated when using water-tight microsutures on a piece of the pericranium/dura around the edge of the defective dura in the sellar region and the open sphenoid sinus cavity.
Collapse
Affiliation(s)
- Mengqing Hu
- Department of Neurosurgery, Fuxing Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Xiang'en Shi
- Department of Neurosurgery, Fuxing Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China.
| | - Fangjun Liu
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Yuming Sun
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Hai Qian
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Zhongqing Zhou
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Xiaocui Shi
- Department of Clinical Laboratory Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
14
|
Nuijts MA, Veldhuis N, Stegeman I, van Santen HM, Porro GL, Imhof SM, Schouten–van Meeteren AYN. Visual functions in children with craniopharyngioma at diagnosis: A systematic review. PLoS One 2020; 15:e0240016. [PMID: 33002047 PMCID: PMC7529266 DOI: 10.1371/journal.pone.0240016] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/18/2020] [Indexed: 02/06/2023] Open
Abstract
Childhood craniopharyngioma is a rare and slow growing brain tumour, often located in the sellar and suprasellar region. It commonly manifests with visual impairment, increased intracranial pressure and hypothalamic and/or pituitary deficiencies. Visual impairment in childhood adversely affects a child’s daily functioning and quality of life. We systematically reviewed the literature to provide an extensive overview of the visual function in children with craniopharyngioma at diagnosis in order to estimate the diversity, magnitude and relevance of the problem of visual impairment. Of the 543 potentially relevant articles, 84 studies met our inclusion criteria. Visual impairment at diagnosis was reported in 1041 of 2071 children (50.3%), decreased visual acuity was reported in 546 of 1321 children (41.3%) and visual field defects were reported in 426 of 1111 children (38.3%). Other ophthalmological findings described were fundoscopic (32.5%) and orthoptic abnormalities (12.5%). Variations in ophthalmological testing methods and ophthalmological definitions precluded a meta-analysis. The results of this review confirm the importance of ophthalmological examination in children with craniopharyngioma at diagnosis in order to detect visual impairment and provide adequate support. Future studies should focus on long-term visual follow-up of childhood craniopharyngioma in response to different treatment strategies to provide insight in risks and ways to prevent further loss of vision.
Collapse
Affiliation(s)
- Myrthe A. Nuijts
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- * E-mail:
| | - Nienke Veldhuis
- Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
| | - Inge Stegeman
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hanneke M. van Santen
- Department of Pediatric Endocrinology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Giorgio L. Porro
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Saskia M. Imhof
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | |
Collapse
|
15
|
Wang Y, Deng J, Wang L, Zhou T, Yang J, Tian Z, Yang J, Chen H, Tang X, Zhao S, Zhou L, Tong A, Xu J. Expression and clinical significance of PD-L1, B7-H3, B7-H4 and VISTA in craniopharyngioma. J Immunother Cancer 2020; 8:jitc-2019-000406. [PMID: 32958683 PMCID: PMC7507895 DOI: 10.1136/jitc-2019-000406] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2020] [Indexed: 02/05/2023] Open
Abstract
Background Craniopharyngioma (CP) is a common refractory tumor of the central nervous system. However, little is known about the expression and clinical significance of B7 family ligands/receptors in CP patients. Thus, we conducted the present study to address this issue in a cohort of 132 CP cases. Methods We mapped and quantified the expression of B7 family ligands/receptors molecules programmed cell death ligand 1 (PD-L1), B7-H3, B7-H4 and V-domain Ig-containing suppressor of T cell activation (VISTA) in 89 adamantinomatous-type CP and 43 papillary-type CP samples using immunohistochemistry and immunofluorescence. Associations between the marker levels, clinicopathological variables and survival were evaluated. Results The positive rates of PD-L1, B7-H3, B7-H4 and VISTA in the cohort of 132 CP cases were 76.5%, 100%, 40.2% and 80.3%, respectively. The cut-off values of PD-L1, B7-H3, B7-H4 and PD-L1 expression were determined by survival receiver operating characteristic (ROC) package, which was 70, 182, 0 and 20, respectively. Elevated expressions of PD-L1, B7-H3, B7-H4 and VISTA were significantly associated with some clinicopathological characteristics. Kaplan-Meier analysis indicated that higher VISTA expressions correlated with better overall survival (OS) and progression-free survival (PFS) (p=0.0053 and p=0.0066, respectively). Multivariate Cox regression analysis indicated that VISTA was an independent prognostic factor for OS (p=0.018) but not for PFS (p=0.898). Conclusions We found variable expression of PD-L1, B7-H3, B7-H4 and VISTA proteins in CPs. The results suggest that the expression level of VISTA may be used as an important indicator to predict the OS and PFS of CPs. B7 family ligands/receptors could be potential immunotherapeutic targets when treating CPs.
Collapse
Affiliation(s)
- Yuelong Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China.,State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Jiaojiao Deng
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Lin Wang
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Tingyue Zhou
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Jinlong Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zerong Tian
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jinhao Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Hongxu Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Tang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Shasha Zhao
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Liangxue Zhou
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Aiping Tong
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Jianguo Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
16
|
Algattas H, Setty P, Goldschmidt E, Wang EW, Tyler-Kabara EC, Snyderman CH, Gardner PA. Endoscopic Endonasal Approach for Craniopharyngiomas with Intraventricular Extension: Case Series, Long-Term Outcomes, and Review. World Neurosurg 2020; 144:e447-e459. [PMID: 32890848 DOI: 10.1016/j.wneu.2020.08.184] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Traditionally, craniopharyngiomas with intraventricular extension were approached transcranially; however, endoscopic approaches are now increasingly used. We sought to study the endoscopic endonasal approach (EEA) in the setting of complex craniopharyngiomas with intraventricular extension and to compare it with existing literature. METHODS Patients undergoing EEA for resection of craniopharyngioma with ventricular involvement from 2002 to 2015 were retrospectively reviewed. Outcomes were compared with previously published EEA and transcranial approach (TCA) studies for all craniopharyngioma locations. RESULTS Sixty-two patients were included. Average tumor and intraventricular volume were 13.93 cm3 and 2.61 cm3, respectively. Patients presented with visual impairment, endocrinopathy, and, headache. Gross total resection (GTR) was achieved in 47% of all cases and increased to 77% after 2012 Approximately 98% experienced improvement or stability of vision. Postoperative cerebrospinal fluid (CSF) leak and meningitis rates were 19% and 8.1%, respectively. However, nasoseptal flap (NSF) use reduced CSF leak rate to 10%. Six (9.6%) patients required shunting before resection and 25% were shunted postoperatively. Seven of 10 patients (70%) treated before NSF use required shunting, whereas only 7 of 46 (15%) required shunting with NSF reconstruction. Review demonstrated similar outcomes between the present cohort and EEA or TCA for all craniopharyngioma locations. TCA had a greater GTR, however, with large study variation. EEA showed improved visual outcomes but also increased CSF leaks. CONCLUSIONS EEA for craniopharyngiomas with intraventricular extension shows similar outcomes to TCA and EEA for all craniopharyngiomas, expanding this anatomic limit. Given ventricular involvement, CSF leak rates are expectedly high. GTR increased and CSF leak rates dramatically decreased with time, suggestive of the steep learning curve to complex resection.
Collapse
Affiliation(s)
- Hanna Algattas
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania, USA.
| | - Pradeep Setty
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania, USA
| | - Ezequiel Goldschmidt
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania, USA
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania, USA
| | - Elizabeth C Tyler-Kabara
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania, USA
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania, USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
17
|
Prieto R, Rosdolsky M, Hofecker V, Barrios L, Pascual JM. Craniopharyngioma treatment: an updated summary of important clinicopathological concepts. Expert Rev Endocrinol Metab 2020; 15:261-282. [PMID: 32615875 DOI: 10.1080/17446651.2020.1770081] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/13/2020] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Craniopharyngiomas (CPs) are benign histological tumors that may develop at different positions along the hypothalamic-pituitary axis. Their close, heterogenous relationship to the hypothalamus makes surgical removal challenging even though this remains the primary treatment strategy. AREAS COVERED This article presents a critical overview of the pathological and clinical concepts regarding CPs that should be considered when planning treatment. Thus, we have performed a comprehensive review of detailed CP reports published between 1839 and 2020. EXPERT OPINION CP surgery should pursue maximal tumor resection while minimizing the risk of injuring the hypothalamus. Therefore, surgical strategies should be individualized for each patient. Accurate assessment of presenting symptoms and preoperative MRI has proven useful to predict the type of CP-hypothalamus relationship that will be found during surgery. CPs with dense and extensive adhesions to the hypothalamus should be highly suspected when MRI shows the hypothalamus positioned around the mid-third of the tumor and an amputated upper portion of the pituitary stalk. Symptoms related to functional impairment of the infundibulo-tuberal area of the third ventricle floor, such as obesity/hyperphagia, Fröhlich's syndrome, diabetes insipidus, and/or somnolence, also indicate risky CP-hypothalamic adhesions. In these cases, limited tumor removal is strongly advocated followed by radiation therapy.
Collapse
Affiliation(s)
- Ruth Prieto
- Department of Neurosurgery, Puerta de Hierro University Hospital , Madrid, Spain
| | | | - Verena Hofecker
- Pathologisch-anatomische Sammlung Im Narrenturm - NHM , Vienna, Austria
| | - Laura Barrios
- Statistics Department, Computing Center, CSIC , Madrid, Spain
| | - José M Pascual
- Department of Neurosurgery, La Princesa University Hospital , Madrid, Spain
| |
Collapse
|
18
|
Drapeau A, Walz PC, Eide JG, Rugino AJ, Shaikhouni A, Mohyeldin A, Carrau RL, Prevedello DM. Pediatric craniopharyngioma. Childs Nerv Syst 2019; 35:2133-2145. [PMID: 31385085 DOI: 10.1007/s00381-019-04300-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 07/07/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Craniopharyngioma has historically been recognized to be a formidable pathology primarily due to its proximity to critical neurovascular structures and the challenging surgical corridors that surgeons have tried to reach this lesion. FOCUS OF REVIEW In this work, we review the medical and surgical management of these tumors with a focus on clinical presentation, diagnostic identification, surgical approach, and associated adjuvant therapies. We will also discuss our current treatment paradigm using endoscopic, open, and combined approaches to craniopharyngiomas. The management of craniopharyngiomas requires a multidisciplinary team of surgeons, endocrinologists, and neuroanesthesiologists as well as neurocritical care specialists to deliver the most comprehensive and safest surgical resection with minimal postoperative morbidity.
Collapse
Affiliation(s)
- Annie Drapeau
- Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Patrick C Walz
- Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, USA. .,Department of Pediatric Otolaryngology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, 43205, OH, USA.
| | - Jacob G Eide
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Ammar Shaikhouni
- Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ahmed Mohyeldin
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ricardo L Carrau
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Daniel M Prevedello
- Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, USA
| |
Collapse
|
19
|
Prieto R, Pascual JM, Barrios L. Harvey Cushing’s craniopharyngioma treatment: Part 2. Surgical strategies and results of his pioneering series. J Neurosurg 2019; 131:964-978. [DOI: 10.3171/2018.5.jns18154] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/29/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEHarvey Cushing (1869–1939) developed pioneering surgical techniques for craniopharyngioma (CP) removal. This study exhaustively analyzes the pathological variables and surgical strategies that influenced Cushing’s results in his entire series of CP patients.METHODSThe CP records from Cushing’s Brain Tumor Registry were carefully reviewed, as were his CP cases published in medical monographs and scientific reports.RESULTSOne hundred twenty-four tumors with characteristics typical of CP comprise Cushing’s entire series (CP124). Cushing performed 198 surgical procedures in the patients in whom these tumors were treated, with a 23% mortality rate within the first 2 months after surgery. Three periods in Cushing’s CP surgical career can be differentiated: an early period (1901–1917, 39 patients) characterized by his use of the transsphenoidal approach and limited cyst drainage procedures, an intermediate period (1919–1925, 42 patients) in which the subfrontal approach was the standard procedure and maximal removal was attempted, and a late period (1926–1932, 43 patients) characterized by the use of air ventriculography for topographical diagnosis and limited resections via a transventricular approach. Among Cushing’s CP series were 92 cases that were pathologically verified (CP92). In this subcohort, the unilateral subfrontal approach was predominantly used (72% of cases), followed by the transsphenoidal (15%) and frontal transcortical-transventricular (8%) approaches. Drainage of the CP cystic component or partial excision of the solid component was achieved in 61% of the cases, subtotal removal in 23%, and macroscopic total removal in 10%. Satisfactory outcomes were obtained in 55% of the patients in CP92, whereas poor outcomes and/or death related to hypothalamic injury was observed in 28%. Postoperative symptoms related to hypothalamic dysfunction occurred 53% of the time. The subfrontal approach yielded the highest rates of radical removal (p < 0.001) and good outcomes (p = 0.01). Partial removals were associated with the highest rates of poor outcomes, including death (p = 0.009). Cushing’s removal of CPs with a primary infundibulo-tuberal topography or showing third ventricle invasion was associated with the highest rates of hypothalamic injury (p < 0.001) and the worst outcomes (p = 0.009).CONCLUSIONSHarvey Cushing’s techniques and surgical philosophy varied substantially throughout his career. The experience he gained with this large CP series made him aware of the importance of limiting the extent of tumor removal and leaving untouched the tumor portion strongly adhered to the hypothalamus.
Collapse
Affiliation(s)
- Ruth Prieto
- 1Department of Neurosurgery, Puerta de Hierro University Hospital
| | | | - Laura Barrios
- 3Statistics Department, Computing Center, CSIC, Madrid, Spain
| |
Collapse
|
20
|
Lin D, Wang Y, Zhou Z, Lin Z. Immune Microenvironment of Primary and Recurrent Craniopharyngiomas: A Study of the Differences and Clinical Significance. World Neurosurg 2019; 127:e212-e220. [DOI: 10.1016/j.wneu.2019.02.212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 01/22/2023]
|
21
|
|
22
|
Ni W, Shi X. Interventions for the Treatment of Craniopharyngioma-Related Hypothalamic Obesity: A Systematic Review. World Neurosurg 2018; 118:e59-e71. [PMID: 29945001 DOI: 10.1016/j.wneu.2018.06.121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 06/12/2018] [Accepted: 06/14/2018] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Craniopharyngiomas (CPs) and their treatment are associated with hypothalamic damage that causes hypothalamic obesity (HO) in 30%-70% of cases. Thus, there is ongoing research regarding tangible solutions for HO, because these patients have unrelenting resistance to basic weight-loss interventions. This review aims to summarize the interventions that are used to treat CP-related HO (CP-HO), including pharmacotherapy and bariatric surgery. METHODS The Cochrane Library, EMBASE, and PubMed databases were searched up to June 2017 for relevant reports. Two reviewers conducted independent evaluations of the studies identified. RESULTS Eighteen articles were included in the systematic review, with 3 reports describing pharmacotherapy in randomized controlled trials and 15 reports describing bariatric surgery. Although several studies described effective interventions for treating CP-HO, the evidence base was limited by its low quality and our inability to perform a meta-analysis, which was related to a lack of adequate or integrated data. CONCLUSIONS Octreotide appears to be a preferred treatment for patients with CP-HO, based on limited data. Gastric bypass surgery may also be suitable for select patients with CP-HO, based on a review of various procedures in this setting. Microsurgical preservation of the hypothalamic structures is mandatory to decrease CP-HO-related morbidity and mortality. Further studies with adequate analytical power and sufficient follow-up are needed to identify effective strategies for CP-HO treatment.
Collapse
Affiliation(s)
- Weimin Ni
- Department of Neurosurgery, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Xiang'en Shi
- Department of Neurosurgery, Fu Xing Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
23
|
Guo F, Wang G, Suresh V, Xu D, Zhang X, Feng M, Wang F, Liu X, Song L. Clinical study on microsurgical treatment for craniopharyngioma in a single consecutive institutional series of 335 patients. Clin Neurol Neurosurg 2018; 167:162-172. [PMID: 29501046 DOI: 10.1016/j.clineuro.2018.02.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 02/19/2018] [Accepted: 02/20/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The optimal management of craniopharyngioma is still controversial. The aim of this study is to explore microsurgical outcomes of craniopharyngioma in 335 cases. PATIENTS AND METHODS Clinical data of 335 consecutive patients with craniopharyngioma between March 2011 and March 2017 were retrospectively analyzed. RESULTS Gross total resection (GTR) was achieved in 265 cases (79.1%), subtotal resection (STR) was obtained in 70 cases (20.9%). The GTR rate was 81.93% in pediatric group and 78.17% in adult group respectively, no significant difference regarding the GTR rate was found in adult group compared with in pediatric group (p > 0.05). However, there was a noticeable difference in the elevated hypothalamic obesity in children group compared with in adult group after operation (p < 0.05). Multivariate analysis indicated that the tumor recurrence and surgical times played a negative role in the resection extent, the odds ratio and 95% confidence interval of the tumor recurrence and surgical times is [0.306 (0.155-0.603), (p < 0.01)] and [2.135 (1.101-4.142), (p < 0.05)] respectively. There was significant difference on panhypopituitarism between GTR and STR group (p < 0.05). However, No significant difference regarding the postoperative visual dysfunction and indepent quality of life respectively between GTR and STR group was found (p > 0.05). Additionally, there were no statistically significant differences for recurrence-free curves between GTR and STR plus adjuvant radiotherapy (p > 0.05). CONCLUSIONS Present findings demonstrated that tumor recurrence and surgical times contribute to negative total resection for craniopharyngioma. Postoperative precise adjuvant radiotherapy was considered in selected cases if pursuit of GTR was rather dangerous under disadvantageous removal factors.
Collapse
Affiliation(s)
- Fuyou Guo
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, 450052 PR China; Key Laboratory of Neurosurgical Diseases, The First Affiliated Hospital of Zhengzhou University, Jianshe East Road, No 1, Zhengzhou, Henan Province, 450052, PR China.
| | - Guoqing Wang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, 450052 PR China
| | - Vigneyshwar Suresh
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, 450052 PR China
| | - Dingkang Xu
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, 450052 PR China
| | - Xiaoyang Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, 450052 PR China
| | - Mengzhao Feng
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, 450052 PR China
| | - Fang Wang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, 450052 PR China
| | - Xianzhi Liu
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, 450052 PR China
| | - Laijun Song
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, 450052 PR China
| |
Collapse
|
24
|
Wijnen M, Olsson DS, van den Heuvel-Eibrink MM, Hammarstrand C, Janssen JAMJL, van der Lely AJ, Johannsson G, Neggers SJCMM. Excess morbidity and mortality in patients with craniopharyngioma: a hospital-based retrospective cohort study. Eur J Endocrinol 2018; 178:93-102. [PMID: 29046325 DOI: 10.1530/eje-17-0707] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 10/08/2017] [Accepted: 10/16/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Most studies in patients with craniopharyngioma did not investigate morbidity and mortality relative to the general population nor evaluated risk factors for excess morbidity and mortality. Therefore, the objective of this study was to examine excess morbidity and mortality, as well as their determinants in patients with craniopharyngioma. DESIGN Hospital-based retrospective cohort study conducted between 1987 and 2014. METHODS We included 144 Dutch and 80 Swedish patients with craniopharyngioma identified by a computer-based search in the medical records (105 females (47%), 112 patients with childhood-onset craniopharyngioma (50%), 3153 person-years of follow-up). Excess morbidity and mortality were analysed using standardized incidence and mortality ratios (SIRs and SMRs). Risk factors were evaluated univariably by comparing SIRs and SMRs between non-overlapping subgroups. RESULTS Patients with craniopharyngioma experienced excess morbidity due to type 2 diabetes mellitus (T2DM) (SIR: 4.4, 95% confidence interval (CI): 2.8-6.8) and cerebral infarction (SIR: 4.9, 95% CI: 3.1-8.0) compared to the general population. Risks for malignant neoplasms, myocardial infarctions and fractures were not increased. Patients with craniopharyngioma also had excessive total mortality (SMR: 2.7, 95% CI: 2.0-3.8), and mortality due to circulatory (SMR: 2.3, 95% CI: 1.1-4.5) and respiratory (SMR: 6.0, 95% CI: 2.5-14.5) diseases. Female sex, childhood-onset craniopharyngioma, hydrocephalus and tumour recurrence were identified as risk factors for excess T2DM, cerebral infarction and total mortality. CONCLUSIONS Patients with craniopharyngioma are at an increased risk for T2DM, cerebral infarction, total mortality and mortality due to circulatory and respiratory diseases. Female sex, childhood-onset craniopharyngioma, hydrocephalus and tumour recurrence are important risk factors.
Collapse
Affiliation(s)
- Mark Wijnen
- Department of Medicine Section Endocrinology, Pituitary Centre Rotterdam, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Paediatric Oncology/Haematology Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Daniel S Olsson
- Department of Endocrinology Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Marry M van den Heuvel-Eibrink
- Department of Paediatric Oncology/Haematology Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
- Princess Maxima Centre for Paediatric Oncology Utrecht, The Netherlands
| | - Casper Hammarstrand
- Department of Endocrinology Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Joseph A M J L Janssen
- Department of Medicine Section Endocrinology, Pituitary Centre Rotterdam, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Aart J van der Lely
- Department of Medicine Section Endocrinology, Pituitary Centre Rotterdam, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Gudmundur Johannsson
- Department of Endocrinology Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sebastian J C M M Neggers
- Department of Medicine Section Endocrinology, Pituitary Centre Rotterdam, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Paediatric Oncology/Haematology Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| |
Collapse
|