Craniopharyngioma: improving outcome by early recognition and treatment of acute complications

Adamantinomatous craniopharyngioma: evolution in the management

BACKGROUND

In spite of the continuous progresses in pediatric neurosurgery, adamantinomatous craniopharyngioma (AC) remains a challenging tumor due to its proximity to optic pathways, pituitary gland, hypothalamus, and Willis' circle, which can result in significant endocrine, cognitive, and neurological morbidity after treatment with subsequent impact on the patient's quality of life (QoL). The relevance that QoL has today explains the changes in the management of AC observed over the time. The goal of the present article is to provide a historical background, to show the milestones in the changes of the AC treatment, and to analyze the current main options to manage such a challenging tumor.

MATERIAL AND METHODS

The pertinent literature has been reviewed. Moreover, a comparison between the past and recent personal series is reported.

RESULTS

Three main eras have been identified. The first (named Cushing era) was characterized by the need to realize a harmless surgery and to define the best way to approach AC; the second (microscope era) was characterized by a tremendous technical and technological development, with remarkable results in term of safe tumor resection and control but relatively poor QoL outcomes; and the third one (current period) is characterized by an increasing integration between surgery and adjuvant treatments, with relatively minor tumor control but significant improvement of QoL (comparable overall survival). The authors' experience reflects these changes. Two groups of children were compared: 52 cases (mean follow-up: 17.5 years) belong to the historical series (group 1, 1985-2003, aggressive surgical management) and 41 (mean follow-up: 8.5 years) to the current one (Group 2, 2004-2021, integrated management). No significant differences between the two groups were detected about recurrence rate, surgical mortality, and overall survival. However, Group 2 showed significant lower rates of postoperative panhypopituitarism, obesity, and visual deterioration.

CONCLUSIONS

Radical surgery allows for a good AC control with a low rate of recurrence but high risk of permanent morbidity. Despite the greater number of recurrences and surgeries, the more conservative policy, based on a combination of treatments, seems to provide the same tumor control with a better QoL. The advances in trans-nasal and trans-ventricular endoscopy, in proton therapy and in the management of the AC cyst are the main factors that allowed such an improvement.

Margin-Free Fractionated Stereotactic Radiation Therapy for Pediatric Brain Tumors

PURPOSE

Conventional radiation therapy (RT) to pediatric brain tumors exposes a large volume of normal brain to unwarranted radiation causing late toxicity. We hypothesized that in well demarcated pediatric tumors lacking microscopic extensions, fractionated stereotactic RT (SRT), without target volume expansions, can reduce high dose normal tissue irradiation without affecting local control.

METHODS AND MATERIALS

Between 2008 and 2017, 52 pediatric patients with brain tumors were treated using the CyberKnife (CK) with SRT in 180 to 200 cGy per fraction. Thirty representative cases were retrospectively planned for intensity modulated RT (IMRT) with 4-mm PTV expansion. We calculated the volume of normal tissue within the high or intermediate dose region adjacent to the target. Plan quality and radiation dose-volume dosimetry parameters were compared between CK and IMRT plans. We also reported overall survival, progression-free survival (PFS), and local control.

RESULTS

Tumors included low-grade gliomas (n = 28), craniopharyngiomas (n = 16), and ependymomas (n = 8). The volumes of normal tissue receiving high (≥80% of prescription dose or ≥40 Gy) or intermediate (80% > dose ≥50% of the prescription dose or 40 Gy > dose ≥25 Gy) dose were significantly smaller with CK versus IMRT plans (P < .0001 for all comparisons). With a median follow-up of 3.7 years (range, 0.1-9.0), 3-year local control was 92% for all patients. Eight failures occurred: 1 craniopharyngioma (marginal), 2 ependymomas (both in-field), and 5 low-grade gliomas (2 in-field, 1 marginal, and 2 distant).

CONCLUSIONS

Fractionated SRT using CK without target volume expansion appears to reduce the volume of irradiated tissue without majorly compromising local control in pediatric demarcated brain tumors. These results are hypothesis generating and should be tested and validated in prospective studies.

Long-term disease control and toxicity outcomes following surgery and intensity modulated radiation therapy (IMRT) in pediatric craniopharyngioma

PURPOSE

To report long-term progression-free survival (PFS) and late-toxicity outcomes in pediatric craniopharyngioma patients treated with IMRT.

PATIENTS AND METHODS

Twenty-four children were treated with IMRT to a median dose of 50.4Gy (range, 49.8-54Gy). The clinical target volume (CTV) was the gross tumor volume (GTV) with a 1cm margin. The planning target volume (PTV) was the CTV with a 3-5mm margin. Median follow-up was 107.3months.

RESULTS

The 5- and 10-year PFS rates were 65.8% and 60.7%. The 5- and 10-year cystic PFS rates were 70.2% and 65.2% while the 5- and 10-year solid PFS were the same at 90.7%. Endocrinopathy was seen in 42% at initial diagnosis and in 74% after surgical intervention, prior to IMRT. Hypothalamic dysfunction and visual deficits were associated with increasing PTV and number of surgical interventions.

CONCLUSIONS

IMRT is a viable treatment option for pediatric craniopharyngioma. Despite the use of IMRT, majority of the craniopharyngioma patients experienced long-term toxicity, many of which present prior to radiotherapy. Limitations of retrospective analyses on small patient cohort elicit the need for a prospective multi-institutional study to determine the absolute benefit of IMRT in pediatric craniopharyngioma.

Management of craniopharyngiomas

Craniopharyngiomas are rare epithelial tumours arising along the path of the craniopharyngeal duct. Their pathogenesis remains uncertain and they can present with a variety of manifestations attributed to pressure effects to surrounding structures. The optimal management of craniopharyngiomas remains challenging mainly due to their sharp, irregular borders and their tendency to adhere to vital neurovascular structures making surgical manipulations potentially hazardous to vital brain areas. Non-aggressive surgery followed by radiotherapy is currently the most widely used option possibly achieving the most optimal long-term outcome. Other treatment modalities including intracystic irradiation, intracystic instillation of antineoplasmatic agents and stereotactic radiotherapy are also available in our armamentarium. The long-term morbidities related with the craniopharyngiomas and their treatment remain significant, with hypothalamic damage playing the protagonist role and requiring further studies to identify measures that will improve the prognosis of the patients.

Clinical controversies: proton therapy for pediatric tumors

Despite the claim in the published literature, the introduction of proton therapy for children is not analogous to the evolution of conformal photon irradiation relying on the understanding of the impact of altered dose distributions. The differences in radiobiological effect when comparing photons with protons mean that we are comparing a known entity with an unknown entity: the dose-volume histogram for proton therapy might mean something substantially different from the dose-volume histogram for photon therapy. The multifaceted difference between the 2 modalities supports the argument for careful evaluation, follow-up, and clinical trials with adverse event monitoring when using proton therapy in children. We review the current data on the outcome of proton therapy in a range of pediatric tumors and compare them with the often excellent results of photon therapy in the setting of multidisciplinary management of childhood cancer. It is hoped that the apparent dosimetric advantage of proton therapy over photons will lead to improved indications for therapy, disease control, and functional outcomes. Although physical dose distribution is of clear importance, the multimodality management of children by an expert pediatric oncology team and the availability of ancillary measures that improve the quality of treatment delivery may be more important than the actual beam. In addition, current estimates of the benefit of proton therapy over photon therapy based on toxicity reduction will only be realized when survivorship has been achieved. Once substantive proton therapy data become available, it will be necessary to demonstrate benefit in clinically relevant outcome measures in comparison with best existing photon outcome data. Such an effort will require improved funding and appreciation for late effects research. Only real clinical outcome data combined with better understanding of the radiobiological differences between protons and photons will help us to further reduce side effects in children and exploit the full curative potential of this relatively new modality.

Endoscopic skull base surgery: a comprehensive comparison with open transcranial approaches

Little data exists comparing endoscopic endonasal approaches to pathology of the anterior skull base with more traditional transcranial and transsphenoidal microscopic approaches. In order to more fully characterize the role of endoscopy in the management of pathology of the anterior cranial base, we conducted a systematic review of case series and case reports documenting surgical and clinical outcomes. We found that for craniopharyngiomas, clival chordomas, esthesioneuroblastomas and giant pituitary adenomas, the endonasal endoscopic approach can result in equivalent or higher rates of gross total resection than open approaches. For meningiomas, however, open transcranial approaches are still able to achieve higher rates of total resection. CSF leak rates are higher for patients undergoing endoscopic surgery for meningiomas and craniopharyngiomas, but not for chordomas, esthesioneuroblastomas or giant pituitary adenomas. In certain patients, the endonasal endoscopic approach may be a safe and effective alternative for the treatment of a wide variety of skull base pathology, particularly those with small midline tumours.

Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of craniopharyngiomas

OBJECTIVE

Craniopharyngiomas have traditionally represented a challenge for open transcranial or transsphenoidal microscopic neurosurgery because of their anatomical location and proximity to vital neurovascular structures. The extended endoscopic endonasal transsphenoidal approach has been more recently developed as a potentially surgically aggressive, yet minimal access, alternative. To gain a more comprehensive assessment of the benefits and limitations of the various approaches to resection of craniopharyngiomas, we performed a systematic review of the available published reports after endoscope-assisted endonasal approaches and compared their results with transsphenoidal purely microscope-based or transcranial microscope-based techniques.

METHODS

We performed a MEDLINE search of the modern literature (1995-2010) to identify open and endoscopic surgical series for pediatric and adult craniopharyngiomas. Comparisons were made for patient and tumor characteristics as well as extent of resection, morbidity, and visual outcome. Statistical analyses of categorical variables were undertaken by the use of χ(2) and Fisher exact tests with post-hoc Bonferroni analysis to compare endoscopic, microsurgical transsphenoidal, and transcranial approaches.

RESULTS

Eighty eight studies, involving 3470 patients, were included. The endoscopic cohort had a significantly greater rate of gross total resection (66.9% vs. 48.3%; P < 0.003) and improved visual outcome (56.2% vs. 33.1%; P < 0.003) compared with the open cohort. The transsphenoidal cohort had similar outcomes to the endoscopic group. The rate of cerebrospinal fluid leakage was greater in the endoscopic (18.4%) and transsphenoidal (9.0%) than in the transcranial group (2.6%; P < 0.003), but the transcranial group had a greater rate of seizure (8.5%), which did not occur in the endonasal or transsphenoidal groups (P < 0.003).

CONCLUSIONS

The endoscopic endonasal approach is a safe and effective alternative for the treatment of certain craniopharyngiomas. Larger lesions with more lateral extension may be more suitable for an open approach, and further follow-up is needed to assess the long-term efficacy of this minimal access approach.

Modern radiotherapy approaches in the management of craniopharyngiomas

An audit of treatment regimens at presentation, recurrence and survival rates spanning 37 years were reviewed for children and adults with craniopharyngioma treated at The Prince of Wales or the Sydney Children's hospitals. Eligibility criteria stipulated all patients (n=41) received radiotherapy as part of their treatment course. The primary end point for evaluation was the incidence of radiological progression post-radiotherapy, and secondary end-points were the symptomatic and hormonal status post-radiotherapy. There were 12 paediatric patients (age, <16 years) and 29 adults (age range, 16-80 years). Of the 41 patients, 39 had a suprasellar tumour component, and 38 had radiologically persistent disease post-surgery. Four patients were treated by radiosurgery (median volume treated, 3.5 cm(3)); four patients progressed post-radiotherapy, of whom two were salvaged by further radiotherapy, one succumbed to progressive local disease, and one had a small intrasellar recurrence surgically resected. Progression-free survival (95.12%) was followed for up to 23 years. Thus, subtotal resection and the modern radiotherapy approach is likely to provide excellent patient and disease outcomes.

The role of radiosurgery in the treatment of craniopharyngiomas

The treatment of craniopharyngiomas is composed of an intricate balance of multiple modalities. Resection and radiotherapy have been combined to synergistically control tumor growth while preventing undue harm to crucial neurovascular structures. Although a craniopharyngioma is a benign lesion pathologically, it may induce severe neurological injury due to its location and rate of growth. More recently, the advent of targeted, fractionated radiotherapy has allowed for more aggressive tumor control while reducing the necessity for large resections. Initial studies have demonstrated significant tumor control in patients who are treated with resection combined with radiation therapy, versus surgery alone, with a lower rate of treatment-associated neurological deficits. In this review, a detailed account of the current studies evaluating the role of stereotactic radiosurgery in the management of craniopharyngiomas is presented. The authors also provide a short account of their experience to aid in defining the role of CyberKnife radiosurgery.

Craniopharyngioma: a comparison of tumor control with various treatment strategies

OBJECT

Craniopharyngiomas have a propensity to recur after resection, potentially causing death through their aggressive local behavior in their critical site of origin. Recent data suggest that subtotal resection (STR) followed by adjuvant radiotherapy (XRT) may be an appealing substitute for gross-total resection (GTR), providing similar rates of tumor control without the morbidity associated with aggressive resection. Here, the authors summarize the published literature regarding rates of tumor control with various treatment modalities for craniopharyngiomas.

METHODS

The authors performed a comprehensive search of the English language literature to identify studies publishing outcome data on patients undergoing surgery for craniopharyngioma. Rates of progression-free survival (PFS) and overall survival (OS) were determined through Kaplan-Meier analysis.

RESULTS

There were 442 patients who underwent tumor resection. Among these patients, GTR was achieved in 256 cases (58%), STR in 101 cases (23%), and STR+XRT in 85 cases (19%). The 2- and 5-year PFS rates for the GTR group versus the STR+XRT group were 88 versus 91%, and 67 versus 69%, respectively. The 5- and 10-year OS rates for the GTR group versus the STR+XRT group were 98 versus 99%, and 98 versus 95%, respectively. There was no significant difference in PFS (log-rank test) or OS with GTR (log-rank test).

CONCLUSIONS

Given the relative rarity of craniopharyngioma, this study provides estimates of outcome for a variety of treatment combinations, as not all treatments are an option for all patients with these tumors.

Endocrinologic, neurologic, and visual morbidity after treatment for craniopharyngioma

Craniopharyngiomas are locally aggressive tumors which typically are focused in the sellar and suprasellar region near a number of critical neural and vascular structures mediating endocrinologic, behavioral, and visual functions. The present study aims to summarize and compare the published literature regarding morbidity resulting from treatment of craniopharyngioma. We performed a comprehensive search of the published English language literature to identify studies publishing outcome data of patients undergoing surgery for craniopharyngioma. Comparisons of the rates of endocrine, vascular, neurological, and visual complications were performed using Pearson’s chi-squared test, and covariates of interest were fitted into a multivariate logistic regression model. In our data set, 540 patients underwent surgical resection of their tumor. 138 patients received biopsy alone followed by some form of radiotherapy. Mean overall follow-up for all patients in these studies was 54 ± 1.8 months. The overall rate of new endocrinopathy for all patients undergoing surgical resection of their mass was 37% (95% CI = 33–41). Patients receiving GTR had over 2.5 times the rate of developing at least one endocrinopathy compared to patients receiving STR alone or STR + XRT (52 vs. 19 vs. 20%, χ²P < 0.00001). On multivariate analysis, GTR conferred a significant increase in the risk of endocrinopathy compared to STR + XRT (OR = 3.45, 95% CI = 2.05–5.81, P < 0.00001), after controlling for study size and the presence of significant hypothalamic involvement. There was a statistical trend towards worse visual outcomes in patients receiving XRT after STR compared to GTR or STR alone (GTR = 3.5% vs. STR 2.1% vs. STR + XRT 6.4%, P = 0.11). Given the difficulty in obtaining class 1 data regarding the treatment of this tumor, this study can serve as an estimate of expected outcomes for these patients, and guide decision making until these data are available.

Intracystic treatments for craniopharyngioma

Craniopharyngioma is a benign tumor histopathologically and in theory should be curable by radical resection. In practice, this tumor behaves like a chronic disease, with many issues related to the effect of the tumor itself and the various treatments on the adjacent structures, such as the pituitary stalk and gland, hypothalamus, visual apparatus, and suprasellar arteries. A multimodality approach to the management of these tumors may produce the optimal outcome, balancing disease control and quality of life. In this paper, the role of intracystic therapies is reviewed, with the major focus on intracystic bleomycin and interferon-α.

Radiation therapy for pediatric craniopharyngioma

Object

The treatment of craniopharyngioma is highly controversial. Continued advances in limited surgery and radiation therapy have maintained excellent local disease control while minimizing treatment-related sequelae. Further analyses of outcomes are necessary to characterize the long-term effects of radiation therapy.

Methods

An extensive literature review was performed for all studies including radiation therapy, with or without surgery, for pediatric craniopharyngioma.

Results

The authors identified 32 papers describing radiation therapy for treatment of pediatric craniopharyngioma, with disease control ranging from 44 to 100%. Modern studies report at least 90% disease control with 5-year follow-up. Fifteen studies reported outcomes, demonstrating that more than two-thirds of patients treated with surgery and radiation therapy have favorable outcomes, and this rate is more than 85% in the modern era.

Conclusions

Conservative surgery and radiation therapy results in long-term disease control in pediatric patients with craniopharyngioma that is comparable to results obtained with radical surgery alone. However, children with craniopharyngioma remain vulnerable to late treatment failures and side effects from radiation therapy, including endocrinopathies, vasculopathies, and secondary tumors, which may be detrimental to the quality of life. Long-term follow-up beyond 5–10 years is necessary to assess tumor control relative to functional outcomes.

Radiosurgery for craniopharyngioma

PURPOSE

To analyze the outcomes of gamma knife stereotactic radiosurgery (SRS) for residual or recurrent craniopharyngiomas and evaluate the factors that optimized the tumor control rates.

METHODS AND MATERIALS

A total of 46 patients with craniopharyngiomas underwent 51 SRS procedures at University of Pittsburgh between 1988 and 2007. The median tumor volume was 1.0 cm(3) (range, 0.07-8.0). The median prescription dose delivered to the tumor margin was 13.0 Gy (range, 9-20). The median maximal dose was 26.0 Gy (range, 20-50). The mean follow-up time was 62.2 months (range, 12-232).

RESULTS

The overall survival rate after SRS was 97.1% at 5 years. The 3- and 5-year progression-free survival rates (solid tumor control) were both 91.6%. The overall local control rate (for both solid tumor and cyst control) was 91%, 81%, and 68% at 1, 3, and 5 years, respectively. No patients with normal pituitary function developed hypopopituitarism after SRS. Two patients developed homonymous hemianopsia owing to tumor progression after SRS. Among the factors examined, complete radiosurgical coverage was a significant favorable prognostic factor.

CONCLUSION

SRS is a safe and effective minimally invasive option for the management of residual or recurrent craniopharyngiomas. Complete radiosurgical coverage of the tumor was associated with better tumor control.

Modified orbitozygomatic craniotomy for craniopharyngioma resection in children

OBJECT

In this study, the authors evaluated the efficacy and safety of modified orbitozygomatic craniotomy for resection of craniopharyngioma in children.

METHODS

A prospective, institutional review board-approved database was retrospectively reviewed for pediatric patients undergoing craniopharyngioma resection performed by a single surgeon.

RESULTS

Ten patients underwent craniopharyngioma resection surgery between July 2000 and January 2006 (4 girls and 6 boys, ages 1.5-17 years). Nine patients presented to the authors' institution, and 1 patient was referred after surgery and radiation therapy were administered elsewhere. Nine patients presented with visual field deficits (2 with unilateral or bilateral light perception only) and 5 with endocrine dysfunction. Eight patients had large tumors that significantly displaced the optic chiasm and hypothalamus. All patients underwent a modified frontotemporal orbitozygomatic osteotomy in a single piece. The lamina terminalis was opened in 4 patients with third ventricular extension. One patient required a staged transsphenoidal operation to remove residual tumor in the sella turcica, and 1 patient underwent a contralateral subtemporal approach to resect a daughter lesion in the prepontine cistern. Complete radiographic resection was achieved in all patients. Follow-up averaged 55 months (range 12-95 months). Vision was improved in 8 patients and remained stable in 2. All patients had postoperative endocrine dysfunction. One patient experienced transient cranial nerve IV palsy and 1 suffered a small caudate stroke 5 months after surgery without sequelae. Two patients experienced polyphagia and weight gain without other symptoms of hypothalamic dysfunction. There were no other new neurological deficits.

CONCLUSIONS

Modified orbitozygomatic craniotomy provides excellent exposure of the suprasellar region with minimal brain retraction, allowing complete resection of craniopharyngiomas with good visual and neurological results.

Surgical management of craniopharyngiomas

Surgical treatment of craniopharyngiomas has been historically challenging and, despite advancements in microsurgical and skull base techniques, continues to pose a challenge to modern day surgeons. In particular, proponents of subtotal resection in conjunction with radiotherapy argue that this less aggressive approach can yield equivalent control rates with lower morbidity, while others argue that gross total resection is superior. Regardless of whether gross total or subtotal resection is the goal, surgical planning must include a thorough endocrine and neuro-ophthalmologic evaluation as well as imaging, and the approach, whether transsphenoidal or transcranial, must take into account the nature of the tumor and its location. In addition, optimal management of craniopharyngiomas must consist of an individualized and multidisciplinary approach not only including neurological surgery, but also including endocrinology, neuro-ophthalmology, neuropsychology, and, often, radiation-oncology.

Radiotherapy of other sellar lesions

Radiotherapy has been used as primary or adjuvant treatment in a number of non-adenomatous masses arising from within the sella. It is particularly important in the therapeutic algorithm of craniopharyngiomas and meningiomas and has also been used in chordomas/chordosarcomas and less commonly, in other lesions. This review describes the place of irradiation in the management of these masses.

Radiation therapy and CyberKnife radiosurgery in the management of craniopharyngiomas

OBJECT

Many benign intracranial tumors are amenable to radiotherapy treatment including meningiomas, schwannomas, pituitary tumors, and craniopharyngiomas. The authors present their experience in the treatment of craniopharyngiomas in 16 patients using frameless CyberKnife stereotactic radiosurgery (SRS). The authors discuss the role of radiation therapy in the management of these tumors, and more specifically, the role of CyberKnife SRS.

METHODS

Sixteen patients were treated for residual or recurrent craniopharyngioma between 2000 and 2007 with CyberKnife SRS at Stanford University Medical Center. All patients underwent magnetic resonance imaging and visual and neuroendocrine evaluations before and at regular intervals after SRS. A multisession treatment regimen and a nonisocentric treatment plan for each patient were used with a mean marginal dose of 21.6 Gy and a mean maximal dose of 29.9 Gy.

RESULTS

There were adequate clinical data to assess outcomes in 11 of 16 patients. Evaluation of patients between 13 and 71 years of age (mean 34.5 years) with a mean follow-up period of 15.4 months revealed no deterioration in visual or neuroendocrine function. Tumor shrinkage was achieved in 7 of these 11 patients, and tumor control in another 3. One patient had cystic enlargement of the residual tumor.

CONCLUSIONS

The authors' early experience with the application of CyberKnife SRS to residual or recurrent craniopharyngiomas has been positive; control or shrinkage of the tumor was achieved in 91% of patients, with no visual or neuroendocrine complications. Longer-term follow-up with a larger group of patients is required to fully evaluate the safety and effectiveness of this treatment modality.

Craniopharyngiomas

Craniopharyngiomas are epithelial tumors arising along the path of the craniopharyngeal duct and presenting with a variety of manifestations. Their optimal management remains a subject of debate. Currently, surgical excision followed by external beam irradiation is the main treatment option. Craniopharyngiomas are associated with significant long-term morbidity and mortality rates.

Fractionated stereotactic conformal radiotherapy following conservative surgery in the control of craniopharyngiomas

PURPOSE

To describe the technique and results of stereotactically guided conformal radiotherapy (SCRT) in patients with craniopharyngioma after conservative surgery.

METHODS AND MATERIALS

Thirty-nine patients with craniopharyngioma aged 3-68 years (median age 18 years) were treated with SCRT between June 1994 and January 2003. All patients were referred for radiotherapy after undergoing one or more surgical procedures. Treatment was delivered in 30-33 daily fractions over 6-6.5 weeks to a total dose of 50 Gy using 6 MV photons. Outcome was assessed prospectively.

RESULTS

At a median follow-up of 40 months (range 3-88 months) the 3- and 5-year progression-free survival (PFS) was 97% and 92%, and 3- and 5-year survival 100%. Two patients required further debulking surgery for progressive disease 8 and 41 months after radiotherapy. Twelve patients (30%) had acute clinical deterioration due to cystic enlargement of craniopharyngioma following SCRT and required cyst aspiration. One patient with severe visual impairment prior to radiotherapy had visual deterioration following SCRT. Seven out of 10 patients with a normal pituitary function before SCRT had no endocrine deficits following treatment.

CONCLUSION

SCRT as a high-precision technique of localized RT is suitable for the treatment of incompletely excised craniopharyngioma. The local control, toxicity and survival outcomes are comparable to results reported following conventional external beam RT. Longer follow-up is required to assess long-term efficacy and toxicity, particularly in terms of potential reduction in treatment related late toxicity.

Craniopharyngiomas

Craniopharyngiomas are rare, mainly sellar/parasellar, epithelial tumors diagnosed during childhood or adult life. Histologically, two primary subtypes have been recognized (adamantinomatous and papillary) with an as yet, unclarified pathogenesis. They may present with a variety of manifestations (neurological, visual, and hypothalamo-pituitary). Despite their benign histological appearance, they often show an unpredictable growth pattern, which, combined with the lack of randomized studies, poses significant difficulties in the establishment of an optimal therapeutic protocol. This should focus on the prevention of recurrence(s), improvement of survival, reduction of the significant disease and treatment-related morbidity (endocrine, visual, hypothalamic, neurobehavioral, and cognitive), and preservation of the quality of life. Currently, surgical excision followed by external beam irradiation, in cases of residual tumor, is the main treatment option. Intracystic irradiation or bleomycin, stereotactic radiosurgery, or radiotherapy and systemic chemotherapy are alternative approaches; their place in the management plan remains to be assessed in adequately powered long-term trials. Apart from the type of treatment, the identification of clinical and imaging parameters that will predict patients with a better prognosis is difficult. The central registration of patients with these challenging tumors may provide correlates between treatments and outcomes and establish prognostic factors at the pathological or molecular level that may further guide us in the future.

Pituitary radiotherapy: current controversies

External beam radiotherapy has been used extensively in the management of patients with pituitary disease. However, in view of advances in the techniques of radiotherapy planning and administration, neurosurgery and pharmacological manipulation of the pituitary, there are a growing number of questions and controversies surrounding the current and future use of pituitary radiotherapy in the management of pituitary disease.

Experience of external beam radiotherapy given adjuvantly or at relapse following surgery for craniopharyngioma

BACKGROUND AND PURPOSE

Evaluation of effect of timing of external beam radiation therapy (EBRT) following surgery for craniopharyngioma.

MATERIALS AND METHODS

Between 1976 and 2002, 87 patients (28 children) received EBRT in a regional referral centre. Forty-four patients received EBRT adjuvantly and 43 on relapse. The median total dose was 42.5Gy (range 34.7-52.5Gy) in 2.25-2.83Gy fractions over a median of 20 days (range 17-32). Effect of EBRT timing, type of original surgery, age on survival, progression-free survival (PFS) and quality of life (QOL) was studied.

RESULTS

Survival from diagnosis was 86 and 76% and PFS was 78 and 66% at 10 and 20 years, respectively, with no significant difference seen between those treated adjuvantly or at relapse or according to age. QOL deteriorated significantly from diagnosis to last follow-up. Excluding patients who relapsed following EBRT, QOL did not deteriorate significantly overall (P=0.35). Children had worse QOL and greater morbidity at all timepoints compared to adults.

CONCLUSIONS

EBRT is effective both adjuvantly and at relapse. QOL deteriorates over time-relapse following EBRT was the only significant factor. Children have greater morbidity compared to adults, but no evidence for greater EBRT-induced toxicity was seen.

Craniopharyngiomas in children: surgical experience at Children's Memorial Hospital

OBJECTIVES

Craniopharyngioma during childhood poses difficulty in management because of the high incidence of surgical complications and treatment failure. In order to identify less detrimental and more effective treatment, a personal series of craniopharyngioma was reviewed in regard to various clinical factors, patient factors (age and sex), tumor factors (location and extension, relationship with chiasm, and hydrocephalus), and therapeutic modes [extent of resection and radiation therapy (RT)].

MATERIALS AND METHODS

Fifty-four childhood craniopharyngiomas treated from 1984 to 2003 were reviewed. Preoperative neuroimaging studies were classified depending upon tumor location and extension. In this series of 54 patients, 43 had total tumor resection and 11 had subtotal resection. Of the total resection group, ten showed evidence of residual tumor on postoperative neuroimaging studies. Following the initial resection, 46 did not have RT whereas 8 with subtotal resection received RT.

RESULTS

There were no surgical deaths. Postoperative complications included pseudoaneurysm in 1, hemiparesis in 3, severe obesity in 5, panhypopituitarism in 50, and worsening of visual function in 7. During follow-up ranging from 12 months to 21 years, 24 patients had recurrence. Of the 33 patients with radiographic total resection, 9 (27.3%) had recurrence. Among the patients with total resection but radiographic residual and those with subtotal resection, the craniopharyngioma recurred in 90% and 100%, respectively. Three (37.5%) of eight patients with subtotal resection with RT had recurrence. Overall recurrence-free survival was 62% at 5 years and 49% at 10 years. The sex and age, location and extension of the tumor, nature of the optic chiasm, and hydrocephalus did not influence survival with statistical significance. However, the extent of surgical resection and use of RT showed significant differences for survival. Patients with total resection had a recurrence-free survival rate of 83% and 70% at 5 and 10 years, respectively. Patients with subtotal resection with RT had 71% at 5 years and 36% at 10 years. Patients who had subtotal resection or radiographically residual tumor without RT had a recurrence-free survival rate of only 9%. Among 22 patients whose recurrent tumor was treated with RT, a second recurrence-free survival rate was 90% at 5 years.

CONCLUSION

Total resection provided the best outcome. However, recurrence rates and surgical complications remained high following radical tumor resection. RT was effective for recurrent tumors and should be considered being the primary treatment for recurrences or difficult tumors, which are not amenable to total resections.

Radiation therapy in the management of pediatric craniopharyngiomas--a review

Craniopharyngiomas are benign suprasellar tumors that arise from epithelial remnants of the Rathke's pouch. The two standard treatment options are primary total resection or limited surgery followed by external beam radiation. The 10- and 20-year progression-free survival rates following limited surgery and radiation therapy are superior to those achieved by primary surgery alone. The side effect profiles for these two treatment approaches are different. Following total resection there is a very high incidence of panhypopituitarism requiring lifelong multiple hormone replacement therapy. The other side effects include potential damage to adjacent structures such as optic chiasm, vasculature and hypothalamus. Following limited surgery and radiation therapy the incidence of endocrine deficits is significantly lower compared to radical surgery, as is the risk of neurovascular and hypothalamic injury. Optic neuropathy and brain necrosis are rare in modern radiation therapy series. Second malignant neoplasms, although rare, can occur. In children with recurrent craniopharyngiomas following radical surgery, the recommended salvage treatment is radiation therapy, as further surgical attempts at salvage are associated with high relapse rates and increased morbidity and mortality. There have been significant technological advances in the field of radiation treatment planning and delivery that have great potential for reducing the incidence of long-term irradiation sequelae in the developing brain. The general availability of megavoltage linear accelerators and modern radiotherapy innovations such as three-dimensional conformal radiation treatment (3D CRT), stereotactic radiosurgery (SRS), stereotactic radiotherapy (SRT), and intensity modulated radiation therapy (IMRT) should further limit the rate of complications and improve cure rates in children with primary or recurrent craniopharyngioma.

Craniopharyngiomas in children and adults: systematic analysis of 121 cases with long-term follow-up

BACKGROUND

Craniopharyngiomas account for 2-5% of all primary intracranial tumours. Despite their benign histological appearance, they are often associated with an unfavourable prognosis and their optimal treatment remains controversial.

AIM

To analyse the natural history and treatment outcome of children and adults presenting to the Departments of Paediatrics and Endocrinology with craniopharyngioma between 1964 and 2003.

PATIENTS AND METHODS

The records of 121 patients (age range 2.5-83 years, 42 aged < 16 and 79 aged > or = 16) were identified. The mean follow-up period since presentation was 103 months (8.6 years) (range 0.3-468 months). Sixteen patients underwent gross total removal (A), 3 gross total removal + radiotherapy (B), 51 partial removal (C), 33 partial removal + radiotherapy (D), 6 cyst evacuation alone (E) and 3 cyst evacuation + radiotherapy (F). The clinical, imaging and endocrinological data at presentation and during follow-up were analysed.

RESULTS

Headache and visual field defects were the most common presenting clinical features (64% and 55%, respectively). Ninety-four per cent of the tumours had an extrasellar component and 23% of them were associated with hydrocephalus. There was a significant difference in the recurrence-free survival rates between groups A-D [at 10 years: 100% (A), 100% (B), 38% (C) and 77% (D), P < 0.01], which persisted even when analysing patients operated after 1980. The median time of first recurrence was 2.5 years (range 0.5-36). The peri-operative mortality of the patients who had any type of neurosurgical intervention due to recurrence was higher than that observed after primary surgery (24%vs. 1.8%) (P < 0.01). The rate of re-accumulation of the cyst fluid was 58% during the first year in patients of group E, whereas none of the subjects of group F experienced such an event during their follow-up period. There was no reversal of pre-existing pituitary hormone deficits after any surgical intervention. The probabilities of GH, FSH/LH, ACTH, TSH deficiency and diabetes insipidus at the 10-year follow-up were 88%, 90%, 86%, 80% and 65%, respectively. After excluding the non-tumour-related deaths, the 10-year survival rate following presentation was 90%. Patients with recurrence had a significantly lower probability for survival compared with those without it (at 10 years: 70%vs. 99%, P < 0.01). At the 10-year follow-up the probability of the presence of major visual field defects was 48%, hyperphagia/obesity 39%, epilepsy 12% and hemi-/monoparesis 11%. In this large series no substantial differences in the outcome of tumours diagnosed during childhood or adult life were found.

CONCLUSIONS

Craniopharyngiomas remain tumours associated with significant morbidity. Gross total removal provides favourable results in terms of recurrences. If this cannot be achieved safely, adjuvant radiotherapy is beneficial in preventing tumour re-growth. Childhood- and adult-onset lesions generally behave similarly.

Radiotherapy for craniopharyngioma in children: a national audit

A survey of current radiotherapy practices in the United Kingdom for treatment of craniopharyngioma in children was undertaken in view of the need to optimize control and minimize side effects in a patient group who can expect to survive for prolonged periods after treatment. Useable replies were received from 16 practitioners. A high level of conformity was reported in some areas but practice varied considerably in others. Thus whereas 15 employed magnetic resonance imaging (MRI) alone or with computed tomography (CT) to establish the gross tumour volume (GTV), six exclusively used pre-operative and seven exclusively used post-operative studies. Twelve added a margin of 1 cm to establish the planning target volume (PTV). Nine used CT planning. Fourteen gave radiation doses of between 50 and 55 Gy, but eight different dose/fractionation combinations were used. The most favoured regime (used by six) was 50 Gy in 30 fractions. Two centres provided written information on possible side effects of treatment. We suggest that it might prove helpful if a national treatment protocol was developed.

The psychosocial impacts on families of low-incidence, complex conditions in children: the case of craniopharyngioma

This paper reports qualitative data from a multidisciplinary, multimethod Craniopharyngioma Child and Family Impact Study conducted at the Royal Children's Hospital, Melbourne. The study aimed to assess the psychosocial impact on children and their families of a childhood craniopharyngioma, a congenital non-hereditary brain tumour that is 'benign' by histology, but often locally invasive. The condition may result in significant morbidity and mortality due to location in the brain, which tends to precipitate multisystemic abnormalities either at the time of presentation, or in conjunction with treatment. The condition has a high survival rate with approximately 90 percent of children alive ten years after diagnosis and although the diagnosis and treatment of craniopharyngioma may result in severe physical and emotional burden for the child and family, there have been few studies to date on the psychosocial impact of this multifaceted condition. Interviews incorporating a purpose-designed Craniopharyngioma Symptom and Treatment Impact Scale were held with 13 families. Impacts on both the family and the children were identified as well as information about the child's coping capacity; parents' fear, uncertainty and trust; family managing and mastery; the experience of hospital; service use and illness specific support. Implications for social work practice are discussed.

The neurological abnormalities and operative findings in the transcallosal approach for large juxtasellar-ventricular craniopharyngiomas

From February 1994 to June 1999, there were 36 patients who underwent microsurgical resection for craniopharyngiomas. Of6 adult patients, large tumours (>4 cm) with extension from intrasellar or parasellar space to the foramen of Monro were found. There were 4 male and 2 female patients with ages from 18 to 44 years (mean 32.4 years). All of them underwent one-stage interhemispheric transcallosal total exc ision of tumours. This approach affords good overhead view of tumours and surrounding structures.Preoperatively, decreased visual acuity and restriction in the visual field was found in 5 patients. Studies of anterior pituitary function revealed far below the normal range in all patients. Polyuria was noted in 4 patients. All of 6 patients showed abnormally high levels of blood cholesterol and triglyceride and 4 patients were obese. Tumours with extension into the pituitary fossa were found in 2 cases. A relatively caudal location in the third Ventricle was found in case 6, who showed better preoperative visual function and no polyuria. There were no major surgical complications encountered. One patient with high cholesterol (731 mg%) died of acute pancreatitis 6 months after surgery. For large craniopharyngiomas without pre-chiasmatic extension, proper treatment could be achieved under substitution therapy and one stage transcallosal total excision of tumours with preservation of important neural structures.

Craniopharyngioma

Current management for craniopharyngioma, a low-grade developmental neoplasm of the sellar region, is complicated by the tumor's proximity to critical neuroanatomical structures, including the optic chiasm and hypothalamus. Recommended preoperative investigations include MRI with and without gadolinium infusion, a neuro-ophthalmologic examination and a complete endocrine evaluation. Strict management of fluids and electrolytes, the judicious use of desmopressin (DDAVP), and the provision of "stress" doses of gluocorticoids will help guide the patient through the perioperative period. Although radical resection has a role as the sole therapeutic modality in some instances, the majority of patients can be appropriately managed by a subtotal resection followed by adjuvant external beam radiotherapy to the involved field using three dimensional treatment planning. The use of external ventricular drains may obviate the requirement for an indwelling cerebrospinal fluid shunt device. Patients with recurrent or progressive disease, in particular those with cystic tumors, may benefit from other therapies, including stereotactic radiosurgery (gamma knife) or intracavitary irradiation. Currently, stereotactic radiotherapy, intracavitary bleomycin, and systemic chemotherapy remain investigational treatment modalities for this challenging disorder.