Endoscope-assisted microsurgery for treatment of a suprasellar craniopharyngioma presenting precocious puberty

Central precocious puberty secondary to postoperative craniopharyngioma: two case reports and a literature review

BACKGROUND

Craniopharyngioma is a common intracranial tumour in children. Clinical manifestations are related to hypothalamic/pituitary deficiencies, visual impairment, and increased intracranial pressure. Defects in pituitary function cause shortages of growth hormone, gonadotropin, corticotropin, thyrotropin, and vasopressin, resulting in short stature, delayed puberty, feebleness, lethargy, polyuria, etc. However, manifestations involving precocious puberty (PP) are rare.

CASE REPORT

In both patients, surgical resection was performed after the diagnosis of craniopharyngioma, and breast development occurred postoperatively at one month in one patient and at one year and three months in the other patient. Central precocious puberty (CPP) was diagnosed via relevant examinations. Leuprorelin was injected subcutaneously every 28 days, and changes in height, weight, bone age, gonadal ultrasound and sex hormones were recorded. During the follow-up of the two children, the sex hormone levels were significantly reduced, and significant acceleration in bone age was not observed.

CONCLUSIONS

CPP was induced by craniopharyngioma surgery, and treatment with gonadotropin-releasing hormone analogues (GnRHa) inhibited sexual development and bone age progression. More attention should be given to monitoring for CPP during long-term follow-up of craniopharyngiomas in the clinic.

Surgical Treatment of Pediatric Incidentally Found Brain Tumors: A Single-Center Experience

There remains much debate about the correct management of incidentally found brain tumors in the pediatric population. This study aimed to evaluate the efficacy and safety of surgical treatment of incidentally found pediatric brain tumors. A retrospective analysis of pediatric patients who underwent surgical resection of incidentally found brain tumors between January 2010 and April 2016 was performed. A total of seven patients were included. The median age at the time of diagnosis was 9.7 years. The reasons for performing neuroimaging were as follows: impeded speech development (n = 2), shunt control (n = 1), paranasal sinuses control (n = 1), behavior changes (n = 1), head trauma (n = 1), and preterm birth (n = 1). Five patients underwent gross total tumor resection (71.4%), while subtotal resection was performed in two patients (28.6%). There was no surgery-related morbidity. Patients were followed up for a mean of 79 months. One patient with atypical neurocytoma experienced tumor recurrence 45 months following primary resection. All patients remained neurologically intact. The majority of pediatric incidentally found brain tumors were histologically benign. Surgery remains a safe therapeutic approach associated with favorable long-term outcomes. Considering the expected long lifetime of pediatric patients, as well as the psychological burden associated with having a brain tumor as a child, surgical resection can be considered an initial approach.

Management of pediatric craniopharyngioma: 10-year experience from high-flow center

PURPOSE

To report our experience and management strategies during 10 years for 137 childhood craniopharyngiomas treated at a single institution.

METHODS

Medical records of children with craniopharyngioma treated at Children's Cancer Hospital Egypt (CCHE-57357) from July 2007 to December 2017 were retrospectively reviewed. Beta-catenin as an immunohistochemical marker was assessed also in available specimens.

RESULTS

Our registry included 137 patients. Headache (n = 122), visual failure (n = 118), and hypothyroidism(n = 78) were the most common findings on presentation. Three management protocols were identified; 65 patients were primarily followed up after surgery, 71 patients had radiotherapy after surgery, and one patient underwent surgery for Ommaya insertion with intracystic interferon injection. Overall, gross total resection/near total resection was achieved in 48 cases (35.04%), subtotal resection was achieved in 58 patients (42.33%), 29 (21.16%) had biopsy and Ommaya reservoir, and two patients with calcified lesions had no operations. Fifty-four patients showed recurrence/progression of their lesions. Allover, 5-year progression-free survival (PFS) was 52.3%, while it was 34.49% and 72.25% for the follow-up group and the radiotherapy group, respectively. Beta-catenin mutations were positive in 61/95 patients; 5-year PFS for beta-catenin negative and positive cases was 65.5% and 39.4% respectively (p = 0.087). Mortality was reported in eight patients. Intraoperative endoscopy-assisted assessment was the cornerstone of tailored decision-making.

CONCLUSION

The concepts of conservative surgery and multimodal management should be applied to reach the perfect balance between the quality of life and the best tumor control rates. Beta-catenin mutations more than 5% are associated with statistically trending aggressive clinical behavior. The CCHE-57357 algorithm of individualized management protocol was presented.

Displacement of mammillary bodies by craniopharyngiomas involving the third ventricle: surgical-MRI correlation and use in topographical diagnosis

OBJECT

Accurate diagnosis of the topographical relationships of craniopharyngiomas (CPs) involving the third ventricle and/or hypothalamus remains a challenging issue that critically influences the prediction of risks associated with their radical surgical removal. This study evaluates the diagnostic accuracy of MRI to define the precise topographical relationships between intraventricular CPs, the third ventricle, and the hypothalamus.

METHODS

An extensive retrospective review of well-described CPs reported in the MRI era between 1990 and 2009 yielded 875 lesions largely or wholly involving the third ventricle. Craniopharyngiomas with midsagittal and coronal preoperative and postoperative MRI studies, in addition to detailed descriptions of clinical and surgical findings, were selected from this database (n = 130). The position of the CP and the morphological distortions caused by the tumor on the sella turcica, suprasellar cistern, optic chiasm, pituitary stalk, and third ventricle floor, including the infundibulum, tuber cinereum, and mammillary bodies (MBs), were analyzed on both preoperative and postoperative MRI studies. These changes were correlated with the definitive CP topography and type of third ventricle involvement by the lesion, as confirmed surgically.

RESULTS

The mammillary body angle (MBA) is the angle formed by the intersection of a plane tangential to the base of the MBs and a plane parallel to the floor of the fourth ventricle in midsagittal MRI studies. Measurement of the MBA represented a reliable neuroradiological sign that could be used to discriminate the type of intraventricular involvement by the CP in 83% of cases in this series (n = 109). An acute MBA (< 60°) was indicative of a primary tuberal-intraventricular topography, whereas an obtuse MBA (> 90°) denoted a primary suprasellar CP position, causing either an invagination of the third ventricle (pseudointraventricular lesion) or its invasion (secondarily intraventricular lesion; p < 0.01). A multivariate model including a combination of 5 variables (the MBA, position of the hypothalamus, presence of hydrocephalus, psychiatric symptoms, and patient age) allowed an accurate definition of the CP topography preoperatively in 74%-90% of lesions, depending on the specific type of relationship between the tumor and third ventricle.

CONCLUSIONS

The type of mammillary body displacement caused by CPs represents a valuable clue for ascertaining the topographical relationships between these lesions and the third ventricle on preoperative MRI studies. The MBA provides a useful sign to preoperatively differentiate a primary intraventricular CP originating at the infundibulotuberal area from a primary suprasellar CP, which either invaginated or secondarily invaded the third ventricle.

Combined endoscopic and microscopic management of pediatric pituitary region tumors through one nostril: technical note with case illustrations

OBJECTIVE

Sellar and parasellar lesions in the pediatric population have traditionally been approached through either a transsphenoidal hypophysectomy or craniotomy or a combination of the two, with the surgical approach being dictated by the anatomical location and extent of the pathology. The introduction and evolution of the endonasal endoscopic technique has provided a minimally invasive method alone or in combination with the operative microscope for removal of these lesions in the pediatric population. The authors have implemented in their practice the use of endonasal endoscopic-assisted microsurgery in the pediatric population harboring sellar and/or lesions extending to the suprasellar space and report our experience in nine patients.

MATERIALS AND METHODS

Five craniopharyngiomas, one Rathke's cleft cyst, and two pituitary tumors were treated via endonasal endoscopic-assisted microsurgery. Histopathologic examination revealed lymphocytic hypophysitis in one patient with an enhancing lesion in the pituitary stalk. The approach utilized by the authors is performed through one nostril without any resection of the nasal turbinates or nasal septum. The middle turbinate is displaced laterally, while the nasal septum is moved medially.

CONCLUSION

Gross total, near-total, and subtotal resections and a diagnostic biopsy were obtained in six, one, one, and one patients, respectively. The authors were able to safely perform this procedure in nine pediatric patients, and the lack of turbinate or septum resection minimized postoperative discomfort.

Endocrine late effects of cancer treatment

Endocrinopathies are significant consequences of the treatment of childhood cancers. The risk of developing these adverse events is related to the underlying disease and its treatment with cytotoxic agents and radiation therapy. This article reviews hypothalamic-pituitary, thyroid, and gonadal dysfunction, as well as osteopenia-osteoporosis and obesity.

Rathke's cleft cyst in two girls with precocious puberty

Rathke's cleft cysts arise from remnants of Rathke's pouch and are usually found incidentally on MRI or autopsy. In childhood, the most common presenting symptoms of Rathke's cleft cysts are endocrine abnormalities, such as reduced growth hormone secretion, hyperprolactinemia, or diabetes insipidus. Non-specific symptoms, such as headache and visual disturbance, may also occur. Although precocious puberty has occasionally been described in association with suprasellar lesions, such as hamartomas, arachnoid cysts, and craniopharyngiomas, to our knowledge there have been no documented cases secondary to Rathke's cleft cysts. We report here two patients, both of whom presented with precocious puberty, and were found to have Rathke's cleft cysts.

History of neuroendoscopy

Since the beginnings of medicine, physicians have sought minimally invasive ways to peer into body cavities. It is only in the last several decades that the promises of endoscopy have begun to be answered. What follows is a brief outline of the development of endoscopic technology and its application to the nervous system both for diagnostic and therapeutic procedures.

Limited benefit of intraoperative low-field magnetic resonance imaging in craniopharyngioma surgery

OBJECTIVE

To investigate the benefit of intraoperative low-field magnetic resonance imaging (MRI) in craniopharyngioma surgery.

METHODS

We used a 0.2-T Magnetom Open scanner (Siemens Medical Solutions, Erlangen, Germany) that was located in a radiofrequency-shielded operating theater for intraoperative MRI. The head of the patient was placed in the fringe field of the scanner, so that standard microinstruments could be used. In transsphenoidal surgery, T1-weighted coronal and sagittal images were acquired. In transcranial surgery, a three-dimensional, gradient echo, T1-weighted, fast low-angle shot sequence was measured, thus allowing multiplanar reformatting.

RESULTS

A total of 21 surgical procedures in craniopharyngioma patients were investigated. In 10 patients, a bifrontal-translaminar approach was used; in 6 patients, the craniopharyngioma was removed via a transsphenoidal approach; and in 5 patients, intraoperative MRI was used to monitor cyst puncture and aspiration. In the craniotomy group, intraoperative imaging depicted a clear tumor remnant in one patient, which was subsequently removed. In another patient, an area of contrast enhancement was interpreted as artifact; however, postoperative follow-up at 3 months was suspicious for a minor remnant. Two of the eight patients with complete removal developed a recurrence during the follow-up period. In the group of patients who underwent primary transsphenoidal surgery (n = 4), complete removal was estimated by the surgeon in three cases. Intraoperative imaging depicted a remaining tumor in one case, leading to further tumor removal; however, follow-up revealed recurrent cysts.

CONCLUSION

Intraoperative low-field MRI allows an ultraearly evaluation of the extent of tumor removal in craniopharyngioma surgery in most cases. Imaging showing an incomplete resection offers the chance for further tumor removal during the same operation. However, intraoperative low-field MRI depicting a complete resection does not exclude craniopharyngioma recurrence.

Endocrine late effects of cancer treatment

Endocrinopathies are significant consequences of childhood cancers and their treatments. The risk of developing these adverse events is related to the underlying disease and its treatment with cytotoxic drugs and radiation therapy. This article will explore the current literature about endocrine late effects of hypothalamic-pituitary, thyroid, and gonadal dysfunction, as well as osteoporosis and obesity.