Medical Therapy for Craniopharyngiomas

Recurrent adamantinomatous craniopharyngioma stabilized with tocilizumab and bevacizumab: illustrative case

BACKGROUND

Adamantinomatous craniopharyngiomas (ACPs) are slow-growing, cystic, highly morbid central nervous system tumors located adjacent to vital structures including the pituitary, hypothalamus, and optic chiasm. Tumor recurrence is common. Treatment relies on resection with or without adjuvant radiation and is highly individualized. Targeted chemotherapies have not been routinely used in the treatment of ACPs.

OBSERVATIONS

The authors present the case of an adult patient with recurrent ACP that was clinically and radiologically stabilized with a combination of bevacizumab and tocilizumab every 3 weeks.

LESSONS

The combination of tocilizumab and bevacizumab could be an effective therapy for shrinkage of the cystic and solid components of ACP, sparing patients from further neurological damage from the tumor, additional surgery, or radiation. The patient's positive response to tocilizumab and bevacizumab supports the growing literature that interleukin-6 and vascular endothelial growth factor are important for ACP pathogenesis. The patient's response supports prior research, suggesting that systemic chemotherapy can be effectively delivered to this rare brain tumor. https://thejns.org/doi/10.3171/CASE24410.

Endoscopic endonasal resection of a craniopharyngioma in a 23-month-old patient: illustrative case

BACKGROUND

Treatment of pediatric craniopharyngioma requires a multidisciplinary approach to counsel patients and families on the spectrum of treatment options, including biopsy, radiation, and/or resection. Gross-total resection can avoid radiation and its long-term comorbidities. In very young patients, this is of particular importance but is especially challenging because of anatomical considerations.

OBSERVATIONS

A 23-month-old boy was found to have a partially calcified and cystic sellar and suprasellar mass. A fully endoscopic endonasal transtuberculum and transsellar approach was performed for gross-total resection of a subdiaphragmatic adamantinomatous craniopharyngioma. Postoperatively, the patient was diagnosed with panhypopituitarism with diabetes insipidus, though without other hypothalamic dysfunction or new visual deficits. To date, there is no evidence of tumor recurrence.

LESSONS

In a high-volume center with an experienced multidisciplinary skull base team, endoscopic endonasal approaches to sellar and suprasellar pathology in children younger than 2 years can be safely performed. A smaller nasal cavity and lack of sinus aeration necessitate wide exposure via bone removal and complete opening of the sinuses to enable an adequate working corridor to perform not only tumor resection but also reconstruction. Safe gross-total resection can avoid, or at least delay, radiation and its long-term morbidity when performed in a developing child. https://thejns.org/doi/10.3171/CASE24209.

Ferroptosis-related biomarkers for adamantinomatous craniopharyngioma treatment: conclusions from machine learning techniques

Introduction

Adamantinomatous craniopharyngioma (ACP) is difficult to cure completely and prone to recurrence after surgery. Ferroptosis as an iron-dependent programmed cell death, may be a critical process in ACP. The study aimed to screen diagnostic markers related to ferroptosis in ACP to improve diagnostic accuracy.

Methods

Gene expression profiles of ACP were obtained from the gene expression omnibus (GEO) database. Limma package was used to analyze the differently expressed genes (DEGs). The intersection of DEGs and ferroptosis-related factors was obtained as differently expressed ferroptosis-related genes (DEFRGs). Enrichment analysis was processed, including Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), disease ontology (DO), gene set enrichment analysis (GSEA), and Gene Set Variation Analysis (GSVA) analysis. Machine learning algorithms were undertaken for screening diagnostic markers associated with ferroptosis in ACP. The levels of DEFRGs were verified in ACP patients. A nomogram was drawn to predict the relationship between key DEFRG expression and risk of disease. The disease groups were then clustered by consensus clustering analysis.

Results

DEGs were screened between ACP and normal samples. Ferroptosis-related factors were obtained from the FerrDb V2 and GeneCard databases. The correlation between DEFRGs and ferroptosis markers was also confirmed. A total of 6 overlapped DEFRGs were obtained. Based on the results of the nomogram, CASP8, KRT16, KRT19, and TP63 were the protective factors of the risk of disease, while GOT1 and TFAP2C were the risk factors. According to screened DEFRGs, the consensus clustering matrix was differentiated, and the number of clusters was stable. CASP8, KRT16, KRT19, and TP63, were upregulated in ACP patients, while GOT1 was downregulated. CASP8, KRT16, KRT19, TP63, CASP8, and GOT1 affect multiple ferroptosis marker genes. The combination of these genes might be the biomarker for ACP diagnosis via participating ferroptosis process.

Discussion

Ferroptosis-related genes, including CASP8, KRT16, KRT19, TP63, and GOT1 were the potential markers for ACP, which lays the theoretical foundation for ACP diagnosis.

Genomic drivers in craniopharyngiomas: Analysis of the AACR project GENIE database

PURPOSE

Craniopharyngiomas are rare tumors originating in the sellar region, with limited information on their somatic mutational landscape. In this study, we utilized a publicly available genomic database to profile the somatic mutational landscape of craniopharyngioma patients and interrogate differences based on histologic subtype.

METHODS

We utilized the American Association for Cancer Research (AACR) Project Genomics Evidence Neoplasia Information Exchange (GENIE)® database accessed from cBioPortal (v13.1-public) to query all patients with craniopharyngiomas.

RESULTS

Of the 336 patients with sellar tumors, 51 (15.2%) had craniopharyngiomas. Of these 51 patients, 42 (82.4%) were adamantinomatous subtype and 9 (17.6%) were papillary subtype. In this cohort, 32 (62.7%) patients were pediatric, while 19 (37.3%) were adult. The top mutations in the cohort were: CTNNB1 (n = 37; 73%), BRAF (n = 7; 14%), ARID1B (n = 5; 10%), KMT2D (n = 4; 8%), FANCA (n = 4; 8%), ATM (n = 4; 8%), and TERT (n = 3; 8%). Of the 37 patients with CTNNB1 mutations, 8 (21.6%) had S33X, 9 (24.3%) had S37X, 7 (18.9%) had T41X, and 5 (13.5%) had D32X. In this cohort, CTNNB1 mutations tended to co-occur with ATM (n = 4; 10.8%), KMT2C (n = 4; 10.8%), TERT (n = 3; 8.1%), BLM (n = 3; 8.1%), and ERBB2/3 (n = 3; 8.1%), suggesting CTNNB1 mutations tended to co-occur with mutations in genes important in cell growth and survival, chromatin accessibility, and DNA damage response pathways.

CONCLUSIONS

CTNNB1 mutations account for a large proportion of somatic mutations in craniopharyngiomas. Identification of specific point mutations and secondary drivers may advance development of novel craniopharyngioma preclinical models for targeted therapy testing.

Visual outcomes after treatment of craniopharyngioma in children: A systematic review

OBJECTIVE

Craniopharyngiomas (CP) are rare brain tumors that often result in visual impairment due to their proximity to the optic pathway. The optimal management approach to preserve visual function in these patients remains controversial. We sought to investigate visual outcomes of children with craniopharyngiomas based on treatment modality.

METHODS

A systematic review was performed according to PRISMA guidelines. PubMed, Embase, and Scopus databases were searched in December 2022 for relevant articles. Articles were screened by title/abstract for relevance, then by full-text. Relevant demographic, intervention, and outcome data were extracted from included studies.

RESULTS

A total of 59 studies were included, representing 2655 patients. The overall visual status (OVS) of patients receiving surgery alone was improved in 27.6% of reported outcomes, unchanged in 50.3%, and deteriorated in 22.1%. The OVS for patients receiving radiation alone was improved in 21.1%, unchanged in 42.1%, and deteriorated in 36.8%. Patients receiving surgery plus adjuvant radiotherapy had OVS improvement in 27.4%, unchanged in 63.2%, and deteriorated in 9.4%. Of those receiving intracystic bleomycin, 23.1% had improvement in OVS, 46.2% remained unchanged, and 30.8% deteriorated. Of patients receiving interferon-α, 34.8% improved, 54.5% remained unchanged, and 10.6% deteriorated.

CONCLUSION

OVS most frequently remained unchanged regardless of intervention. The greatest improvement in OVS was seen in those receiving interferon-α or surgery alone. The greatest OVS deterioration was noted with radiation alone. Future standardized, randomized, large-scale studies with focused assessment of ophthalmologic findings are key to further understanding the impact different interventions have on visual outcomes in these children.

The evolution of pediatric neurosurgery: reflection of personal experience of the last half-century

OBJECTIVES

In the past 50 years, pediatric neurosurgery has made tremendous strides, and gained its own identity as a distinct subspecialty. I have personally observed this progress and evolution in pediatric neurosurgery in multiple dimensions, which are described based upon my own experience and reflection.

METHODS

The development and evolutions of multiple domains of pediatric neurosurgery, including neuroimaging, hydrocephalus, pediatric brain tumor, spinal dysraphism, craniosynostosis, vascular malformation, functional neurosurgery and spinal disorders were reviewed and commented on based upon my own experience and reflection.

RESULTS

The field of pediatric neurosurgery has grown in all aspects of diagnosis and therapy owing to the introduction of computers, innovative techniques and technologies and new discoveries of scientific data including molecular investigations.

CONCLUSION

A minimally invasive approach and molecular target therapy are a current trend. The past half century's clinical experience and advances in biomedical knowledge and techniques provide foundation for further improvement in the care of children of the next generation. Prospective artificial intelligence will likely promote further advances in pediatric neurosurgery.