Recent results of primary transnasal surgery for infradiaphragmatic craniopharyngioma

Neuroendoscopic Transventricular Approach for Cystic Craniopharyngioma

The literature is rich with many studies reporting different treatment modalities and approaches for cystic craniopharyngioma (CC), including microsurgery, neuroendoscopic transventricular approach, endoscopic transnasal surgery, stereotactic drainage, and Ommaya reservoir insertion. The goals of this manuscript are to report the successful treatment of an atypical case of CC using the neuroendoscopic transventricular approach (NTVA) as well as discuss the different surgical modalities for these tumors following a comprehensive review of the literature. Our patient is a nine-year-old female with a large CC who was managed using the NTVA. No complications or recurrence occurred over two years of follow-up. Results of our literature review showed lower recurrence and complication rates of the NTVA compared to other surgical modalities.The NTVA is potentially efficient, reliable, and safe for managing CC and cystic-dominant craniopharyngiomas, with low recurrence and complication rates compared to microsurgery and Ommaya reservoir insertion. Future randomized clinical studies comparing the various treatment modalities of CC are needed to solidify these conclusions.

Endoscopic Endonasal Surgery for Subdiaphragmatic Type Craniopharyngiomas

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

Craniopharyngioma

This report is a review of findings on the diagnosis, treatment, clinical course, and prognosis of craniopharyngioma patients. Craniopharyngiomas are rare, partly cystic and calcified embryonic malformations of the sellar/parasellar region with low histological grade (WHO I°). A bimodal age distribution has been shown, with peak incidence rates in childhood-onset at 5-14 years and adult-onset craniopharyngioma at 50-74 years. Clinical manifestations are related to hypothalamic/pituitary deficiencies, visual impairment, and increased intracranial pressure. If the tumor is favorably localized, the therapy of choice is complete resection, with care taken to preserve optical and hypothalamic functions. In patients with unfavorable tumor localization (i.e., hypothalamic involvement), recommended therapy is a limited hypothalamus-sparing surgical strategy followed by local irradiation. Although overall survival rates are high (92%), recurrences and progressions are frequent. Irradiation has proven effective in reducing recurrences and progression, and timing of postsurgical irradiation in childhood-onset cases is currently under investigation in a randomized multinational trial (KRANIOPHARYNGEOM 2007). Anatomical involvement and/or surgical lesions of posterior hypothalamic areas can result in serious quality of life-compromising sequelae such as hypothalamic obesity, psychopathological symptoms, and/or cognitive problems. It is crucial that craniopharyngioma be managed as a frequently chronic disease, providing ongoing care of pediatric and adult patients' clinical and quality of life consequences by experienced multidisciplinary teams.

Surgical management of craniopharyngiomas in children: meta-analysis and comparison of transcranial and transsphenoidal approaches

BACKGROUND

Controversy persists regarding the optimal treatment of pediatric craniopharyngiomas.

OBJECTIVE

We performed a meta-analysis of reported series of transcranial (TC) and transsphenoidal (TS) surgery for pediatric craniopharyngiomas to determine whether comparisons between the outcomes in TS and TC approaches are valid.

METHODS

Online databases were searched for English-language articles reporting quantifiable outcome data published between 1990 and 2010 pertaining to the surgical treatment of pediatric craniopharyngiomas. Forty-eight studies describing 2955 patients having TC surgery and 13 studies describing 373 patients having TS surgery met inclusion criteria.

RESULTS

Before surgery, patients who had TC surgery had less visual loss, more frequent hydrocephalus and increased intracranial pressure, larger tumors, and more suprasellar disease. After surgery, patients in the TC group had lower rates of gross total resection (GTR), more frequent recurrence after GTR, higher neurological morbidity, more frequent diabetes insipidus, less improvement, and greater deterioration in vision. There was no difference in operative mortality, obesity/hyperphagia, or overall survival percentages.

CONCLUSION

Directly comparing outcomes after TC and TS surgery for pediatric craniopharyngiomas does not appear to be valid. Baseline differences in patients who underwent each approach create selection bias that may explain the improved rates of disease control and lower morbidity of TS resection. Although TS approaches are becoming increasingly used for smaller tumors and those primarily intrasellar, tumors more amenable to TC surgery include large tumors with significant lateral extension, those that engulf vascular structures, and those with significant peripheral calcification.

Surgical strategies in childhood craniopharyngioma

Craniopharyngiomas are biologically benign lesions (WHO Grade 1) of the sellar and suprasellar region, associated with a serious morbidity. About 50% of these tumors become clinically apparent during childhood. Clinical symptoms include headaches, chiasm syndrome, hydrocephalus, pituitary insufficiencies, and obesity. Growth arrest is a typical symptom in children. The treatment of craniopharyngiomas includes surgery as well as radiotherapy. The goal of surgery varies according to the tumor location and extension and may range from complete resection to biopsy. Surgical complications are well known and cause constant evaluation of surgical strategies. Diencephalic obesity is related to surgical manipulation of hypothalamic tissue. Therefore, a classification system for craniopharyngiomas based on preoperative MRI is suggested by the authors. Recurrences are frequent in craniopharyngiomas, even after complete or gross-total resection. Radiotherapy is therefore recommended to patients with incomplete resections. However, the ideal time for radiotherapy after surgery is under discussion. The treatment of craniopharyngiomas requires an interdisciplinary and multimodal approach. Each patient should receive an individually tailored treatment. Surgically, different approaches as well as different degrees of resection can be considered, depending on tumor location and tumor extension.

New devices for direct transnasal surgery on pituitary adenomas

A micro-pressure-suction-irrigation system (MPSIS) is a surgical device that cleans the operative field of blood and tumor tissues with one-hand manipulation, dissects tumor tissue with its rapid flow, and removes debris by suction without injury to the normal tissue structures. Since 1997, good transnasal surgical results for pituitary adenomas have been achieved in Japan using this system. However, the surgical results for large, fibrous pituitary adenomas were unfavorable. Ultrasonic surgical aspirators with needle-type probes and an electromagnetic field system, all recently developed in Japan, are improving the results of direct transnasal surgery on pituitary adenomas. The MPSIS effectively dissects typical adenoma tissue with rapid irrigation and removes it by suction. A tumor in the cavernous sinus was removed by this system under direct vision in combination with pituitary mirrors. Fibrous adenomas were resected using ultrasonic surgical aspirators with needle-type probes. Thick mucosa and a firm tumor were vaporized with an electromagnetic field system. The sellar floor was reconstructed with combined ceramics, used in cases requiring additional surgery or drainage of cerebrospinal fluid leakage during surgery. Direct transnasal surgery with these devices was performed to remove 143 pituitary adenomas. Most of these pituitary adenomas could be selectively removed except for those lesions with extensive cavernous sinus invasion. There was no surgical morbidity or mortality. With the advancement of surgical technique and the development of surgical devices, most pituitary adenomas, even those that are fibrous or firm, can be removed via the transnasal route.