Aggressive surgery based on an anatomical subclassification of craniopharyngiomas

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>Craniopharyngiomas remain a particularly formidable challenge in the neurosurgical field. Because these lesions involve the hypothalamus and ophthalmological systems, their resection is associated with either higher rates of mortality and recurrence or a lower rate of radical resection. The authors report the outcomes of aggressive surgeries based on an anatomical subclassification of craniopharyngiomas.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>Clinical and ophthalmological examinations, imaging studies, endocrinological studies, neuropsychological function, and surgical complications in all patients who had undergone microsurgical resection for craniopharyngioma at Osaka City University hospital between January 2000 and December 2014 were retrospectively reviewed through the medical records. Radical resections were planned in all of the patients. To help choose the correct surgical approach, craniopharyngiomas were classified based on tumor origin. The 4 possible groups included the intrasellar type, prechiasmatic type, retrochiasmatic type, and intra–third ventricle type. A multistage surgery was planned in some cases.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>Seventy-two cases of craniopharyngioma were resected. Thirty-two patients (44.4%) had undergone previous surgical procedures at other institutions. Thirty-five cases (48.6%) were classified as retrochiasmatic, 19 (26.4%) as prechiasmatic, 12 (16.7%) as intra–third ventricle, and 6 (8.3%) as intrasellar. In 26 cases (36.1%), multistage surgery was required to complete the radical resection. Overall, 41 cases involved an orbitozygomatic approach; 21, a transpetrosal approach; 21, an interhemispheric approach; and 14, a transsphenoidal approach. In 3 cases, other approaches were applied. Gross-total resection was achieved in 43 patients (59.7%), near-total resection in 28 (38.9%), and partial resection in only 1 patient (1.4%). The mean follow-up period after resection was 4.7 years. Tumor recurrence or regrowth occurred in 15 (20.8%) of the 72 patients, with 14 of the 15 cases successfully controlled after additional resections and stereotactic radiosurgery. However, 1 patient died of uncontrollable tumor progression, and 2 patients died of unrelated diseases during the follow-up. Overall, disease in 69 (95.8%) of 72 patients was well controlled at the last follow-up.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>Aggressive tumor resection is the authors' treatment policy for craniopharyngioma. Using an anatomical subclassification of craniopharyngioma to choose the most appropriate surgical approach is helpful in achieving that goal of aggressive resection.</jats:p></jats:sec>

Letter to the Editor. Surgical strategy for craniopharyngiomas and the tumor-infundibulum relationship

“…We read with interest the article by Morisako et al 2 (Morisako H, Goto T, Goto H, et al: Aggressive surgery based on an anatomical subclassification of craniopharyngiomas. Neurosurg Focus 41 [6]:E10, December 2016).…”

“…Type III was further subdivided into IIIa (extending into the third ventricle) and IIIb (extending into the interpeduncular cistern). Despite being cited thereafter by almost all articles discussing approaches for craniopharyngiomas, Kassam et al was not cited in the recent work by Morisako et al 2 In 2008, the expanded EEA was emerging as a surgical alternative for the treatment of ventral skull base tumors, and it was not widely accepted. Over the past 9 years, the advantages of this approach were supported by surgical results data and the technique became standard for some types of craniopharyngiomas.…”

“…In the paper published by Morisako et al, 2 the authors proposed a new subclassification of craniopharyngiomas that would guide the surgical approach selection. Their classification was based on the anatomical location, growth pattern, and origin of the tumor.…”

“…Morisako et al 2 recommended in their article that the EEA should be performed only for intrasellar and prechiasmatic (without lateral extension) craniopharyngiomas. These are equivalent, in our classification, to Types 0 and I tumors.…”

“…In Illustrative Case 3, Morisako et al 2 chose an orbitozygomatic approach to resect a Type I craniopharyngioma. Although we agree that extensive lateral tumor extensions are better resected via a transcranial or combined EEA/ transcranial approach, the lateral extension of this particular case could most likely be addressed through an EEA.…”