Craniopharyngiomas: Transsphenoidal Method of Approach—for the Virtuoso Only?

Cirić, Ivan; Cozzens, Jeffrey W.

doi:10.1093/neurosurgery/27.cn_suppl_1.169

Cited by 86 publications

(33 citation statements)

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“…2,7,8,18,20,25,31,40,45,[50][51][52]54,59,60 Our study confirms that this layer of reactive gliosis, forming the cleavage plane be- tween the tumor and brain tissue, is a feature typically observed in the circumferential and ring-like types of attachment, usually observed in infundibulo-tuberal CPs that are fused to or replacing the TVF (Table 1). Some authors assume that this "glial envelope" may serve as a safety margin for resection.…”

Section: Adherence Of Cps: a Factor Determining The Surgical Risk Of supporting

confidence: 72%

Craniopharyngioma adherence: a comprehensive topographical categorization and outcome-related risk stratification model based on the methodical examination of 500 tumors

Prieto

Pascual

Rosdolsky³

et al. 2016

FOC

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OBJECTIVE Craniopharyngioma (CP) adherence strongly influences the potential for achieving a radical and safe surgical treatment. However, this factor remains poorly addressed in the scientific literature. This study provides a rational, comprehensive description of CP adherence that can be used for the prediction of surgical risks associated with the removal of these challenging lesions. METHODS This study retrospectively analyzes the evidence provided in pathological, neuroradiological, and surgical CP reports concerning 3 components of the CP attachment: 1) the intracranial structures attached to the tumor; 2) the morphology of the adhesion; and 3) the adhesion strength. From a total of 1781 CP reports published between 1857 and 2016, a collection of 500 CPs providing the best information about the type of CP attachment were investigated. This cohort includes autopsy studies (n = 254); surgical studies with a detailed description or pictorial evidence of CP adherence (n = 298); and surgical CP videos (n = 61) showing the technical steps for releasing the attachment. A predictive model of CP adherence in hierarchical severity levels correlated with surgical outcomes was generated by multivariate analysis. RESULTS The anatomical location of the CP attachment occurred predominantly at the third ventricle floor (TVF) (54%, n = 268), third ventricle walls (23%, n = 114), and pituitary stalk (19%, n = 94). The optic chiasm was involved in 56% (n = 281). Six morphological patterns of CP attachment were identified: 1) fibrovascular pedicle (5.4%); 2) sessile or patch-like (21%); 3) cap-like (over the CP top, 14%); 4) bowl-like (around the CP bottom, 13.5%); 5) ring-like (encircling central band, 19%); and 6) circumferential (enveloping the entire CP, 27%). Adhesion strength was classified in 4 grades: 1) loose (easily dissectible, 8%); 2) tight (requires sharp dissection, 32%); 3) fusion (no clear cleavage plane, 40%); and 4) replacement (loss of brain tissue integrity, 20%). The types of CP attachment associated with the worst surgical outcomes are the ring-like, bowl-like, and circumferential ones with fusion to the TVF or replacement of this structure (p < 0.001). The CP topography is the variable that best predicts the type of CP attachment (p < 0.001). Ring-like and circumferential attachments were observed for CPs invading the TVF (secondary intraventricular CPs) and CPs developing within the TVF itself (infundibulo-tuberal CPs). Brain invasion and peritumoral gliosis occurred predominantly in the ring-like and circumferential adherence patterns (p < 0.001). A multivariate model including the variables CP topography, tumor consistency, and the presence of hydrocephalus, infundibulo-tuberal syndrome, and/or hypothalamic dysfunction accurately predicts the severity of CP attachment in 87% of cases. CONCLUSIONS A comprehensive descriptive model of CP adherence in 5 hierarchical levels of increased severity—mild, moderate, serious, severe, and critical—was generated. This model, based on the location, morphology, and strength of the attachment can be used to anticipate the surgical risk of hypothalamic injury and to plan the degree of removal accordingly.

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Section: Adherence Of Cps: a Factor Determining The Surgical Risk Of supporting

confidence: 72%

Craniopharyngioma adherence: a comprehensive topographical categorization and outcome-related risk stratification model based on the methodical examination of 500 tumors

Prieto

Pascual

Rosdolsky³

et al. 2016

FOC

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“…Regarding these two latter areas, it should be understood that pial invasion can represent a further limitation preventing a safe radical removal. 16 In cases of lesions growing in the retrochiasmatic area, often with a prefixed (anteriorly displaced) chiasm, we achieved a higher GTR rate (80%). On the other hand, the GTR rate falls (39.1%) when approaching lesions involving both the pre-and retrochiasmatic spaces; these tumors are often multilobulated (that is, they are composed of several large cysts), and their wall cannot be easily dissected from vessels and nerves.…”

Section: Discussionmentioning

confidence: 70%

The endoscopic endonasal approach for the management of craniopharyngiomas: a series of 103 patients

Cavallo

Günther

Cappabianca

et al. 2014

JNS

190

198

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Object Despite their benign histological appearance, craniopharyngiomas can be considered a challenge for the neurosurgeon and a possible source of poor prognosis for the patient. With the widespread use of the endoscope in endonasal surgery, this route has been proposed over the past decade as an alternative technique for the removal of craniopharyngiomas. Methods The authors retrospectively analyzed data from a series of 103 patients who underwent the endoscopic endonasal approach at two institutions (Division of Neurosurgery of the Università degli Studi di Napoli Federico II, Naples, Italy, and Division of Neurosurgery of the Bellaria Hospital, Bologna, Italy), between January 1997 and December 2012, for the removal of infra- and/or supradiaphragmatic craniopharyngiomas. Twenty-nine patients (28.2%) had previously been surgically treated. Results The authors achieved overall gross-total removal in 68.9% of the cases: 78.9% in purely infradiaphragmatic lesions and 66.3% in lesions involving the supradiaphragmatic space. Among lesions previously treated surgically, the gross-total removal rate was 62.1%. The overall improvement rate in visual disturbances was 74.7%, whereas worsening occurred in 2.5%. No new postoperative defect was noted. Worsening of the anterior pituitary function was reported in 46.2% of patients overall, and there were 38 new cases (48.1% of 79) of postoperative diabetes insipidus. The most common complication was postoperative CSF leakage; the overall rate was 14.6%, and it diminished to 4% in the last 25 procedures, thanks to improvement in reconstruction techniques. The mortality rate was 1.9%, with a mean follow-up duration of 48 months (range 3–246 months). Conclusions The endoscopic endonasal approach has become a valid surgical technique for the management of craniopharyngiomas. It provides an excellent corridor to infra- and supradiaphragmatic midline craniopharyngiomas, including the management of lesions extending into the third ventricle chamber. Even though indications for this approach are rigorously lesion based, the data in this study confirm its effectiveness in a large patient series.

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“…The transcranial and the transsphenoidal route should be considered two complementary options at the surgeon's disposal to enable access to the target; one does not exclude the other. We completely agree with Prof. Ciric's philosophy when he stated in a published paper (33) : "a virtuoso is one who knows the relevant anatomy perfectly, correctly applies microsurgical technique, masters endoscopic skills, nds the optimal solution to speci c surgical problems, and applies wise judgment, with consummate respect for his or her patients. " (34) .…”

Section: Resultsmentioning

confidence: 99%

Endoscopic endonasal surgery for skull base tumours: technique and preliminary results in a consecutive case series report

Esenat¹,

Notaris²,

Sanchez³

et al. 2013

Rhin

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Craniopharyngiomas: Transsphenoidal Method of Approach—for the Virtuoso Only?

Cited by 86 publications

References 0 publications

Craniopharyngioma adherence: a comprehensive topographical categorization and outcome-related risk stratification model based on the methodical examination of 500 tumors

Craniopharyngioma adherence: a comprehensive topographical categorization and outcome-related risk stratification model based on the methodical examination of 500 tumors

The endoscopic endonasal approach for the management of craniopharyngiomas: a series of 103 patients

Endoscopic endonasal surgery for skull base tumours: technique and preliminary results in a consecutive case series report

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