Development of intracranial approaches for craniopharyngiomas: an analysis of the first 160 historical procedures

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>The development of surgical procedures for the removal of craniopharyngiomas (CPs) was greatly influenced by the enormous topographical and morphological heterogeneity displayed by these lesions. In this study the authors reviewed the intracranial approaches designed to treat CPs during the early historical period (1891–1938) with the aim of finding the CP topographical and pathological features that influence patient outcomes.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The authors conducted a systematic retrospective review of well-described cases of surgically treated CPs in publications from the period 1891–1938. Valuable information regarding the diagnosis of the lesion, type of craniotomy performed, CP topography, and outcome was selected from 418 reports included in medical publications from this period. The type of surgical procedure used, degree of tumor removal, CP position and histological variety, and clinical evidence of postoperative hypothalamic injury were the variables analyzed with the aim of defining their influence on the final patient outcome.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>A collection of 160 cases was eligible for analysis. Craniopharyngioma topography was significantly related to the existence of postoperative hypothalamic damage and the degree of tumor removal achieved (p &lt; 0.001). The infundibulo-tuberal, or not strictly intraventricular, topography was associated with the highest rate of hypothalamic injury (84%) and impossibility of tumor removal (51%). This topography also showed the worst prognosis (p = 0.001). Additional variables correlated with patient outcome were the presence of hypothalamic damage, type of surgical approach used, and degree of tumor removal. Patients having a poor outcome, suffering from permanent coma, or dying after surgery presented with symptoms of hypothalamic injury in 40% of cases (p &lt; 0.001). The surgical approach associated with the best outcome was the transsphenoidal (58%), followed by the subfrontal (45%) and the transcallosal (45%). Subtotal resection of the lesion yielded the best postoperative results, with only 17% of patients dying or suffering from a poor outcome, in contrast to the 39% reported for gross-total removal of the lesion (p = 0.001).</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Two major variables influenced the results of early surgical experience with CPs for the period from 1891 to 1938: 1) the inaccuracy in defining CP topography with the diagnostic methods available at that time; and 2) the ignorance about the risks associated with the dissection of lesions showing tenacious adherence to the hypothalamus. The degree of functional and morphological disturbance of the hypothalamus caused by a CP remains a fundamental variable helping the surgeon to predict the risks associated with the radical excision of the tumor and patient outcome.</jats:p></jats:sec>

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

“…A full description of our search and the list of medical libraries explored in the US and several European countries can be found in our group's previous papers. 29,31,32,35,44 Our initial database included 1781 scientific documents. From these, a final cohort of 500 CPs was selected (see Supplemental Table and Reference List), in accordance with the following inclusion criteria: 1) the CP diagnosis was confirmed pathologically, and reliable anatomical information regarding the tumors' relationship with surrounding structures was provided; 2) recurrent cases were excluded from the analysis; 3) for nonsurgically treated CPs reported in autopsy studies, we selected preferentially the ones providing high-quality pictures or illustrations of the brain specimen with the tumor in situ; 4) for CPs reported in surgical studies, we included cases providing a detailed description of tumor relationships to surrounding structures, preferably those illustrating the location of CP adherence with surgical images as well as those providing a complete clinical history and pre-and/or postoperative MRI scans; and 5) surgical videos showing the complete sequence of technical steps for releasing the CP attachments were also included.…”

Craniopharyngioma recurrence: the impact of tumor topography

“…Patient outcome following surgery for recurrent CPs has been found to depend mainly on the hypothalamic injury caused by surgical manipulation, 1,8,12 as was evidenced by early attempts at removing primary CPs. 20 In the particular case of recurrent CPs involving the third ventricle, the worst surgical outcome has been related to the loss of the gliotic envelope associated with previous surgical maneuvers. 8,15,28,30 However, this general assertion should be questioned given the compelling histological evidence available.…”

Sir Victor Horsley: pioneer craniopharyngioma surgeon

“…Only in infradiaphragmatic CPs Exceptionally High ICP symptoms 42,44 Rare Usual Frequent Endocrine disturbances 12,17 Common (65% active secretion) Frequent Unusual Hypothalamic disturbances [43][44][45] Rare Possible Frequent Mental disturbances 43 …”

“…Mortality rates for transcranial surgery around the pituitary region ranged from 50% to 80% in those days. 45 Archibald Church knew about the series of pituitary cases in which surgery had been performed by Sir Victor Horsley through a subtemporal procedure very similar to those for extirpation of the gasserian ganglion. 24,26 For Church, the transsphenoidal route represented a less disturbing avenue of approach, save for the problem of infection, than through a lateral aspect of the skull, which necessitates violent handling of the brain.…”

“…10 Identification of calcifications above a normalshaped sella turcica in cranial radiographs would mean major progress for the next half a century to accurately diagnose the presence of CPs, especially among children and young patients. 45,46 Table 1 presents the list of the fundamental epidemiological, clinical and pathological features that help to make the macroscopic distinction between hypophyseal macroadenomas and the two CP variants. Macroscopically, adamantinomatous CPs are characterized by their preferential occurrence among children or adolescents, a typical suprasellar topography, a multilobular solid-cystic morphology, a brownish hemorrhagic fluid content, and easily identifiable gross nodular calcifications in skull radiographs 41,43,51 (Fig.…”