Early outcome in endoscopic extended endonasal approach for removal of supradiaphragmatic craniopharyngiomas: a case series and a comprehensive review

Abstract

BackgroundThe choice of endoscopic expanded endonasal approach introduces the possibility of improved gross total resection of craniopharyngioma while minimizing surgical morbidity in a significant subset of patients.MethodsFrom our trans-sphenoidal surgical series of 331 cases, we retrospectively reviewed visual, endocrine and neuro-cognitive outcomes in the first consecutive eight patients (median age 63 years; range 47–73 years) with newly diagnosed supradiaphragmatic craniopharyngioma (median tumour height 23 mm; range 15–34 mm), removed by expanded endonasal approach (median follow-up 27 months; range 10–69 months). Gross total resection was attempted in all patients.ResultsGross total resection was achieved in 6 of 8 patients. Visual improvement was present in 6 of 8 patients of patients or in 14 of 16 eyes. New endocrinopathy, including diabetes insipidus, appeared in 5 of 8 patients. Stalk was preserved in 4 patients. Cognitive decline was present in 2 cases. Five of 8 patients retained previous quality of life.ConclusionsOur early outcome results are comparable to the recent few expanded endonasal approach series, except for the incidence of new endocrinopathy and cerebrospinal fluid leak rate. This was influenced by higher number of transinfundibular tumours in our series, where stalk preservation is less likely, and not using nasoseptal flap or gasket closure in the first half of cases. Including data from the literature and ours, expanded endonasal approach shows a trend for improved gross total resection rate with less morbidity, more obviously for visual outcome and quality of life than for endocrine outcome. However, validity of expanded endonasal approach should be confirmed in a larger number of patients with a longer follow-up period.

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

“…41,43,58 The patients at the greatest risk of surgery-related hypothalamic injury are those with preoperative hypothalamic symptoms, such as psychiatric disturbances and/or severe memory defects, which are typical of intraventricular CPs showing the strongest (fusion/replacement) and more extensive (circumferential/ring-like/bowl-like) types of attachment. 3,11,12,18,19,47,59 Overall, our findings highlight the high risk associated with indiscriminate attempts at total removal of infundibulo-tuberal and secondary intraventricular CPs that are fused to the TVF or have replaced it, and present a circumferential or ring-like attachment to the hypothalamus.…”

Craniopharyngioma recurrence: the impact of tumor topography

“…Nevertheless, in previous suprasellar-pseudointraventricular tumor operations, the thin arachnoid film between the tumor and the pia mater over the tuber cinereum may have been torn off, leading to the development of tight adherences at the dome of recurrent tumors, which may add to the risk of hypothalamic injury in subsequent surgeries. 2,27 Finally, an additional topographical category of CPs involving the hypothalamus must be considered: the group of tumors originating either within the sella turcica below the diaphragma sellae or in the suprasellar compartment above the diaphragma sellae, which initially displace the TVF upward but eventually break into the hypothalamus and invade the third ventricle. This category of CPs, known in our classification scheme as secondary intraventricular CPs, may occupy 3 compartments at the time of diagnosis-the sellar area, suprasellar region, and third ventricle-presenting potentially tight adherences to each of them.…”

Prognostic factors of craniopharyngioma with special reference to autocrine/paracrine signaling: underestimated implication of growth hormone receptor

“…Tight adhesion and significant local infiltration are also common, so long-term tumor control and maintenance of quality of life are sometimes difficult to achieve despite modern microsurgery techniques and precise anatomical understanding [2,16]. Fractionated irradiation or infusions of bleomycin hydrochloride are sometimes preferred for the treatment of cystic craniopharyngioma, but surgical outcome is the most significant prognostic factor for longterm survival and recurrence-free survival [7, 11, 14, 16, 17, 21,26].…”

“…Fractionated irradiation or infusions of bleomycin hydrochloride are sometimes preferred for the treatment of cystic craniopharyngioma, but surgical outcome is the most significant prognostic factor for longterm survival and recurrence-free survival [7, 11, 14, 16, 17, 21,26]. Recent advances in skull base repair have increased the performance of extended transsphenoidal surgeries without craniotomy [2,4,5,8,9,20,22], but close coordination between endocrinologists, pediatricians, and neurosurgeons is essential for a good outcome for patients with multiple endocrinological disturbances controlled by long-term hormonal supplementation. However, very little is known about the effect of the molecular characters of this tumor on the prognosis.…”