Harvey Cushing’s craniopharyngioma treatment: Part 2. Surgical strategies and results of his pioneering series

Abstract

OBJECTIVEHarvey Cushing (1869–1939) developed pioneering surgical techniques for craniopharyngioma (CP) removal. This study exhaustively analyzes the pathological variables and surgical strategies that influenced Cushing’s results in his entire series of CP patients.METHODSThe CP records from Cushing’s Brain Tumor Registry were carefully reviewed, as were his CP cases published in medical monographs and scientific reports.RESULTSOne hundred twenty-four tumors with characteristics typical of CP comprise Cushing’s entire series (CP124). Cushing performed 198 surgical procedures in the patients in whom these tumors were treated, with a 23% mortality rate within the first 2 months after surgery. Three periods in Cushing’s CP surgical career can be differentiated: an early period (1901–1917, 39 patients) characterized by his use of the transsphenoidal approach and limited cyst drainage procedures, an intermediate period (1919–1925, 42 patients) in which the subfrontal approach was the standard procedure and maximal removal was attempted, and a late period (1926–1932, 43 patients) characterized by the use of air ventriculography for topographical diagnosis and limited resections via a transventricular approach. Among Cushing’s CP series were 92 cases that were pathologically verified (CP92). In this subcohort, the unilateral subfrontal approach was predominantly used (72% of cases), followed by the transsphenoidal (15%) and frontal transcortical-transventricular (8%) approaches. Drainage of the CP cystic component or partial excision of the solid component was achieved in 61% of the cases, subtotal removal in 23%, and macroscopic total removal in 10%. Satisfactory outcomes were obtained in 55% of the patients in CP92, whereas poor outcomes and/or death related to hypothalamic injury was observed in 28%. Postoperative symptoms related to hypothalamic dysfunction occurred 53% of the time. The subfrontal approach yielded the highest rates of radical removal (p < 0.001) and good outcomes (p = 0.01). Partial removals were associated with the highest rates of poor outcomes, including death (p = 0.009). Cushing’s removal of CPs with a primary infundibulo-tuberal topography or showing third ventricle invasion was associated with the highest rates of hypothalamic injury (p < 0.001) and the worst outcomes (p = 0.009).CONCLUSIONSHarvey Cushing’s techniques and surgical philosophy varied substantially throughout his career. The experience he gained with this large CP series made him aware of the importance of limiting the extent of tumor removal and leaving untouched the tumor portion strongly adhered to the hypothalamus.

Cushing’s dogged struggle against death: the astonishing case of a patient under cardiac arrest surviving craniopharyngioma surgery

“…30 Cushing modified Kanavel's sublabial TSA, and this would become the standard route he used to approach CPs during the following decade. 30,37 Simultaneously, Oskar Hirsch devised the endonasal TSA for pituitary adenomas and CPs. 24,30 After that, the major advance in CP surgery came from Charles Frazier, who in the early 1910s championed the transition from the TSA to the intracranial approach.…”

“…45 At that time, Cushing was the world's most experienced CP surgeon, as he had operated on 81 patients. 29,37,45 Nevertheless, he had been unable to find almost a third of the tumors during his surgical procedures. 37 Three of these cases deserve special mention as they profoundly marked Cushing's obsessive search for a successful CP treatment.…”

“…Meticulous study of their postmortem brain specimens was fundamental for Cushing to change his techniques and philosophy with regard to CPs over the course of his career. 29,37 The year 1926 marks the beginning of Cushing's last surgical CP period, which was characterized by his discontinuation of the TSA that was predominantly used in his first period (1901)(1902)(1903)(1904)(1905)(1906)(1907)(1908)(1909)(1910)(1911)(1912)(1913)(1914)(1915)(1916)(1917), and by his abandonment of the radical tumor removal that characterized the middle period (1919)(1920)(1921)(1922)(1923)(1924)(1925)). 37…”

“…5B and C). 10,37 Critically analyzing the decisions that he had made in the MD and DA cases allowed Cushing to mentally prepare himself for the challenge of treating HW. Aware of the close relationships between CPs and the vital hypothalamus, he knew with certainty that any forceful, blind manipulation of HW's tumor would invariably injure the hypothalamus, leading to comatose status with uncontrollable hyperthermia and the patient's eventual death.…”

Craniopharyngiomas: An Appropriate Surgical Treatment based on Topographical and Pathological Concepts

“…The reason is that upper trans-ventricular approaches do not offer a direct view of the basal hypothalamus, the region to which most not-strictly intraventricular and secondary intraventricular CPs are strongly attached. The trans-lamina terminalis approach, either through a pterional, subfrontal or interhemispheric route, provides a direct view of the TVF, the usual attachment site of CPs involving the 3V, and is therefore suitable to remove either strictly or notstrictly intraventricular tumors [5,6,31,46,92,95]. Some authors such as Yasargil and Steno favored the use of combined basal and upper approaches to have a complete view of the tumorhypothalamus surface [2,49].…”