Outcomes in transcranial microsurgery versus extended endoscopic endonasal approach for primary resection of adult craniopharyngiomas

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>Craniopharyngiomas have historically been resected via transcranial microsurgery (TCM). In the last 2 decades, the extended endoscopic endonasal (transtuberculum) approach to these tumors has become more widely accepted, yet there remains controversy over which approach leads to better outcomes. The purpose of this study is to determine whether differences in outcomes were identified between TCM and extended endoscopic endonasal approaches (EEEAs) in adult patients undergoing primary resection of suprasellar craniopharyngiomas at a single institution.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>A retrospective review of all patients who underwent resection of their histopathologically confirmed craniopharyngiomas at the authors' institution between 2005 and 2015 was performed. Pediatric patients, revision cases, and patients with tumors greater than 2 standard deviations above the mean volume were excluded. The patients were divided into 2 groups: those undergoing primary TCM and those undergoing a primary EEEA. Preoperative patient demographics, presenting symptoms, and preoperative tumor volumes were determined. Extent of resection, tumor histological subtype, postoperative complications, and additional outcome data were obtained. Statistical significance between variables was determined utilizing Student t-tests, chi-square tests, and Fisher exact tests when applicable.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>After exclusions, 21 patients satisfied the aforementioned inclusion criteria; 12 underwent TCM for resection while 9 benefitted from the EEEA. There were no significant differences in patient demographics, presenting symptoms, tumor subtype, or preoperative tumor volumes; no tumors had significant lateral or prechiasmatic extension. The extent of resection was similar between these 2 groups, as was the necessity for additional surgery or adjuvant therapy. CSF leakage was encountered only in the EEEA group (2 patients). Importantly, the rate of postoperative visual improvement was significantly higher in the EEEA group than in the TCM group (88.9% vs 25.0%; p = 0.0075). Postoperative visual deterioration only occurred in the TCM group (3 patients). Recurrence was uncommon, with similar rates between the groups. Other complication rates, overall complication risk, and additional outcome measures were similar between these groups as well.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>Based on this study, most outcome variables appear to be similar between TCM and EEEA routes for similarly sized tumors in adults. The multidisciplinary EEEA to craniopharyngioma resection represents a safe and compelling alternative to TCM. The authors' data demonstrate that postoperative visual improvement is statistically more likely in the EEEA despite the increased risk of CSF leakage. These results add to the growing evidence that the EEEA may be considered the approach of choice for resection of select confined primary craniopharyngiomas without significant lateral extension in centers with experienced surgeons. Further prospective, multiinstitutional collaboration is needed to power studies capable of fully evaluating indications and appropriate approaches for craniopharyngiomas.</jats:p></jats:sec>

ICAR: endoscopic skull‐base surgery

“…DI rates after endoscopic endonasal removal of craniopharyngiomas range between 31.6% found in the series of Jeswani et al . up to the 55.5% reported by Wannemuehler et al …”

“…It is worth observing that rates of postoperative endocrinopathy using EEA are slightly lower compared to those reported per transcranial approaches . DI rates after endoscopic endonasal removal of craniopharyngiomas range between 31.6% found in the series of Jeswani et al .…”

Lessons learned in the evolution of endoscopic skull base surgery

“…Recently published studies of ESBS have further supported this route as the treatment of choice for the majority of craniopharyngiomas. 84 This approach has continued to demonstrate higher rates of GTR (66.9%-96.0% ESBS vs 40.0%-89.6% TCS), visual improvement (56.2%-88.9% ESBS vs 0.0%-47.1% TCS), fewer neurological and other complications (4.0%-20.0% ESBS vs 33.0%-80.0% TCS), and shorter length of hospitalization (4 days ESBS vs 10 days TCS). 3,12,38,63,91,97 CSF leak rates with ESBS in more recent large series in which nasal septal flap closure was used are now 2.9%-5.2%, much lower than in previous reports.…”

Clinical study of pituitary tumors with EEA resection and its influence on the expression of tumor necrosis factor-α, interleukin-6, and interleukin-12 in patients

“…At the same time, this treatment method is prone to cause hypothalamic and pituitary damage, and poses a serious threat to the patient's life safety. 9,10 With the progress of endoscopic sinus surgery, many scholars 11,12 have adopted EEA resection for the treatment of pituitary adenoma. This method has short path, small damage, simple operation, faster postoperative recovery, good illumination and magnification, clear image and multiple perspectives, as well as a good panoramic view of the suprasellar and saddle region.…”