Preserve or sacrifice the stalk? Endocrinological outcomes, extent of resection, and recurrence rates following endoscopic endonasal resection of craniopharyngiomas

Abstract

OBJECTIVEGross-total resection (GTR) of craniopharyngiomas (CPs) is potentially curative and is often the goal of surgery, but endocrinopathy generally results if the stalk is sacrificed. In some cases, GTR can be attempted while still preserving the stalk; however, stalk manipulation or devascularization may cause endocrinopathy and this strategy risks leaving behind small tumor remnants that can recur.METHODSA retrospective review of a prospective cohort of patients who underwent initial resection of CP using the endoscopic endonasal approach over a period of 12 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital, was performed. Postresection integrity of the stalk was retrospectively assessed using operative notes, videos, and postoperative MRI. Tumors were classified based on location into type I (sellar), type II (sellar-suprasellar), and type III (purely suprasellar). Pre- and postoperative endocrine function, tumor location, body mass index, rate of GTR, radiation therapy, and complications were reviewed.RESULTSA total of 54 patients who had undergone endoscopic endonasal procedures for first-time resection of CP were identified. The stalk was preserved in 33 (61%) and sacrificed in 21 (39%) patients. GTR was achieved in 24 patients (73%) with stalk preservation and 21 patients (100%) with stalk sacrifice (p = 0.007). Stalk-preservation surgery achieved GTR and maintained completely normal pituitary function in only 4 (12%) of 33 patients. Permanent postoperative diabetes insipidus was present in 16 patients (49%) with stalk preservation and in 20 patients (95%) following stalk sacrifice (p = 0.002). In the stalk-preservation group, rates of progression and radiation were higher with intentional subtotal resection or near-total resection compared to GTR (67% vs 0%, p < 0.001, and 100% vs 12.5%, p < 0.001, respectively). However, for the subgroup of patients in whom GTR was achieved, stalk preservation did not lead to significantly higher rates of recurrence (12.5%) compared with those in whom it was sacrificed (5%, p = 0.61), and stalk preservation prevented anterior pituitary insufficiency in 33% and diabetes insipidus in 50%.CONCLUSIONSWhile the decision to preserve the stalk reduces the rate of postoperative endocrinopathy by roughly 50%, nevertheless significant dysfunction of the anterior and posterior pituitary often ensues. The decision to preserve the stalk does not guarantee preserved endocrine function and comes with a higher risk of progression and need for adjuvant therapy. Nevertheless, to reduce postoperative endocrinopathy attempts should be made to preserve the stalk if GTR can be achieved.

Quality of life and olfactory function after suprasellar craniopharyngioma surgery—a single-center experience comparing transcranial and endoscopic endonasal approaches

“…The slightly better endocrinological results in the endonasal group of our study might be associated to the fact that the pituitary stalk can be seen early during surgery and by that preserved more easily. However, even the preservation of the pituitary stalk is no guarantee for a favorable pituitary outcome [ 24 ].…”

Diagnosis, Background, and Treatment of Hypothalamic Damage in Craniopharyngioma

“…Importantly, overall survival was not related to degree of resection, sex, age at diagnosis, or year of diagnosis [15]. Gross total removal of a CP will reduce the recurrence rate, but it increases the rate of loss of endocrine function to 85% [16]. Preservation of the stalk reduces the rate of GTR but increases the tumor progression and the need for radiation.…”

“…Preservation of the stalk reduces the rate of GTR but increases the tumor progression and the need for radiation. However, subtotal resection is the goal as it will reduce the risk of hypothalamic damage [16]. After adjustment for age in a mixed population of childhood and adult on- Reproduced from Bülow et al [12] with permission from Oxford University Press.…”

“…Preservation of the stalk reduces the rate of GTR but increases the tumor progression and the need for radiation. However, subtotal resection is the goal as it will reduce the risk of hypothalamic damage [ 16 ]. After adjustment for age in a mixed population of childhood and adult onset CP, a protective effect of radiotherapy and an increased risk of death after recurrence were found (HR = 4.4; 95% CI 1.4–14), but no obvious effect of radicality at surgery was seen [ 12 ] (Table 1 ).…”

Postoperative and Long-Term Endocrinologic Complications of Craniopharyngioma

“…Gross total resection (GTR) is associated with the highest recurrence-free survival and is aimed when hypothalamic integrity can be preserved. Treatment strategies in CPs have undergone significant changes over the last years and vary from radical surgical strategies such as GTR and the extended transsphenoidal endoscopic endonasal approach to conservative surgical approaches (hypothalamus-sparing surgery) and radio-oncological approaches such as proton beam therapy [3][4][5][6][7][8] Avoiding irreversible hypothalamic damage is especially important in pediatric patients and a key goal in the treatment of CPs. Hence, the focus of this review, "early postoperative and long-term endocrine complications of CP," depends very much on the treatment strategy, which should be carefully optimized for each individual patient.…”