Surgical Approaches and Techniques for Radical Resection of Craniopharyngioma based on Histopathological Analysis of the Dissection Plane

Abstract

It is widely reported that complete tumor resection is the most certain method for successful radical craniopharyngioma resection. However, radical resection and endocrinic function preservation are often opposing goals in craniopharyngioma surgery. Also, as for the context of total removal , there are no reports that clearly examine the complete total removal method with pathological specimens. Therefore we discuss radical resection that has a high curative rate from the view point of long term prognosis in our experiences. Between 1991 and 2012, 57 patients underwent surgery for craniopharyngioma in 71 instances at our institution. The follow up period ranged from 6 months to 21 years mean 8.4 years. We aimed to remove the tumor totally in almost all cases with a combined supra and infra chiasmatic approach or orbitozygomatic multi trajectory approach. Although the surgical approach should be deliberately selected in order to obtain a better view of the tumor origin and to preserve this axis anatomically priority should be given to radical resection when functional preservation is considered to be impracticable. For many of the non recurrent cases we partially perforated the hypothalamus and removed the tumor totally with the pituitary stalk and gland in recent years, but in a few of the non recurrent cases we removed the tumor totally while preserving the pituitary stalk and gland. So almost all of the non recurrent cases required hormone replacement postoperatively independent of whether we preserve the pituitary stalk and gland or not. The feasibility of functional preservation of the hypothalamic pituitary axis is determined primarily by the exact site of tumor origin, i. e. proximal or distal to the hypothalamus pituitary stalk junction. Finally for the purpose of attaining truly radical resection of the tumor, intraoperative frequent and frozen histopathological examination is mandatory to confirm that accurate surgical margins have been obtained.

Radical resection of craniopharyngioma: Discussions based on long-term clinical course and histopathology of the dissection plane

“…Namely, in addition to bIHA, the crista galli was removed, the anterior communicating artery or unilateral anterior cerebral artery (A1) was cut, and the lamina terminalis was opened. [ 17 18 19 ] Meanwhile for mainly suprasellar tumors or tumors with lateral deviation [Figure 1c and d ], we use transtemporal transchoroidal fissure approach. Namely, in addition to OZA, the choroidal fissure in the temporal horn was opened and we performed with manipulation behind the optic chiasm from posteriorly manipulation, and manipulation within the sella from anteriorly while looking downward.…”

“…Namely, in addition to OZA, the choroidal fissure in the temporal horn was opened and we performed with manipulation behind the optic chiasm from posteriorly manipulation, and manipulation within the sella from anteriorly while looking downward. [ 6 18 20 21 ] Whichever approach is used, we begin with operations on the inferior surface of the chiasm to preserve pituitary function. If the tumor is of the distal type, ideal total resection is more likely to be feasible; however, if preservation of the pituitary stalk is judged as impossible, then priority is given to total resection of the tumor.…”

“…Mean duration of follow-up was 146.3 months (range, 12–310 months). The surgical approach was a basal interhemispheric approach (bIHA)[ 17 ] or an expanded and improved version of this approach (combined supra- and infra-chiasmatic approach[ 18 ] or median splitting[ 19 ]) in 54 cases, an orbitozygomatic approach (OZA) or an expanded and improved version of this approach (transtemporal transchoroidal fissure approach[ 20 21 ]) in 25, and pterional approach in 2. The histopathological diagnosis was adamantinomatous type in 34 cases, squamous-papillary type in 30, mixed type[ 22 ] in 2, and ciliated type[ 23 ] in 1.…”

Unicystic Ameloblastomatoid Cystic Craniopharyngioma: Pathological Discussion and Clinical Significance of Cyst Formation in Adamantinomatous Craniopharyngioma

“…As the tumor in this case showed a long anteroposterior axis, we initially considered two-stage surgery from both an anterior approach (orbitozygomatic, transtemporal lobe, transchoroidal fissure approach [3]) and a posterior approach (posterior transpetrosal approach [9]). Fortunately, however, we were easily able to extirpate the single cystic component en bloc in a single procedure via the anterior approach, and also to carry out successful total extirpation of the tumor at the site of origin while preserving anatomical structures.…”

“…Total extirpation via a right orbitozygomatic, transtemporal, transchoroidal fissure approach [3] was performed the week after admission. As soon as the tumor was reached, cystic fluid resembling motor oil was aspirated to reduce the bulk of the tumor.…”