The role of transsphenoidal surgery in the treatment of craniopharyngiomas

Restricted access

Object. The optimal approach for the surgical treatment of craniopharyngiomas is still debated. In all cases involving the sella turcica, the authors have exclusively used transsphenoidal surgery (TSS), assuming that this approach is less traumatic than an intracranial one. Moreover, TSS was also performed in some cases of purely suprasellar craniopharyngiomas. In this study the surgical indications and the results obtained in all patients who had undergone TSS were analyzed.

Methods. In a series of 92 patients who underwent surgery for craniopharyngiomas, TSS was the first choice of approach in 57 cases (62%) consisting of 29 female and 28 male patients with ages ranging from 12 to 79 years (mean 35 years). The follow-up duration ranged from 2 to 20 years. A standard transsphenoidal approach was used in patients with an exclusively intrasellar (11 patients) or an intrasellar and suprasellar tumor (37 patients); in nine cases of tumors located exclusively above the sella turcica, a transsphenoidal presellar approach (seven patients) or a transsellar—transdiaphragmatic approach (two patients) was used. Total removal was performed in 36 patients (63%). All patients had good clinical results. Postoperative cerebrospinal fluid leakage occurred in 10 cases, but only one case required a surgical repair of the sella. Two patients died of late complications (3.5%). There were eight cases (14%) of tumor regrowth.

Conclusions. The authors assert that, when used in appropriately located craniopharyngiomas and by neurosurgeons with extensive experience in pituitary surgery, TSS offers excellent results with minor risks.

Article Information

Address reprint requests to: Giulio Maira, M.D., Istituto di Neurochirurgia, Università Cattolica del Sacro Cuore, Largo. A. Gemelli 8, 00168 Rome, Italy. email: gmaira@rm.unicatt.it.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Left: Sagittal T1-weighted MR image exhibiting a tumor in contact with the planum sphenoidale. The transsphenoidal presellar approach (arrow) together with removal of bone of the tuberculum sella and planum sphenoidale was used. Right: Sagittal T1-weighted MR image demonstrating the retrochiasmatic location of the tumor and the low position of the chiasm and anterior arteries complex (upper arrow) via the transsellar—transdiaphragmatic approach (lower arrow).

  • View in gallery

    Preoperative (left) and postoperative (right) sagittal T1-weighted Gd-enhanced MR images. The exclusively intrasellar craniopharyngioma is located behind the pituitary gland. The follow up in this case was 10 years.

  • View in gallery

    Preoperative (left) and postoperative (right) sagittal T1-weighted Gd-enhanced MR images. The exclusively intrasellar craniopharyngioma is located above the pituitary gland. The follow up in this case was 4 years.

  • View in gallery

    Preoperative (left) and postoperative (right) sagittal T1-weighted Gd-enhanced MR images. The intrasellar and suprasellar craniopharyngioma is located inside the pituitary gland. The follow up in this case was 4 years.

  • View in gallery

    Upper: Sagittal T1-weighted Gd-enhanced MR image (left) and sagittal computerized tomography scan (right) demonstrating cystic intrasellar and suprasellar craniopharyngioma with a calcified capsule. Lower: Postoperative sagittal (left) and coronal (right) T1-weighted Gd-enhanced MR images. The follow up in this case was 12 years.

  • View in gallery

    A and B: Suprasellar craniopharyngioma in contact with the planum sphenoidale. A transsphenoidal presellar approach was used to treat this tumor. Sagittal T1-weighted postcontrast MR images obtained preoperatively (the surgical route is indicated by the arrow; A) and immediately following partial resection (B). C–E: Coronal T1-weighted postcontrast MR images. One year later, a regrowth of the residual mass in the suprasellar cisterns was evident (C). A complete removal was realized using an intracranial approach (D). Six years later, we observed signs of tumor recurrence and the patient underwent a radiosurgical treatment (E).

  • View in gallery

    Suprasellar craniopharyngioma in contact with the planum sphenoidale. A transsphenoidal presellar approach was used. Sagittal T1-weighted postcontrast MR images obtained preoperatively (left) and immediately post—partial resection (right). The follow up in this case was 2 years.

  • View in gallery

    A transsellar—transdiaphragmatic approach was used to treat a suprasellar retrochiasmatic craniopharyngioma. Sagittal T1-weighted postcontrast MR images obtained preoperatively (left) and after subtotal resection (right). The follow up in this case was 2 years.

References

  • 1.

    Amacher AL: Craniopharyngiomas: the controversy regarding radiotherapy. Childs Brain 6:57641980Amacher AL: Craniopharyngiomas: the controversy regarding radiotherapy. Childs Brain 6:57–64 1980

    • Search Google Scholar
    • Export Citation
  • 2.

    Barbarino ADe Marinis LMenini Eet al: Prolactin-secreting pituitary adenomas: prolactin dynamics before and after transsphenoidal surgery. Acta Endocrinol 91:3974091979Barbarino A De Marinis L Menini E et al: Prolactin-secreting pituitary adenomas: prolactin dynamics before and after transsphenoidal surgery. Acta Endocrinol 91:397–409 1979

    • Search Google Scholar
    • Export Citation
  • 3.

    Baskin DSWilson CB: Surgical management of craniopharyngiomas: a review of 74 cases. J Neurosurg 65:22271986Baskin DS Wilson CB: Surgical management of craniopharyngiomas: a review of 74 cases. J Neurosurg 65:22–27 1986

    • Search Google Scholar
    • Export Citation
  • 4.

    Bergland RMRay BSTorack RM: Anatomical variations in the pituitary gland and adjacent structures in 225 human autopsy cases. J Neurosurg 28:93991968Bergland RM Ray BS Torack RM: Anatomical variations in the pituitary gland and adjacent structures in 225 human autopsy cases. J Neurosurg 28:93–99 1968

    • Search Google Scholar
    • Export Citation
  • 5.

    Carmel PW: Craniopharyngiomas in Wilkins RHRengachary SS (eds): Neurosurgery. New York: McGraw-Hill1985 vol 1 pp 905916Carmel PW: Craniopharyngiomas in Wilkins RH Rengachary SS (eds): Neurosurgery. New York: McGraw-Hill 1985 vol 1 pp 905–916

    • Search Google Scholar
    • Export Citation
  • 6.

    Choux MLena GGenitori L: Le craniopharyngiome de l'enfant. Neurochirurgie 37 (Suppl 1):121651991Choux M Lena G Genitori L: Le craniopharyngiome de l'enfant. Neurochirurgie 37 (Suppl 1):12–165 1991

    • Search Google Scholar
    • Export Citation
  • 7.

    Ciric ISCozzens JW: Craniopharyngiomas: transsphenoidal method of approach—for the virtuoso only? Clin Neurosurg 27:1691871980Ciric IS Cozzens JW: Craniopharyngiomas: transsphenoidal method of approach—for the virtuoso only? Clin Neurosurg 27:169–187 1980

    • Search Google Scholar
    • Export Citation
  • 8.

    Cushing HW: The craniopharyngiomas in Intracranial Tumors: Notes Upon a Series of Two Thousand Verified Cases with Surgical Mortality Percentage Pertaining Thereto. Springfield, ILCharles C Thomas: 1932 pp 9398Cushing HW: The craniopharyngiomas in Intracranial Tumors: Notes Upon a Series of Two Thousand Verified Cases with Surgical Mortality Percentage Pertaining Thereto. Springfield IL Charles C Thomas: 1932 pp 93–98

    • Search Google Scholar
    • Export Citation
  • 9.

    De Marinis LMancini AMaira Get al: Postoperative evaluation of dopaminergic tone in prolactinoma patients: II. Plasma thyrotropin response to metoclopramide. J Clin Endocrinol Metab 58:4054091984De Marinis L Mancini A Maira G et al: Postoperative evaluation of dopaminergic tone in prolactinoma patients: II. Plasma thyrotropin response to metoclopramide. J Clin Endocrinol Metab 58:405–409 1984

    • Search Google Scholar
    • Export Citation
  • 10.

    Fahlbusch RHonegger JPaulus Wet al: Surgical treatment of craniopharyngiomas: experience with 168 patients. J Neurosurg 90:2372501999Fahlbusch R Honegger J Paulus W et al: Surgical treatment of craniopharyngiomas: experience with 168 patients. J Neurosurg 90:237–250 1999

    • Search Google Scholar
    • Export Citation
  • 11.

    Fisher PGJenab JGoldthwaite PTet al: Outcomes and failure patterns in childhood craniopharyngiomas. Childs Nerv Syst 14:5585631998Fisher PG Jenab J Goldthwaite PT et al: Outcomes and failure patterns in childhood craniopharyngiomas. Childs Nerv Syst 14:558–563 1998

    • Search Google Scholar
    • Export Citation
  • 12.

    Garcia-Uria J: Surgical experience with craniopharyngioma in adults. Surg Neurol 9:11141978Garcia-Uria J: Surgical experience with craniopharyngioma in adults. Surg Neurol 9:11–14 1978

    • Search Google Scholar
    • Export Citation
  • 13.

    Grisoli FVincentelli FFarnarnier Pet al: Trans-sphenoidal microsurgery in the management of non-pituitary tumours of the sella turcica in Brock M (ed): Modern Neurosurgery. Berlin: Springer-Verlag1982 vol 1 pp 193204Grisoli F Vincentelli F Farnarnier P et al: Trans-sphenoidal microsurgery in the management of non-pituitary tumours of the sella turcica in Brock M (ed): Modern Neurosurgery. Berlin: Springer-Verlag 1982 vol 1 pp 193–204

    • Search Google Scholar
    • Export Citation
  • 14.

    Habrand JLGanry OCouanet Det al: The role of radiation therapy in the management of craniopharyngioma: a 25-year experience and review of the literature. Int J Radiat Oncol Biol Phys 44:2552631999Habrand JL Ganry O Couanet D et al: The role of radiation therapy in the management of craniopharyngioma: a 25-year experience and review of the literature. Int J Radiat Oncol Biol Phys 44:255–263 1999

    • Search Google Scholar
    • Export Citation
  • 15.

    Hamberger CAHammer GNorlen Get al: Surgical treatment of craniopharyngiomas: radical removal by transantrosphenoidal approach. Acta Otolaryngol 52:2852921960Hamberger CA Hammer G Norlen G et al: Surgical treatment of craniopharyngiomas: radical removal by transantrosphenoidal approach. Acta Otolaryngol 52:285–292 1960

    • Search Google Scholar
    • Export Citation
  • 16.

    Hardy J: Trans-sphenoidal approach to the pituitary gland in Wilkins RHRengachary SS (eds): Neurosurgeryed 2. New York: McGraw-Hill1996 Vol 2 pp 13751384Hardy J: Trans-sphenoidal approach to the pituitary gland in Wilkins RH Rengachary SS (eds): Neurosurgery ed 2. New York: McGraw-Hill 1996 Vol 2 pp 1375–1384

    • Search Google Scholar
    • Export Citation
  • 17.

    Hardy J: Transsphenoidal hypophysectomy. J Neurosurg 34:5825941971Hardy J: Transsphenoidal hypophysectomy. J Neurosurg 34:582–594 1971

    • Search Google Scholar
    • Export Citation
  • 18.

    Hardy J: Transsphenoidal microsurgery of the normal and pathological pituitary. Clin Neurosurg 16:1852171969Hardy J: Transsphenoidal microsurgery of the normal and pathological pituitary. Clin Neurosurg 16:185–217 1969

    • Search Google Scholar
    • Export Citation
  • 19.

    Hardy JLalonde JL: Exérèse par voie trans-sphénoidale d'un craniopharyngiome géant. Union Med Can 92:112411291963Hardy J Lalonde JL: Exérèse par voie trans-sphénoidale d'un craniopharyngiome géant. Union Med Can 92:1124–1129 1963

    • Search Google Scholar
    • Export Citation
  • 20.

    Hardy JMaira G: Microsurgical anatomy in trans-sphenoidal hypophysectomy. J Neurosurg Sci 21:1511571977Hardy J Maira G: Microsurgical anatomy in trans-sphenoidal hypophysectomy. J Neurosurg Sci 21:151–157 1977

    • Search Google Scholar
    • Export Citation
  • 21.

    Hardy JVezina JL: Transsphenoidal neurosurgery of intracranial neoplasm. Adv Neurol 15:2612741976Hardy J Vezina JL: Transsphenoidal neurosurgery of intracranial neoplasm. Adv Neurol 15:261–274 1976

    • Search Google Scholar
    • Export Citation
  • 22.

    Hashimoto NHanda HYamagami T: Transsphenoidal extracapsular approach to pituitary tumors. J Neurosurg 64:16201986Hashimoto N Handa H Yamagami T: Transsphenoidal extracapsular approach to pituitary tumors. J Neurosurg 64:16–20 1986

    • Search Google Scholar
    • Export Citation
  • 23.

    Hoff JTPatterson RH Jr: Craniopharyngiomas in children and adults. J Neurosurg 36:2993021972Hoff JT Patterson RH Jr: Craniopharyngiomas in children and adults. J Neurosurg 36:299–302 1972

    • Search Google Scholar
    • Export Citation
  • 24.

    Honegger JBuchfelder MFahlbusch Ret al: Transsphenoidal microsurgery for craniopharyngioma. Surg Neurol 37:1891961992Honegger J Buchfelder M Fahlbusch R et al: Transsphenoidal microsurgery for craniopharyngioma. Surg Neurol 37:189–196 1992

    • Search Google Scholar
    • Export Citation
  • 25.

    Kaptain GJVincent DASheehan JPet al: Transsphenoidal approaches for the extracapsular resection of midline suprasellar and anterior cranial base lesions. Neurosurgery 49:941012001Kaptain GJ Vincent DA Sheehan JP et al: Transsphenoidal approaches for the extracapsular resection of midline suprasellar and anterior cranial base lesions. Neurosurgery 49:94–101 2001

    • Search Google Scholar
    • Export Citation
  • 26.

    Kato TSawamura YAbe Het al: Transsphenoidal-transtuberculum sellae approach for supradiaphragmatic tumours: technical note. Acta Neurochir 140:7157191998Kato T Sawamura Y Abe H et al: Transsphenoidal-transtuberculum sellae approach for supradiaphragmatic tumours: technical note. Acta Neurochir 140:715–719 1998

    • Search Google Scholar
    • Export Citation
  • 27.

    Khafaga YJenkin DKanaan Iet al: Craniopharyngioma in children. Int J Radiat Oncol Biol Phys 42:6016061998Khafaga Y Jenkin D Kanaan I et al: Craniopharyngioma in children. Int J Radiat Oncol Biol Phys 42:601–606 1998

    • Search Google Scholar
    • Export Citation
  • 28.

    Konig ALudecke DKHerrmann HD: Transnasal surgery in the treatment of craniopharyngiomas. Acta Neurochir 83:171986Konig A Ludecke DK Herrmann HD: Transnasal surgery in the treatment of craniopharyngiomas. Acta Neurochir 83:1–7 1986

    • Search Google Scholar
    • Export Citation
  • 29.

    Konovalov AN: Commentary B. Technique and strategies of direct surgical management of craniopharyngiomas in Apuzzo MLJ (ed): Surgery of the Third Ventricle. Baltimore: Williams & Wilkins1987 pp 542553Konovalov AN: Commentary B. Technique and strategies of direct surgical management of craniopharyngiomas in Apuzzo MLJ (ed): Surgery of the Third Ventricle. Baltimore: Williams & Wilkins 1987 pp 542–553

    • Search Google Scholar
    • Export Citation
  • 30.

    Kouri JGChen MYWatson JCet al: Resection of suprasellar tumors by using a modified transsphenoidal approach. Report of four cases. J Neurosurg 92:102810352000Kouri JG Chen MY Watson JC et al: Resection of suprasellar tumors by using a modified transsphenoidal approach. Report of four cases. J Neurosurg 92:1028–1035 2000

    • Search Google Scholar
    • Export Citation
  • 31.

    Landolt AMZachmann M: Results of transsphenoidal extirpation of craniopharyngiomas and Rathke's cysts. Neurosurgery 28:4104151991Landolt AM Zachmann M: Results of transsphenoidal extirpation of craniopharyngiomas and Rathke's cysts. Neurosurgery 28:410–415 1991

    • Search Google Scholar
    • Export Citation
  • 32.

    Laws ER Jr: Transsphenoidal approach to lesions in and about the sella turcica in Schmidek HHSweet WH (eds): Operative Neurosurgical Technique. Indications Methods and Results. New York: Grune & Stratton1982 pp 327341Laws ER Jr: Transsphenoidal approach to lesions in and about the sella turcica in Schmidek HH Sweet WH (eds): Operative Neurosurgical Technique. Indications Methods and Results. New York: Grune & Stratton 1982 pp 327–341

    • Search Google Scholar
    • Export Citation
  • 33.

    Laws ER Jr: Transsphenoidal microsurgery in the management of craniopharyngioma. J Neurosurg 52:6616661980Laws ER Jr: Transsphenoidal microsurgery in the management of craniopharyngioma. J Neurosurg 52:661–666 1980

    • Search Google Scholar
    • Export Citation
  • 34.

    Laws ER Jr: Transsphenoidal removal of craniopharyngioma. Pediatr Neurosurg 21 (Suppl 1):57631994Laws ER Jr: Transsphenoidal removal of craniopharyngioma. Pediatr Neurosurg 21 (Suppl 1):57–63 1994

    • Search Google Scholar
    • Export Citation
  • 35.

    Laws ER Jr: Transsphenoidal surgery in Apuzzo MLJ (ed): Brain Surgery. Complication Avoidance and Management. New York: Churchill Livingstone1993 pp 357361Laws ER Jr: Transsphenoidal surgery in Apuzzo MLJ (ed): Brain Surgery. Complication Avoidance and Management. New York: Churchill Livingstone 1993 pp 357–361

    • Search Google Scholar
    • Export Citation
  • 36.

    Lindgren EDi Chiro G: Suprasellar tumours with calcification. Acta Radiol 36:1731951951Lindgren E Di Chiro G: Suprasellar tumours with calcification. Acta Radiol 36:173–195 1951

    • Search Google Scholar
    • Export Citation
  • 37.

    Love JGMarshall TM: Craniopharyngiomas (Pituitary adamantinomas). Surg Gynecol Obstet 90:5916011950Love JG Marshall TM: Craniopharyngiomas (Pituitary adamantinomas). Surg Gynecol Obstet 90:591–601 1950

    • Search Google Scholar
    • Export Citation
  • 38.

    Maira GAnile CColosimo Cet al: Craniopharyngiomas of the third ventricle: trans-lamina terminalis approach. Neurosurgery 47:8578652000Maira G Anile C Colosimo C et al: Craniopharyngiomas of the third ventricle: trans-lamina terminalis approach. Neurosurgery 47:857–865 2000

    • Search Google Scholar
    • Export Citation
  • 39.

    Maira GAnile CRossi GFet al: Surgical treatment of craniopharyngiomas: an evaluation of the transsphenoidal and pterional approaches. Neurosurgery 36:7157241995Maira G Anile C Rossi GF et al: Surgical treatment of craniopharyngiomas: an evaluation of the transsphenoidal and pterional approaches. Neurosurgery 36:715–724 1995

    • Search Google Scholar
    • Export Citation
  • 40.

    Mason RBNieman LKDoppman JLet al: Selective excision of adenomas originating in or extending into the pituitary stalk with preservation of pituitary function. J Neurosurg 87:3433511997Mason RB Nieman LK Doppman JL et al: Selective excision of adenomas originating in or extending into the pituitary stalk with preservation of pituitary function. J Neurosurg 87:343–351 1997

    • Search Google Scholar
    • Export Citation
  • 41.

    Page RB: Craniopharyngioma: indications for transsphenoidal surgery. Curr Ther Endocrinol Metab 5:33341994Page RB: Craniopharyngioma: indications for transsphenoidal surgery. Curr Ther Endocrinol Metab 5:33–34 1994

    • Search Google Scholar
    • Export Citation
  • 42.

    Petito CKDeGirolami UEarle KM: Craniopharyngiomas: a clinical and pathological review. Cancer 37:194419521976Petito CK DeGirolami U Earle KM: Craniopharyngiomas: a clinical and pathological review. Cancer 37:1944–1952 1976

    • Search Google Scholar
    • Export Citation
  • 43.

    Raybaud CRabehanta PGirard N: Aspects radiologiques des craniopharyngiomes. Neurochirurgie 37:44581991Raybaud C Rabehanta P Girard N: Aspects radiologiques des craniopharyngiomes. Neurochirurgie 37:44–58 1991

    • Search Google Scholar
    • Export Citation
  • 44.

    Rougerie J: Intrasellar and suprasellar tumors of the infant and adolescent in Bushe KASpoerri OShaw J (eds): Progress in Pediatric Neurosurgery: Proceedings of the 3rd European Congress of Paediatric Neurosurgery in Göttingen September 3–7 1972: With 103 Original Articles. Stuttgart: Hippokrates Verlag1974 pp 3445Rougerie J: Intrasellar and suprasellar tumors of the infant and adolescent in Bushe KA Spoerri O Shaw J (eds): Progress in Pediatric Neurosurgery: Proceedings of the 3rd European Congress of Paediatric Neurosurgery in Göttingen September 3–7 1972: With 103 Original Articles. Stuttgart: Hippokrates Verlag 1974 pp 34–45

    • Search Google Scholar
    • Export Citation
  • 45.

    Rougerie J: What can be expected from the surgical treatment of craniopharyngiomas in children. Report of 92 cases. Childs Brain 5:4334491979Rougerie J: What can be expected from the surgical treatment of craniopharyngiomas in children. Report of 92 cases. Childs Brain 5:433–449 1979

    • Search Google Scholar
    • Export Citation
  • 46.

    Sorva RHeiskanen O: Craniopharyngioma in Finland. A study of 123 cases. Acta Neurochir 81:85891986Sorva R Heiskanen O: Craniopharyngioma in Finland. A study of 123 cases. Acta Neurochir 81:85–89 1986

    • Search Google Scholar
    • Export Citation
  • 47.

    Van Effenterre RBoch AL: Craniopharyngioma in adults and children: a study of 122 surgical cases. J Neurosurg 97:3112002Van Effenterre R Boch AL: Craniopharyngioma in adults and children: a study of 122 surgical cases. J Neurosurg 97:3–11 2002

    • Search Google Scholar
    • Export Citation
  • 48.

    Weiss MH: The transnasal transsphenoidal approach in Apuzzo MLJ (ed): Surgery of the Third Ventricle. Baltimore: Williams and Wilkins1987 pp 476494Weiss MH: The transnasal transsphenoidal approach in Apuzzo MLJ (ed): Surgery of the Third Ventricle. Baltimore: Williams and Wilkins 1987 pp 476–494

    • Search Google Scholar
    • Export Citation
  • 49.

    Wisoff JH: Surgical management of recurrent craniopharyngiomas. Pediatr Neurosurg 21 (Suppl 1):1081131994Wisoff JH: Surgical management of recurrent craniopharyngiomas. Pediatr Neurosurg 21 (Suppl 1):108–113 1994

    • Search Google Scholar
    • Export Citation
  • 50.

    Yaşargil MGCurcis MKis Met al: Total removal of craniopharyngiomas. Approaches and long-term results in 144 patients. J Neurosurg 73:3111990Yaşargil MG Curcis M Kis M et al: Total removal of craniopharyngiomas. Approaches and long-term results in 144 patients. J Neurosurg 73:3–11 1990

    • Search Google Scholar
    • Export Citation

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 112 112 10
Full Text Views 155 155 0
PDF Downloads 100 100 0
EPUB Downloads 0 0 0

PubMed

Google Scholar