Endoscopic endonasal surgery for craniopharyngiomas: surgical outcome in 64 patients

Clinical article

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Object

The proximity of craniopharyngiomas to vital neurovascular structures and their high recurrence rates make them one of the most challenging and controversial management dilemmas in neurosurgery. Endoscopic endonasal surgery (EES) has recently been introduced as a treatment option for both pediatric and adult craniopharyngiomas. The object of the present study was to present the results of EES and analyze outcome in both the pediatric and the adult age groups.

Methods

The authors retrospectively reviewed the records of patients with craniopharyngioma who had undergone EES in the period from June 1999 to April 2011.

Results

Sixty-four patients, 47 adults and 17 children, were eligible for this study. Forty-seven patients had presented with primary craniopharyngiomas and 17 with recurrent tumors. The mean age in the adult group was 51 years (range 28–82 years); in the pediatric group, 9 years (range 4–18 years). Overall, the gross-total resection rate was 37.5% (24 patients); near-total resection (> 95% of tumor removed) was 34.4% (22 patients); subtotal resection (≥ 80% of tumor removed) 21.9% (14 patients); and partial resection (< 80% of tumor removed) 6.2% (4 patients). In 9 patients, EES had been combined with radiation therapy (with radiosurgery in 6 cases) as the initial treatment. Among the 40 patients (62.5%) who had presented with pituitary insufficiency, pituitary function remained unchanged in 19 (47.5%), improved or normalized in 8 (20%), and worsened in 13 (32.5%). In the 24 patients who had presented with normal pituitary function, new pituitary deficit occurred in 14 (58.3%). Nineteen patients (29.7%) suffered from diabetes insipidus at presentation, and the condition developed in 21 patients (46.7%) after treatment. Forty-four patients (68.8%) had presented with impaired vision. In 38 (86.4%) of them, vision improved or even normalized after surgery; in 5, it remained unchanged; and in 1, it temporarily worsened. One patient without preoperative visual problems showed temporary visual deterioration after treatment. Permanent visual deterioration occurred in no one after surgery. The mean follow-up was 38 months (range 1–135 months). Tumor recurrence after EES was discovered in 22 patients (34.4%) and was treated with repeat surgery (6 patients), radiosurgery (1 patient), combined repeat surgery and radiation therapy (8 patients), interferon (1 patient), or observation (6 patients). Surgical complications included 15 cases (23.4%) with CSF leakage that was treated with surgical reexploration (13 patients) and/or lumbar drain placement (9 patients). This leak rate was decreased to 10.6% in recent years after the introduction of the vascularized nasoseptal flap. Five cases (7.8%) of meningitis were found and treated with antibiotics without further complications. Postoperative hydrocephalus occurred in 7 patients (12.7%) and was treated with ventriculoperitoneal shunt placement. Five patients experienced transient cranial nerve palsies. There was no operative mortality.

Conclusions

With the goal of gross-total or maximum possible safe resection, EES can be used for the treatment of every craniopharyngioma, regardless of its location, size, and extension (excluding purely intraventricular tumors), and can provide acceptable results comparable to those for traditional craniotomies. Endoscopic endonasal surgery is not limited to adults and actually shows higher resection rates in the pediatric population.

Abbreviations used in this paper:BMI = body mass index; CN = cranial nerve; DI = diabetes insipidus; EES = endoscopic endonasal surgery; GH = growth hormone; GTR = gross-total resection; HPA = hypothalamic-pituitary-adrenal; HPG = hypothalamic-pituitarygonadal; HPT = hypothalamic-pituitary-thyroid; TSS = transsphenoidal surgery; SIADH = syndrome of inappropriate antidiuretic hormone secretion.
Article Information

Contributor Notes

Address correspondence to: Paul A. Gardner, M.D., Department of Neurosurgery, UPMC Presbyterian, 200 Lothrop St., Ste. B400, Pittsburgh, PA 15213. email: gardpa@upmc.edu.Please include this information when citing this paper: published online August 2, 2013; DOI: 10.3171/2013.6.JNS122259.

© AANS, except where prohibited by US copyright law.

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References
  • 1

    Bunin GRSurawicz TSWitman PAPreston-Martin SDavis FBruner JM: The descriptive epidemiology of craniopharyngioma. J Neurosurg 89:5475511998

    • Search Google Scholar
    • Export Citation
  • 2

    Campbell PGMcGettigan BLuginbuhl AYadla SRosen MEvans JJ: Endocrinological and ophthalmological consequences of an initial endonasal endoscopic approach for resection of craniopharyngiomas. Neurosurg Focus 28:4E82010

    • Search Google Scholar
    • Export Citation
  • 3

    Cavallo LMPrevedello DMSolari DGardner PAEsposito FSnyderman CH: Extended endoscopic endonasal transsphenoidal approach for residual or recurrent craniopharyngiomas. Clinical article. J Neurosurg 111:5785892009

    • Search Google Scholar
    • Export Citation
  • 4

    Chakrabarti IAmar APCouldwell WWeiss MH: Long-term neurological, visual, and endocrine outcomes following transnasal resection of craniopharyngioma. J Neurosurg 102:6506572005

    • Search Google Scholar
    • Export Citation
  • 5

    de Divitiis ECappabianca PCavallo LMEsposito Fde Divitiis OMessina A: Extended endoscopic transsphenoidal approach for extrasellar craniopharyngiomas. Neurosurgery 61:5 Suppl 22192282007

    • Search Google Scholar
    • Export Citation
  • 6

    de Vile CJGrant DBHayward RDKendall BENeville BGStanhope R: Obesity in childhood craniopharyngioma: relation to post-operative hypothalamic damage shown by magnetic resonance imaging. J Clin Endocrinol Metab 81:273427371996

    • Search Google Scholar
    • Export Citation
  • 7

    Elliott REHsieh KHochm TBelitskaya-Levy IWisoff JWisoff JH: Efficacy and safety of radical resection of primary and recurrent craniopharyngiomas in 86 children. Clinical article. J Neurosurg Pediatr 5:30482010

    • Search Google Scholar
    • Export Citation
  • 8

    Elliott REJane JA JrWisoff JH: Surgical management of craniopharyngiomas in children: meta-analysis and comparison of transcranial and transsphenoidal approaches. Neurosurgery 69:6306432011

    • Search Google Scholar
    • Export Citation
  • 9

    Fahlbusch RHonegger JPaulus WHuk WBuchfelder M: Surgical treatment of craniopharyngiomas: experience with 168 patients. J Neurosurg 90:2372501999

    • Search Google Scholar
    • Export Citation
  • 10

    Fernandez-Miranda JCGardner PASnyderman CHDevaney KOStrojan PSuárez C: Craniopharyngioma: a pathologic, clinical, and surgical review. Head Neck 34:103610442012

    • Search Google Scholar
    • Export Citation
  • 11

    Frank GPasquini EDoglietto FMazzatenta DSciarretta VFarneti G: The endoscopic extended transsphenoidal approach for craniopharyngiomas. Neurosurgery 59:1 Suppl 1ONS75ONS832006

    • Search Google Scholar
    • Export Citation
  • 12

    Gardner PAPrevedello DMKassam ABSnyderman CHCarrau RLMintz AH: The evolution of the endonasal approach for craniopharyngiomas. J Neurosurg 108:104310472008

    • Search Google Scholar
    • Export Citation
  • 13

    Hadad GBassagasteguy LCarrau RLMataza JCKassam ASnyderman CH: A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 116:188218862006

    • Search Google Scholar
    • Export Citation
  • 14

    Haupt RMagnani CPavanello MCaruso SDama EGarrè ML: Epidemiological aspects of craniopharyngioma. J Pediatr Endocrinol Metab 19:Suppl 12892932006

    • Search Google Scholar
    • Export Citation
  • 15

    Honegger JBuchfelder MFahlbusch R: Surgical treatment of craniopharyngiomas: endocrinological results. J Neurosurg 90:2512571999

    • Search Google Scholar
    • Export Citation
  • 16

    Jane JA JrLaws ER: Craniopharyngioma. Pituitary 9:3233262006

  • 17

    Jane JA JrPrevedello DMAlden TDLaws ER Jr: The transsphenoidal resection of pediatric craniopharyngiomas: a case series. Clinical article. J Neurosurg Pediatr 5:49602010

    • Search Google Scholar
    • Export Citation
  • 18

    Karavitaki N: Radiotherapy of other sellar lesions. Pituitary 12:23292009

  • 19

    Karavitaki NBrufani CWarner JTAdams CBTRichards PAnsorge O: Craniopharyngiomas in children and adults: systematic analysis of 121 cases with long-term follow-up. Clin Endocrinol (Oxf) 62:3974092005

    • Search Google Scholar
    • Export Citation
  • 20

    Karavitaki NCudlip SAdams CBWass JA: Craniopharyngiomas. Endocr Rev 27:3713972006

  • 21

    Kassam ASnyderman CHMintz AGardner PCarrau RL: Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus 19:1E32005

    • Search Google Scholar
    • Export Citation
  • 22

    Kassam ABThomas ACarrau RLSnyderman CHVescan APrevedello D: Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 63:1 Suppl 1ONS44ONS532008

    • Search Google Scholar
    • Export Citation
  • 23

    Kiehna ENMerchant TE: Radiation therapy for pediatric craniopharyngioma. Neurosurg Focus 28:4E102010

  • 24

    Komotar RJRoguski MBruce JN: Surgical management of craniopharyngiomas. J Neurooncol 92:2832962009

  • 25

    Kouri JGChen MYWatson JCOldfield EH: Resection of suprasellar tumors by using a modified transsphenoidal approach. Report of four cases. J Neurosurg 92:102810352000

    • Search Google Scholar
    • Export Citation
  • 26

    Laws ER Jr: Surgical outcome in 90 patients with craniopharyngiomas: an evaluation of the transsphenoidal approach. World Neurosurg 74:2542552010

    • Search Google Scholar
    • Export Citation
  • 27

    Maira GAnile CAlbanese ACabezas DPardi FVignati A: The role of transsphenoidal surgery in the treatment of craniopharyngiomas. J Neurosurg 100:4454512004

    • Search Google Scholar
    • Export Citation
  • 28

    Merchant TEKiehna ENSanford RAMulhern RKThompson SJWilson MW: Craniopharyngioma: the St. Jude Children's Research Hospital experience 1984–2001. Int J Radiat Oncol Biol Phys 53:5335422002

    • Search Google Scholar
    • Export Citation
  • 29

    Müller HLBueb KBartels URoth CHarz KGraf N: Obesity after childhood craniopharyngioma—German multicenter study on pre-operative risk factors and quality of life. Klin Padiatr 213:2442492001

    • Search Google Scholar
    • Export Citation
  • 30

    Müller HLEmser AFaldum ABruhnken GEtavard-Gorris NGebhardt U: Longitudinal study on growth and body mass index before and after diagnosis of childhood craniopharyngioma. J Clin Endocrinol Metab 89:329833052004

    • Search Google Scholar
    • Export Citation
  • 31

    Nelson JS: Principles and Practice of Neuropathology ed 2New YorkOxford University Press2003

  • 32

    Parisi JEMena HNonglial tumors. Nelson JSParisi JESchochet SS Jr: Principles and Practice of Neuropathology St. LouisMosby1993. 203266

    • Search Google Scholar
    • Export Citation
  • 33

    Pereira AMSchmid EMSchutte PJVoormolen JHBiermasz NRvan Thiel SW: High prevalence of long-term cardiovascular, neurological and psychosocial morbidity after treatment for craniopharyngioma. Clin Endocrinol (Oxf) 62:1972042005

    • Search Google Scholar
    • Export Citation
  • 34

    Puget SGarnett MWray AGrill JHabrand JLBodaert N: Pediatric craniopharyngiomas: classification and treatment according to the degree of hypothalamic involvement. J Neurosurg 106:1 Suppl3122007

    • Search Google Scholar
    • Export Citation
  • 35

    Rennert JDoerfler A: Imaging of sellar and parasellar lesions. Clin Neurol Neurosurg 109:1111242007

  • 36

    Scott RMHetelekidis SBarnes PDGoumnerova LTarbell NJ: Surgery, radiation, and combination therapy in the treatment of childhood craniopharyngioma—a 20-year experience. Pediatr Neurosurg 21:Suppl 175811994

    • Search Google Scholar
    • Export Citation
  • 37

    Van Effenterre RBoch AL: Craniopharyngioma in adults and children: a study of 122 surgical cases. J Neurosurg 97:3112002

  • 38

    van Overbeeke JJCraniopharyngiomas. Sekhar LNFessler RG: Atlas of Neurosurgical Techniques: Brain New YorkThieme Medical Publishers2006. 680686

    • Search Google Scholar
    • Export Citation
  • 39

    Yang ISughrue MERutkowski MJKaur RIvan MEAranda D: Craniopharyngioma: a comparison of tumor control with various treatment strategies. Neurosurg Focus 28:4E52010

    • Search Google Scholar
    • Export Citation
  • 40

    Yaşargil MGCurcic MKis MSiegenthaler GTeddy PJRoth P: Total removal of craniopharyngiomas. Approaches and long-term results in 144 patients. J Neurosurg 73:3111990

    • Search Google Scholar
    • Export Citation
  • 41

    Zanation AMCarrau RLSnyderman CHGermanwala AVGardner PAPrevedello DM: Nasoseptal flap reconstruction of high flow intraoperative cerebral spinal fluid leaks during endoscopic skull base surgery. Am J Rhinol Allergy 23:5185212009

    • Search Google Scholar
    • Export Citation
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