Clinical features and operative technique of transinfundibular craniopharyngioma

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OBJECTIVE

Transinfundibular craniopharyngioma (TC) is one of the 4 subtypes of suprasellar craniopharyngioma. In this study, the authors analyzed the clinical features of and operative technique for TC.

METHODS

A total of 95 consecutive cases of suprasellar craniopharyngioma that had been resected via the endoscopic expanded endonasal approach were retrospectively reviewed. Patients were divided into 2 groups: 34 in the TC group and 61 in the nontransinfundibular craniopharyngioma (NC) group. Clinical and radiographic features, intraoperative findings, histopathological and genetic findings, and surgical outcomes were analyzed and compared between groups.

RESULTS

Compared with NC, TC was mostly seen in adult patients (97.1%); it was rare in children (2.9%). Clinical presentations tended toward headache, hydrocephalus, and diabetes insipidus. The relatively smaller volume, midline location (consistent with the stalk position), unidentifiable stalk, no shift of the third ventricle, and greater likelihood to involve the third ventricle and cause hydrocephalus were the characteristic features of TC in the preoperative MRI study. According to the degree of vertical extension of the tumor, the 34 TCs could be classified into 3 subtypes: type 1, entity was limited to stalk (n = 2, 5.9%); type 2, tumor extended up to the third ventricle (type 2a) or down to the subdiaphragmatic cavity (type 2b) (n = 23, 67.6%); and type 3, tumor extended in both directions (n = 9, 26.5%). For TC resection, the chiasm–pituitary corridor, lamina terminalis corridor, and pituitary corridor could be used separately or jointly. Most of the TCs originated from the infundibulum–tuber cinereum, grew within and along the long axis of the infundibulum, and the pituitary stalk was not usually preserved in TCs (20.6%), whereas the rate of preservation was higher (80.3%) in NCs. Bilateral hypothalamic injury was found in nearly all TCs if radical resection was performed, whereas the relationship between NCs and hypothalamus was either compression (32.8%) or unilateral invasion (67.2%). Meanwhile, the postoperative endocrine and neuropsychological function outcomes in patients with TC were worse than in patients with NC. The genetic analysis with whole-exome sequencing studies showed no differential mutations of CTNNB1 (β-catenin) and BRAF (V600E) between TC and NC subtypes, but there was a difference between adamantinomatous craniopharyngioma and papillary craniopharyngioma.

CONCLUSIONS

TC is a special subtype of suprasellar craniopharyngioma, which is remarkably different from NC. Identification of this type of tumor preoperatively is essential for the planning of appropriate surgical approach and degree of excision.

ABBREVIATIONS ACP = adamantinomatous craniopharyngioma; DI = diabetes insipidus; EEA = expanded endonasal approach; GTR = gross-total resection; KPS = Karnofsky Performance Scale; MOCA = Montreal Cognitive Assessment; NC = nontransinfundibular craniopharyngioma; PCP = papillary craniopharyngioma; PR = partial resection; SSS = Stanford Sleepiness Scale; STR = subtotal resection; TC = transinfundibular craniopharyngioma.

Article Information

Correspondence Tao Hong: The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China. ht2000@vip.sina.com.

INCLUDE WHEN CITING Published online June 14, 2019; DOI: 10.3171/2019.3.JNS181953.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Bar graphs showing comparison of clinical features between the TC and NC groups. Distribution of age (A), sex (B), clinical presentations (C), imaging findings (D), intraoperative findings (E), extent of resection (F), headache and visual improvement rate (G), and complications (H). The asterisks indicate that there is a significant difference between the TC and NC groups (p < 0.05). 3rd V = third ventricle. Figure is available in color online only.

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    Illustrative case 1 of TC (type 1). A and B: Preoperative sagittal (A) and coronal (B) postcontrast T1-weighted MR images showing a TC that is relatively smaller and located in the midline. C and D: Postoperative sagittal (C) and coronal (D) postcontrast T1-weighted MR images obtained after GTR. Note the vascularized nasoseptal flap (white arrow) at the posterior aspect of the sphenoid sinus in panel C and the preserved pituitary gland stalk (white arrow in panel D). E–H: Intraoperative photographs showing that the tumor was located in the suprasellar cistern and grew within the stalk, and that the vertically located striated structure could be identified around the surface of tumor (white arrows in panel E). Tumor capsule, which was the expanded and thinned stalk (white arrows), was then entered, and debulking was performed (F). Tumor was removed from any adherent normal structures by using sharp dissection. White star indicates the intact third ventricle floor (G). Pituitary stalk (white arrow) was preserved after tumor removal (H). Tu = tumor. Figure is available in color online only.

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    Preoperative MR images of NCs. A and B: Preoperative sagittal (A) and coronal (B) postcontrast T1-weighted MR images showing a type I craniopharyngioma. The tumor is located slightly toward to the right side and entirely anterior to the pituitary stalk (white arrow in panel A). Meanwhile, the stalk is located on the left side of the tumor (white arrow in panel B). C and D: Preoperative sagittal (C) and coronal (D) postcontrast T1-weighted MR images showing a type III craniopharyngioma. The tumor is located slightly toward to the left side and extends posteriorly to the cisterna interpeduncularis and prepontine cistern; the stalk is located in the front and right side of the tumor (white arrow in panels C and D).

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    Illustrative case 2 of TC (type 2a). A and B: Preoperative sagittal (A) and coronal (B) postcontrast T1-weighted MR images showing a TC growing up to the third ventricle. C–F: Intraoperative photographs showing that tumor grew with and along the stalk, and extended up to the third ventricle. After tumor removal, the defect of the third ventricle floor was observed, and hypothalamic injury was limited to the tuber cinereum area (F). Black star in panel E indicates the right hypothalamus, and the black triangles and white arrows in panel F indicate the mammillary bodies and the residual pituitary stalk, respectively. G and H: Postoperative sagittal (G) and coronal (H) postcontrast T1-weighted MR images obtained after GTR. White arrows in panel H indicate the residual pituitary stalk. P = pituitary. Figure is available in color online only.

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    Illustrative case 3 of TC (type 3). A and B: Preoperative sagittal (A) and coronal (B) postcontrast T1-weighted MR images showing a TC that grew longer along the stalk axis and extended up into the third ventricle and the foramen of Monro. C and D: Postoperative sagittal (C) and coronal (D) postcontrast T1-weighted MR images obtained after GTR. E–J: Intraoperative photographs. The typical vertically located striated structure could be identified around the surface of tumor (white arrows) in the chiasm–pituitary corridor (E). First, the tumor below the optic chiasm was removed (F and G), then the suprachiasmatic translamina terminalis corridor (H) was combined to remove the tumor, which extended up into the third ventricle and the foramen of Monro (I). After total tumor removal, the chiasm–pituitary corridor and lamina terminalis corridor could be observed (J). BA = basilar artery; Ch = optic chiasm; Ps = pituitary stalk. Figure is available in color online only.

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    Illustrative case 4 of TC (type 3). A and B: Preoperative sagittal (A) and coronal (B) postcontrast T1-weighted MR images showing a TC that grew up into the third ventricle and down into the sella turcica. C and D: Sagittal (C) and coronal (D) postcontrast T1-weighted MR images obtained after GTR demonstrating extensive, safe resection of the tumor. E–J: Intraoperative photographs. The tumor was behind the pituitary gland (P; panels E–G), and the anterior lobe of pituitary gland was unilaterally transposed to one side (white dashed line, panel G) to expose and remove the tumor. Ht = hypothalamus; MM = mammillary body. Figure is available in color online only.

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    Histopathological examination of a TC. A and B: Preoperative sagittal (A) and coronal (B) postcontrast T1-weighted MR images showing a TC (type 3). C: Intraoperative photograph showing that the specimen was obtained from the tuber cinereum and hypothalamus (yellow box). D: Histopathological examination of tissue in the yellow box in panel C, showing that tumor invades the hypothalamus with the finger-like infiltration. H & E, original magnification ×200. E: Intraoperative photograph showing that the specimen was obtained from the tumor close to the lower part of the pituitary stalk (yellow box). F: Histopathological examination of tissue in the yellow box in panel E, showing a clear interface between tumor and pituitary stalk, which is without any tumor cell invasion. H & E, original magnification ×200. Figure is available in color online only.

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