Endoscopic endonasal resection versus open surgery for pediatric craniopharyngioma: comparison of outcomes and complications

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OBJECTIVE

Craniopharyngioma represents up to 10% of pediatric brain tumors. Although these lesions are benign, attempts at gross-total resection (GTR) can lead to serious complications. More conservative approaches have emerged but require adjuvant radiation. Endoscopic endonasal surgery (EES) aimed at GTR has the potential to result in fewer complications, but there has been limited comparison to open surgery. The authors performed a review of these two approaches within their institution to elucidate potential benefits and complication differences.

METHODS

The authors performed a retrospective review of pediatric patients undergoing resection of craniopharyngioma at their institution between 2001 and 2017. Volumetric analysis of tumor size and postoperative ischemic injury was performed. Charts were reviewed for a number of outcome measures.

RESULTS

A total of 43 patients with an average age of 8.2 years were identified. Open surgery was the initial intervention in 15 and EES in 28. EES was performed in patients 3–17 years of age. EES has been the only approach used since 2011. In the entire cohort, GTR was more common in the EES group (85.7% vs 53.3%, p = 0.03). Recurrence rate (40% vs 14.2%, p = 0.13) and need for adjuvant radiation (20.0% vs 10.7%, p = 0.71) were higher in the open surgical group, although not statistically significant. Pseudoaneurysm development was only observed in the open surgical group. Volumetric imaging analysis showed a trend toward larger preoperative tumor volumes in the open surgical group, so a matched cohort analysis was performed with the largest tumors from the EES group. This revealed no difference in residual tumor volume (p = 0.28), but the volume of postoperative ischemia was still significantly larger in the open group (p = 0.004). Postoperative weight gain was more common in the open surgical group, a statistically significant finding in the complete patient group that trended toward significance in the matched cohort groups. Body mass index at follow-up correlated with volume of ischemic injury in regression analysis of the complete patient cohort (p = 0.05).

CONCLUSIONS

EES was associated with similar, if not better, extent of resection and significantly less ischemic injury than open surgery. Pseudoaneurysms were only seen in the open surgical group. Weight gain was also less prevalent in the EES cohort and appears be correlated with extent of ischemic injury at time of surgery.

ABBREVIATIONS BMI = body mass index; DWI = diffusion-weighted imaging; EES = endoscopic endonasal surgery; EOR = extent of resection; FDCA = fusiform dilatation of the carotid artery; GTR = gross-total resection; RT = radiation therapy; STR = subtotal resection.

Article Information

Correspondence Phillip B. Storm: Children’s Hospital of Philadelphia, Philadelphia, PA. storm@email.chop.edu.

INCLUDE WHEN CITING Published online June 7, 2019; DOI: 10.3171/2019.4.PEDS18612.

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

  • View in gallery

    Box-and-whisker plots of preoperative (A) and residual postoperative (B) tumor volumes of the open surgical and EES groups showing a near-significant difference in preoperative tumor volumes but equivalent residual volumes. Plotting the preoperative tumor volumes of both groups (C) showed that the EES group had a large percentage of smaller tumors. Patients with the largest tumors in the EES group were then matched with the open surgical cohort, resulting in statistically similar median volumes (D). Box-and-whisker plots of preoperative (E) and postoperative (F) tumor volumes in the matched cohort analysis show no difference, but the range in residual volumes for the open surgical group was much larger (F).

  • View in gallery

    Box-and-whisker plots from unmatched (A) and matched (B) analysis of extent of ischemic injury as measured by DWI signal change in the open and EES groups. Both analyses reveal significant levels of ischemic injury in the open surgical group compared to the EES group. Presence of FDCA was extracted from chart and imaging review and only found to occur in the open surgical group, reaching statistical significance (C).

  • View in gallery

    Box-and-whisker plot of patient BMI for the open surgical and EES groups (A) shows a significantly higher median BMI in the open group at last recorded follow-up. The rate of obesity (BMI > 30 kg/m2) was also found to be higher in the open group, but this did not reach significance (B). The change in BMI from preoperatively to the most recent postoperative visit was found to be significantly larger in the open surgical group (C). Regression analysis of BMI and volume of ischemic injury on postoperative MRI, irrespective of surgical type, demonstrated a significant positive correlation between the two variables (D, p = 0.05).

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