Endoscopic endonasal approach for craniopharyngioma: the importance of the relationship between pituitary stalk and tumor

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OBJECTIVE

The endoscopic endonasal approach (EEA) is commonly used for the treatment of craniopharyngioma; therefore, it is essential to analyze outcomes in order to understand the benefits and drawbacks. The goal of this paper was to evaluate the clinical features and outcomes associated with this treatment approach.

METHODS

From July 2010 to March 2016, 82 adult craniopharyngioma patients underwent an EEA at the authors’ institution. Of these cases, intraoperative records and immediate postoperative MR images were available for 68 patients. The patients underwent systemized endocrinological evaluation. Eighteen of 68 patients who underwent EEA for recurrence or regrowth of residual lesions after previous surgical management were excluded in the analysis of the anatomical tumor classification. The authors retrospectively analyzed preoperative clinical features and previous anatomical classifications, focusing on the relationship of the pituitary stalk and tumor, to determine predictive factors for the clinical outcome, such as the extent of resection, visual function, endocrinological function, recurrence rate, and complications.

RESULTS

The mean tumor size was 2.5 cm (3.1 cm for primary tumors and 1.9 cm for recurrent lesions). Gross-total resection (GTR) was achieved in 62 (91.1%) patients (48 [96.0%] patients with primary tumors and 14 [77.8%] patients with recurrent tumors). The rate of GTR was higher in the primary group than in the group with recurrence (p = 0.038). The overall pre- and postoperative visual impairment scale (VIS) scores were 40.8 and 22.1, respectively (50.9 and 14.3 in the primary group and 30.7 and 29.9 in patients with recurrence, respectively). The improvement rate in VIS score was higher in the primary group than in the recurrent group (p = 0.001). Endocrinological function was improved in 4 patients (5.9%) and deteriorated in 32 of 68 patients (47.1%). Tumor invasion into the center of the pituitary stalk affected the postoperative outcomes most significantly. Cognitive dysfunction was observed in 22 patients before surgery and improved in 20 patients (90.9%) after surgery. Hydrocephalus was found in 7 patients and resolved after surgery in all cases. CSF leakage occurred in 2 (2.9%) of 68 patients and was repaired by revision surgery in both patients. Ten patients without CSF leakage also received antibiotics for the treatment of meningitis. The infection rate was higher in the recurrent group. Postoperative endocrinological evaluation showed no deficits in 12 patients and panhypopituitarism in 55 patients. The remaining patient had growth hormone deficiency. Forty-three patients had new-onset diabetes insipidus, and 1 patient had persistent diabetes insipidus after surgery. There were 2 (2.9%) cases of recurrence during the mean 30.7-month follow-up period; one patient underwent radiosurgery and the other underwent reoperation.

CONCLUSIONS

The EEA resulted in excellent surgical outcomes and acceptable morbidity rates, regardless of the anatomical location of the tumor. Invasion of the craniopharyngioma into the center of the pituitary stalk has strong predictive power for postoperative endocrinological outcome.

ABBREVIATIONS BMI = body mass index; EEA = endoscopic endonasal approach; GH = growth hormone; GTR = gross-total resection; ICA = internal carotid artery; STR = subtotal resection; VIS = visual impairment scale.

Article Information

Correspondence Yong Hwy Kim, Department of Neurosurgery, Seoul National University Hospital, Daehak-ro 101, Jongno-gu, Seoul 110-744, Republic of Korea. email: kimyh96@snu.ac.kr.

INCLUDE WHEN CITING Published online September 29, 2017; DOI: 10.3171/2017.4.JNS162143.

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

    Example of a peripheral-type craniopharyngioma. A and B: Coronal (A) and sagittal (B) MR images showing poor demarcation of the pituitary stalk. C and D: Intraoperative photographs showing that the tumor was attached to the surface of pituitary stalk and did not invade it. E: Intraoperative photograph showing that the pituitary stalk was completely preserved after tumor removal. Figure is available in color online only.

  • View in gallery

    Example of a central-type craniopharyngioma. A and B: Coronal (A) and sagittal (B) MR images showing enlargement of the pituitary stalk by the tumor. C: Intraoperative photograph obtained after dural incision, showing the stalk and optic chiasm. The stalk was enlarged and thinned by the tumor. D and E: Intraoperative photographs with (D) and without (E) surgical equipment, showing tumor dissection from the stalk, which covered the tumor surface after the incision on the site where the thinnest stalk tissue remained. Figure is available in color online only.

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