Original ArticleClinical Outcome After Extended Endoscopic Endonasal Resection of Craniopharyngiomas: Two-Institution Experience
Introduction
Craniopharyngiomas have been described as the most challenging intracranial tumors.1, 2, 3 Although surgical morbidity and mortality have been reduced substantially with advances in surgical techniques, technology, and anesthetic capabilities, surgical treatment of craniopharyngiomas remains a challenge given the intimate relation of these tumors with the hypothalamus, optic apparatus, internal carotid arteries, and surrounding perforator vessels. In the 20th century, these tumors were almost exclusively surgically treated via the frontotemporal transsylvian, subfrontal, or interhemispheric transcallosal approaches. The introduction of the expanded endoscopic endonasal approaches (EEAs) in the early 2000s has renewed interest in removing craniopharyngiomas transnasally.4, 5, 6, 7, 8 EEA eliminates the need for brain retraction and improves visualization of the small perforating vessels to the optic chiasm and relationship of the tumor capsule to the walls of the hypothalamus. However, EEA treatment of these challenging tumors requires a significant learning curve. At Thomas Jefferson University Hospital (TJU), EEA has been used for surgical treatment of craniopharyngiomas in select cases since 2005. Through mutual collaboration, this technique was adopted at Seoul National University Hospital (SNU), which has used EEA for craniopharyngiomas since 2010. The purpose of this study is to present the combined clinical outcomes in 2 large institutional series with similar techniques of endoscopic endonasal surgery for the surgical treatment of craniopharyngiomas. We also compare recurrence-free survival rates between conservative resection followed by adjuvant radiotherapy and aggressive surgical resection alone.
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Study Population
This study was approved by the Institutional Review Boards of TJU and SNU. Forty-three patients who underwent EEA for craniopharyngiomas at TJU between November 2005 and December 2015 and 73 patients at SNU between October 2010 and March 2016 were included.
All patients underwent a preoperative endocrinologic biochemical workup including morning (7−8 a.m.) cortisol or adrenocorticotropin hormone stimulation test, adrenocorticotropin hormone, growth hormone, insulin-like growth factor−1,
Patient Population
Between 2005 and 2015, 43 consecutive patients (42 adults and one child) underwent surgery for the removal of craniopharyngioma via EEA at TJU. EEA has been performed since 2010 at SNU; 73 consecutive patients (69 adults and 4 children) underwent EEA for craniopharyngioma between 2010 and 2016. A total of 116 patients were included in this retrospective 2-institution study.
The 63 (54%) men and 53 (46%) women had a mean age of 43.8 years (range 14–74 years) (Table 1). Five pediatric patients
Extent of Tumor Removal
GTR was achieved in 54 patients (46%) and NTR in 45 patients (39%). Only 17 patients (15%) underwent STR (Table 2). No significant relationship was identified between the mean maximum tumor diameter and the extent of tumor removal (GTR, 2.69 ± 1.05 cm; NTR, 2.83 ± 1.23 cm; STR, 3.33 ± 1.42 cm; P = 0.141).
Review of the pathologic findings revealed 83 adamantinomatous (71%) and 31 papillary (27%) tumors. Pathology of the remaining 2 cases was not identified. There was no difference in the rate of
Relationship Between Recurrence and Extent of Resection
Tumor recurrence occurred in 18 of 116 patients, for an overall recurrence rate of 15.5%. The median interval period between EEA and radiographic tumor recurrence was 14.5 months (range, 3–58). We analyzed the relationship between tumor recurrence and the extent of tumor resection. In the GTR group (n = 54), 5 patients (9.3%) experienced tumor recurrence. Actuarial recurrence-free survival rates at 1, 3, and 5 years were 97.2 ± 2.7%, 94.4 ± 3.9%, and 76.6 ± 9.8%, respectively. In the NTR group (
Role of Adjuvant Radiotherapy/Radiosurgery
To investigate the role of adjuvant radiotherapy or radiosurgery, the patients were divided into 3 groups on the basis of treatment modality: GTR only, NTR/STR followed by adjuvant radiotherapy or radiosurgery, and NTR/STR only. Kaplan-Meier survival curves based on the treatment modality are presented in Figure 2. In 18 patients who underwent NTR/STR followed by adjuvant radiation, the tumor recurrence rate was 16.7%. Actuarial recurrence-free survival rates at 1, 3, and 5 years were 88.1% ±
Endocrinologic Outcomes
Endocrinologic evaluation was performed in 114 patients preoperatively and 1 month postoperatively (Figure 3). Among the 39 patients who underwent GTR, only 6 of them (9.2%) displayed preserved pituitary stalk and normal pituitary function postoperatively. Overall, of the 36 patients who had normal anterior pituitary function preoperatively, 15 of them (42%) maintained normal function, 5 of them (14%) developed partial hypopituitarism and 16 of them (44%) developed panhypopituitarism. Of the 49
Ophthalmologic Outcomes
Postoperative ophthalmologic evaluation was performed in 109 patients. Of the 89 patients with preoperative visual deficits, there was normalization of visual field testing in 43 patients (48%), and improvement in 25 patients (28%). Fifteen patients (17%) had no change in their visual field deficits postoperatively. Eight (7.3%) of the 109 patients with objective preoperative and postoperative visual assessments experienced visual deterioration. Among those with visual deterioration, 6 had
Perioperative Complications
Postoperative CSF leakage was the most common complication (n = 13; 11.2%). All patients with CSF leakage underwent endoscopic repair without additional morbidity. A lumbar drain was placed at the time of endoscopic endonasal tumor resection in 15 patients (12.9%). Meningitis occurred in 7 patients (6%), and all cases were successfully treated with antibiotic therapy. New postoperative hydrocephalus developed in 4 patients (3%). Three patients required treatment for hyponatremia within 1 month
Optimal Treatment Strategy
The optimal therapeutic management of craniopharyngiomas remains controversial. Total surgical removal is considered the optimal primary treatment modality for the majority of craniopharyngiomas due to its ability to achieve long-term tumor control.10, 11, 12 Aggressive surgical therapy has been associated with the best outcome in terms of overall survival and recurrence-free survival.13 However, complete surgical resection is not always possible and depends on tumor location, size, and
Conclusions
EEA is an effective surgical treatment for removal of craniopharyngiomas in terms of surgical outcome and tumor control. The extent of resection was the only significant factor associated with tumor recurrence. However, adjuvant radiotherapy could be a useful method for tumor control after incomplete resection. The goal of craniopharyngioma surgery should be a maximal safe removal of tumors while avoiding complications that can significantly impair quality of life, with adjuvant radiotherapy
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Hye Ran Park and Varun R. Kshettry are co−first authors.