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Approach selection and outcomes of craniopharyngioma resection: a single-institute study

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Abstract

Since there are many approaches for successful craniopharyngioma resection, how to choose a suitable approach remains problematic. The aim of this study was to summarize experience of approach selection and outcomes of craniopharyngioma resection in our institute. The data of 182 primary craniopharyngiomas between January 2013 and June 2019 were retrospectively reviewed. Craniopharyngiomas were classified into intrasellar, intra-suprasellar, suprasellar, and intra-third ventricle types based on the location. The surgical approaches, extent of resection, endocrine and ophthalmological outcomes, and complications were evaluated. Gross total resection (GTR) was achieved in 158 (86.8%) patients, near-total resection (NTR) in 20 (11%), and partial resection (PR) in 4 (2.2%). New-onset hypopituitarism occurred in 90 (49.5%) and new-onset diabetes insipidus in 48 (26.4%). Visual function was improved in 110 of the 182 patients, unchanged in 52, and deteriorated in 20. For intra-suprasellar and suprasellar tumors, patients in the endoscopic endonasal approach (EEA) group had higher GTR rate, lower incidence of new-onset hypopituitarism, and better visual outcome than patients in transcranial approach group, but no significant difference in the incidence of new-onset diabetes insipidus was found. There were no surgery-related deaths, and the common complications included permanent oculomotor nerve palsy, hemorrhage, and cerebrospinal fluid leaks. During the follow-up period, tumor recurrence or regrowth occurred in 6.6% of the cases. Tumor location is key for choosing an optimal surgical approach for craniopharyngioma resection. The EEA should be considered as the first choice for intra-suprasellar and suprasellar craniopharyngiomas to achieve better visual outcomes and fewer pituitary hormonal disorders.

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Acknowledgments

Thanks to Yang Zhongjin from Beijing Neurosurgical Institute for drawing the schematic diagrams of the subclassification of craniopharyngiomas for approach selection.

Funding

This study was supported by Beijing Municipal Science & Technology Commission (grant no. Z19110700660000) and the Capital’s Funds for Health Improvement and Research (2020-4-1077). The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

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Authors and Affiliations

  1. Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, People’s Republic of China

    Cao Lei, Liu Chunhui, Zhao Peng, Bai Jiwei, Wang Xinsheng & Gui Songbai

  2. Beijing Neurosurgical Institute, Capital Medical University, Beijing, 100070, People’s Republic of China

    Li Chuzhong & Zhang Yazhuo

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  1. Cao Lei
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Correspondence to Gui Songbai.

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Ethical approval

This retrospective study was approved by the Ethics Committee of Beijing Tiantan Hospital, Capital Medical University (KYSQ 2019-287-01).

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Informed consent was obtained from all adult participants or the parents of 2 minor participants included in the study.

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Supplemental Figure 1.

Pre- and post-operative MRI and intraoperative findings of intra-suprasellar craniopharyngiomas. Case 9 showed the space between the pituitary gland and the optic chiasm is enough to remove the tumor though EEA. EEA showed its advantage to remove the left-superior part under direct vision. Case 10 was a 4 years old boy, we did not choose EEA because the huge tumor extends extremely to lateral side, the poorly pneumatized sinuses, smaller facial structure and the difficulty for skull base reconstruction. The tumor was totally removed via the lateral subfrontal approach. Case 11, for this patient, we chose lateral subfrontal approach rather than EEA because the tumor extends extremely ahead and it was difficult to see the front interface of the tumor through EEA. OC= optic chiasm; PS= pituitary stalk; ON= optic nerve; T= tumor; P= pituitary; ICA= internal carotid artery; MCA= middle cerebral artery; ACA= anterior cerebral artery; LT= lamina terminalis. (PNG 3889 kb)

High resolution image (TIF 23056 kb)

Supplemental Figure 2.

Pre- and post-operative MRI and intraoperative findings of suprasellar craniopharyngiomas. Case 12, the tumor extended into the 3rd ventricle. Removing the tumor through EEA with two corridors: infra-chiasm and supra- chiasm (translamina terminalis). After the tumor was removed via EEA, the posterior wall of third ventricle, Monro foramen, and upper outlet of aqueduct can be seen clearly. Case 13, the tumor was cystic. After the tumor was removed through infra-chiasm corridor via EEA approach, the posterior wall of third ventricle, Monro foramen, and upper outlet of aqueduct could be seen clearly. Case 14, we chose lateral subfrontal approach because the tumor mainly located behind the saddle, which leading to the corridor between the chiasm and the pituitary gland to be narrow and long to remove the tumors located in the retrochiasmatic space through EEA. During the operation, the tumor could not be seen through prechiasmatic space and the lamina terminalis was obstructed by the anterior communicating artery. There were three blind spots for this approach: the undersurface of the optic chiasm and optic nerves, intrasellar and interface between tumor and hypothalamus. Case 15, the tumor mainly located behind the saddle and was severe calcified. The calcification could be resected en bloc through lamina terminalis for it was too hard to resect it piece by piece. Post-operatively, the girl had a temporary bilateral oculomotor nerve palsy and blurred vision in both eyes because of retraction-related injury of the optic apparatus and oculomotor nerve, which was recovered in two weeks. Case 16, we used left pterional approach because the tumor extended outside the carotid bifurcation. Case 17, we chose lateral subfrontal approach because the tumor extended to the retro-clival area. OC= optic chiasm; PS= pituitary stalk; ON= optic nerve; T= tumor; CT= calcified tumor; P= pituitary; ICA= internal carotid artery; 3rd V. = 3rd ventricle; LT= lamina terminalis; HT, hypothalamus; MF, Monro’s foramen. (PNG 8021 kb)

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Lei, C., Chuzhong, L., Chunhui, L. et al. Approach selection and outcomes of craniopharyngioma resection: a single-institute study. Neurosurg Rev 44, 1737–1746 (2021). https://doi.org/10.1007/s10143-020-01370-8

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