Comparative analysis of outcomes following craniotomy and expanded endoscopic endonasal transsphenoidal resection of craniopharyngioma and related tumors: a single-institution study

Abstract

Surgeons have advocated for both approaches, and at present there is no consensus whether one approach is superior to the other. The authors therefore compared surgical outcomes between craniotomy and endoscopic endonasal transsphenoidal surgery (EETS) for suprasellar tumors treated at their institution. methods A retrospective review of patients undergoing resection of suprasellar lesions at Cedars-Sinai Medical Center between 2000 and 2013 was performed. Patients harboring suspected craniopharyngioma were selected for extensive review. Other pathologies or predominantly intrasellar masses were excluded. Cases were separated into 2 groups, based on the surgical approach taken. One group underwent EETS and the other cohort underwent craniotomy. Patient demographic data, presenting symptoms, and previous therapies were tabulated. Preoperative and postoperative tumor volume was calculated for each case based on MRI. Student t-test and the chi-square test were used to evaluate differences in patient demographics, tumor characteristics, and outcomes between the 2 cohorts. To assess for selection bias, 3 neurosurgeons who did not perform the surgeries reviewed the preoperative imaging studies and clinical data for each patient in blinded fashion and indicated his/her preferred approach. These data were subject to concordance analysis using Cohen's kappa test to determine if factors other than surgeon preference influenced the choice of surgical approach. results Complete data were available for 53 surgeries; 19 cases were treated via EETS, and 34 were treated via craniotomy. Patient demographic data, preoperative symptoms, and tumor characteristics were similar between the 2 cohorts, except that fewer operations for recurrent tumor were observed in the craniotomy cohort compared with EETS (17.6% vs 42.1%, p = 0.05). The extent of resection was similar between the 2 groups (85.6% EETS vs 90.7% craniotomy, p = 0.77). An increased rate of cranial nerve injury was noted in the craniotomy group (0% EETS vs 23.5% craniotomy, p = 0.04). Postoperative CSF leak rate was higher in the EETS group (26.3% EETS vs 0% craniotomy, p = 0.004). The progression-free survival curves (log-rank p = 0.99) and recurrence rates (21.1% EETS vs 23.5% craniotomy, p = 1.00) were similar between the 2 groups. Concordance analysis of cases reviewed by 3 neurosurgeons indicated that individual surgeon preference was the only factor that determined surgical approach (kappa coefficient -0.039, p = 0.762) coNclusioNs Surgical outcomes were similar for tumors resected via craniotomy or EETS, except that more CSF leaks occurred in the EETS cohort, whereas more neurological injuries occurred in the craniotomy cohort. Surgical approach appears to mostly reflect surgeon preference rather than specific tumor characteristics. These data support the view that EETS is a viable alternative to craniotomy, providing a similar extent of resection with less neurological injury.

Outcomes in transcranial microsurgery versus extended endoscopic endonasal approach for primary resection of adult craniopharyngiomas

“…24,25 Other midline suprasellar tumors that may also occupy this location include meningiomas, pituitary adenomas, gliomas, and germinomas, among others. 15 The incidence of craniopharyngioma is estimated at approximately 1 to 3 per 100,000 and occurs without sex or racial predilection. 1,13 Diagnosis and referral to neurological surgery is often delayed because of the tumor's slow growth and the insidious onset of symptoms, including headache, endocrine dysfunction, and visual disturbance, classically in the form of bitemporal hemianopia.…”

“…2,3,23,27 EEEA resection of craniopharyngiomas employs expanded transsphenoidal craniocaudal access via transtuberculum, transplanum, and transclival osteotomies. 2,15,18 EEEA is a sensible approach for a subchiasmatic lesion extending into the third ventricle as it allows for exploration via a subchiasmatic operative corridor. Importantly, the tumor is debulked, and the optic apparatus is decompressed early before the nerves are handled.…”

“…[4][5][6]12,17 The increased rate of CSF leakage and the limited selection of tumors that are appropriate candidates for this approach are some of the drawbacks of this corridor. 12,15,16 Tumors with lateral extension beyond the carotid bifurcation or with vascular encasement are considered poor candidates for EEEA. In addition, the required specialized expertise limits the use of the approach.…”

“…17 Since that time, only one single-institution series has compared the outcomes of TCM and EEEA in the hands of a single group of surgeons. 15 The studies included in the meta-analysis and single-institution series included both primary and revision resections as well as noncraniopharyngioma suprasellar pathologies. 15,17 There remains a lack of consensus and evidence regarding the benefits of TCM versus EEEA in the setting of primary resection.…”

“…15 The studies included in the meta-analysis and single-institution series included both primary and revision resections as well as noncraniopharyngioma suprasellar pathologies. 15,17 There remains a lack of consensus and evidence regarding the benefits of TCM versus EEEA in the setting of primary resection. In the current study, we aimed to evaluate the outcomes of TCM and EEEA operations for primary resection of craniopharyngiomas in adults at our institution.…”