Endonasal endoscopic reoperation for residual or recurrent craniopharyngiomas

Abstract

OBJECTIVE Craniopharyngiomas can be difficult to remove completely based on their intimate relationship with surrounding visual and endocrine structures. Reoperations are not uncommon but have been associated with higher rates of complications and lower extents of resection. So radiation is often offered as an alternative to reoperation. The endonasal endoscopic transsphenoidal approach has been used in recent years for craniopharyngiomas previously removed with craniotomy. The impact of this approach on reoperations has not been widely investigated. METHODS The authors reviewed a prospectively acquired database of endonasal endoscopic resections of craniopharyngiomas over 11 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital, performed by the senior authors. Reoperations were separated from first operations. Pre- and postoperative visual and endocrine function, tumor size, body mass index (BMI), quality of life (QOL), extent of resection (EOR), impact of prior radiation, and complications were compared between groups. EOR was divided into gross-total resection (GTR, 100%), near-total resection (NTR, > 95%), and subtotal resection (STR, < 95%). Univariate and multivariate analyses were performed. RESULTS Of the total 57 endonasal surgical procedures, 22 (39%) were reoperations. First-time operations and reoperations did not differ in tumor volume, radiological configuration, or patients' BMI. Hypopituitarism and diabetes insipidus (DI) were more common before reoperations (82% and 55%, respectively) compared with first operations (60% and 8.6%, respectively; p < 0.001). For the 46 patients in whom GTR was intended, rates of GTR and GTR+NTR were not significantly different between first operations (90% and 97%, respectively) and reoperations (80% and 100%, respectively). For reoperations, prior radiation and larger tumor volume had lower rates of GTR. Vision improved equally in first operations (80%) compared with reoperations (73%). New anterior pituitary deficits were more common in first operations compared with reoperations (51% vs 23%, respectively; p = 0.08), while new DI was more common in reoperations compared with first-time operations (80% vs 47%, respectively; p = 0.08). Nonendocrine complications occurred in 2 (3.6%) first-time operations and no reoperations. Tumor regrowth occurred in 6 patients (11%) over a median follow-up of 46 months and was not different between first versus reoperations, but was associated with STR (33%) compared with GTR+NTR (4%; p = 0.02) and with not receiving radiation after STR (67% vs 22%; p = 0.08). The overall BMI increased significantly from 28.7 to 34.8 kg/m over 10 years. Six months after surgery, there was a significant improvement in QOL, which was similar between first-time operations and reoperations, and negatively correlated with STR. CONCLUSIONS Endonasal endoscopic transsphenoidal reoperation results in similar EOR, visual outcome, and improvement in QOL as first-time operations, with no significant increase in complications. EOR is more imp...

Management and outcome of recurrent adult craniopharyngiomas: an analysis of 42 cases with long-term follow-up

“…These patients did not receive RT or any other alternative therapy. We agree with the philosophy of Dhandapani et al, 10 who stated when the goal of surgery is GTR but GTR is not achieved during the first operation, the patient should be offered another reoperation via the EEA by an experienced surgeon if feasible. RT should be used only if this second attempt at GTR is unsuccessful.…”

“…It serves as an untouched route and direct inferior access to the chiasm, pituitary stalk, and third ventricle, including tumors with retrosellar interpeduncular extensions that can be difficult to reach using standard open approaches. 6,10,18,31 It offers the advantage of facing the tumor immediately after the dural opening without brain retraction, and optimizes visualization of the relevant anatomy through a straight surgical trajectory. 17 The EEA is also particularly useful in the surgical management of tumors with residual lesions and those that have regrown from these areas that were presumably not reached or manipulated during the first transcranial surgery.…”

Endoscopic endonasal versus open transcranial resection of craniopharyngiomas: a case-matched single-institution analysis

“…19 Others have additionally shown the utility of EEA for the recurrent disease or staged residual resection. 5,8,17 Together, these data support the use of EEA for the upfront treatment of amenable craniopharyngiomas via a purely endoscopic approach. Though some institutions now advocate the use of endoscopy for the treatment of every craniopharyngioma, we still believe in the reservation of transcranial staging for tumors with significant middle fossa, ambient, or third ventricular roof disease.…”

Microscopic versus endoscopic approaches for craniopharyngiomas: choosing the optimal surgical corridor for maximizing extent of resection and complication avoidance using a personalized, tailored approach

“…13,32 However, with advances in endoscopic endonasal skull base surgery and expanded techniques, a pure EEA has gained increased acceptance for removing more extensive craniopharyngiomas associated with a normal-sized sella and suprasellar tumors of supradiaphragmatic origin. 5,6,12,14,22,23,33,[35][36][37][42][43][44][45][46][47][48] The pure EEA has a major advantage when removing retrochiasmatic craniopharyngiomas with suprasellar third ventricular extension since it provides direct visualization of the undersurface of the optic nerves, chiasm, and hypothalamus. The prior aforementioned blind spots underneath the optic chiasm encountered with an approach from above (transbasal interhemispheric or pterional/orbitozygomatic approach) can be well visualized with an EEA from below.…”

“…9,14 It can also be used in combination with an open transcranial approach for extensive craniopharyngiomas occupying multiple compartments.…”