Indication and Limitations of Endoscopic Extended Transsphenoidal Surgery for Craniopharyngioma

Matsuo, Takayuki; Kamada, Kensaku; Izumo, Tsuyoshi; Nagata, Izumi

doi:10.2176/nmc.oa.2014-0038

Cited by 26 publications

(22 citation statements)

References 27 publications

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“…A narrow CPC with a large tumor extending up and behind the chiasm has been considered a contraindication to EEA, with a high risk of visual deterioration and consequent STR. 25 Our review reveals that neither a narrow corridor nor a high-rising tumor behind the chiasm should be considered a contraindication for craniopharyngiomas. Although pituitary transposition has been described to increase the working corridor into the suprasellar cistern, this maneuver really only increases the view to the interpeduncular cistern, and it increases the rate of pituitary dysfunction and the rate of CSF leak.…”

Section: Discussionmentioning

confidence: 86%

“…However, a narrow CPC with a large tumor extending up and behind the chiasm has been considered a contraindication to EEA, with a high risk of visual deterioration and consequent STR. 25 Patients with prefixed chiasms will tend to have a narrow CPC, while those with postfixed chiasms will have a large CPC. Classifications based on the location of craniopharyngiomas with respect to the infundibulum have been used to provide guidance for approach strategies.…”

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confidence: 99%

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Is the chiasm-pituitary corridor size important for achieving gross-total resection during endonasal endoscopic resection of craniopharyngiomas?

Omay

Almeida

Chen

et al. 2018

Journal of Neurosurgery

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OBJECTIVE Craniopharyngiomas arise from the pituitary stalk, and in adults they are generally located posterior to the chiasm extending up into the third ventricle. The extended endonasal approach (EEA) can provide an ideal corridor between the bottom of the optic chiasm and the top of the pituitary gland (chiasm-pituitary corridor [CPC]) for their removal. A narrow CPC in patients with a prefixed chiasm and a large tumor extending up and behind the chiasm has been considered a contraindication to EEA, with a high risk of visual deterioration and subtotal resection. METHODS A database of all patients treated in the authors' center (Weill Cornell Medical College, NewYork-Presbyterian Hospital) between July 2004 and August 2016 was reviewed. Patients with craniopharyngiomas who underwent EEA with the goal of gross-total resection (GTR) were included in the study. Patients with postfixed chiasm or limited available preoperative imaging were excluded. Using preoperative contrast-enhanced T1-weighted sagittal midline MR images, the authors calculated the CPC as well as the distance from the chiasm to the top of the tumor (CTOT). From these numbers, they calculated a ratio of the CPC to the CTOT as a measure of difficulty in removing the tumors through the EEA and called this ratio the corridor index (CI). The relationship between the CI and the ability to achieve GTR and visual outcome were measured. RESULTS Thirty-four patients were included in the study. The mean CPC was 10.1 mm (range 5.2-19.1 mm). The mean CTOT was 12.8 mm (range 0-28.3 mm). The median CI was 0.8; the CI ranged from 0.4 to infinity (for tumors with a CTOT of 0). Thirty-two patients had GTR (94.1%) and 2 had subtotal resection. The CPC value had no relationship with our ability to achieve GTR and no effect on visual or endocrine outcome. CONCLUSIONS EEA for craniopharyngioma is generally considered the first-line surgical approach. Although a narrow corridor between the top of the pituitary gland and the bottom of the chiasm may seem to be a relative contraindication to surgery for larger tumors, the authors' data do not bear this out. EEA appears to be a successful technique for the majority of midline craniopharyngiomas.

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Section: Discussionmentioning

confidence: 86%

mentioning

confidence: 99%

Is the chiasm-pituitary corridor size important for achieving gross-total resection during endonasal endoscopic resection of craniopharyngiomas?

Omay

Almeida

Chen

et al. 2018

Journal of Neurosurgery

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“…The basis of these classifications was the relation with the diaphragm, 44 the relation with the ventricle, 14,32 the tumor extension, 36 the relation with the stalk, 21 the growth pattern of the arachnoid envelope around the stalk, 35 the anatomical extension of the tumor, 12 the infundibular endoscopic view, 18 and the anatomical association between the tumor, sellar diaphragm, hypophyseal stalk, and optic nerve. 26 The re-production of these classifications is difficult due to the variability in the interpretation of the CT and MR images and the multiple types for each classification system, as well as the limited surgical visualization of all the neurovascular structures in relation to these tumors through the different approaches. We used a simplified classification that divided the tumors into 3 groups.…”

Section: Classification According To Tumor Topographymentioning

confidence: 99%

Preserve or sacrifice the stalk? Endocrinological outcomes, extent of resection, and recurrence rates following endoscopic endonasal resection of craniopharyngiomas

Ordóñez-Rubiano

Forbes

Morgenstern

et al. 2019

Journal of Neurosurgery

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OBJECTIVEGross-total resection (GTR) of craniopharyngiomas (CPs) is potentially curative and is often the goal of surgery, but endocrinopathy generally results if the stalk is sacrificed. In some cases, GTR can be attempted while still preserving the stalk; however, stalk manipulation or devascularization may cause endocrinopathy and this strategy risks leaving behind small tumor remnants that can recur.METHODSA retrospective review of a prospective cohort of patients who underwent initial resection of CP using the endoscopic endonasal approach over a period of 12 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital, was performed. Postresection integrity of the stalk was retrospectively assessed using operative notes, videos, and postoperative MRI. Tumors were classified based on location into type I (sellar), type II (sellar-suprasellar), and type III (purely suprasellar). Pre- and postoperative endocrine function, tumor location, body mass index, rate of GTR, radiation therapy, and complications were reviewed.RESULTSA total of 54 patients who had undergone endoscopic endonasal procedures for first-time resection of CP were identified. The stalk was preserved in 33 (61%) and sacrificed in 21 (39%) patients. GTR was achieved in 24 patients (73%) with stalk preservation and 21 patients (100%) with stalk sacrifice (p = 0.007). Stalk-preservation surgery achieved GTR and maintained completely normal pituitary function in only 4 (12%) of 33 patients. Permanent postoperative diabetes insipidus was present in 16 patients (49%) with stalk preservation and in 20 patients (95%) following stalk sacrifice (p = 0.002). In the stalk-preservation group, rates of progression and radiation were higher with intentional subtotal resection or near-total resection compared to GTR (67% vs 0%, p < 0.001, and 100% vs 12.5%, p < 0.001, respectively). However, for the subgroup of patients in whom GTR was achieved, stalk preservation did not lead to significantly higher rates of recurrence (12.5%) compared with those in whom it was sacrificed (5%, p = 0.61), and stalk preservation prevented anterior pituitary insufficiency in 33% and diabetes insipidus in 50%.CONCLUSIONSWhile the decision to preserve the stalk reduces the rate of postoperative endocrinopathy by roughly 50%, nevertheless significant dysfunction of the anterior and posterior pituitary often ensues. The decision to preserve the stalk does not guarantee preserved endocrine function and comes with a higher risk of progression and need for adjuvant therapy. Nevertheless, to reduce postoperative endocrinopathy attempts should be made to preserve the stalk if GTR can be achieved.

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“…Additionally, a poorly developed sinus precludes intraoperative visualization of bony landmarks (i.e., opticocarotid recess) for locating crucial neurovascular structures . This has led many to propose that incomplete sphenoid sinus pneumatization represents a relative contraindication to the EEA due to the theoretical increased risk of major intraoperative complications . However, more recent proficiency with endoscopic access and widespread adoption of intraoperative navigational imaging appears to have augmented the skull base surgeon's ability to safely perform skull base resection in even the youngest of patients …”

Section: Introductionmentioning

confidence: 99%

“…3,[8][9][10] This has led many to propose that incomplete sphenoid sinus pneumatization represents a relative contraindication to the EEA due to the theoretical increased risk of major intraoperative complications. [10][11][12] However, more recent proficiency with endoscopic access and widespread adoption of intraoperative navigational imaging appears to have augmented the skull base surgeon's ability to safely perform skull base resection in even the youngest of patients. 2,4 As surgeons become more adept in utilizing the EEA in skull base tumor resection, it is important to assess whether incomplete sphenoid sinus development poses a clinically significant barrier to employing this approach for pediatric patients.…”

Section: Introductionmentioning

confidence: 99%

Lack of Sphenoid Pneumatization Does Not Affect Endoscopic Endonasal Pediatric Skull Base Surgery Outcomes

et al. 2018

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Objectives/Hypothesis Currently, due to the rarity of pathology, there are limited data surrounding outcomes of pediatric skull base surgery. Traditionally, surgeons have proceeded with caution when electing endonasal endoscopic transsellar/transplanum approaches to the skull base in pediatric patients due to poor sphenoid pneumatization. In this study, we review outcomes of endoscopic pediatric skull base surgery based on sphenoid pneumatization patterns. Study Design Retrospective chart review. Methods A review of all cases of pediatric (age < 18 years) craniopharyngioma managed via an endoscopic endonasal approach at a tertiary academic medical center. Results A total of 27 patients were included in the analysis. The median age was 8 years. Nineteen (70%) patients were male. Presellar, sellar/postsellar, and conchal sphenoid pneumatizations were found in 6, 11, and 10 patients, respectively. There was no significant association between sphenoid pneumatization pattern and extent of resection (gross vs. subtotal, P = .414), postoperative cerebrospinal fluid (CSF) leak (P = .450), intraoperative estimated blood loss (P = .098), total operative time (P = .540), and length of stay (P = .336). On multivariate analysis, after accounting for age, sex, preoperative cranial nerve involvement, and cavernous sinus invasion, there remained no significant association between sphenoid pneumatization pattern and extent of resection (P = .999) and postoperative CSF leak (P = .959). Conclusions Sphenoid pneumatization pattern does not appear to affect outcomes in endoscopic skull base surgery in the pediatric population. Importantly, lack of sphenoid pneumatization does not impede gross total resection or increase complications. Thorough knowledge of the anatomy during the endoscopic approach is critical to optimize outcomes. Level of Evidence 4 Laryngoscope, 129:832–836, 2019

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Indication and Limitations of Endoscopic Extended Transsphenoidal Surgery for Craniopharyngioma

Cited by 26 publications

References 27 publications

Is the chiasm-pituitary corridor size important for achieving gross-total resection during endonasal endoscopic resection of craniopharyngiomas?

Is the chiasm-pituitary corridor size important for achieving gross-total resection during endonasal endoscopic resection of craniopharyngiomas?

Preserve or sacrifice the stalk? Endocrinological outcomes, extent of resection, and recurrence rates following endoscopic endonasal resection of craniopharyngiomas

Lack of Sphenoid Pneumatization Does Not Affect Endoscopic Endonasal Pediatric Skull Base Surgery Outcomes

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