Stereotactic cysto-ventricular catheters in craniopharyngiomas: an effective minimally invasive method to improve visual impairment and achieve long-term cyst volume reduction

Abstract

Craniopharyngiomas are typically located in the sellar region and frequently contain space-occupying cysts. They usually cause visual impairment and endocrine disorders. Due to the high potential morbidity associated with radical resection, several less invasive surgical approaches have been developed. This study investigated stereotactic-guided implantation of cysto-ventricular catheters (CVC) as a new method to reduce and control cystic components. Twelve patients with cystic craniopharyngiomas were treated with CVC in our hospital between 04/2013 and 05/2017. The clinical and radiological data were retrospectively analysed to evaluate safety aspects as well as ophthalmological and endocrine symptoms. The long-term development of tumour and cyst volumes was assessed by volumetry. The median age of our patients was 69.0 years and the median follow-up period was 41.0 months. Volumetric analyses demonstrated a mean reduction of cyst volume of 64.2% after CVC implantation. At last follow-up assessment, there was a mean reduction of cyst volume of 92.0% and total tumour volume of 85.8% after completion of radiotherapy. Visual acuity improved in 90% of affected patients, and visual field defects improved in 70% of affected patients. No patient showed ophthalmological deterioration after surgery, and endocrine disorders remained stable. Stereotactic implantation of CVC proved to be a safe minimally invasive method for the long-term reduction of cystic components with improved ophthalmological symptoms. The consequential decrease of total tumour volumes optimised conditions for adjuvant radiotherapy. Given the low surgical morbidity and the effective drainage of tumour cysts, this technique should be considered for the treatment of selected cystic craniopharyngiomas.

Neoadjuvant B-RAF and MEK Inhibitor Targeted Therapy for Adult Papillary Craniopharyngiomas: A New Treatment Paradigm

“…This justifies their frequent presentation with hypothalamic symptoms including neuropsychiatric disorders, neurocognitive impairment and also neuroendocrine dysfunction (14,16). Thus, complex PCPs represent a perfect example in which an effective neoadjuvant medical therapy, producing tumor shrinkage, could provide a reduction in long-term morbidity and facilitate both surgery and radiotherapy (5,7,21).…”

“…Future studies are required to confirm the validity of looking for BRAF V600E mutation in peripheral blood (liquid biopsy) prior to surgery (which may mobilize tumor cells into the general circulation). Currently, a tissue biopsy for definitive diagnosis is mandatory and can be safely performed using stereotaxic or transventricular neuroendoscopic techniques, as well as via transsphenoidal endoscopic techniques (21,(31)(32)(33)(34)(35)(36). Regardless of the technique used, a simple biopsy is definitely less aggressive than extended surgical resection.…”

“…Nonetheless, target therapy with B-RAF and MEK inhibitor agents has shown good results in the treatment of a number of human cancers (6,(16)(17)(18) and glial tumors (16,18,19) harboring the V600E BRAF mutation. These results have led to successful use of these agents for aggressive PCPs that present with a high frequency of BRAF V600E mutation (3,(16)(17)(18)(19)(20)(21).…”

The Role of Surgical Approaches in the Multi-Modal Management of Adult Craniopharyngiomas

“…A more recent study by Steiert et al validated this finding in 12 patients with cystic craniopharyngiomas who underwent stereotactic catheter placement into the ventricular system with the tip in the cyst, thus creating a cysto-ventricular shunt. This resulted in mean reduction of cyst volume of 92% at median follow-up of 41 months [66].…”

Craniopharyngioma surgery for rhinologists

“…This increase in treatment options will likely result in expansion of multidisciplinary management of this tumor, especially with the evolution of other techniques such as stereotactic radiosurgery, which can be used as an adjunct to surgery or in patients unwilling or unable to undergo surgery [52][53][54]. For those patients unable to tolerate surgery, cysto-ventricular catheter placement has also been explored as an option to improve mass effect on optic pathways by using minimally invasive methods to stereotactically place catheters that connect cystic craniopharyngiomas to the ventricular system for drainage [55]. Furthermore, with the advent of molecular therapies targeting BRAF tumorigenesis in papillary craniopharyngioma, CTNNB1 and EGFR in adamantinomatous craniopharyngioma, and VEGF in sub-types of both tumors, medical management will play a role in future treatment these tumors as well [56].…”