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

Abstract

Craniopharyngiomas are rare, benign primary brain tumors that arise from remnants of the craniopharyngeal duct epithelium within the sellar and suprasellar region. Despite their benign biology, they may cause significant morbidity, secondary to involvement of nearby eloquent neural structures, such as the pituitary gland, hypothalamus, and optic apparatus. Historically, aggressive surgical resection was the treatment goal to minimize risk of tumor recurrence via open transcranial midline, anterolateral, and lateral approaches, but could lead to clinical sequela of visual, endocrine, and hypothalamic dysfunction. However, recent advances in the endoscopic endonasal approach over the last decade have mostly supplanted transcranial surgery as the optimal surgical approach for these tumors. With viable options for adjuvant radiation therapy, targeted medical treatment, and alternative minimally invasive surgical approaches, the management paradigm for craniopharyngiomas has shifted from aggressive open resection to more minimally invasive but maximally safe resection, emphasizing quality of life issues, particularly in regards to visual, endocrine, and hypothalamic function. This review provides an update on current multi-modal approaches for craniopharyngiomas, highlighting the modern surgical treatment paradigm for this disease entity.

Effects of two different radiotherapies for craniopharyngiomas using stereotactic radiosurgery/ stereotactic radiotherapy or fractionated stereotactic radiotherapy

“…[9] An analysis of adult patients with cystic craniopharyngiomas concluded that the use of the Ommaya reservoir with SRT could minimize radiation exposure to the optic apparatus and brain stem. [8,12,15] In this study, only one tumor was identified to have enlarged and categorized as TP, which was mainly a cystic lesion. We selected FSRT because the tumor compressed the optic nerve.…”

“…The previous studies have indicated tumor enlargement during or after the treatment, especially in craniopharyngiomas with cystic components. [ 1 , 8 , 12 ] A group of pediatric patients with this tumor received proton beam therapy and intensity-modulated RT after RT. In 52 patients, 40% had cyst growth during RT and 20% required intervention such as cyst decompression or adaptive replanning.…”

“…[ 9 ] An analysis of adult patients with cystic craniopharyngiomas concluded that the use of the Ommaya reservoir with SRT could minimize radiation exposure to the optic apparatus and brain stem. [ 8 , 12 , 15 ]…”

The Challenging Management of Craniopharyngiomas in Adults: Time for a Reappraisal?

“…Surgery can be proposed in several settings: as an emergency for chiasmatic decompression or reduction of intracranial pressure; as a preventive measure to avoid chiasmatic compression or intracranial hypertension in the case of recurrence; or to reduce the tumor volume which may then be subjected to radiotherapy [ 17 ]. The question of the degree of extension of the surgery has been controversial: some have advocated radical surgery, which could either lead to the removal of the pituitary stalk and/or damage to the hypothalamic structures, while others have proposed less radical surgery, with a higher risk of recurrence but less morbidity for the surrounding structures (especially the hypothalamus).…”

Craniopharyngioma surgery for rhinologists

“…Optimal management with STR and adjuvant XRT versus gross total resection (GTR) is still debated, with the overall strategy being maximum resection of tumor without damage to surrounding neurovascular structures (Fig. 5) [11][12][13].…”