Craniopharyngioma: Surgical experience of 309 cases in China

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Abstract

Objective

The objective of the present study was to retrospectively review the surgical outcome of 309 craniopharyngioma cases treated by a single neurosurgeon in China.

Patients and methods

A total of 309 cases of craniopharyngioma that were treated surgically from January 1996 to May 2006. Among them, 162 (52.4%) patients were male and 147 (47.6%) were female. There were 259 (83.8%) patients older than 15 years (mean 35.8 years) and 50 (16.2%) younger than 15 years (mean 8.8 years). The tumor size varied in diameter from 2.0 cm to 9.0 cm (mean 34.5 mm). Pterional approach was performed in 211 (68.3%) cases, trans-laminal terminal approach through frontobasal interhemispheric fissure in 55 (17.8%) cases, subfrontal approach in 20 (6.5%) cases, and transcallosum approach into the anterior third ventricle in 11 (3.6%) cases.

Results

Total, subtotal, and partial removal of tumors were achieved in 276 (89.3%), 20 (6.5%), and 13 (4.2%) patients, respectively. The pituitary stalk was preserved in 186 (60.2%) cases, severed in 49 (15.9%) cases, and unidentified in 74 (23.9%) cases during surgery. There were 12 (3.9%) patients died within 1 month after surgery. A total of 204 (66%) patients were followed from 6 months to 8 years (mean 2.1 years). In the 167 patients with total tumor removal, 23 (13.7%) had tumor recurrence within an average of 1.8 years. While, in the 32 patients with subtotal or partial resection, 24 (75%) had recurrence within an average of 0.5 years. There were five deaths occurred during follow-up.

Conclusion

Pre-surgery neuroimaging evaluations have improved our knowledge of intricate anatomical relationship between craniopharyngioma and the structures of the hypothalamus, pituitary stalk, and optic apparatus, which make total tumor resection feasible with the preservation of these vital structures to ensure a lower recurrence rate with acceptable mortality. However, excessive long-term morbidity, mostly related to hypopituitarism, which leads to the poor quality of life for the craniopharyngioma patients, is still remained. Further effort should be invested to monitor and maintain the normal hormone levels, hence improve the quality of life for craniopharyngioma patients.

Introduction

Craniopharyngiomas are benign tumors that arise from cells of Rathke's pouch remnants. They occur in anywhere around infundibular stalk, extending from the infundibulum to the anterior pituitary gland. Histological as a benign tumor, total surgical removal of craniopharyngioma is generally believed to result in the best outcome with few recurrences. However, the extensive adherence of craniopharyngioma to the hypothalamic structures, including pituitary stalk, infundibulum, tuber cinereum, mamillary bodies, optic nerve, and optic chiasm, makes it difficult, if not impossible, for a total resection. When a total resection cannot be completed, craniopharyngioma is prone to a higher recurrent rate [1], [2], [3]. The advantage of neuroimage and microsurgical technologies has lead to a better knowledge of intricate relationship between craniopharyngiomas, hypothalamus, pituitary stalk, and optic apparatus, hence, ensure proper selection of surgical approaches. As a result, the mortality of craniopharyngioma patients underwent aggressive surgical resection has been reduced markedly to 4% in recent surgical series from 16.7% in earlier series [1], [3], [4], [5], [6]. We reported here a series of 309 cases of craniopharyngioma that were surgically treated from January 1996 to May 2006, and summarized microsurgical experience in our practice.

Section snippets

Patients

There were 162 male and 147 female patients, ranging in age from 1 to 73 years, including 50 (16.2%) children younger than 15-year-old (mean 8.8 years) and 259 (83.8%) over 15 years (mean 35.8 years). The initial manifestations presented were moderate to severe headache in 107 patients, decrease in visual acuity and deficits of visual field in 133, diabetes insipidus in 27, amenorrhea in 21 women, growth retardation in 11, loss of libido in 5, memory deficit in 2, paralysis in 1, oculomotor

Extent of tumor resection and preservation of pituitary stalk

Total, subtotal, and partial removal of the tumor was achieved in 276 (89.3%), 20 (6.5%), and 13 (4.2%) patients, respectively. The extent of tumor resection was mainly affected by the size of tumor, but not location (Table 1, Table 2). The large tumors with a diameter more than 6 cm have a much lower rate for total resection, when compared to the tumors with a diameter less than 6 cm. In our experience, the tumors with a diameter between 3 cm and 6 cm have a slightly higher rate for total

Discussion

Craniopharyngioma locates in the infundibulalohypophyseal axial structures and has been considered benign as it is characterized as curable and free of recurrence if radical resection of the tumor can be achieved. However, the tumor usually adheres to the critical neural and vascular structures of hypothalamus, which makes complete tumor resection very difficult, if not impossible. Partial and subtotal resection is usually associated with a higher recurrence compared with total resection [7],

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