Surgery Update on the Surgical Management of Craniopharyngiomas Ricardo J Komotar,1 Christopher P Kellner2 and Jeffrey N Bruce3
1. Chief Resident; 2. Junior Resident; 3. Professor of Neurological Surgery, Department of Neurological Surgery, The Neurological Institute of New York, Columbia University Medical Center
Abstract
Despite advances in microsurgical and skull base techniques, the surgical treatment of craniopharyngiomas continues to pose a challenge to surgeons. Controversy continues to exist between proponents of subtotal resection in conjunction with radiotherapy, who argue that this less aggressive approach can yield equivalent control rates with lower morbidity, and others who argue for the superiority of gross total resection. Regardless of whether gross total or subtotal resection is the goal, surgical planning must include a thorough endocrine and neuro- ophthamological evaluation as well as imaging, and the approach, whether trans-sphenoidal or transcranial, must take into account the nature of the tumour and its location. In addition, optimal management of craniopharyngiomas must consist of individualised and multidisciplinary therapy including an array of subspeciality fields such as endocrinology, neuro-ophthalmology, neuropsychology and radiation oncology.
Keywords Neurosurgery, craniopharyngioma, craniotomy
Disclosure: The authors have no conflicts of interest to declare. Received: 25 May 2010 Accepted: 29 June 2010 Citation: European Neurological Review, 2010;5(1):107–12 Correspondence: Jeffrey N Bruce, Department of Neurological Surgery, The Neurological Institute of New York, Columbia University Medical Center, 710 West 168th Street, New York, NY 10032, US. E:
jnb2@columbia.edu
Craniopharyngiomas are epithelial tumours that arise from embryonic epithelial cells of the craniopharyngeal duct. They account for 1.2–4% of all primary intracranial neoplasms and 5–10% of intracranial tumours in children.1
Although these tumours are rarely malignant,
they often grow adjacent to and distort critical neurovascular structures, particularly the visual pathways and hypothalamus, leading to significant morbidity and mortality. In addition, their sellar or parasellar location poses a challenge to surgical access. However, recent advances in microsurgical and skull base techniques have made resection possible in many patients.2
Historical Perspective
Early attempts at resecting skull base tumours, among them craniopharyngiomas, were limited by a lack of exogenously administered steroids, inadequate visualisation secondary to poor illumination and magnification techniques, poor diagnostic imaging modalities and mortality associated with hypothalamic injury. Despite these extraordinary limitations, early neurosurgeons made significant contributions to the management of craniopharyngiomas. As early as 1912, McArthur addressed the surgical section of the American Medical Association (AMA) regarding surgery of the hypophysis and famously stated: “long considered safe from invasion by the most daring surgeon, both because of its almost inaccessible location and because of its intimate relation to life, the question of its feasibility to surgical attack has been answered in the affirmative.”3
Due to the proximity of craniopharyngiomas to pituitary tumours, the original surgical approaches were very similarly described as either intracranial or extracranial/transphenoidal. Early intracranial
© TOUCH BRIEFINGS 2010
approaches for the resection of pituitary tumours were met with significant failure and high mortality. Following consistent failure of the intracranial approach and given the anatomical belief that these tumours grew downward from the floor of the sella, surgeons often preferred to work through the trans-sphenoidal approach. By contrast, early trans-sphenoidal approaches were more successful. In November 1909, Kanavel devised an infranasal technique that contrasted with other trans-sphenoidal approaches because it passed through the upper part of the nasal cavity. Albert Edward Halstead became the first surgeon to use this technique for the resection of a sellar tumour, notably a craniopharyngioma. Despite success with the trans-sphenoidal approach, not all surgeons were satisfied with the technique. For example, Harvey Cushing initially used the trans-sphenoidal approach, but abandoned it later in his career for the transfrontal approach, likely for better access to suprasellar lesions. Despite improvements in surgical techniques and the occasional success story, the prognosis of hypophyseal tumours in the early 1900s remained dismal.
As knowledge and experience accumulated throughout the early 1900s, intracranial approaches from the side of worse vision improved enough to supplant the trans-sphenoidal approach. By the end of the first half of the 20th century, radical resection was thought to give the best chance of cure, but the high morbidity and mortality associated with radical surgery prevented total resection in the majority of cases. The use of hormonal preparations and ‘Roentgen therapy’ laid the foundation for future craniopharyngioma treatment.4
107
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116