Departments of1Neurological Surgery.
5Department of Neurosurgery, Barlicki University Hospital, Lodz, Poland; and.
J Neurosurg. 2023 Apr 28;139(5):1235-1246. doi: 10.3171/2023.3.JNS222607. Print 2023 Nov 1.
Craniopharyngioma is a benign but surgically challenging brain tumor. Controversies exist regarding its ideal treatment strategy, goals of surgery, efficacy of radiation, and the long-term outcomes of these decisions. The authors of this study performed a detailed analysis of factors predictive of the extent of resection and recurrence in large series of craniopharyngiomas removed via an endoscopic endonasal approach (EEA) with long-term follow-up.
From a prospective database of all EEAs done at Weill Cornell Medical College by the senior author from 2004 to 2022, a consecutive series of histologically proven craniopharyngiomas were identified. Gross-total resection (GTR) was generally the goal of surgery. Radiation was often given if GTR had not been achieved. The stalk was preserved if not infiltrated with tumor but was sacrificed to achieve GTR. Intentional subtotal resection (STR) was performed in select cases to avoid hypothalamic injury.
Among the 111 identified cases were 88 adults and 23 children. Newly diagnosed cases comprised 58.6% of the series. GTR was attempted in 77.5% of the patients and among those cases was achieved in 89.5% of treatment-naive tumors and 72.4% of recurrent tumors. An inability to achieve GTR was predicted by prior surgical treatment (OR 0.13, 95% CI 0.03-0.6, p = 0.009), tumor diameter ≥ 3.5 cm (OR 0.11, 95% CI 0.02-0.53, p = 0.006), and encasement of the optic nerve or a major artery (OR 0.11, 95% CI 0.01-0.8, p = 0.03). GTR with stalk preservation maintained some anterior pituitary function in 64.5% of cases and prevented diabetes insipidus in 25.8%. After a median follow-up of 51 months (IQR 17-80 months), the recurrence rate after GTR was 12.5% compared with 38.5% after non-GTR. The median recurrence-free survival was 5.5 years after STR, 8.3 years after near-total resection (≥ 98%), and not reached after GTR (p = 0.004, log-rank test). GTR was the strongest predictor of recurrence-free survival (OR 0.09, 95% CI 0.02-0.42, p = 0.002), whereas radiation did not show a statistically significant impact (OR 1.17, 95% CI 0.45-3.08). In GTR cases, the recurrence rate was higher if the stalk had been preserved (22.6%) as opposed to a sacrificed stalk (4.9%; OR 5.69, 95% CI 1.09-29.67).
The study data show that GTR should be the goal of surgery in craniopharyngiomas if it can be achieved safely. Although stalk preservation can maintain some endocrine function, the risk of recurrence is higher in such cases. Radiation may not be as effective as previously reported.
颅咽管瘤是一种良性但具有挑战性的脑肿瘤。对于其理想的治疗策略、手术目标、放疗效果以及这些决策的长期结果，仍存在争议。本文作者对通过内镜经鼻入路（EEA）进行长期随访的大型颅咽管瘤切除系列中预测切除范围和复发的因素进行了详细分析。
从作者 2004 年至 2022 年在威尔康奈尔医学院进行的所有 EEA 的前瞻性数据库中，确定了一系列经组织学证实的颅咽管瘤。大体全切除（GTR）通常是手术的目标。如果未达到 GTR，则通常给予放疗。如果肿瘤未浸润视交叉，则保留视交叉，否则为了实现 GTR 而牺牲视交叉。为避免下丘脑损伤，选择性进行了意向性次全切除（STR）。
在确定的 111 例病例中，有 88 例成人和 23 例儿童。新诊断病例占该系列的 58.6%。77.5%的患者尝试了 GTR，其中 89.5%的初治肿瘤和 72.4%的复发性肿瘤实现了 GTR。先前的手术治疗（OR 0.13，95%CI 0.03-0.6，p = 0.009）、肿瘤直径≥3.5cm（OR 0.11，95%CI 0.02-0.53，p = 0.006）和视神经或主要动脉包埋（OR 0.11，95%CI 0.01-0.8，p = 0.03）是无法实现 GTR 的预测因素。保留视交叉的 GTR 使 64.5%的病例保留了部分垂体前叶功能，并预防了 25.8%的尿崩症。在中位随访 51 个月（IQR 17-80 个月）后，GTR 后的复发率为 12.5%，而非 GTR 后的复发率为 38.5%。STR 后的无复发生存率为 5.5 年，接近全切除（≥98%）后的无复发生存率为 8.3 年，GTR 后的无复发生存率未达到（p = 0.004，对数秩检验）。GTR 是无复发生存的最强预测因素（OR 0.09，95%CI 0.02-0.42，p = 0.002），而放疗并未显示出统计学上的显著影响（OR 1.17，95%CI 0.45-3.08）。在 GTR 病例中，如果保留了视交叉（22.6%），而不是牺牲了视交叉（4.9%），复发率更高（OR 5.69，95%CI 1.09-29.67）。
研究数据表明，如果能够安全实现，GTR 应作为颅咽管瘤手术的目标。尽管保留视交叉可以维持部分内分泌功能，但这种情况下的复发风险更高。放疗的效果可能不如以前报道的那样有效。
