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Frontobasal interhemispheric approach for large superasellar craniopharyngiomas: do the benefits outweigh the risks?

  • Clinical Article - Brain Tumors
  • Published:
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Abstract

Objective

Large suprasellar craniopharyngiomas are surgically challenging. The aim of our study was to explore the therapeutic efficacy of the frontobasal interhemispheric approach for these lesions.

Methods

Twenty-nine consecutive adult patients with large suprasellar craniopharyngiomas (diameter >4 cm) who underwent the frontobasal interhemispheric approach were retrospectively evaluated. Surgical and clinical outcomes were analyzed.

Results

Gross total removal was achieved in 23 cases (79.3 %) and subtotal removal in 6 cases (20.7 %). The mean follow-up period was 76.5 ± 33.2 months (range, 12-132 months). Twenty-four patients (82.7 %) had improvement of the visual impairment score (VIS) after surgery. VIS was unchanged in five patients (17.3 %), and no patients experienced visual deterioration. Among 23 patients who had preoperative hypopituitarism, 8 (34.8 %) had an improvement. Postoperative new or aggravated hypopituitarism was observed in four patients (13.8 %). Permanent diabetes insipidus was observed in ten patients (34.4 %). Postoperative anosmia occurred in two earlier cases (6.9 %). There was no intracranial infection or cerebrospinal fluid fistula. At last follow-up, >9 % BMI gain was observed in 34.5 % of patients, and 65.5 % of patients returned to work. Four patients (13.8 %) suffered recurrence.

Conclusion

Although the frontobasal interhemispheric approach has some disadvantages, it provides ideal access to the suprasellar region and the third ventricle with limited brain retraction. The surgically visible angle is adequate; thus, vital structures can be better protected. For large suprasellar craniopharyngiomas, the benefits of this approach can outweigh its potential risks.

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Authors and Affiliations

  1. Department of Neurosurgery, The First Hospital of China Medical University, Nanjing street 155, Heping District, Shenyang, 110001, China

    Sheng Han, Xinxin Tie, Xiaofei Qin, Yunjie Wang & Anhua Wu

Authors
  1. Sheng Han
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  2. Xinxin Tie
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  3. Xiaofei Qin
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  4. Yunjie Wang
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  5. Anhua Wu
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Corresponding author

Correspondence to Anhua Wu.

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Comment

Han et al. show that the interhemispheric approach has several advantages in the treatment of large craniopharyngiomas in adults. This is a well-recognised approach in children (using either a uni- or bilateral approach), and as the authors describe, this approach gives good access both superiorly (towards the IIIrd ventricle) and inferiorly (into the sella), as well as allowing for the optic apparatus to be suitably decompressed.

More importantly, as a result of their systematic data collection, Han et al. ask an important question: is it time to reconsider the role of surgery in adult patients with craniopharyngiomas? Certainly, in most paediatric centres there is at present a very different philosophy for the management of children with craniopharyngiomas as compared that in adult centres. Aggressive surgery with the aim of GTR has been considered the gold standard in both children and adults, but over the last decade or so, the paediatric literature has shown that:

1. GTR is still associated with a significant rate of recurrence

2. Subtotal resection with radiotherapy offers equivalent rates of tumour control

3. Damage to the hypothalamus on post-operative imaging is associated with significant morbidity, mainly with obesity and lethargy

However, these aspects have not been studied in detail in adults and the mantra for GTR continues unchallenged. Han et al. are to be congratulated on showing us that hypothalamic damage after craniopharyngioma surgery in adults is also associated with a significant increase in BMI. The authors are also to be congratulated on setting the standard by which future papers should be compared — with detailed information being made available on the pre- and post-operative visual function, BMI, endocrine function and employment status. Formal neuro-cognitive and quality-of-life assessments of these patients would also help determine the best treatment for adults with craniopharyngiomas (GTR or maximal safe resection with radiotherapy). Han et al. have asked an important question and the neurosurgical community now needs to work with their colleagues in endocrinology, ophthalmology and radiotherapy to try and answer this.

Paul Chumas

Leeds, UK

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Han, S., Tie, X., Qin, X. et al. Frontobasal interhemispheric approach for large superasellar craniopharyngiomas: do the benefits outweigh the risks?. Acta Neurochir 156, 123–131 (2014). https://doi.org/10.1007/s00701-013-1905-8

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  • DOI: https://doi.org/10.1007/s00701-013-1905-8

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