Impact of Pituitary Stalk Preservation on Tumor Recurrence/Progression and Surgically Induced Endocrinopathy After Endoscopic Endonasal Resection of Suprasellar Craniopharyngiomas.

Zhengyuan Chen,Hongying Ye,Zhaoyun Zhang,Zengyi Ma,Zhao Ye,Ming Shen,Nidan Qiao,Min He,Xiaoyun Cao,Yiming Li,Yao Zhao,Xuefei Shou,Yongfei Wang,Shiqi Li,Qilin Zhang,Xiang Zhou,Yichao Zhang,Wenqiang He

doi:10.3389/fneur.2021.753944

Abstract

Objective: To investigate the factors associated with recurrence/progression after endoscopic endonasal resection of suprasellar craniopharyngiomas. Special attention was paid to assess the impact of pituitary stalk preservation on tumor recurrence/progression and endocrinological outcomes.Methods: We retrospectively recruited 73 patients with suprasellar craniopharyngiomas undergone endoscopic endonasal approach (EEA) surgery from September 2014 to May 2019 and assessed their clinical characteristics, surgical outcomes, and recurrence/progression. Stalk preservation or sacrifice was determined by reviewing operative records, videos, and post-operative magnetic resonance imaging.Results: Gross total resection (GTR) was achieved in 51 cases (69.9%). Tumor recurrence was seen in 5 cases (9.8%) and progression was seen in 8 cases (36.4%), respectively. GTR (OR = 0.248 CI 0.081–0.759; p = 0.015) was the only independent factor influencing recurrence/progression. Kaplan-Meier survival analysis showed that the mean recurrence/progression-free survival were 53 (95% CI 48–59) and 39 (95% CI 28–50) months, respectively, in patients with and without GTR (p = 0.011). Pituitary stalk preservation was more common in cases with peripheral type tumors (83% vs. 30%, p < 0.01). Preserving the pituitary stalk does not appear to decrease the percentage of GTR (75.5% vs. 55.0%, p = 0.089), or increase the rate of tumor recurrence (12.5% vs. 0%, p = 0.508) or progression (46.2% vs. 22.2%, p = 0.486). However, surgically induced hypothyroidism (60.5% vs. 100%, p = 0.041) and diabetes insipidus (35.1% vs. 81.8%, p = 0.017) were significantly lower in patients with stalk preservation. For patients who had hypopituitarism before EEA, there was no difference between those with and without stalk preservation regarding post-operative hypopituitarism (p > 0.05).Conclusion: GTR is the only independent predictor of recurrence/progression after EEA surgery for suprasellar craniopharyngiomas. Preserving the pituitary stalk does not appear to increase the risk of non-GTR and tumor recurrence/progression and might help reduce the risk of surgically induced hypothyroidism and diabetes insipidus. We recommend preserving the pituitary stalk in peripheral type suprasellar craniopharyngiomas with normal pituitary function, especially in cases without hypothyroidism or diabetes insipidus. On the other hand, stalk sacrifice could be considered in central type tumors with severe pre-operative endocrinopathy.

Highlights

Craniopharyngioma is a common congenital tumor that constitutes about 2–6% of primary intracranial tumors, leading to visual disturbance, endocrine dysfunction, or cranial nerve palsy [1]
Does preserving the pituitary stalk lead to a higher risk of recurrence or progression? Does it contribute to a more favorable pituitary function? In the present study, we addressed these issues by evaluating the outcomes of endoscopic endonasal approach (EEA) in 73 suprasellar craniopharyngiomas with a median follow-up time of 19 months
Kaplan-Meier survival analysis showed that the mean recurrence/progression-free survival was 53 and 39 months, respectively, in patients with and without gross total resection (GTR) (p = 0.011; Figure 1)

Summary

Introduction

Craniopharyngioma is a common congenital tumor that constitutes about 2–6% of primary intracranial tumors, leading to visual disturbance, endocrine dysfunction, or cranial nerve palsy [1]. It is ideal if gross total resection (GTR) with preservation of the hypothalamic function could be achieved [3]. Adjuvant radiotherapy is reserved in selected cases of residual or recurrent tumors [4]. Due to their origin from remnants of the craniopharyngeal duct epithelium, craniopharyngiomas may arise anywhere along the pituitary-hypothalamic axis. The pituitary stalk plays a crucial role in hypothalamic-pituitary functioning and is a vital structure during the surgical resection of suprasellar craniopharyngiomas. The choice of preserving or sacrificing the pituitary stalk is of great significance during surgical resection of suprasellar craniopharyngiomas. Stalk-preservation without achieving GTR will inevitably put patients at the risk of tumor recurrence

Methods

Results

Discussion

Conclusion