Abstract
Craniopharyngiomas are difficult to treat. The extended transsphenoidal approach has recently been described in several small series. We describe the usefulness of microscopy-assisted angled endoscopy for visualizing vital structures such as tumor attachment or tumor invasion to the pituitary stalk to achieve confident radical tumor removal. Between 2006 and 2010, 15 patients underwent the microscopy-assisted extended transsphenoidal approach for resection of entirely suprasellar craniopharyngiomas. Fourteen patients had the transinfundibular type, and one had the transinfundibular type with extension to the third ventricle. We observed color change within the pituitary stalk by endoscopy. The pituitary stalk was cut intentionally in 10 patients because of suspected tumor invasion surrounding the stalk. Total removal was accomplished in nine patients. Pathological specimens from the pituitary stalk showed tumor invasion spreading over the surface of the pituitary stalk, shown by a discolored pituitary stalk, and this was essential for confident radical tumor removal. Even after stalk resection, postoperative diabetes insipidus was minimal when a bright signal on T1 in the posterior lobe was not observed with preoperative magnetic resonance imaging. Confident radical tumor removal is possible with the introduction of the endoscopy-assisted microscopic extended transsphenoidal approach.
Highlights
Various approaches including the transcranial and transsphenoidal routes (Suzuki et al, 1984; Koenig et al, 1986; Hoffman et al, 1992; Maira et al, 1995) have been proposed for removal of craniopharyngiomas
Despite the benign histological appearance of these tumors, they are a major challenge for the neurosurgeon because of their tendency to adhere to vital structures such as the optic apparatus, pituitary stalk, hypothalamus, and third ventricle (Laws et al, 2005)
In the case where the pituitary stalk was intentionally cut, pathological study revealed that the epithelial nature of the craniopharyngioma tended to grow surrounding the whole surface of the pituitary stalk in all seven cases examined (Figure 2)
Summary
Various approaches including the transcranial and transsphenoidal routes (Suzuki et al, 1984; Koenig et al, 1986; Hoffman et al, 1992; Maira et al, 1995) have been proposed for removal of craniopharyngiomas. The transcranial approach (Suzuki et al, 1984) is insufficient for providing a wide scope of exposure for craniopharyngiomas that originate from the pituitary stalk or upper surface of the pituitary gland. Tumor removal is usually insufficient because of the limited space of manipulation and limited view scope of the origin of the craniopharyngioma. The endoscopy-assisted extended transsphenoidal approach has the advantage of identifying the origin of the craniopharyngioma and preserving the blood supply for the optic chiasm and pituitary stalk by applying microsurgical methods and careful dissection
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