Is Gross Total Resection Reasonable in Adults with Craniopharyngiomas with Hypothalamic Involvement?
Is Gross Total Resection Reasonable in Adults with Craniopharyngiomas with Hypothalamic Involvement?
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DOI：
10.1016/j.wneu.2019.06.037
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发表时间：
2019-09-01
影响因子：
2
通讯作者：
Jouanneau, Emmanuel
中科院分区：
文献类型：
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作者：
Apra, Caroline;Enachescu, Ciprian;Jouanneau, Emmanuel
目的：根据儿科经验，侵犯下丘脑的颅咽管瘤的治疗方法是次全切除(STR)加放射治疗。这种策略有时会导致无法控制的肿瘤进展。在成人中，使用内窥镜鼻腔手术(EES)，尽可能地切除下丘脑部分肿瘤是否会影响患者的预后？方法：我们纳入了2008-2016年间由资深神经外科医生(E.J.)首次接受EES治疗的成人颅咽管瘤患者。回顾收集了内分泌、眼科和下丘脑的数据，包括体重指数(BMI)、认知和社会状况，并进行了系统的随访。磁共振成像扫描按Puget分级：0，无下丘脑受累；1，下丘脑移位；2，下丘脑受累。2级肿瘤分为大体全切除或全切除。结果：22例患者年龄18~79岁。主要症状有视力障碍(14例，%)、内分泌功能障碍(10例，45%)、体重指数和GT；30例(8例，36%)、认知/精神障碍(9例，41%)。2级颅咽管瘤14例(%)。14例(%)患者接受了GTR术。术后视力改善12/14例(86%)，需要激素替代治疗20例(91%)。GTR组和STR组BMI的演变无差异，认知状态除1例外，其余均稳定或改善；8例STR患者中有4例病情进展需要辅助治疗，而未行辅助治疗的患者中有4例进展。结论：与经颅入路手术的儿童相比，2级颅咽管瘤的EES GTR不会导致下丘脑的严重恶化。外科医生的经验是决定何时停止解剖的关键。只要有可能，提供GTR的目的是避免肿瘤进展和放射治疗。
OBJECTIVE: The treatment of hypothalamus-invading craniopharyngiomas, based on pediatric experience, is subtotal resection (STR) with radiotherapy. This strategy sometimes leads to uncontrollable tumor progression. In adults, with the use of endoscopic endonasal surgery (EES), does removing the hypothalamic part of the tumor-whenever possible-compromise the outcome of the patients?METHODS: We included adults with craniopharyngioma treated by a first EES in 2008-2016 by senior neurosurgeon (E.J.). Endocrine, ophthalmologic, and hypothalamic data were retrospectively collected, including body mass index (BMI), cognitive and social status, with a systematic follow-up interview. Magnetic resonance imaging scans were graded according to Puget classification: 0, no hypothalamic involvement; 1, hypothalamic displacement; and 2, hypothalamic involvement. Grade 2 tumors were separated into gross total resection (GTR) or STR.RESULTS: We included 22 patients aged 18-79 years. Presenting symptoms were visual (14, 64%), endocrine dysfunction (10, 45%), BMI >30 (8, 36%), and cognitive/ psychiatric impairment (9, 41%). Fourteen (64%) were grade 2 craniopharyngiomas. GTR was performed in 14 (64%) patients. Postoperatively, 12/14 (86%) cases improved visually, and 20 (91%) needed hormone replacement therapy. There was no difference in BMI evolution in the GTR versus STR group, cognitive status was stable or improved in all patients except 1;4/8 patients with STR experienced progression needing adjuvant treatment versus no patient with GTR.CONCLUSIONS: EES GTR of grade 2 craniopharyngiomas does not cause major hypothalamic worsening, in contrast with children operated by cranial approaches. The surgeon's experience is key in deciding when to stop the dissection. Offering GTR whenever possible aims at avoiding tumor progression and radiotherapy.