title: Endonasal endoscopic reoperation for residual or recurrent craniopharyngiomas.
abstract: OBJECTIVE Craniopharyngiomas can be difficult to remove completely based on their intimate relationship with surrounding visual and endocrine structures. Reoperations are not uncommon but have been associated with higher rates of complications and lower extents of resection. So radiation is often offered as an alternative to reoperation. The endonasal endoscopic transsphenoidal approach has been used in recent years for craniopharyngiomas previously removed with craniotomy. The impact of this approach on reoperations has not been widely investigated. METHODS The authors reviewed a prospectively acquired database of endonasal endoscopic resections of craniopharyngiomas over 11 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital, performed by the senior authors. Reoperations were separated from first operations. Pre- and postoperative visual and endocrine function, tumor size, body mass index (BMI), quality of life (QOL), extent of resection (EOR), impact of prior radiation, and complications were compared between groups. EOR was divided into gross-total resection (GTR, 100%), near-total resection (NTR, > 95%), and subtotal resection (STR, < 95%). Univariate and multivariate analyses were performed. RESULTS Of the total 57 endonasal surgical procedures, 22 (39%) were reoperations. First-time operations and reoperations did not differ in tumor volume, radiological configuration, or patients' BMI. Hypopituitarism and diabetes insipidus (DI) were more common before reoperations (82% and 55%, respectively) compared with first operations (60% and 8.6%, respectively; p < 0.001). For the 46 patients in whom GTR was intended, rates of GTR and GTR+NTR were not significantly different between first operations (90% and 97%, respectively) and reoperations (80% and 100%, respectively). For reoperations, prior radiation and larger tumor volume had lower rates of GTR. Vision improved equally in first operations (80%) compared with reoperations (73%). New anterior pituitary deficits were more common in first operations compared with reoperations (51% vs 23%, respectively; p = 0.08), while new DI was more common in reoperations compared with first-time operations (80% vs 47%, respectively; p = 0.08). Nonendocrine complications occurred in 2 (3.6%) first-time operations and no reoperations. Tumor regrowth occurred in 6 patients (11%) over a median follow-up of 46 months and was not different between first versus reoperations, but was associated with STR (33%) compared with GTR+NTR (4%; p = 0.02) and with not receiving radiation after STR (67% vs 22%; p = 0.08). The overall BMI increased significantly from 28.7 to 34.8 kg/m2over 10 years. Six months after surgery, there was a significant improvement in QOL, which was similar between first-time operations and reoperations, and negatively correlated with STR. CONCLUSIONS Endonasal endoscopic transsphenoidal reoperation results in similar EOR, visual outcome, and improvement in QOL as first-time operations, with no significant increase in complications. EOR is more impacted by tumor volume and prior radiation. Reoperations should be offered to patients with recurrent craniopharyngiomas and may be preferable to radiation in patients in whom GTR or NTR can be achieved.
authors.affiliation: Departments of 1 Neurosurgery.|Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
authors.forename: Sivashanmugam
authors.initials: S
authors.lastname: Dhandapani
authors.affiliation: Departments of 1 Neurosurgery.|Department of Neurosurgery, Stanford University School of Medicine, Stanford, California.
authors.forename: Harminder
authors.initials: H
authors.lastname: Singh
authors.affiliation: Departments of 1 Neurosurgery.|Department of Neurosurgery, Menoufia University, Shebeen El Kom, Egypt; and.
authors.forename: Hazem M
authors.initials: HM
authors.lastname: Negm
authors.affiliation: Departments of 1 Neurosurgery.|Department of Neurosurgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico.
authors.forename: Salomon
authors.initials: S
authors.lastname: Cohen
authors.affiliation: Departments of 1 Neurosurgery.
authors.forename: Mark M
authors.initials: MM
authors.lastname: Souweidane
authors.affiliation: Departments of 1 Neurosurgery.
authors.forename: Jeffrey P
authors.initials: JP
authors.lastname: Greenfield
authors.affiliation: Otolaryngology, and.
authors.forename: Vijay K
authors.initials: VK
authors.lastname: Anand
authors.affiliation: Departments of 1 Neurosurgery.|Otolaryngology, and.|Neuroscience, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York.
authors.forename: Theodore H
authors.initials: TH
authors.lastname: Schwartz
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015992:Body Mass Index; D002648:Child; D002675:Child, Preschool; D003397:Craniopharyngioma / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery; D009364:Neoplasm Recurrence, Local / Q000473:pathology / Q000601:surgery*; D018365:Neoplasm, Residual / Q000473:pathology / Q000601:surgery; D010911:Pituitary Neoplasms / Q000473:pathology / Q000601:surgery*; D011788:Quality of Life; D012086:Reoperation; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult
keywords: ASBS-Q = anterior skull base surgery questionnaire; BMI = body mass index; DI = diabetes insipidus; EOR = extent of resection; GTR = gross-total resection; IQR = interquartile range; NTR = near-total resection; OR = odds ratio; PRL = prolactin; QOL = quality of life; STR = subtotal resection; craniopharyngioma; endonasal; endoscope; minimally invasive; oncology; radiation; recurrence; reoperation; skull base; surgery