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Minim Invasive Neurosurg 2004; 47(1): 32-40
DOI: 10.1055/s-2003-812467
Original Article
© Georg Thieme Verlag Stuttgart · New York

Multimodality Stereotactic Approach to the Treatment of Cystic Craniopharyngiomas

A.  Nicolato1 , R.  Foroni1 , L.  Rosta1 , M.  Gerosa1 , A.  Bricolo1
  • 1Department of Neurosurgery, University Hospital, Verona, Italy
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Publication History

Publication Date:
18 July 2005 (online)

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Abstract

Objectives: To present the therapeutic reliability of a multimodality stereotactic approach (MSA) to cystic craniopharyngiomas (CPs), combining neuroendoscopy, intracavitary bleomycin and gamma knife (GK) radiosurgery.

Methods: 8 patients with mono- or multicystic CP (7/8 regrowths/recurrence) underwent stereotactic neuroendoscopy and subsequently treatment with intracavitary bleomycin and GK. They were clinically characterized by hypopituitarism (7 cases), visual impairment (7), endocranial hypertension (7), cognitive and behavioral disturbances (3), and cranial nerve deficits or focal signs (3). Concomitant hydrocephalus was observed in 3/8 patients. According to Backlund's classification, the treated CPs were classified as type A (3 cases), type Cc (4 cases) and type Dc (1 case). In all 8 patients, neuroendoscopy allowed evacuation of the cyst and, in multi-cystic CPs, fenestration of the interposed septa so as to create a single communicating cavity. Thus, a single catheter and Ommaya reservoir system was sufficient both for subsequent aspirations and for bleomycin injection (doses of 1.5 - 3 mg, usually repeated every 7 - 8 days, with total doses ranging from 3 - 35 mg). GK radiosurgery was carried out at a later stage on the collapsed cyst in type A forms, while in types Cc and Dc, it was used on the solid nodule on the same day as the neuroendoscopy.

Results: The median follow-up period was 42.5 months. Neurological improvement was observed in 8/8 patients. A complete response (reduction of the entire tumor volume > 90 %) was observed in 3/8 cases (type A), a subtotal response (reduction > 50 %) in 4/8 cases (types Cc and Dc), and a partial response (reduction < 50 %) in 1/8 cases (type Cc). Treatment of CP alone led to normalization of the ventricular morphology in the 3 patients with associated hydrocephalus. Transient GK-related visual worsening was recorded in one case only. One patient died because of ventriculitis after repeated shunt replacements.

Conclusions: This MSA seems to be an effective and safe treatment alternative to microsurgery, above all in patients with regrowing/recurrent cystic CPs.

Key words

Cystic craniopharyngioma - stereotactic treatment - neuroendoscopy - bleomycin - radiosurgery - gamma knife - minimally invasive neurosurgery

References

  • 1 De Vile C J, Grant D B, Kendall B E, Neville B GR, Stanhope R, Watkins K E, Hayward R D. Management of childhood craniopharyngioma: can the morbidity of radical surgery be predicted.  J Neurosurg. 1996;  85 73-81
    CrossrefPubMedGoogle Scholar
  • 2 Hayward R. The present and future management of childhood craniopharyngioma.  Child's Nerv Syst. 1999;  15 764-769
    PubMedGoogle Scholar
  • 3 Villani R M, Tomei G, Bello L, Sganzerla E, Ambrosi B, Re T, Giovanelli Barilari . Long-term results of treatment for craniopharyngioma in children.  Child's Nerv Syst. 1997;  13 397-405
    CrossrefPubMedGoogle Scholar
  • 4 Wara W, Sneed P K, Larson D A. The role of radiation therapy in the treatment of craniopharyngioma.  Pediatr Neurosurg. 1994;  21 (Suppl 1) 98-100
    PubMedGoogle Scholar
  • 5 Barlas O, Bayindir Ç, Can M. Interstitial irradiation for craniopharyngioma.  Acta Neurochir (Wien). 2000;  142 389-395
    CrossrefPubMedGoogle Scholar
  • 6 Backlund E-O. Treatment of craniopharyngiomas: the multimodality approach.  Pediatr Neurosurg. 1994;  21 (Suppl 1) 82-89
    PubMedGoogle Scholar
  • 7 Weiner H L, Wisoff J H, Rosenberg M E, Kupersmith M J, Cohen H, Zagzag D, Shiminski-Maher T, Flamm E S, Epstein F J, Miller D C. Craniopharyngiomas: a clinicopathological analysis of factors predictive of recurrence and functional outcome.  Neurosurgery. 1994;  35 1001-1011
    CrossrefPubMedGoogle Scholar
  • 8 Yasargil M G, Curcic J, Kis M, Siegenthaler G, Teddy P J, Roth P. Total removal of craniopharyngiomas: Approaches and long-term results in 144 patients.  J Neurosurg. 1990;  73 3-11
    CrossrefPubMedGoogle Scholar
  • 9 Caldarelli M, Di Rocco C, Papacci F, Colosimo Jr C. Management of recurrent craniopharyngioma.  Acta Neurochir (Wien). 1998;  140 447-454
    Google Scholar
  • 10 Fahlbusch R, Honneger J, Paulus W, Huk W, Buchfelder M. Surgical treatment of craniopharyngiomas: experience with 168 patients.  J Neurosurg. 1999;  90 237-250
    Google Scholar
  • 11 Prasad D, Steiner M, Steiner L. Gamma knife radiosurgery for craniopharyngioma.  Acta Neurochir (Wien). 1995;  134 167-176
    CrossrefPubMedGoogle Scholar
  • 12 Rajan B, Ashley S, Gorman C, Jose C C, Horwich A, Bloom H JG, Marsh H, Brada M. Craniopharyngioma - long-term results following limited surgery and radiotherapy.  Radiother Oncol. 1993;  26 1-10
    CrossrefPubMedGoogle Scholar
  • 13 Flickinger J C, Lunsford L D, Singer J, Cano E R, Deutsch M. Megavoltage external beam irradiation of craniopharyngiomas: analysis of tumor control and morbidity.  Int J Radiat Oncol Biol Phys. 1990;  19 117-122
    PubMedGoogle Scholar
  • 14 Harris J R, Levene M B. Visual complications following irradiation for pituitary adenomas and craniopharyngiomas.  Radiology. 1976;  120 167-171
    PubMedGoogle Scholar
  • 15 Regine W F, Mohiuddin M, Kramer S. Long-term results of pediatric and adult craniopharyngiomas treated with combined surgery and radiation. Review.  Radiother Oncol. 1993;  27 13-21
    CrossrefPubMedGoogle Scholar
  • 16 Scott R M, Hetelekidis S, Barnes P D, Goumnerova L, Tarbell N J. Surgery, radiation, and combination therapy in the treatment of childhood craniopharyngiomas - a 20 year experience.  Pediatr Neurosurg. 1994;  21 (Suppl 1) 75-81
    PubMedGoogle Scholar
  • 17 Backlund E-O, Axelsson B, Bergstrand C-G, Eriksson A-L, NorÉn G, Ribbesjö E, Rahn T, Scnell P-O, Tallstedt L, Sääf M, ThorÉn M. Treatment of craniopharyngiomas - the stereotactic approach in a ten to twenty-three years' perspective. I. Surgical, radiological and ophthalmological aspects.  Acta Neurochir (Wien). 1989;  99 11-19
    CrossrefPubMedGoogle Scholar
  • 18 Broggi G, Giorgi C, Franzini A, Leocata F, Riva D. Therapeutic contribution of intracavitary bleomycin administration in cystic craniopharyngioma. In: Broggi G (ed.). Craniopharyngioma. Surgical Treatment. Milan: Springer-Verlag 1995: 113-119
    Google Scholar
  • 19 Chung W Y, Pan H C, Guo W Y, Small C Y, Wang L W, Wu H M, Lee L S. Protection of visual pathway in gamma knife radiosurgery for craniopharyngiomas.  Stereotact Funct Neurosurg. 1998;  70 (Suppl 1) 139-151
    PubMedGoogle Scholar
  • 20 Chung W Y, Pan D H-C, Shiau C-Y, Guo W-Y, Wang L-W. Gamma knife radiosurgery for craniopharyngiomas.  J Neurosurg. 2000;  93 (Suppl 3) 47-56
    PubMedGoogle Scholar
  • 21 Frank F, Fabrizi A P, Frank G, Fioravanti A. Stereotactic management of craniopharyngiomas.  Stereotact Funct Neurosurg. 1995;  65 176-183
    PubMedGoogle Scholar
  • 22 Kobayashi T, Tanaka T, Kida Y. Stereotactic radiosurgery for craniopharyngiomas.  Pediatr Neurosurg. 1994;  21 (Suppl 1) 69-74
    PubMedGoogle Scholar
  • 23 Lunsford L D, Pollock B E, Kondziolka D S, Levine G, Flickinger J C. Stereotactic options in the management of craniopharyngioma.  Pediatr Neurosurg. 1994;  21 (Suppl 1) 90-97
    PubMedGoogle Scholar
  • 24 Savas A, Arasil E, Batay F, Selcuki M, Kanpolat Y. Intracavitary chemotherapy of polycystic craniopharyngioma with bleomycin.  Acta Neurochir (Wien). 1999;  141 547-549
    CrossrefPubMedGoogle Scholar
  • 25 Voges J, Sturm V, Lehrke R, Treuer H, Gauss C, Berthold F. Cystic craniopharyngioma: long-term results after intracavitary irradiation with stereotactically applied colloidal β-emitting radioactive sources.  Neurosurgery. 1997;  40 263-270
    CrossrefPubMedGoogle Scholar
  • 26 Decq P h, Yepes C, Anno Y, Djindjian M, Nguyen J P, Keravel Y. L'endoscopie neurochirurgicale. Indications diagnostiques et therapeutiques.  Neurochirurgie. 1994;  14 313-321
    PubMedGoogle Scholar
  • 27 Torrens M J. Endoscopic neurosurgery.  Neurosurgery Quarterly. 1995;  5 18-33
    PubMedGoogle Scholar
  • 28 Savas A, Erdem A, Tun K, Kanpolat Y. Fatal toxic effect of bleomycin on brain tissue after intracystic chemotherapy for a craniopharyngioma: case report.  Neurosurgery. 2000;  46 213-217
    PubMedGoogle Scholar
  • 29 Cavalheiro S, Veiga de Castro Sparapani F, Bidò Franco J O, Da Silva M C, Menezes Braga F. Use of bleomycin in intratumoral chemotherapy for cystic craniopharyngioma.  J Neurosurg. 1996;  84 124-126
    CrossrefPubMedGoogle Scholar
  • 30 Hader W J, Steinbok P, Hukin J, Fryer C. Intratumoral therapy with bleomycin for cystic craniopharyngiomas in children.  Pediatr Neurosurg. 2000;  33 211-218
    CrossrefPubMedGoogle Scholar
  • 31 Mottolese C, Stan H, Hermier M, Berlier P, Convert J, Frappaz D, Lapras C. Intracystic chemotherapy with bleomycin in the treatment of craniopharyngiomas.  Child's Nerv Syst. 2001;  17 724-730
    PubMedGoogle Scholar
  • 32 Leksell L. Stereotaxis and radiosurgery. An operative system. Springfield, III: Charles C Thomas 1971: 1-66
    Google Scholar
  • 33 Lunsford L D, Flickinger J, Lindner G, Maitz A. Stereotactic radiosurgery of the brain using the first United States 201 cobalt-60 source gamma knife.  Neurosurgery. 1989;  24 151-159
    CrossrefPubMedGoogle Scholar
  • 34 Effenterre R van, Boch A-L. Craniopharyngiomes de l'adulte et de l'enfant. Etude d'une serie chirurgicale de 106 cas consécutifs.  Neurochirurgie. 1997;  43 187-211
    PubMedGoogle Scholar
  • 35 Hoffman H J, DeSilva M, Humphreys R P, Drake J M, Smith M L, Blaser S I. Aggressive surgical management of craniopharyngiomas in children.  J Neurosurg. 1992;  76 47-52
    Google Scholar
  • 36 Abdullah J, Caemaert J. Endoscopic management of craniopharyngiomas: a review of three cases.  Minim Invas Neurosurg. 1995;  38 79-84
    PubMedGoogle Scholar

Dr. Antonio Nicolato

Department of Neurosurgery · University Hospital

Piazzale Stefani 1

37126 Verona

Phone: +39-045 807-3023

Fax: +39-045 807-2939

Email: antonio.nicolato@mail.azosp.vr.it

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