Multimodality Stereotactic Approach to the Treatment of Cystic Craniopharyngiomas

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.

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
• 2 Hayward R. The present and future management of childhood craniopharyngioma.  Child's Nerv Syst. 1999;  15 764-769
• 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
• 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
• 5 Barlas O, Bayindir Ç, Can M. Interstitial irradiation for craniopharyngioma.  Acta Neurochir (Wien). 2000;  142 389-395
• 6 Backlund E-O. Treatment of craniopharyngiomas: the multimodality approach.  Pediatr Neurosurg. 1994;  21 (Suppl 1) 82-89
• 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
• 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
• 9 Caldarelli M, Di Rocco C, Papacci F, Colosimo Jr C. Management of recurrent craniopharyngioma.  Acta Neurochir (Wien). 1998;  140 447-454
• 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
• 11 Prasad D, Steiner M, Steiner L. Gamma knife radiosurgery for craniopharyngioma.  Acta Neurochir (Wien). 1995;  134 167-176
• 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
• 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
• 14 Harris J R, Levene M B. Visual complications following irradiation for pituitary adenomas and craniopharyngiomas.  Radiology. 1976;  120 167-171
• 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
• 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
• 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
• 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
• 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
• 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
• 21 Frank F, Fabrizi A P, Frank G, Fioravanti A. Stereotactic management of craniopharyngiomas.  Stereotact Funct Neurosurg. 1995;  65 176-183
• 22 Kobayashi T, Tanaka T, Kida Y. Stereotactic radiosurgery for craniopharyngiomas.  Pediatr Neurosurg. 1994;  21 (Suppl 1) 69-74
• 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
• 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
• 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
• 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
• 27 Torrens M J. Endoscopic neurosurgery.  Neurosurgery Quarterly. 1995;  5 18-33
• 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
• 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
• 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
• 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
• 32 Leksell L. Stereotaxis and radiosurgery. An operative system. Springfield, III: Charles C Thomas 1971: 1-66
• 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
• 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
• 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
• 36 Abdullah J, Caemaert J. Endoscopic management of craniopharyngiomas: a review of three cases.  Minim Invas Neurosurg. 1995;  38 79-84