The Endoscopic Endonasal Approach (EEA) in the Management of Recurrent Craniopharyngiomas

Background: Recurrent craniopharyngiomas remain a significant management problem. The choice of surgical approach, the timing and use of adjuvant therapy are controversial with no uniform accepted protocol.

Objective: To report and evaluate our experience with the endoscopic endonasal approach (EEA) for resection of recurrent craniopharyngiomas.

Patients and Methods: From a retrospective cohort of 40 consecutive patients who underwent 43 EEA procedures between 2006–2012, 21 patients (48.8%) had recurrent tumors. The clinico-radiological presentation, surgical results, visual, endocrinological and functional outcomes were evaluated and compared between primary and recurrent tumors. The median follow up period was 23 months.

Results: The disease was recurrent following one transcranial (TC) procedure in 12 patients, one TC and one microscopic transsphenoidal procedure in 2 patients and one TC and one EEA in 2 patients. One patient had two previous TC surgeries and one microscopic transsphenoidal approach. Two patients had a TC procedure and an endoscopic cyst fenestration. One patient had two TC surgeries and one EEA. Three of the 21 patients with recurrent disease had previous radiotherapy.

The mean age (40.6 vs 41.9 years), maximum tumor diameter (2.9 cm vs 3.3 cm) and preoperative Karnofsky performance status (KPS) score was similar in both primary and recurrent groups. (p>0.05) Preoperative panhypopituitarusm (13.6 vs 61.9%) and diabetes insipidus (13.6 vs 52.4%) was significantly higher in the recurrent group. (p < 0.05)

Recurrent tumors were mainly of type II and type III of the Pittsburgh Classification. Total resection was achieved in 77% with primary lesions but only in 10% with recurrent lesions (p < 0.001). The postoperative visual improvement (100 Vs 86.6%) as well as worsening of vision (0 vs 5%) was comparable in both groups. Worsening of anterior pituitary (52.6 vs 50%) as well as posterior pituitary function (42.1 vs 40%) was similar in both groups. No patient had a postoperative KPS score of <80 in the primary group, where as 25% in the recurrent group had a postoperative KPS <80. (p < 0.05)

Conclusions: While there was no difference in the mean age at presentation, tumor size and preoperative KPS between primary and recurrent tumors, recurrent tumors presented with increased anterior and posterior pituitary deficits. In our series, recurrent surgery was associated with significantly lower rates of gross total resection. There were no statistical differences in visual outcomes, postoperative diabetes insipidus, and other surgical complication rates between patients with primary and recurrent tumors. A significantly higher number of patient s had a poorer KPS score at follow-up in the recurrent group.

The endoscopic endonasal approach has a significant role to play in recurrent cranioppharyngiomas especially if the original procedure was a TC approach and should be integrated in the overall management of these challenging lesions.