Outcomes of Pediatric Craniopharyngioma Resections after Open versus Expanded Endonasal Surgical Approach

Introduction: Craniopharyngioma is a benign tumor arising from remnants of Rathke’s pouch that primarily affects individuals aged 5 to 14 and 50 to 75 years old. Surgery is the primary treatment modality and is accomplished through an open or endoscopic expanded endonasal approach (EEA). Post-operative sequelae are related to the difficulty of surgical approach due to the proximity of vital structures such as the pituitary gland, hypothalamus, cavernous sinus, carotid arteries, and optic chiasm. Prior studies have found recurrence rates in patients managed openly or endoscopically to be equivocal and primarily influenced by the extent of resection and post-operative radiation therapy. This study aims to explore differences in outcome measures including post-operative recurrence rates in pediatric patients undergoing open versus endoscopic approach for craniopharyngioma.

Methods: A retrospective review of pediatric craniopharyngioma resections at two academic medical centers from January 1, 1993 to December 31, 2015 identified 39 patients. Demographic information, operative reports, imaging, pathology, recurrence rate, and long-term complications were collected. Statistical analysis was performed using Spearman’s rank-order correlation and Fisher’s exact tests to identify differences in outcomes among patients managed with open versus EEA.

Results: Thirty-nine patients (23 male) were identified who underwent primary surgery for craniopharyngioma, of which 15 (38.5%) were managed through an open approach and 24 (61.5%) were managed through an endoscopic approach. Mean age was 7.9 years (range, 1–17) with a mean follow-up time of 51.9 months (range, 0–231). Four patients in the open approach group (26.7%) received post-operative radiation therapy compared with one (4.2%) in the EEA group. Overall, a greater extent of resection was associated with the occurrence of post-operative cerebrospinal fluid leak (p = 0.031). Nine patients (23.1%) experienced a recurrence following their first surgery at their respective institution. Tumors managed through an open approach were more likely to recur compared with tumors managed through an EEA (OR: 6.0, 95% CI 1.003–35.910, p = 0.05). However, median follow-up time for patients undergoing an open resection was significantly longer than those undergoing EEA (open: 61.0 months, EEA: 27.0 months, p = 0.0002). There is a trend toward significance on Kaplan-Meyer curve analysis with log-rank test (p = 0.2787). There was no significant difference in tumor size based on surgical approach (open: 3.0 cm, EEA: 3.2 cm, p = 0.870) Cavernous sinus extension was associated with increased post-operative pain requirements (p = 0.019). Finally, a pre-operative diagnosis of hydrocephalus was associated with an increased duration of both intensive care unit admission (p = 0.009) and total length of stay (p = 0.007).

Conclusion: The EEA is a valuable technique for management of craniopharyngiomas in a minimally invasive manner and appears to result in a lower recurrence rate than an open approach. This study builds upon the knowledge of predictors of post-operative outcomes in pediatric craniopharyngioma patients.