Risk Factors for Complications and Long-Term Sequelae in Endoscopic Resection of Pediatric Craniopharyngioma

Background: Craniopharyngiomas are relatively rare neoplasms overall, but they represent 6 to 9% of brain tumors in the pediatric population. While histologically benign, the close proximity of a craniopharyngioma to a variety of neural and endocrine structures can lead to numerous complications, including vision changes, hormone imbalance, or deterioration in psychological function. Craniopharyngiomas frequently recur after treatment, and surgical morbidity is quite high, with a many patients requiring hormone replacement therapy, and a large majority of patients experiencing worsening of vision or weight gain. While endoscopic resection of craniopharyngioma has become increasingly prevalent in adult patients, it remains limited in use in pediatric surgery, and sparse data exists examining the endoscopic approach in this demographic. This study examines the risk factors for complications and long-term sequelae including psycho-social issues and obesity with endoscopic resection of craniopharyngiomas in the pediatric population.

Methods: Demographic and outcomes data from pediatric patients with craniopharyngioma was collected from the Children’s Hospital of Philadelphia and Mattel Children’s Hospital at the University of California Los Angeles. Patient, symptom, and tumor characteristics were analyzed for association with surgical or post-operative complications, including psychosocial issues and weight gain. Fisher’s Exact test was used for all categorical and dichotomous variable comparisons, a general linear model for continuous variables, and a linear longitudinal mixed model for BMI over time.

Results: 39 pediatric patients with craniopharyngioma from 1993 to 2015 were included in the analysis. 8 patients experienced a recurrence, 26 patients underwent an endoscopic approach and 13 patients had an open approach, 14 patients experienced complications, and 12 patients experienced permanent psychosocial issues after surgery. Preoperative cranial nerve deficits were significantly associated with surgical complications (p = 0.017). Increasing age also led to a greater likelihood of complications (p = 0.011), while other factors such as cavernous sinus extension, suprasellar extension, or positive margins were not associated with surgical complications. Patients with gross total resection had a significantly higher BMI trajectory from 0 to 24 weeks post-surgery compared with patients with subtotal resection (0.20 BMI pts per week; p = 0.027). Surgical approach, whether open or endoscopic, resulted in no significant difference in short-term complications or long-term sequelae such as permanent psychosocial issues or increased BMI.

Conclusion: Craniopharyngioma in the pediatric population remains a clinical challenge given the morbidity of treatment modalities, long-term endocrinologicl sequelae, and propensity for recurrence. Our findings indicate that increasing age is associated with surgical complications, while anatomical tumor extension was not. Physical exam demonstrating cranial nerve deficits may also be predictive of complications in this population. When considering risk for weight gain, only extent of resection significantly altered outcomes in the 6-month period following surgery. Endoscopic resection of craniopharyngiomas in the pediatric population is a viable approach with no difference in complication rates or long-term sequelae compared with the open approach.