Effect of Stalk Preservation during Craniopharyngioma Removal on Pituitary Function, Extent of Resection and Recurrence: Systematic Review and Meta-Analysis

Background: The optimal management of the pituitary stalk during craniopharyngioma resection remains a controversial subject due to differing outcomes reported in the literature, specifically pertaining to pituitary function and recurrence.

Aim: This meta-analysis aims to evaluate the effect of pituitary stalk preservation on postoperative diabetes insipidus (DI), anterior pituitary function (PF), gross total resection (GTR) attainment and tumor recurrence.

Methods: MEDLINE was searched via Ovid for relevant articles from inception to 02/09/2022. Studies reporting any of the rates of DI and anterior PF postoperatively and/or at last follow up, the rate of GTR and tumor recurrence at last follow up were eligible for inclusion. A comparative meta-analysis was performed for each outcome to calculate the risk ratio (RR). We also included studies reporting single-arm outcomes, for which meta-analyses of proportions for all outcomes were conducted. Random-effects method was utilized in both analyses.

Results: A total of 3,488 abstracts and 150 full-text articles were reviewed to result in 33 studies for inclusion. In the comparative meta-analysis, pituitary stalk preservation significantly decreased the risk of postoperative DI (17 studies, RR: 0.67, 95% CI: 0.55–0.81) and abnormal anterior PF (15 studies, RR: 0.78, 95% CI: 0.69–0.89). Fewer number of studies reported longitudinal data on DI and anterior PF. Stalk preservation continued to significantly confer reduced risk from DI (6 studies, RR: 0.54, 95% CI: 0.41–0.72) but not from abnormal anterior PF (4 studies, RR: 0.38, 95% CI: 0.09–1.63). There was no significant difference in the risk for incomplete (non-GTR) resection (12 studies, RR: 1.59, 95% CI: 0.77–3.28) or in tumor recurrence (9 studies, RR: 1.18, 95% CI: 0.92–1.51) between stalk preservation and sacrifice groups. However, subgroup analysis on pediatric patients revealed a higher risk for incomplete (non-GTR) resection (RR: 3.29, 95% CI: 1.17–9.26) and a trend toward higher risk for recurrence (RR: 2.01, 95% CI: 0.88–4.60) in the stalk preservation group, each reported in 3 studies. In proportional meta-analysis including studies reporting single-arm outcomes, stalk preservation demonstrated lower proportions for DI (51%, 95% CI: 36–67 vs 84%, 95% CI: 70–95), abnormal anterior PF (69%, 95% CI: 54–83 vs. 100%, 95% CI: 100), DI at last follow-up (28%, 95% CI: 5–58 vs. 75%, 95% CI: 43–98) and abnormal anterior PF at last follow-up (49%, 95% CI: 2–97 vs. 100%, 95% CI: 99–100), but higher proportions for incomplete (non-GTR) resection (24%, 95% CI: 12–38 vs. 13%, 95% CI: 4–25) and tumor recurrence (19%, 95% CI: 13–26 vs. 11%, 95% CI: 7–15).

Conclusion: Pituitary stalk preservation was demonstrated to confer protective benefit on pituitary function, with the benefit persisting longitudinally for posterior pituitary function only. However, the decision for stalk preservation in pediatric patients should be given careful consideration due to increased risk for incomplete resection and recurrence. These results need to be interpreted with caution due to inclusion of studies with small sample sizes and inadequate reporting of outcomes in the literature specific to stalk preservation and sacrifice.

Publikationsverlauf

Artikel online veröffentlicht:
01. Februar 2023