Surgery

Craniopharyngioma is primarily a surgical disease. Gross total resection is reported in up to 70%, with 90% of this group going on to enjoy a surgical cure [28]. Because of their sellar/ parasellar location and the tendency for the tumor to adhere to adjacent structures (optic apparatus, hypothalamus, pituitary stalk), postoperative neurologic morbidity can be as high as 30%, panhypopituitarism develops in up to 90% and overall operative mortality reaches 12% [28]. Operative mortality associated with recurrent craniopharyngioma surgery has been reported to be as high as 42% in the best of hands [29], including late mortality related to chronic endocrinopathy and shunt malfunction.

By limiting surgical resection, neurologic morbidity decreases, as does tumor control. In light of the significant morbidity and mortality associated with craniopharyngioma resection, many pediatric neurosurgeons have used minimally invasive techniques to effectively treat these lesions, with far fewer operative complications. Endoscopic endonasal transphenoidal techniques have been successfully employed in a select patient population, with promising results, primarily in patients with sella-based lesions. Increasingly, stereotactic techniques are being used, with excellent results in cystic craniopharyngiomas. Stereotactic intracavitary irradiation with 32P or 90Y has shown complete cyst resolution in 80% of patients, while installation of bleomycin can provide adequate tumor control in approximately 70%. Finally, stereo-tactic radiosurgery has shown to be effective treatment for the non-cystic craniopharyn-giomas, either as initial treatment or for treatment of the solid portion of mixed tumors following intracavitary treatment and cyst involution. Tumor control rates of 90% have been achieved when combined intracavitary and stereotactic irradiation are used as first-line therapy, and tumor control rates of approximately 60% have been shown in recurrent cran-iopharyngiomas using stereotactic radiosurgery alone. Given the low rate of post-operative complications, these minimally invasive techniques offer new options in the surgical management of this tumor.

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