Female, 6 years old. A type Q-CP case. Pre-surgical radiological images. (a, b) MRI revealed that a tumor in the intrasellar and suprasellar region. Partially tumor resection via the right-side pterional approach was performed in October 2013 in another hospital
7.3 Case 2: The Preservation of Pituitary Stalk and Pituitary Capsule May Lead to Recurrence of the Type Q Tumor (Figs. 7.12, 7.13, 7.14, 7.15, 7.16, 7.17, and 7.18)
In this case, pre-surgical radiological images revealed a tumor in the intrasellar and suprasellar regions; the surgical classification of the craniopharyngioma was Q type. The first operation was performed through fronto-basal interhemispheric approach; the tumor in the intrasellar and suprasellar regions was totally removed. For the postoperative endocrine function retention, the pituitary stalk and pituitary capsule were preserved during the first operation, resulting in postoperative tumor recurrence. The surgical classification of recurrent craniopharyngioma is consistent with preoperative classification. Most recurrent craniopharyngioma still retains the initial growth pattern. The recurrent tumor of Q type might be completely restrained in the intrasellar region when the diaphragma sellae was reconstructed. The recurrent tumor may be completely resected via a transsphenoidal approach.
In this case, the patient had several tumor recurrences. In 2009, intrasellar tumor resection combined with the removal of the pituitary capsule was performed, and the diaphragma sellae was reconstructed with artificial dura mater, which limited the tumor to suprasellar invasion, but the intrasellar tumor still recurred. The pathological findings indicated that the tumor had more invasive features and hinted at malignant transformation. The tumor cells were positive for Ki-67 (++, 18%). We believe that pathological malignancy may be one of the causes of tumor recurrence. The most recurrent craniopharyngioma still retains the initial growth pattern. We emphasized that the origin site is the source of tumor recurrence. Some type Q craniopharyngiomas may originate from intrasellar residues. The removal of intrasellar residues may explain why the recurring Q-type tumor may be completely resected via a transsphenoidal approach. We suggest to reconstruct the diaphragma sellae which might limit the tumor to suprasellar invasion in Q-type tumor. Incomplete tumor resection can lead to tumor recurrence. Repeated resection and repeated radiotherapy may lead to malignant changes of the tumor, but even if it is malignant, it can still not relapse if the total resection is performed. This patient has no recurrence for 5 years. This patient returned to normal work and life through endocrine therapy after operation.
In this case, the patient had only mild hypothalamic-pituitary dysfunction before surgery, and the clinical symptoms were mild. The pituitary stalk was clearly identifiable during the operation. For postoperative endocrine function retention, the pituitary stalk was preserved during the first operation, resulting in postoperative tumor recurrence. Once the tumor recurs, it is recommended to perform surgery as soon as possible. The origin site of recurrent craniopharyngioma was consistent with the first operation. Due to the destruction of the diencephalon lobe and mesencephalic lobe of Liliequist membrane in the first operation, the recurrent tumor could have serious adhesion to the peripheral blood vessels, nerves, and third VF, which increases the difficulty of surgery, and sometimes, even smaller recurrent tumors require complex procedures. Due to the peripheral arachnoid membrane structural destruction in the first operation, the resulting recurrent craniopharyngioma could have involved several subarachnoid spaces, including the posterior cranial fossa, which restricts the application of transsphenoidal surgery in recurrent tumors. Therefore, in our opinion, for type S recurrent CP, especially several subarachnoid spaces expanding the tumor, the transcranial approach is preferred.