of Recurrent Craniopharyngioma


Fig. 7.1

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


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig2_HTML.jpg

Fig. 7.2

In March 2013 (half a year after the first operation), the vision sharply declined. (a, b) MRI revealed the recurrence of the tumor in the intrasellar and suprasellar regions. Due to the diaphragma sellae structural destruction in the first operation, the recurrent craniopharyngioma could have involved several subarachnoid spaces


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig3_HTML.jpg

Fig. 7.3

Radical gross tumor removal (GTR) via the fronto-basal interhemispheric approach was performed in our hospital in March 2013. Intrasurgical findings. Dissect the arachnoidal trabecula and membrane between the two lobes to expose of the sellar region. (1) Tumor


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig4_HTML.jpg

Fig. 7.4

The tumor was separated from the left-side optic nerve. (1) Left-side optic nerve, (2) tumor


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig5_HTML.jpg

Fig. 7.5

The morphologically thin optic chiasm and right-side optic nerve were pushed by the tumor. (1) Left-side optic nerve, (2) optic chiasm, (3) tumor


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig6_HTML.jpg

Fig. 7.6

The origin site of the tumor is located in the intrasellar region. The intrasellar tumor could be extensively exposed after drilling the tuberculum sellae. The laser knife was used to open the dura mater of the tuberculum sellae


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig7_HTML.jpg

Fig. 7.7

The ultrasonic bone scalpel was used to drill the tuberculum sellae to expose the intrasellar tumor


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig8_HTML.jpg

Fig. 7.8

Resection of the tumor in the intrasellar region, the pituitary stalk was located behind the tumor, expanding like a funnel, and the origin site of the tumor was located in the intrasellar region. (1) Pituitary stalk, (2) tumor


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig9_HTML.jpg

Fig. 7.9

Resection of intrasellar tumor along the pituitary capsule. The tumor grew throughout the arachnoidal sleeve segment of pituitary stalk. Due to the diaphragma sellae structural destruction in the first operation, the recurrent craniopharyngioma had direct contact with pituitary stalk. The pituitary stalk exhibited severe tumor involvement, and it was sacrificed to avoid tumor recurrence. (1) Pituitary stalk, (2) tumor


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig10_HTML.png

Fig. 7.10

The tumor was en bloc removed. (1) Tumor


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig11_HTML.jpg

Fig. 7.11

(a, b) MRI postsurgery showed no residual tumor, and the neurohypophysis was preserved. The vision of the patient was significantly improved



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.

../images/464048_1_En_7_Chapter/464048_1_En_7_Fig12_HTML.jpg

Fig. 7.12

Female, 14 years old. A type Q-CP case. Preoperative radiological images. (a, b) MRI revealed a tumor in the intrasellar and suprasellar regions


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig13_HTML.jpg

Fig. 7.13

Radical gross tumor removal (GTR) by the fronto-basal interhemispheric approach was performed in our hospital in May 2014. After total tumor removal, the diaphragma sellae was reconstructed with artificial dura mater, and the neurovascular structures of the sellar region were preserved. (1) Artificial dura mater


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig14_HTML.png

Fig. 7.14

Postoperative radiological images. (a, b) MRI indicated no residual tumor. The neurohypophysis and partial adenohypophysis were preserved


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig15_HTML.png

Fig. 7.15

In October 2014, (ac) MRI revealed the recurrence of the tumor in the intrasellar region. The diaphragma sellae was reconstructed with an artificial dura mater in the first operation, which limited the recurrent tumor to suprasellar invasion


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig16_HTML.jpg

Fig. 7.16

Radical gross tumor removal by the transsphenoidal approach was performed in our hospital in October 2014. Intrasurgical findings. After drilling the sellar floor bone, and opening the dura, the intrasellar tumor was exposed. (1) Tumor, (2) artificial dura mater


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig17_HTML.jpg

Fig. 7.17

The artificial dura mater which was used to reconstruct the diaphragma sellae in the first operation was exposed after the total intrasellar tumor removal. (1) Artificial dura mater


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig18_HTML.jpg

Fig. 7.18

In 2016 (2 years after the last operation), postsurgical radiological images. (ac) MRI indicated total tumor removal and proved that the tumor had not recurred


7.4 Case 3: Repeated Resection and Radiotherapy May Lead to Malignant Transformation of the Tumor (Figs. 7.19., 7.20, 7.21, 7.22, 7.23, 7.24, 7.25, 7.26, 7.27, 7.28, 7.29, 7.30, 7.31, 7.32, 7.33, 7.34, and 7.35)



../images/464048_1_En_7_Chapter/464048_1_En_7_Fig19_HTML.jpg

Fig. 7.19.

Male, 9 years old. A type Q-CP case. Pre-surgical radiological images. (a, b) Magnetic resonance imaging revealed a cystic predominantly tumor in the sellar region


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig20_HTML.jpg

Fig. 7.20

In 1998, subtotal tumor resection via the left-side pterional with lateral frontal expanding approach was performed in another hospital. Postsurgical radiological images. (a, b) MRI revealed the patient with residual tumor in the sellar region. There was visual improvement in the left eye, but there was complete loss of vision in the right eye after surgery


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig21_HTML.jpg

Fig. 7.21

The first recurrence of the type Q-CP case. In 2004, the vision in the left eye decreased. MRI showed the recurrence of the tumor; irradiation with gamma knife was performed in another hospital


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig22_HTML.png

Fig. 7.22

The second recurrence of the type Q-CP case. Early in 2006, the vision in the left eye began to decline. The tumor recurred, predominantly growing through cysts


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig23_HTML.png

Fig. 7.23

Cystic fluid drainage followed by P32 intra-cystic irradiation was used to treat the recurrent tumor. However, the patient’s vision had no improvement; MRI showed no significant shrink of the tumor


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig24_HTML.jpg

Fig. 7.24

Radical gross tumor removal (GTR) by the fronto-basal interhemispheric approach was performed in our hospital in October 2007. The purpose of the operation was to save the vison. (a, b) Intrasurgical findings. (1) Degenerative optic nerve (left side), (2) tumor, (3) optic nerve (right side), (4) internal carotid artery


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig25_HTML.jpg

Fig. 7.25

Radical gross tumor removal (GTR) was performed in our hospital in 2007, and the postoperative MRI showed no visibly residual tumor. The neurovascular structures of the sellar region were preserved. The vision in the left eye of the patient was significantly improved


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig26_HTML.jpg

Fig. 7.26

In March 2008, there was intrasellar tumor recurrence in postoperative MRI (a, b)


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig27_HTML.jpg

Fig. 7.27

In April 2008, radical gross tumor removal was performed. in postoperative MRI (a, b)


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig28_HTML.jpg

Fig. 7.28

In March 2009, the tumor recurred again in postoperative MRI (a, b)


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig29_HTML.jpg

Fig. 7.29

In April 2009, radical gross tumor removal was performed. The tumor was separated from the surrounding neurovascular structures along the suprasellar arachnoid interface. The diaphragma sellae was reconstructed with artificial dura mater. (1) Artificial dura mater


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig30_HTML.png

Fig. 7.30

Postoperative radiological images. (a, b) MRI indicated no residual tumor. The reconstructed diaphragma sellae remained intact


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig31a_HTML.jpg../images/464048_1_En_7_Chapter/464048_1_En_7_Fig31b_HTML.jpg

Fig. 7.31

The pathological findings indicated that the tumor had more invasive features and hinted at malignant transformation. Immunohistochemically, the tumor cells were positive for Ki-67 (++, 18%) (a), p53 (++) (b), p63 (+) (c), and VEGF (+) (d). And HE staining showed malignant transformation including increased cell density (e) and pathologic mitosi (f).


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig32_HTML.jpg

Fig. 7.32

In 2010, there was intrasellar tumor recurrence and the tumor was intrasellarly restricted


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig33_HTML.jpg

Fig. 7.33

After drilling the sellar floor bone and opening the dura, (a, b) the intrasellar tumor was exposed. The tumor grew from the intrasellar residues to intrasellar region, and the intrasellar tumor was removed together with the dura mater. (1) Dura, (2) tumor


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig34_HTML.jpg

Fig. 7.34

The artificial dura mater which was used to reconstruct the diaphragma sellae was exposed after the total intrasellar tumor removal. (1) Artificial dura mater


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig35_HTML.jpg

Fig. 7.35

In 2013 (3 years after the last operation), postoperative radiological images. (a, b) MRI indicated total tumor removal and proved that the tumor had not recurred


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.


7.5 Case 4: Inappropriate Preservation of the Pituitary Stalk Retention May Lead to Tumor Recurrence (Figs. 7.36, 7.37, 7.38, 7.39, 7.40, 7.41, 7.42, 7.43, 7.44, 7.45, 7.46, 7.47, 7.48, 7.49, 7.50, and 7.51)


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.

../images/464048_1_En_7_Chapter/464048_1_En_7_Fig36_HTML.jpg

Fig. 7.36

A type S-CP case. Preoperative radiological images obtained in November 2016. (ac) MRI revealed a cystic-solid tumor in the suprasellar region. The tumor arose from the arachnoidal sleeve segment of the pituitary stalk and mainly spread forward through the pre-chiasmatic cistern into the anterior fossa, lateral fissure cistern, and frontotemporal lobe


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig37_HTML.jpg

Fig. 7.37

Radical gross tumor removal (GTR) via the fronto-basal interhemispheric approach was performed in our hospital in December 2016. Intraoperative findings. The tumor arose from the arachnoidal sleeve segment of the pituitary stalk; the lower segment of the pituitary stalk remained intact. The tumor was mainly dissected through the pre-chiasmatic space and optic-internal carotid artery space. The pituitary stalk was pushed back to the right by the tumor. (1) Tumor, (2) pituitary stalk, (3) internal carotid artery, (4) optic nerve


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig38_HTML.jpg

Fig. 7.38

The tumor tightly adhered to the third VF and was separated from the floor of the third VF. (1) Tumor, (2) third VF, (3) pituitary stalk, (4) internal carotid artery, (5) optic nerve


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig39_HTML.jpg

Fig. 7.39

After total tumor removal, the neurovascular structures of the sellar region were preserved. In addition to the origin site, the pituitary stalk remained intact. The origin site of the tumor was clearly visible. (1) internal carotid artery (left), (2) optic nerve (left), (3) basilar artery and its branches, (4) the origin site of the tumor in pituitary stalk, (5) optic nerve (right), (6) internal carotid artery (right)


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig40_HTML.jpg

Fig. 7.40

Postoperative radiological images. (ac) MRI indicated no residual tumor


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig41_HTML.jpg

Fig. 7.41

In November 2017, postoperative MRI (ac) showed the recurrence of the tumor and the recurrent tumor was closely related to pituitary stalk


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig42_HTML.jpg

Fig. 7.42

In March 2018, postoperative MRI (ac) showed that the recurrent tumor was larger


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig43_HTML.jpg

Fig. 7.43

Pre-surgical radiological images (ac) obtained in June 2018


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig44_HTML.jpg

Fig. 7.44

Radical gross tumor removal (GTR) via the fronto-basal interhemispheric approach was performed in our hospital in May 2018. Intraoperative findings. The tumor was dissected through the pre-chiasmatic space. (1) Tumor, (2) optic nerve, (3) optic chiasm


../images/464048_1_En_7_Chapter/464048_1_En_7_Fig45_HTML.jpg

Fig. 7.45

The morphologically thin optic chiasm was pushed by the tumor. (1) Optic chiasm, (2) tumor

Only gold members can continue reading. Log In or Register to continue

Mar 25, 2020 | Posted by in NEUROSURGERY | Comments Off on of Recurrent Craniopharyngioma
Premium Wordpress Themes by UFO Themes