gms | German Medical Science

Objective: The lateral pteryonal (PT) and the fronto-lateral (FL) approaches to pediatric craniopharyngeomas don't allow for full exposure of third ventricle and retro-chiasmatic cisterns due to anatomical barriers. The bifrontal approach, however, enabling midline vision is too invasive. The unilateral fronto-basal midline approach approach (FBM) combines midline vision with unilateral invasiveness. We compared resection rates and patient outcome of FBM versus PT/FL approaches.

Method: 17 children with craniopharyngeomas underwent 29 transcranial surgical interventions. Sequence of used approaches, extend of resection/residual tumor volume, outcome and follow-up were analyzed for each intervention.

Results: In 9 kids a PT (n=5) or FL (n=4) approach was used as first intervention. Mean preoperative tumor volume was 18.3 ml (6 - 42ml). 1/9 had total tumor removal. In 8/9 mean residual tumor volume was 3.5 ml (0.1 - 11ml). All had regrowth (± radiotherapy) and second surgery at a mean interval of 45 months, 2 via FBM approach. All 9 are on hormonal replacement therapy. Mean FU after last surgery is 38 months.

In 8 primary and 2 secondary resections via FBM approach mean preoperative tumor volume was 12.5 ml (2-36 ml). In 7/10 gross total resection was achieved. 1/7 had a recurrence treated by PT approach. In the remaining 3 intentionally left mean tumor volume was 2,4 ml (0.2 - 4.3ml). All residuals are stable so far. 1/10 had an unacceptable hypothalamic morbidity, 9/10 needed hormonal replacement therapy. Mean FU after last surgery is 26 months. Non had olfactory loss of function.

Conclusions: Using the FBM approach a much higher rate of total resection (7/10 vs 1/9) was achieved. Only 1/10 in the FBM group had secondary surgery, whereas all 8 children with residual tumor after PT/FP approach underwent further interventions (up to 3). However, follow-up in FBM group is shorter by a mean of 12 months. The mean residual tumor volume after FBM was smaller than after PT/FL approach (2.4 ml vs 3.5 ml). Significant hypothalamic morbidity was experienced in one – the second – child with FBM approach and total resection. Consecutively, small tumor residuals were left in 3 other cases of FBM group and hypothalamic injury thereby avoided. The unilateral fronto-basal midline (FBM) approach to pediatric craniopharyngeomas thus is our route of choice for transcranial surgery, since it offers higher chances of total resection without increased hypothalamic morbidity.