Objective : To assess the impact of the complete resection of craniopharyngioma (CP) in adults on oncologic and functional outcomes. Methods : We retrospectively analyzed 82 patients with CP who were surgically treated by the same neurosurgeon at our institution between January 1994 and December 201...
Objective : To assess the impact of the complete resection of craniopharyngioma (CP) in adults on oncologic and functional outcomes. Methods : We retrospectively analyzed 82 patients with CP who were surgically treated by the same neurosurgeon at our institution between January 1994 and December 2012. Results : Gross total resection (GTR) was achieved in 71 patients (86.6%), near total resection (NTR) in 7 patients (8.5%), and subtotal resection (STR) in 3 patients (3.7%). The disease-specific overall survival rate was 100% with the exclusion of 2 surgery-related mortalities. The overall recurrence rate was 12.2% (10 of 82 patients), however the recurrence rate according to extent of resection (EOR) was 9.9% (7 of 71 patients) after GTR, 14.3% (1 of 7 patients) after NTR, and 66.7% (2 of 3 patients) after STR. The overall recurrence-free survival (RFS) rates at 5 and 10 years were 87.0% and 76.8%, respectively. Postoperatively, most patients (86.3%) needed hormone replacement for at least 1 hypothalamic-pituitary axis. Vision improved in 56.4% of the patients with preoperative abnormal vision, but deteriorated in 27.4% of patients. Hypothalamic dysfunction developed in 32.9% of patients. There were no significant differences in the risks of pituitary dysfunction, visual deterioration, or hypothalamic dysfunction between the groups with complete vs. incomplete removal. The overall rate of postoperative complications was 22.0%, which did not differ between groups (p=0.053). Conclusion : The complete removal of a CP at first surgery can provide a chance for a cure with acceptable morbidity and mortality risks.
Objective : To assess the impact of the complete resection of craniopharyngioma (CP) in adults on oncologic and functional outcomes. Methods : We retrospectively analyzed 82 patients with CP who were surgically treated by the same neurosurgeon at our institution between January 1994 and December 2012. Results : Gross total resection (GTR) was achieved in 71 patients (86.6%), near total resection (NTR) in 7 patients (8.5%), and subtotal resection (STR) in 3 patients (3.7%). The disease-specific overall survival rate was 100% with the exclusion of 2 surgery-related mortalities. The overall recurrence rate was 12.2% (10 of 82 patients), however the recurrence rate according to extent of resection (EOR) was 9.9% (7 of 71 patients) after GTR, 14.3% (1 of 7 patients) after NTR, and 66.7% (2 of 3 patients) after STR. The overall recurrence-free survival (RFS) rates at 5 and 10 years were 87.0% and 76.8%, respectively. Postoperatively, most patients (86.3%) needed hormone replacement for at least 1 hypothalamic-pituitary axis. Vision improved in 56.4% of the patients with preoperative abnormal vision, but deteriorated in 27.4% of patients. Hypothalamic dysfunction developed in 32.9% of patients. There were no significant differences in the risks of pituitary dysfunction, visual deterioration, or hypothalamic dysfunction between the groups with complete vs. incomplete removal. The overall rate of postoperative complications was 22.0%, which did not differ between groups (p=0.053). Conclusion : The complete removal of a CP at first surgery can provide a chance for a cure with acceptable morbidity and mortality risks.
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가설 설정
Kaplan-Meier recurrence-free survival curves of the patients who followed up more than 1 year. A : Graph shows the overall recurrence-free survival rates. B : Graph compares recurrence-free survival between the GTR and non-GTR groups.
A : Graph shows the overall recurrence-free survival rates. B : Graph compares recurrence-free survival between the GTR and non-GTR groups. For patients with follow-up ≥12 months (n=73).
제안 방법
S2014-1069-0001). All diagnoses were based on histological examinations, except in one case of cyst aspiration alone, in which the neuroradiological features and the intra-operative findings were consistent with the diagnosis of CP. The medical records were reviewed to extract demographic information, presenting symptoms, operative findings, pre- and postoperative follow-up hormonal results, pre- and postoperative visual acuity (VA) and visual field (VF) findings, neurologic morbidities, complications, and recurrence.
Our present analysis included 9 patients who were lost on follow-up after <1 year. Considering the possibility that a short follow-up duration affected favorable outcome on tumor recurrence, we reevaluated the RFS after excluding these 9 patients. In this group (n=73), the median follow-up duration was 57 months.
Magnetic resonance images of a 15-year-old female patient with headache showing a large complex cystic mass at the prepontine cistern with extension into the suprasellar area. She underwent a staged operation via the lateral suboccipital approach and lateral subfrontal approach in order to achieve gross total resection.
All diagnoses were based on histological examinations, except in one case of cyst aspiration alone, in which the neuroradiological features and the intra-operative findings were consistent with the diagnosis of CP. The medical records were reviewed to extract demographic information, presenting symptoms, operative findings, pre- and postoperative follow-up hormonal results, pre- and postoperative visual acuity (VA) and visual field (VF) findings, neurologic morbidities, complications, and recurrence.
Our surgical philosophy involves first attempting the complete resection of CP, provided this is deemed to be safe. Then, in cases of large tumors that extend into multiple compartments, we perform a staged operation using a combination of different surgical routes in order to achieve GTR. CPs were frequently found to arise from the pituitary stalk and recur around the stalk.
VF defects were evaluated using Goldmann perimetry. To analyze visual outcomes, we compared the visual status on the last follow-up with the preoperative data and categorized the visual outcomes into the following 3 groups :1) improved, which was defined as an increase in VA or decrease in VF defects in either eye (without any deterioration of VA or VF);2) unchanged, which was defined as no change in either VA or VF; and3) worsened, which was defined as the deterioration of either VA or VF.
대상 데이터
Postoperative MRIs were examined 3 months after surgery, and then annual follow-up examinations were performed. At least one follow-up postoperative MRI was obtained for each of the 76 patients.
Tumor size was determined by the maximal diameter on MRI (contrast enhanced T1-weighted imaging). Imaging data at presentation were available for 78 patients. Postoperative MRIs were examined 3 months after surgery, and then annual follow-up examinations were performed.
9%). The tumors extended to the frontal lobe in 3 patients and to the posterior fossa in 2 patients (Fig. 1).
This study included 53 male and 29 female patients (M : F ratio=1.83 : 1) with a median age of 42 years (range, 15–79 years).
데이터처리
Differences in the categorical variables were analyzed using the Fisher’s exact test, and continuous variables were analyzed using the Mann-Whitney U-test.
이론/모형
Variables that impacted the rates of recurrences and surgical complications were estimated using Cox proportional hazards model or logistic regression model. The recurrence-free curve was generated using the Kaplan-Meier method. For this analysis, the date of the first surgical procedure was defined as time zero.
Differences in the categorical variables were analyzed using the Fisher’s exact test, and continuous variables were analyzed using the Mann-Whitney U-test. Variables that impacted the rates of recurrences and surgical complications were estimated using Cox proportional hazards model or logistic regression model. The recurrence-free curve was generated using the Kaplan-Meier method.
성능/효과
The other observed visual field abnormalities included monocular visual loss with unitemporal hemianopsia (15 patients), homonymous hemianopsia (12 patients), unitemporal hemianopsia (7 patients), and monocular visual loss (2 patients). After surgery, 10 of the 18 patients with normal preoperative VA and VF (55.6%) experienced either worsening of VA or VF. Of the 55 patients with abnormal VA or VF, postoperative vision improved in 31 patients (56.
27). In our study, recurrence after GTR developed in 9.9% of all cases, and the overall rate of recurrence was 12.2%.
0 cm). On MRI, 18% of tumors were purely or predominantly solid, 20.5% were purely or predominantly cystic, and 61.5% were mixed. Calcifications were found in 57 patients (73.
. Our analysis also indicated that EOR was the only factor able to predict recurrence; the rate of recurrence of the GTR group was lower than that of the non-GTR group (9.9% vs. 27.3%; p=0.036), and TTR in the non-GTR group was much faster than the GTR group (median TTR, 4 months vs. 34 months). The re-excision of recurrent tumors is very challenging because the recurrent tumors are locally invasive and usually adhere to adjacent critical neurovascular structures; both of these features often result in high levels of surgical morbidity.
Nine patients were observed without any adjuvant treatment. There were no statistically significant differences between the GTR and non-GTR groups in terms of age (p=0.791), sex (p=0.312), tumor size (p=0.732), involvement of the hypothalamus (p=0.345), associated hydrocephalus (p=0.545), or histopathologic subtype (p=0.438). However, all tumors of the non-GTR group demonstrated calcification, and the difference between groups was statistically significant (p=0.
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