- Email: [email protected]
Role of bifrontal basal interhemispheric approach in recurrent suprasellar tumors; craniopharyngioma and pituitary tumors
International Congress Series 1259 (2004) 119 – 127
www.ics-elsevier.com
Role of bifrontal basal interhemispheric approach in recurrent suprasellar tumors; craniopharyngioma and pituitary tumors Joon-Ki Kang *, Kwan-Sung Lee, Tae-Kyu Lee, Sin-Soo Jeun, Yong-Kil Hong, Moon-Chan Kim Department of Neurosurgery, Kangnam Street Mary’s Hospital, Catholic University of Korea, Medical College, 505 Banpo-dong Seocho-ku, Seoul, 137 040, South Korea Received 30 August 2003; received in revised form 30 October 2003; accepted 30 October 2003
Abstract. Recurrent suprasellar tumors, including craniopharyngiomas and pituitary tumors, can be approached with minimal brain retraction, a wider operative field with better orientation and a good view of important neurovascular structures via a bifrontal basal interhemispheric approach (BFBIHA). The authors present their experience of using BFBIHA for removal of recurrent suprasellar tumors, during which they recorded the size and location of each tumor and the degree of tumor extension. Two hundred fifty-four cases of pituitary tumors and 80 cases of craniopharyngiomas were operated on. Recurrent cases were 25 (9.8%) in pituitary tumors and 14 (17.5%) in craniopharyngiomas. Among recurrent cases, nine patients (five recurrent pituitary tumors, four recurrent craniopharyngiomas) were included. Preoperatively, suprasellar extension of the tumors was measured with the aid of radiological images (MRI, MRA, CT). Using line C (mid-sella), the tumors were divided into three groups according to the direction of tumor growth. Group I (one case) contained those with a prechiasmatic location, group II (two cases), those with a suprasellar location, and group III (five cases), those with a retrochiasmatic location. All of the recurrent patients underwent operations by the same approach. All tumors but one were totally resected. There was no operative mortality. In our experience, recurrent suprasellar tumors were safely manipulated with this BFBIHA, preserving important neurovascular structures and hypothalamo – pituitary functions. D 2003 Elsevier B.V. All rights reserved. Keywords: Recurrent craniopharyngiomas; Pituitary tumors; Bifrontal basal interhemispheric approach
1. Introduction Tumors of the suprasellar region and third ventricle pose a surgical challenge, even with modern microneurosurgical advancement. Because of their often-large size, and proximity * Corresponding author. Tel.: +82-2-590-1342,2800; fax: +82-2-594-4248. E-mail address: [email protected] (J.-K. Kang). 0531-5131/ D 2003 Elsevier B.V. All rights reserved. doi:10.1016/S0531-5131(03)01821-1
120
J.-K. Kang et al. / International Congress Series 1259 (2004) 119 – 127
Table 1 Outcomes of primary surgery craniopharyngiomas (n = 80) Type of Tx.
Mortality
Recurrence
Mean times to recurrence (months)
Total removal (26) Subtotal removal (54) without adj. Tx (15) with RT (29) with RS (4) with Ommaya R (6) Total (80)
2
1
84
1
5 5 2 1 14 (17.5%) 7% (Yasargil et al., 1990)
10.5 12.6 72 60 31.9 29% (Hoffman et al., 1992)
3 (3.8%) 5.5% (Symon et al., 1985)
and adherence to important neurovascular structures, these tumors are difficult to remove completely. It is particularly difficult to extirpate totally in cases of recurrent suprasellar tumors, such as craniopharyngiomas and giant pituitary tumors. The ideal surgical approach to the suprasellar area depends on the precise location, size of the tumors and extent of the lesions. Tumors, such as craniopharyngiomas or giant pituitary tumors, are commonly approached via a subfrontal and pterional approach, which provides a somewhat limited visualization of the superior extension of the tumor. In some cases, these approaches are combined with a transventricular or transcallosal approach to achieve a total resection [1,13]. The bifrontal basal interhemispheric approach (BFBIHA), which is a modification of the anterior hemispheric approach [8,9,14], has proved advantageous in the removal of recurrent craniopharyngiomas and pituitary tumors. It allows a bilateral, wider operative field with better anatomical orientation and views of important neural structures and perforating arteries. Most of the bridging veins can be preserved using this approach. To further improve visualization of the retrochiasmatic area and gain access to the superior portions of the recurrent suprasellar tumors (craniopharyngiomas and pituitary tumors), the authors modified the BFIHA and discuss indications and the role of this method in suprasellar recurrent tumors.
Table 2 Outcomes of primary surgery pituitary tumors (n = 254) Type of Tx.
Mortality
Recurrence
Mean times to recurrence (months)
GTR (183) STR (71) without adj. Tx (14) with RT (38) with RS (19) Total (254)
3 2
10
83.5
9 4 2 25 (9.8%)
18.1 33.3 32.7 41.2
5 (1.9%)
J.-K. Kang et al. / International Congress Series 1259 (2004) 119 – 127
121
2. Materials and methods We operated on nine patients who experienced recurrent craniopharyngiomas (four) and pituitary tumors (five), using BFIHA between 1992 and 2002 at the Kangnam St. Mary’s Hospital in Seoul. Between 1992 and 2002, 80 patients with craniopharyngioma and 254 patients with pituitary tumors were operated. Among these 80 craniopharyngiomas, there were 14 recurrent cases (17.5%) and death in 3 cases (3.8%) during a mean follow-up period of 31.9 months (Table 1). Among these 254 pituitary tumors, there were 25 cases of recurrence (9.8%) and death in 5 cases (1.9%) during the mean follow-up period of 41.2 months (Table 2). For the indication of the BFIHA, we have investigated the tumor growth and size on the brain MRI with a referred measurement line as follows: horizontal line (A) passing the planum sphenoidale, vertical line (B) passing dorsum sellae, vertical line (C) passing the mid-seller, vertical line (D) passing the anterior clinoid process and horizontal line (E) passing the Foramen Monro on the lateral view of the MRI (Fig. 1). Among the nine cases of recurrent suprasellar tumors, there was one prechiasmatic (anterior subchiasmatic) case, two subchiasmatic (upward chiasm) cases and five retrochiasmatic cases. Among the 14 recurrent craniopharyngiomas, 4 cases were performed with the BFIHA (Table 3) and 5 cases were operated with this method among the 25 recurrent pituitary tumors (Table 4). 3. Operating technique The patient is placed supine with the neck slightly extended. A bicoronal skin incision is made behind the hairline and subperiosteal dissection of the skin flap is extended to the glabella and the orbital ridge. The dura is intracranially dissected from
Fig. 1. Schematic drawing for measurement of the tumor size and extension with referred lines (A, B, C, D, E) on brain MRI. Reference lines A: horizontal line passing planum sphenoidale, B: vertical line passing dorsum sellae, C: vertical line passing mid-sella, D: vertical line passing anterior clinoid process, E: horizontal line passing planum foramen of Monro.
122
J.-K. Kang et al. / International Congress Series 1259 (2004) 119 – 127
Table 3 Surgical approaches for recurrent cases recurrent craniopharyngiomas (n = 14) Approaches
No. of cases
Pterional Transcallosal Combined Bifrontal basal interhemispheric Total
5 1 4 4 14
the orbital roof. While the dura and periorbita are protected with spatulas, the superior orbital margin and orbital roof are cut perpendicularly and the nasofrontal sutures are cut horizontally with a bone saw. The superomedial orbital bone flap is removed with a chisel. The crista frontalis and the base of the skull in the midline are rongeured to the crista Galli (Fig. 2). The opening of the frontal sinus is packed with gel form, socked with gentamycin solution. The dure is opened horizontally from the right side, and the falx and the superior sagittal sinus are divided after double ligation. The olfactory nerves are dissected from the basal surface of the frontal lobes bilaterally all the way to the olfactory trigone. After interhemispheric dissection, the basal cistern is opened. Most of the bridging veins that drain into the superior sagittal sinus are preserved. The arachnoid dissection is directed toward the pre- and suprachiasmatic region, exposing the A2 segment bilaterally, the genu of the corpus callosum, the AcoA and the chiasm. Usually, the brain becomes sufficiently slack after removal of cerebrospinal fluid from the basal cistern. The lamina terminalis is opened in the midline. Internal decompression is the next step toward removal of the tumor. Sufficient internal decompression facilitates the following step of capsular dissection from adjacent vital structures, such as the hypothalamus. The tumor usually adheres most tightly to the chiasm, pituitary stalk or hypothalamus, where it usually separates easily from the upper wall of the third ventricle. The bilateral, wider exposure obtained by this approach enables the surgeon to view the lesion from many different angles and to locate the dissection plane between the tumor capsule and the important neural structures or perforating arteries on both sides. There is a good chance of preserving the hypothalamus, pituitary stalk and perforating arteries using this approach, and this procedure facilitates complete tumor resection in cases of recurrent suprasellar tumors. Table 4 Surgical approaches for recurrent cases recurrent pituitary tumors (n = 25) Approaches
No. of cases
Transsphenoidal Transcranial pterional bifrontal basal interhemispheric Total
9 16 11 5 25
J.-K. Kang et al. / International Congress Series 1259 (2004) 119 – 127
123
4. Illustrative cases 4.1. Case 1 A 20-year-old girl who was operated on with craniopharyngioma at the age of 12, presented with headaches, bitemporal hemianopsia and DI caused by a large, recurrent craniopharyngioma. The tumor was extended into the retrochiasmatic area and compressing the chiasm and hypothalamus to a moderate degree. The tumor was totally removed by the BflHA, preserving the pituitary stalk and hypothalamus (Fig. 3). She had an uneventful postoperative course, excepting hormonal replacement with vasopressin. 4.2. Case 2 A 58-year-old woman had undergone transsphenoidal partial removal of a solid pituitary tumor 2 years previously. The tumor regrew mainly in the suprasellar and retrochiasmatic region, mildly compressing the hypothalamus and chiasm and causing a progressive decrease in her visual acuity. The tumor was totally removed by the BFIHA. The optic apparatus, the floor of the III ventricle and the pituitary stalk were all visualized and preserved during the operation (Fig. 4). The postoperative course was uneventful and the patient’s hypothalamo –pituitary function was preserved. 5. Results Preoperative measurement of the tumor growth and extension. For the evaluation of the suprasellar recurrent tumors’ growth and their size, we applied the four reference line (A, B, C, D, E) on the brain MRI. The results of the tumor regrowth size, height (H), posterior extension (P) and width (W) are shown in the table. The mean values of the width, height and posterior extension of their recurrent tumors were 35.4 mm (W), 35.3 mm (H) and 29.1 mm (P). Outcome of the recurrent suprasellar tumors performed by the BFIHA (Table 5). All four patients with recurrent craniopharyngioma were able for gross total resections and all had improved vision postoperatively. Among these four patients with recurrent
Fig. 2. Illustrations depicting the surgical technique. Bifrontal craniotomy superior medial orbitotomy sup. sagittal sinus ligation falx cut at the base.
124
J.-K. Kang et al. / International Congress Series 1259 (2004) 119 – 127
Fig. 3. A 20-year-old female with recurrent craniopharyngioma. Preoperative gadolinium-enhanced MRI scans reveal suprasella mass, retrochiasmatic extension and into the third ventricle with contrast enhancement (upper). Postoperative T1-weighted sequence reveals no residual mass (lower).
Fig. 4. A 58-year-old woman with recurrent pituitary adenoma 2 years after transsphenoidal surgery. Gadoliniumenhanced MRI shows the large suprasella mass extending to the retrochiasmatic area and compressing the third ventricle (upper). Postoperative MRI reveals gross total removal of the mass and remaining tumor capsule (lower).
J.-K. Kang et al. / International Congress Series 1259 (2004) 119 – 127
125
Table 5 Outcomes of nine points undergoing bifrontal basal IHA Cases
Dx
12/M 20/F 31/M 50/M 31/M 51/F 54/F 25/M 58/F
Rec. Rec. Rec. Rec. Rec. Rec. Rec. Rec. Rec.
cranioph cranioph cranioph cranioph pituitary pituitary pituitary pituitary pituitary
Resection
Vision (VA/VF)
Endocrine state
GTR GTR GTR GTR STR STR STR GTR STR
improved improved improved improved improved improved improved unchanged improved
panhypopituitarism DI panhypopituitarism normal normal normal normal panhypopituitarism panhypopituitarism
Operative complication CSF leakage (1, case 4).
craniopharyngioma, two patients had panhypopituitarism, one DI and one normal function. Of the five patients with recurrent pituitary tumor, gross total removal was possible in one and subtotal removal in four patients, which means gross removal of the solid tumor, retaining the capsule adherent to the vital neurostructures. Among these five patients with recurrent pituitary tumors, three patients had improved vision postoperatively and one had unchanged vision. Of these five patients, three patients had normal pituitary function and two patients had panhypopituitarism. Surgical mortality did not occur in these nine patients with recurrent suprasellar tumor by this method and only one case had a transient CSF rhinorrhea between 1 and 2 weeks after operation. However, this resolved with bed rest for several days. 6. Discussion Recurrent suprasellar tumors, such as craniopharyngioma and pituitary adenoma, require special consideration to the surgical approach as well as avoiding damage to the surrounding neurovascular structures [3,6,8]. Aggressive, surgical removal of the lesion is often impeded by tumor adherence to arteries, the optic apparatus and hypothalamus [2,4,13]. To minimize surgical morbidity, an approach should be chosen which provides wide exposure of all portions of the lesion, minimizes the sacrifice of brain tissue and neurovascular structures, and gives superior anatomic orientation of these structures in relation to the lesion. The modified bifrontal basal approach with removal of the medial orbital rims that we used to resect recurrent suprasellar tumors in nine patients enabled us to fulfill the above requirements and achieve maximum resection of the tumor. The traditional approaches to suprasellar lesions include pterional, unilateral subfrontal and bifrontal approaches [1,2,12,13]. The pterional and subfrontal approaches offer excellent access to the suprasellar area and to the lateral extension of the tumor. However, only the ipsilateral optic nerve, perforating arteries and carotid artery are visible initially; contralateral structures and retrosellar area are thus at risk for inadvertent injury during the surgery [1]. The bifrontal approach offers better anatomic orientation of the optic apparatus, bilateral carotid arteries and perforating arteries, which are supplying the optic pathway, pituitary stalk and hypothalamus. However, this approach requires significant frontal lobe retraction and may provide limited access to the third ventricle [1].
126
J.-K. Kang et al. / International Congress Series 1259 (2004) 119 – 127
To improve access, a bifrontal anterior interhemispheric approach has been advocated for use in removing third ventricular tumors by Suzuki et al. [10]. This approach provides a wider operative view of the anterior circle of Willis, the optic chiasm and the third ventricle tumor itself, minimizing damage to the surrounding neurovascular structures. One disadvantage of this approach is that it often requires sacrifice of the bridging veins. Division of the bridging veins, combined with prolonged retraction of the frontal lobes, increases the risk of postoperative cerebral ischemia and contusional hemorrhage [7]. A basal interhemispheric approach has been described by Yasui et al. [14] as a modification of the anterior interhemispheric approach for surgery of anterior communicating aneurysms. Advantages of this approach are preserving the most bridging veins, much less dissection in the area of the interhemispheric fissure and better visualization of the upper part of the third ventricular tumor. We have shown the usefulness of the bifrontal basal interhemispheric approach, which was a modified basal interhemispheric approach [14] in nine patients with recurrent suprasellar tumor. We advocated this approach for the surgical management of recurrent suprasellar tumors because of its ability to provide wide exposure to the anatomical structures bilaterally and less damage to the surrounding neurovascular structures during the operation. For the decision to use the BFIHA, we have measured the tumor size and extension on the brain MRI while applying the referred lines. All of the nine patients with recurrent suprasellar tumors have shown 29.1 mm posterior extension of the tumor (mean), 35.4 mm in tumor width and 35.3 mm in tumor height. Recurrence rates of craniopharyngiomas, after what was believed to be a total excision, are surprisingly high in spite of the benign, histological nature of this tumor. The recurrence rate has been reported as 5.5% by Symon and Sprich [11], 7% by Yasargil et al. [13] and 29% by Hoffman et al. [5]. In our series, the recurrence rate was 17.5% (14/ 80). To reduce recurrence of the tumor, it may be important to minimize blind spots during the operation using this BFIHA that allows wider exposure. Baskin and Wilson [2] reported from a series of 74 patients that CSF leaks occurred in 8% of their patients. In our series of nine patients with BFIHA, only one patient had a transient CSF rhinorrhea. In our small series, we obtained a gross total resection in four of the four patients with recurrent craniopharyngioma and in one patient with recurrent pituitary tumor, and subtotal removal in four patients with recurrent pituitary tumor, which means remaining tumor capsules. In conclusion, with recurrent suprasellar tumors as complex as craniopharyngiomas and pituitary tumors, good visualization of the surrounding structures may contribute to a better clinical outcome and decrease the tumor recurrence. The BFIHA enables the surgeon to identify both sides of the optic nerves, chiasm and optic tracts, possibly allowing more chance for postoperative visual improvement.
References [1] M.L.J. Apuzzo, M.L. Levy, I.I. Tung, Surgical strategies and technical methodologies in optimal management of craniopharyngioma and masses affecting the third ventricular chamber, Acta Neurochir. 553 (1991) 77 – 88. [2] D.S. Baskin, C.B. Wilson, Surgical management of craniopharyngiomas, J. Neurosurg. 65 (1986) 22 – 27. [3] J.D. Day, S.L. Giannotta, T. Fukushima, Extradural temporopolar approach to lesions of the upper basal artery and infrachiasmatic region, J. Neurosurg. 81 (1994) 230 – 235.
J.-K. Kang et al. / International Congress Series 1259 (2004) 119 – 127
127
[4] E.G. Fischer, K. Welch, J.A. Belli, J. Wallman, J.J. Shillito Jr., K.R. Winston, R. Cassady, Treatment of craniopharyngiomas in children: 1972 – 1981, J. Neurosurg. 62 (1985) 496 – 591. [5] J.H. Hoffman, M. Desiva, R.P. Humphreys, J.M. Drake, M.L. Smith, S.I. Blasor, Aggressive surgical management of craniopharyngiomas in children, J. Neurosurg. 76 (1992) 47 – 52. [6] H.K. Inoue, H. Fujimaki, H. Kobga, N. Ono, M. Hirato, C. Ohye, Basal interhemispheric supra-and/or infrachiasmal approaches via superomedial orbitotomy for hypothalamic lesions: preservation of hypothalamo – pituitary functions in combination treatment with radiosurgery, Child’s Nerv. Syst. 13 (1997) 250 – 256. [7] T. Kanno, A. Kasama, M. Shoda, A pitfall in the interhemispheric translamina terminalis approach for the removal of craniopharyngioma: significance of preserving draining veins: Part I. Clinical study, Surg. Neurol. 32 (1989) 111 – 115. [8] M. Shibuya, M. Takayasu, Y. Suzuki, K. Saito, Sugidak, Bifrontal basal interhemispheric approach to craniopharyngioma resection with or without division of the anterior communicating artery, J. Neurosurg. 84 (1996) 951 – 956. [9] R. Shirane, Suching-chan, Y. Kusaka, H. Jokura, T. Yoshimoto, Surgical outcomes in 31 patients with craniopharyngiomas extending outside the suprasellar cistern: an evaluation of the frontobasal interhemispheric approach, J. Neurosurg. 96 (2002) 704 – 712. [10] J. Suzuki, R. Katakura, T. Mori, Interhemispheric approach through the lamina terminalis to tumors of the anterior parts of the third ventricle, Surg. Neurol. 22 (1984) 157 – 163. [11] L. Symon, W. Sprich, Radical excision of craniopharyngioma: results in 20 patients, J. Neurosurg. 62 (1985) 174 – 181. [12] T. Tomita, D.C.T. Mc Clone, Radical resections of childhood craniopharyngioma, Pediatr. Neurosurg. 19 (1993) 6 – 14. [13] M.G. Yasargil, M. Curcic, M. Kis, G. Siegenthaler, P.J. Teddy, P. Roth, Total removal of craniopharyngiomas, J. Neurosurg. 73 (1990) 3 – 11. [14] N. Yasui, E. Nathal, H. Fujiwara, The basal interhemispheric approach for acute anterior communicating aneurysms, Acta Neurochir. 118 (1992) 91 – 97.
www.ics-elsevier.com
Role of bifrontal basal interhemispheric approach in recurrent suprasellar tumors; craniopharyngioma and pituitary tumors Joon-Ki Kang *, Kwan-Sung Lee, Tae-Kyu Lee, Sin-Soo Jeun, Yong-Kil Hong, Moon-Chan Kim Department of Neurosurgery, Kangnam Street Mary’s Hospital, Catholic University of Korea, Medical College, 505 Banpo-dong Seocho-ku, Seoul, 137 040, South Korea Received 30 August 2003; received in revised form 30 October 2003; accepted 30 October 2003
Abstract. Recurrent suprasellar tumors, including craniopharyngiomas and pituitary tumors, can be approached with minimal brain retraction, a wider operative field with better orientation and a good view of important neurovascular structures via a bifrontal basal interhemispheric approach (BFBIHA). The authors present their experience of using BFBIHA for removal of recurrent suprasellar tumors, during which they recorded the size and location of each tumor and the degree of tumor extension. Two hundred fifty-four cases of pituitary tumors and 80 cases of craniopharyngiomas were operated on. Recurrent cases were 25 (9.8%) in pituitary tumors and 14 (17.5%) in craniopharyngiomas. Among recurrent cases, nine patients (five recurrent pituitary tumors, four recurrent craniopharyngiomas) were included. Preoperatively, suprasellar extension of the tumors was measured with the aid of radiological images (MRI, MRA, CT). Using line C (mid-sella), the tumors were divided into three groups according to the direction of tumor growth. Group I (one case) contained those with a prechiasmatic location, group II (two cases), those with a suprasellar location, and group III (five cases), those with a retrochiasmatic location. All of the recurrent patients underwent operations by the same approach. All tumors but one were totally resected. There was no operative mortality. In our experience, recurrent suprasellar tumors were safely manipulated with this BFBIHA, preserving important neurovascular structures and hypothalamo – pituitary functions. D 2003 Elsevier B.V. All rights reserved. Keywords: Recurrent craniopharyngiomas; Pituitary tumors; Bifrontal basal interhemispheric approach
1. Introduction Tumors of the suprasellar region and third ventricle pose a surgical challenge, even with modern microneurosurgical advancement. Because of their often-large size, and proximity * Corresponding author. Tel.: +82-2-590-1342,2800; fax: +82-2-594-4248. E-mail address: [email protected] (J.-K. Kang). 0531-5131/ D 2003 Elsevier B.V. All rights reserved. doi:10.1016/S0531-5131(03)01821-1
120
J.-K. Kang et al. / International Congress Series 1259 (2004) 119 – 127
Table 1 Outcomes of primary surgery craniopharyngiomas (n = 80) Type of Tx.
Mortality
Recurrence
Mean times to recurrence (months)
Total removal (26) Subtotal removal (54) without adj. Tx (15) with RT (29) with RS (4) with Ommaya R (6) Total (80)
2
1
84
1
5 5 2 1 14 (17.5%) 7% (Yasargil et al., 1990)
10.5 12.6 72 60 31.9 29% (Hoffman et al., 1992)
3 (3.8%) 5.5% (Symon et al., 1985)
and adherence to important neurovascular structures, these tumors are difficult to remove completely. It is particularly difficult to extirpate totally in cases of recurrent suprasellar tumors, such as craniopharyngiomas and giant pituitary tumors. The ideal surgical approach to the suprasellar area depends on the precise location, size of the tumors and extent of the lesions. Tumors, such as craniopharyngiomas or giant pituitary tumors, are commonly approached via a subfrontal and pterional approach, which provides a somewhat limited visualization of the superior extension of the tumor. In some cases, these approaches are combined with a transventricular or transcallosal approach to achieve a total resection [1,13]. The bifrontal basal interhemispheric approach (BFBIHA), which is a modification of the anterior hemispheric approach [8,9,14], has proved advantageous in the removal of recurrent craniopharyngiomas and pituitary tumors. It allows a bilateral, wider operative field with better anatomical orientation and views of important neural structures and perforating arteries. Most of the bridging veins can be preserved using this approach. To further improve visualization of the retrochiasmatic area and gain access to the superior portions of the recurrent suprasellar tumors (craniopharyngiomas and pituitary tumors), the authors modified the BFIHA and discuss indications and the role of this method in suprasellar recurrent tumors.
Table 2 Outcomes of primary surgery pituitary tumors (n = 254) Type of Tx.
Mortality
Recurrence
Mean times to recurrence (months)
GTR (183) STR (71) without adj. Tx (14) with RT (38) with RS (19) Total (254)
3 2
10
83.5
9 4 2 25 (9.8%)
18.1 33.3 32.7 41.2
5 (1.9%)
J.-K. Kang et al. / International Congress Series 1259 (2004) 119 – 127
121
2. Materials and methods We operated on nine patients who experienced recurrent craniopharyngiomas (four) and pituitary tumors (five), using BFIHA between 1992 and 2002 at the Kangnam St. Mary’s Hospital in Seoul. Between 1992 and 2002, 80 patients with craniopharyngioma and 254 patients with pituitary tumors were operated. Among these 80 craniopharyngiomas, there were 14 recurrent cases (17.5%) and death in 3 cases (3.8%) during a mean follow-up period of 31.9 months (Table 1). Among these 254 pituitary tumors, there were 25 cases of recurrence (9.8%) and death in 5 cases (1.9%) during the mean follow-up period of 41.2 months (Table 2). For the indication of the BFIHA, we have investigated the tumor growth and size on the brain MRI with a referred measurement line as follows: horizontal line (A) passing the planum sphenoidale, vertical line (B) passing dorsum sellae, vertical line (C) passing the mid-seller, vertical line (D) passing the anterior clinoid process and horizontal line (E) passing the Foramen Monro on the lateral view of the MRI (Fig. 1). Among the nine cases of recurrent suprasellar tumors, there was one prechiasmatic (anterior subchiasmatic) case, two subchiasmatic (upward chiasm) cases and five retrochiasmatic cases. Among the 14 recurrent craniopharyngiomas, 4 cases were performed with the BFIHA (Table 3) and 5 cases were operated with this method among the 25 recurrent pituitary tumors (Table 4). 3. Operating technique The patient is placed supine with the neck slightly extended. A bicoronal skin incision is made behind the hairline and subperiosteal dissection of the skin flap is extended to the glabella and the orbital ridge. The dura is intracranially dissected from
Fig. 1. Schematic drawing for measurement of the tumor size and extension with referred lines (A, B, C, D, E) on brain MRI. Reference lines A: horizontal line passing planum sphenoidale, B: vertical line passing dorsum sellae, C: vertical line passing mid-sella, D: vertical line passing anterior clinoid process, E: horizontal line passing planum foramen of Monro.
122
J.-K. Kang et al. / International Congress Series 1259 (2004) 119 – 127
Table 3 Surgical approaches for recurrent cases recurrent craniopharyngiomas (n = 14) Approaches
No. of cases
Pterional Transcallosal Combined Bifrontal basal interhemispheric Total
5 1 4 4 14
the orbital roof. While the dura and periorbita are protected with spatulas, the superior orbital margin and orbital roof are cut perpendicularly and the nasofrontal sutures are cut horizontally with a bone saw. The superomedial orbital bone flap is removed with a chisel. The crista frontalis and the base of the skull in the midline are rongeured to the crista Galli (Fig. 2). The opening of the frontal sinus is packed with gel form, socked with gentamycin solution. The dure is opened horizontally from the right side, and the falx and the superior sagittal sinus are divided after double ligation. The olfactory nerves are dissected from the basal surface of the frontal lobes bilaterally all the way to the olfactory trigone. After interhemispheric dissection, the basal cistern is opened. Most of the bridging veins that drain into the superior sagittal sinus are preserved. The arachnoid dissection is directed toward the pre- and suprachiasmatic region, exposing the A2 segment bilaterally, the genu of the corpus callosum, the AcoA and the chiasm. Usually, the brain becomes sufficiently slack after removal of cerebrospinal fluid from the basal cistern. The lamina terminalis is opened in the midline. Internal decompression is the next step toward removal of the tumor. Sufficient internal decompression facilitates the following step of capsular dissection from adjacent vital structures, such as the hypothalamus. The tumor usually adheres most tightly to the chiasm, pituitary stalk or hypothalamus, where it usually separates easily from the upper wall of the third ventricle. The bilateral, wider exposure obtained by this approach enables the surgeon to view the lesion from many different angles and to locate the dissection plane between the tumor capsule and the important neural structures or perforating arteries on both sides. There is a good chance of preserving the hypothalamus, pituitary stalk and perforating arteries using this approach, and this procedure facilitates complete tumor resection in cases of recurrent suprasellar tumors. Table 4 Surgical approaches for recurrent cases recurrent pituitary tumors (n = 25) Approaches
No. of cases
Transsphenoidal Transcranial pterional bifrontal basal interhemispheric Total
9 16 11 5 25
J.-K. Kang et al. / International Congress Series 1259 (2004) 119 – 127
123
4. Illustrative cases 4.1. Case 1 A 20-year-old girl who was operated on with craniopharyngioma at the age of 12, presented with headaches, bitemporal hemianopsia and DI caused by a large, recurrent craniopharyngioma. The tumor was extended into the retrochiasmatic area and compressing the chiasm and hypothalamus to a moderate degree. The tumor was totally removed by the BflHA, preserving the pituitary stalk and hypothalamus (Fig. 3). She had an uneventful postoperative course, excepting hormonal replacement with vasopressin. 4.2. Case 2 A 58-year-old woman had undergone transsphenoidal partial removal of a solid pituitary tumor 2 years previously. The tumor regrew mainly in the suprasellar and retrochiasmatic region, mildly compressing the hypothalamus and chiasm and causing a progressive decrease in her visual acuity. The tumor was totally removed by the BFIHA. The optic apparatus, the floor of the III ventricle and the pituitary stalk were all visualized and preserved during the operation (Fig. 4). The postoperative course was uneventful and the patient’s hypothalamo –pituitary function was preserved. 5. Results Preoperative measurement of the tumor growth and extension. For the evaluation of the suprasellar recurrent tumors’ growth and their size, we applied the four reference line (A, B, C, D, E) on the brain MRI. The results of the tumor regrowth size, height (H), posterior extension (P) and width (W) are shown in the table. The mean values of the width, height and posterior extension of their recurrent tumors were 35.4 mm (W), 35.3 mm (H) and 29.1 mm (P). Outcome of the recurrent suprasellar tumors performed by the BFIHA (Table 5). All four patients with recurrent craniopharyngioma were able for gross total resections and all had improved vision postoperatively. Among these four patients with recurrent
Fig. 2. Illustrations depicting the surgical technique. Bifrontal craniotomy superior medial orbitotomy sup. sagittal sinus ligation falx cut at the base.
124
J.-K. Kang et al. / International Congress Series 1259 (2004) 119 – 127
Fig. 3. A 20-year-old female with recurrent craniopharyngioma. Preoperative gadolinium-enhanced MRI scans reveal suprasella mass, retrochiasmatic extension and into the third ventricle with contrast enhancement (upper). Postoperative T1-weighted sequence reveals no residual mass (lower).
Fig. 4. A 58-year-old woman with recurrent pituitary adenoma 2 years after transsphenoidal surgery. Gadoliniumenhanced MRI shows the large suprasella mass extending to the retrochiasmatic area and compressing the third ventricle (upper). Postoperative MRI reveals gross total removal of the mass and remaining tumor capsule (lower).
J.-K. Kang et al. / International Congress Series 1259 (2004) 119 – 127
125
Table 5 Outcomes of nine points undergoing bifrontal basal IHA Cases
Dx
12/M 20/F 31/M 50/M 31/M 51/F 54/F 25/M 58/F
Rec. Rec. Rec. Rec. Rec. Rec. Rec. Rec. Rec.
cranioph cranioph cranioph cranioph pituitary pituitary pituitary pituitary pituitary
Resection
Vision (VA/VF)
Endocrine state
GTR GTR GTR GTR STR STR STR GTR STR
improved improved improved improved improved improved improved unchanged improved
panhypopituitarism DI panhypopituitarism normal normal normal normal panhypopituitarism panhypopituitarism
Operative complication CSF leakage (1, case 4).
craniopharyngioma, two patients had panhypopituitarism, one DI and one normal function. Of the five patients with recurrent pituitary tumor, gross total removal was possible in one and subtotal removal in four patients, which means gross removal of the solid tumor, retaining the capsule adherent to the vital neurostructures. Among these five patients with recurrent pituitary tumors, three patients had improved vision postoperatively and one had unchanged vision. Of these five patients, three patients had normal pituitary function and two patients had panhypopituitarism. Surgical mortality did not occur in these nine patients with recurrent suprasellar tumor by this method and only one case had a transient CSF rhinorrhea between 1 and 2 weeks after operation. However, this resolved with bed rest for several days. 6. Discussion Recurrent suprasellar tumors, such as craniopharyngioma and pituitary adenoma, require special consideration to the surgical approach as well as avoiding damage to the surrounding neurovascular structures [3,6,8]. Aggressive, surgical removal of the lesion is often impeded by tumor adherence to arteries, the optic apparatus and hypothalamus [2,4,13]. To minimize surgical morbidity, an approach should be chosen which provides wide exposure of all portions of the lesion, minimizes the sacrifice of brain tissue and neurovascular structures, and gives superior anatomic orientation of these structures in relation to the lesion. The modified bifrontal basal approach with removal of the medial orbital rims that we used to resect recurrent suprasellar tumors in nine patients enabled us to fulfill the above requirements and achieve maximum resection of the tumor. The traditional approaches to suprasellar lesions include pterional, unilateral subfrontal and bifrontal approaches [1,2,12,13]. The pterional and subfrontal approaches offer excellent access to the suprasellar area and to the lateral extension of the tumor. However, only the ipsilateral optic nerve, perforating arteries and carotid artery are visible initially; contralateral structures and retrosellar area are thus at risk for inadvertent injury during the surgery [1]. The bifrontal approach offers better anatomic orientation of the optic apparatus, bilateral carotid arteries and perforating arteries, which are supplying the optic pathway, pituitary stalk and hypothalamus. However, this approach requires significant frontal lobe retraction and may provide limited access to the third ventricle [1].
126
J.-K. Kang et al. / International Congress Series 1259 (2004) 119 – 127
To improve access, a bifrontal anterior interhemispheric approach has been advocated for use in removing third ventricular tumors by Suzuki et al. [10]. This approach provides a wider operative view of the anterior circle of Willis, the optic chiasm and the third ventricle tumor itself, minimizing damage to the surrounding neurovascular structures. One disadvantage of this approach is that it often requires sacrifice of the bridging veins. Division of the bridging veins, combined with prolonged retraction of the frontal lobes, increases the risk of postoperative cerebral ischemia and contusional hemorrhage [7]. A basal interhemispheric approach has been described by Yasui et al. [14] as a modification of the anterior interhemispheric approach for surgery of anterior communicating aneurysms. Advantages of this approach are preserving the most bridging veins, much less dissection in the area of the interhemispheric fissure and better visualization of the upper part of the third ventricular tumor. We have shown the usefulness of the bifrontal basal interhemispheric approach, which was a modified basal interhemispheric approach [14] in nine patients with recurrent suprasellar tumor. We advocated this approach for the surgical management of recurrent suprasellar tumors because of its ability to provide wide exposure to the anatomical structures bilaterally and less damage to the surrounding neurovascular structures during the operation. For the decision to use the BFIHA, we have measured the tumor size and extension on the brain MRI while applying the referred lines. All of the nine patients with recurrent suprasellar tumors have shown 29.1 mm posterior extension of the tumor (mean), 35.4 mm in tumor width and 35.3 mm in tumor height. Recurrence rates of craniopharyngiomas, after what was believed to be a total excision, are surprisingly high in spite of the benign, histological nature of this tumor. The recurrence rate has been reported as 5.5% by Symon and Sprich [11], 7% by Yasargil et al. [13] and 29% by Hoffman et al. [5]. In our series, the recurrence rate was 17.5% (14/ 80). To reduce recurrence of the tumor, it may be important to minimize blind spots during the operation using this BFIHA that allows wider exposure. Baskin and Wilson [2] reported from a series of 74 patients that CSF leaks occurred in 8% of their patients. In our series of nine patients with BFIHA, only one patient had a transient CSF rhinorrhea. In our small series, we obtained a gross total resection in four of the four patients with recurrent craniopharyngioma and in one patient with recurrent pituitary tumor, and subtotal removal in four patients with recurrent pituitary tumor, which means remaining tumor capsules. In conclusion, with recurrent suprasellar tumors as complex as craniopharyngiomas and pituitary tumors, good visualization of the surrounding structures may contribute to a better clinical outcome and decrease the tumor recurrence. The BFIHA enables the surgeon to identify both sides of the optic nerves, chiasm and optic tracts, possibly allowing more chance for postoperative visual improvement.
References [1] M.L.J. Apuzzo, M.L. Levy, I.I. Tung, Surgical strategies and technical methodologies in optimal management of craniopharyngioma and masses affecting the third ventricular chamber, Acta Neurochir. 553 (1991) 77 – 88. [2] D.S. Baskin, C.B. Wilson, Surgical management of craniopharyngiomas, J. Neurosurg. 65 (1986) 22 – 27. [3] J.D. Day, S.L. Giannotta, T. Fukushima, Extradural temporopolar approach to lesions of the upper basal artery and infrachiasmatic region, J. Neurosurg. 81 (1994) 230 – 235.
J.-K. Kang et al. / International Congress Series 1259 (2004) 119 – 127
127
[4] E.G. Fischer, K. Welch, J.A. Belli, J. Wallman, J.J. Shillito Jr., K.R. Winston, R. Cassady, Treatment of craniopharyngiomas in children: 1972 – 1981, J. Neurosurg. 62 (1985) 496 – 591. [5] J.H. Hoffman, M. Desiva, R.P. Humphreys, J.M. Drake, M.L. Smith, S.I. Blasor, Aggressive surgical management of craniopharyngiomas in children, J. Neurosurg. 76 (1992) 47 – 52. [6] H.K. Inoue, H. Fujimaki, H. Kobga, N. Ono, M. Hirato, C. Ohye, Basal interhemispheric supra-and/or infrachiasmal approaches via superomedial orbitotomy for hypothalamic lesions: preservation of hypothalamo – pituitary functions in combination treatment with radiosurgery, Child’s Nerv. Syst. 13 (1997) 250 – 256. [7] T. Kanno, A. Kasama, M. Shoda, A pitfall in the interhemispheric translamina terminalis approach for the removal of craniopharyngioma: significance of preserving draining veins: Part I. Clinical study, Surg. Neurol. 32 (1989) 111 – 115. [8] M. Shibuya, M. Takayasu, Y. Suzuki, K. Saito, Sugidak, Bifrontal basal interhemispheric approach to craniopharyngioma resection with or without division of the anterior communicating artery, J. Neurosurg. 84 (1996) 951 – 956. [9] R. Shirane, Suching-chan, Y. Kusaka, H. Jokura, T. Yoshimoto, Surgical outcomes in 31 patients with craniopharyngiomas extending outside the suprasellar cistern: an evaluation of the frontobasal interhemispheric approach, J. Neurosurg. 96 (2002) 704 – 712. [10] J. Suzuki, R. Katakura, T. Mori, Interhemispheric approach through the lamina terminalis to tumors of the anterior parts of the third ventricle, Surg. Neurol. 22 (1984) 157 – 163. [11] L. Symon, W. Sprich, Radical excision of craniopharyngioma: results in 20 patients, J. Neurosurg. 62 (1985) 174 – 181. [12] T. Tomita, D.C.T. Mc Clone, Radical resections of childhood craniopharyngioma, Pediatr. Neurosurg. 19 (1993) 6 – 14. [13] M.G. Yasargil, M. Curcic, M. Kis, G. Siegenthaler, P.J. Teddy, P. Roth, Total removal of craniopharyngiomas, J. Neurosurg. 73 (1990) 3 – 11. [14] N. Yasui, E. Nathal, H. Fujiwara, The basal interhemispheric approach for acute anterior communicating aneurysms, Acta Neurochir. 118 (1992) 91 – 97.