Is Gross Total Resection Reasonable in Adults with Craniopharyngiomas with Hypothalamic Involvement?

International audienceObjective: The treatment of hypothalamus-invading craniopharyngiomas, based on pediatric experience, is subtotal resection (STR) with radiotherapy. This strategy sometimes leads to uncontrollable tumor progression. In adults, with the use of endoscopic endonasal surgery (EES), does removing the hypothalamic part of the tumor-whenever possible-compromise the outcome of the patients?Methods: We included adults with craniopharyngioma treated by a first EES in 2008-2016 by senior neurosurgeon (E.J.). Endocrine, ophthalmologic, and hypothalamic data were retrospectively collected, including body mass index (BMI), cognitive and social status, with a systematic follow-up interview. Magnetic resonance imaging scans were graded according to Puget classification: 0, no hypothalamic involvement; 1, hypothalamic displacement; and 2, hypothalamic involvement. Grade 2 tumors were separated into gross total resection (GTR) or STR.Results: We included 22 patients aged 18-79 years. Presenting symptoms were visual (14, 64%), endocrine dysfunction (10, 45%), BMI >30 (8, 36%), and cognitive/psychiatric impairment (9, 41%). Fourteen (64%) were grade 2 craniopharyngiomas. GTR was performed in 14 (64%) patients. Postoperatively, 12/14 (86%) cases improved visually, and 20 (91%) needed hormone replacement therapy. There was no difference in BMI evolution in the GTR versus STR group, cognitive status was stable or improved in all patients except 1; 4/8 patients with STR experienced progression needing adjuvant treatment versus no patient with GTR.Conclusions: EES GTR of grade 2 craniopharyngiomas does not cause major hypothalamic worsening, in contrast with children operated by cranial approaches. The surgeon's experience is key in deciding when to stop the dissection. Offering GTR whenever possible aims at avoiding tumor progression and radiotherapy

Pituitary MRI characteristics in 297 acromegaly patients based on T2-weighted sequences.

Context: Responses of GH-secreting adenomas to multimodal management of acromegaly varies widely between patients. Understanding the behavioral patterns of GH-secreting adenomas by identifying predictive factors of their evolution is a research priority. Objective: To clarify the relationship between adenoma T2-weighted signal on diagnostic MRI in acromegaly and clinical and biological features at diagnosis. Design: International, multicenter, retrospective analysis. Setting: 10 endocrine tertiary referral centers. Patients: 297 acromegalic recently diagnosed patients with available diagnostic MRI evaluations were included in the study. Main outcome measure: Clinical, biochemical characteristics and MRI signal findings. Results: T2-hypointense adenomas represented 52.9% of the series, were smaller than their T2-hyper- and isointense counterparts (p<0.0001), were associated with higher IGF1 levels (p=0.0001), invaded the cavernous sinus less frequently (p=0.0002) and rarely caused optic chiasm compression (p<0.0001). Acromegalic men tended to be younger at diagnosis than women (p=0.067) and presented higher IGF1 values (p=0.01). Although in total, adenomas had a predominantly inferior extension in 45.8% of cases, in men this was more frequent (p<0.0001), whereas in women optic chiasm compression of macroadenomas occurred more often (p=0.0067). Most adenomas (45.1%) measured between 11-20mm in maximal diameter and bigger adenomas were diagnosed at younger ages (p=0.0001). Conclusions: T2-weighted signal differentiates GH-secreting adenomas into subgroups with particular behaviors. This raises the question of whether T2-weighted signal could represent a factor in the classification of acromegalic patients in future studies