Craniopharyngioma overview: Difference between revisions
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==Pathophysiology== | ==Pathophysiology== | ||
Craniopharyngiomas are epithelial tumors that usually arise in the pituitary stalk adjacent to the optic chiasm. On gross pathology, craniopharyngiomas are cystic or partially cystic with solid areas.The cyst is filled with a turbid, proteinaceous material of brownish-yellow color that glitters and sparkles because of a high content of floating cholesterol crystals On microscopic histopathology, it is categorized into two subtypes: Adamantinomatous and papillary. | Craniopharyngiomas are [[Epithelial|epithelial tumors]] that usually arise in the [[pituitary stalk]] adjacent to the [[optic chiasm]]. On [[gross pathology]], craniopharyngiomas are [[Cyst|cystic]] or partially cystic with solid areas.The cyst is filled with a [[turbid]], [[Protein|proteinaceous]] material of brownish-yellow color that glitters and sparkles because of a high content of floating [[Cholesterol|cholesterol crystals]] On microscopic [[histopathology]], it is categorized into two subtypes: Adamantinomatous and papillary. | ||
==Differentiating craniopharyngioma from other diseases== | ==Differentiating craniopharyngioma from other diseases== | ||
Craniopharyngioma must be differentiated from other pituitary masses such as sarcoid, pituitary adenoma, aneurysm, teratoma, tuberculosis, rathke cleft cyst, chordoma, hypothalamic glioma, hamartoma of tuber cinereum, histiocytosis, meningioma and optic nerve glioma. | Craniopharyngioma must be differentiated from other [[Pituitary Cancer|pituitary masses]] such as [[Sarcoid|sarcoid,]] [[pituitary adenoma]], [[aneurysm]], [[teratoma]], [[Tuberculosis|tuberculosis,]] [[Rathke pouch tumor|rathke cleft cyst]], [[chordoma]], [[Glioma|hypothalamic glioma]], [[hamartoma]] of [[tuber cinereum]], [[histiocytosis]], [[meningioma]] and [[Glioma|optic nerve glioma.]] | ||
==Epidemiology and demographics== | ==Epidemiology and demographics== | ||
The demographic patterns of craniopharyngioma are not well described because the tumor is rare. In addition, most cancer registries collect data only on malignant conditions and, therefore, they are not useful in the study of craniopharyngioma, considered to be of borderline histological malignancy. Incidence rates are similar in males and females and between Caucasians and African Americans. Tumors are more common among children of age 5 to 15 years and older adults of greater than 65 years,the lowest rates occur among those aged 15 to 34 years. Survival is highest for patients diagnosed at a younger age. | The [[Demographics|demographic]] patterns of craniopharyngioma are not well described because the tumor is rare. In addition, most [[Cancer registry|cancer registries]] collect data only on [[malignant]] conditions and, therefore, they are not useful in the study of craniopharyngioma, considered to be of borderline [[Histological|histological malignancy]]. [[Incidence]] rates are similar in males and females and between Caucasians and African Americans. Tumors are more common among children of age 5 to 15 years and older adults of greater than 65 years,the lowest rates occur among those aged 15 to 34 years. Survival is highest for patients diagnosed at a younger age. | ||
==Risk factors== | ==Risk factors== | ||
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==Natural history, complications and prognosis== | ==Natural history, complications and prognosis== | ||
Common complications of craniopharyngioma are long-term hormonal problems, | Common complications of craniopharyngioma are long-term [[Hormonal|hormonal problems]], [[Visual disturbance|visual defects]] and nervous system deficits. The prognosis of craniopharyngioma is good with treatment. The 5-year and 10-year survival rates are higher than 90%. | ||
==Diagnosis== | ==Diagnosis== | ||
Diagnosis of craniopharyngioma is dependent on good history taking and physical exam. various laboratory and [[Imaging studies|imaging modalities]] are used to diagnose craniopharyngioma. | |||
==History and symptoms== | ==History and symptoms== | ||
Craniopharyngiomas are slow growing, and symptoms often are present for a year or more before the diagnosis is established. A wide range of symptoms may be present, depending upon the precise location of the tumor and its relationship to adjacent normal structures. Most common symptoms of craniopharyngioma include headache, nausea, vomiting, ataxia, polyuria, polydipsia, stunted growth, decreased libido, amenorrhea, weight gain, myxedema, vision loss, behavioral and learning problems. | Craniopharyngiomas are slow growing, and symptoms often are present for a year or more before the diagnosis is established. A wide range of symptoms may be present, depending upon the precise location of the [[tumor]] and its relationship to adjacent normal structures. Most common symptoms of craniopharyngioma include [[headache]], [[Nausea and vomiting|nausea]], [[Nausea and vomiting|vomiting]], [[ataxia]], [[polyuria]], [[polydipsia]], [[stunted growth]], [[decreased libido]], [[amenorrhea]], [[weight gain]], [[Myxedema|myxedema,]] [[vision loss]], [[Behavioral|behavioral and learning problems]]. | ||
==Physical examination== | ==Physical examination== | ||
The diagnosis of craniopharyngioma is often made late after the initial appearance of symptoms. clinical picture at time of diagnosis often dominated by nonspecific manifestations of intracranial pressure like headache, nausea and vomiting. Primary manifestations are visual impairment and endocrine deficits. | The diagnosis of craniopharyngioma is often made late after the [[Symptoms and Signs|initial appearance of symptoms]]. clinical picture at time of diagnosis often dominated by nonspecific manifestations of [[intracranial pressure]] like [[headache]], [[nausea and vomiting]]. Primary manifestations are [[visual impairment]] and [[List of endocrine diseases|endocrine deficits.]] | ||
==Laboratory findings== | ==Laboratory findings== | ||
Patients with craniopharyngioma may have abnormal pituitary hormone levels, which is suggestive of disruption of hormone production due to pressure effects on the pituitary gland. The hypothalamic-pituitary axis hormones, namely growth hormone, thyroid hormone, luteinising and follicle stimulating hormone should be measured together with cortisol levels and an assessment of serum and urine osmolality. In addition, an estimate of bone age and, for young females, ovarian ultrasonography is useful. Ideally, any abnormalities should be corrected pre-operatively but, at the very least, low cortisol levels and diabetes insipidus should be treated prior to a surgical procedure. | Patients with craniopharyngioma may have abnormal [[Pituitary hormone|pituitary hormone levels,]] which is suggestive of disruption of hormone production due to [[Pressure|pressure effects]] on the pituitary gland. The [[Hypothalamic pituitary adrenal axis|hypothalamic-pituitary axis hormones]], namely [[Growth hormone-binding protein|growth hormone]], [[thyroid hormone]], [[Luteinizing hormone|luteinising and follicle stimulating hormone]] should be measured together with cortisol levels and an assessment of serum and [[urine osmolality]]. In addition, an estimate of bone age and, for young females, ovarian [[Medical ultrasonography|ultrasonography]] is useful. Ideally, any abnormalities should be corrected [[Surgery|pre-operatively]] but, at the very least, low [[Cortisol|cortisol levels]] and [[diabetes insipidus]] should be treated prior to a surgical procedure. | ||
==CT== | ==CT== | ||
The CT findings depend on the subtype of craniopharyngioma. On CT, the adamantinomatous type is characterized by large cysts, vivid enhancement and peripheral calcifications. Papillary type tend to be more spherical in outline and usually lack the prominent cystic component; most are solid. Calcification is rare. | The CT findings depend on the [[Craniopharyngioma (classification)|subtype of craniopharyngioma]]. On CT, the [[Craniopharyngioma (classification)|adamantinomatous]] type is characterized by large cysts, vivid enhancement and peripheral calcifications. Papillary type tend to be more spherical in outline and usually lack the prominent [[Cyst|cystic component]]; most are [[solid]]. Calcification is rare. | ||
==MRI== | ==MRI== | ||
The diagnostic evaluation of craniopharyngioma includes high-definition brain imaging. Brain MRI with and without contrast is the gold standard. Computed tomography (CT) scan is optional and may show some calcifications that can be seen in these tumors. However CT is not specific enough as a | The diagnostic evaluation of craniopharyngioma includes [[High Resolution CT|high-definition brain imaging]]. Brain [[MRI|MRI with and without contrast]] is the [[Gold standard (test)|gold standard]]. Computed tomography (CT) scan is optional and may show some [[Calcification|calcifications]] that can be seen in these tumors. However CT is not specific enough as a stand alone [[diagnostic test]]. [[Vascular|vascular imaging]] studies such as [[Magnetic resonance angiography|MR angiography]] (MRA) or [[CT angiography|CTA]], is decided on a case-by-case basis typically for surgical planning or if a possible vascular malformation is spuspected. | ||
==Treatment== | ==Treatment== | ||
The predominant therapy for craniopharyngioma is surgical resection. Medical therapy, Adjunctive chemotherapy and radiation may be required. | The predominant therapy for craniopharyngioma is [[Resection|surgical resection]]. Medical therapy, Adjunctive chemotherapy and [[Radiation therapy|radiation]] may be required. | ||
==Medical therapy== | ==Medical therapy== | ||
The predominant therapy for craniopharyngioma is surgical resection. Adjunctive chemotherapy and radiation may be required. Subcutaneous pegylated interferon alpha-2B has been used to treat cystic recurrences. It can also be treated with intracavitary instillation of radioactive P-32, bleomycin or interferon-alpha via stereotactic delivery or placement of an Ommaya catheter. Paclitaxel and carboplatin have shown to prevent recurrence of malignant craniopharyngiomas.Intracavitary bleomycin reduces cyst size and toughens and thickens the cyst wall, thereby facilitating surgical excision of a cyst membrane that otherwise might fragment at the time of open craniotomy. Reports of intracystic bleomycin use are limited. Other agents like interferon alpha are being tested in recent days. | The predominant therapy for craniopharyngioma is [[Resection|surgical resection]]. Adjunctive [[chemotherapy]] and [[Radiation therapy|radiation]] may be required. [[Subcutaneous tissue|Subcutaneous]] [[Pegylated interferon-alpha-2a|pegylated interferon alpha-2B]] has been used to treat [[Cyst|cystic]] recurrences. It can also be treated with intracavitary instillation of [[Radioactive|radioactive P-32]], [[bleomycin]] or [[interferon-alpha]] via [[Stereotactic surgery|stereotactic]] delivery or placement of an [[Ommaya reservoir|Ommaya catheter.]] [[Paclitaxel]] and [[carboplatin]] have shown to prevent recurrence of [[malignant]] craniopharyngiomas.Intracavitary [[bleomycin]] reduces cyst size and toughens and thickens the cyst wall, thereby facilitating surgical excision of a cyst membrane that otherwise might fragment at the time of open [[Craniotomy|craniotomy.]] Reports of intracystic [[bleomycin]] use are limited. Other agents like [[Interferon type I|interferon alpha]] are being tested in recent days. | ||
==Surgery== | ==Surgery== | ||
Surgery is the mainstay of treatment for craniopharyngioma. Radical surgery is done either by transsphenoidal approach or by craniotomy. Recent studies propose subtotal resection with postoperative radiotherapy as the management paradigm of choice for craniopharyngiomas, especially in the pediatric population. More advanced radiotherapy modalities currently under investigation include Gamma Knife and CyberKnife radiosurgery. | Surgery is the mainstay of treatment for craniopharyngioma. [[Radical surgery]] is done either by [[Sphenoid bone|transsphenoidal]] approach or by [[craniotomy]]. Recent studies propose subtotal resection with postoperative [[Radiation therapy|radiotherapy]] as the management paradigm of choice for craniopharyngiomas, especially in the [[Pediatrics|pediatric population]]. More advanced [[Radiation therapy|radiotherapy]] modalities currently under investigation include [[Gamma Knife]] and [[Gamma Knife|CyberKnife radiosurgery.]] | ||
==References== | ==References== | ||
Revision as of 03:55, 11 February 2019
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Marjan Khan M.B.B.S.[2]
Overview
Craniopharyngioma is a rare, benign tumor of the central nervous system. It is a partly cystic embryonic malformation that can occur in the sellar/parasellar region and can result in a wide array of symptoms such as headaches, nausea and vomiting, visual disturbances, and endocrine disturbances.It has an incidence of 0.5 to 2 cases per million persons per year. Half of these cases occur during the first two decades of life. It represents 1.2% to 4% of all childhood intracranial tumors. It has a classical bimodal distribution of incidence with increased incidence rates in patients aged five to 14 years and 50 to 74 years. Craniopharyngioma has a very high recurrence rate, with reported rates as high as 50%. There are two subtypes of craniopharyngioma: adamantinomatous and papillary. It most commonly presents with signs of increased intracranial pressure (ICP) including a headache and nausea and vomiting along with visual and endocrine disturbances. In children, failure to thrive and decreased growth rate can be the initial presentation. Multiple modalities can be implemented in the management of craniopharyngioma, including neurological surgery, radiotherapy, and instillation of sclerosing substances.
Historical perspective
Primitive concepts of the function of the pituitary gland were formulated in the 4th century BC by Hippocrates. Harvey Cushing (1869–1939), has had a major impact in the understanding of pituitary function and surgery but he was not the first surgeon to attempt pituitary surgery; this honor goes in 1889 to Sir Victor Horsley. Hermann Schloffer (1868–1937), an Austrian surgeon, guided by the works of Davide Giordano, performed the first transfacial transsphenoidal approach in 1907. In the 1960s, transphenoidal surgery underwent a revival and has been universally accepted thanks to great figures such as Guiot and Hardy.
Classification
Craniopharyngiomas occur in two histological subtypes; an adamantinomatous form and Papillary. Adamantinomatous form that is the most common pediatric variant and a Papillary form that is found almost exclusively in adults.The pediatric form is thought to arise from epithelial remnants of the craniophayngeal duct or Rathke's pouch, an embryologic structure that develops into the anterior pituitary. Both forms typically have solid and cystic components and are often calcified on imaging. Recent genetic analysis has also shown differences between these two subtypes. Mutations in B-catenin (CTNNB1), a downstream effector of the Wnt pathway that is, involved in cellular growth and development, has been described in 60–96% of adamantinomatous craniopharyngiomas. Papillary craniopharyngiomas recently have been discovered to frequently harbor V600E mutations of the BRAF gene, which is a key player in the mitogen-activated protein kinase pathway.
Pathophysiology
Craniopharyngiomas are epithelial tumors that usually arise in the pituitary stalk adjacent to the optic chiasm. On gross pathology, craniopharyngiomas are cystic or partially cystic with solid areas.The cyst is filled with a turbid, proteinaceous material of brownish-yellow color that glitters and sparkles because of a high content of floating cholesterol crystals On microscopic histopathology, it is categorized into two subtypes: Adamantinomatous and papillary.
Differentiating craniopharyngioma from other diseases
Craniopharyngioma must be differentiated from other pituitary masses such as sarcoid, pituitary adenoma, aneurysm, teratoma, tuberculosis, rathke cleft cyst, chordoma, hypothalamic glioma, hamartoma of tuber cinereum, histiocytosis, meningioma and optic nerve glioma.
Epidemiology and demographics
The demographic patterns of craniopharyngioma are not well described because the tumor is rare. In addition, most cancer registries collect data only on malignant conditions and, therefore, they are not useful in the study of craniopharyngioma, considered to be of borderline histological malignancy. Incidence rates are similar in males and females and between Caucasians and African Americans. Tumors are more common among children of age 5 to 15 years and older adults of greater than 65 years,the lowest rates occur among those aged 15 to 34 years. Survival is highest for patients diagnosed at a younger age.
Risk factors
No predisposing risk factors have been identified.
Natural history, complications and prognosis
Common complications of craniopharyngioma are long-term hormonal problems, visual defects and nervous system deficits. The prognosis of craniopharyngioma is good with treatment. The 5-year and 10-year survival rates are higher than 90%.
Diagnosis
Diagnosis of craniopharyngioma is dependent on good history taking and physical exam. various laboratory and imaging modalities are used to diagnose craniopharyngioma.
History and symptoms
Craniopharyngiomas are slow growing, and symptoms often are present for a year or more before the diagnosis is established. A wide range of symptoms may be present, depending upon the precise location of the tumor and its relationship to adjacent normal structures. Most common symptoms of craniopharyngioma include headache, nausea, vomiting, ataxia, polyuria, polydipsia, stunted growth, decreased libido, amenorrhea, weight gain, myxedema, vision loss, behavioral and learning problems.
Physical examination
The diagnosis of craniopharyngioma is often made late after the initial appearance of symptoms. clinical picture at time of diagnosis often dominated by nonspecific manifestations of intracranial pressure like headache, nausea and vomiting. Primary manifestations are visual impairment and endocrine deficits.
Laboratory findings
Patients with craniopharyngioma may have abnormal pituitary hormone levels, which is suggestive of disruption of hormone production due to pressure effects on the pituitary gland. The hypothalamic-pituitary axis hormones, namely growth hormone, thyroid hormone, luteinising and follicle stimulating hormone should be measured together with cortisol levels and an assessment of serum and urine osmolality. In addition, an estimate of bone age and, for young females, ovarian ultrasonography is useful. Ideally, any abnormalities should be corrected pre-operatively but, at the very least, low cortisol levels and diabetes insipidus should be treated prior to a surgical procedure.
CT
The CT findings depend on the subtype of craniopharyngioma. On CT, the adamantinomatous type is characterized by large cysts, vivid enhancement and peripheral calcifications. Papillary type tend to be more spherical in outline and usually lack the prominent cystic component; most are solid. Calcification is rare.
MRI
The diagnostic evaluation of craniopharyngioma includes high-definition brain imaging. Brain MRI with and without contrast is the gold standard. Computed tomography (CT) scan is optional and may show some calcifications that can be seen in these tumors. However CT is not specific enough as a stand alone diagnostic test. vascular imaging studies such as MR angiography (MRA) or CTA, is decided on a case-by-case basis typically for surgical planning or if a possible vascular malformation is spuspected.
Treatment
The predominant therapy for craniopharyngioma is surgical resection. Medical therapy, Adjunctive chemotherapy and radiation may be required.
Medical therapy
The predominant therapy for craniopharyngioma is surgical resection. Adjunctive chemotherapy and radiation may be required. Subcutaneous pegylated interferon alpha-2B has been used to treat cystic recurrences. It can also be treated with intracavitary instillation of radioactive P-32, bleomycin or interferon-alpha via stereotactic delivery or placement of an Ommaya catheter. Paclitaxel and carboplatin have shown to prevent recurrence of malignant craniopharyngiomas.Intracavitary bleomycin reduces cyst size and toughens and thickens the cyst wall, thereby facilitating surgical excision of a cyst membrane that otherwise might fragment at the time of open craniotomy. Reports of intracystic bleomycin use are limited. Other agents like interferon alpha are being tested in recent days.
Surgery
Surgery is the mainstay of treatment for craniopharyngioma. Radical surgery is done either by transsphenoidal approach or by craniotomy. Recent studies propose subtotal resection with postoperative radiotherapy as the management paradigm of choice for craniopharyngiomas, especially in the pediatric population. More advanced radiotherapy modalities currently under investigation include Gamma Knife and CyberKnife radiosurgery.