Endoscopic endonasal approach for craniopharyngioma: the importance of the relationship between pituitary stalk and tumor

Dho, Yun-Sik,Kim, Yong Hwy,Se, Young-Bem,Han, Doo Hee,Kim, Jung Hee,Park, Chul-Kee,Wang, Kyu-Chang,Kim, Dong Gyu American Association of Neurological Surgeons 2018 Journal of Neurosurgery Vol.129 No.3

<B>OBJECTIVE</B><P>The endoscopic endonasal approach (EEA) is commonly used for the treatment of craniopharyngioma; therefore, it is essential to analyze outcomes in order to understand the benefits and drawbacks. The goal of this paper was to evaluate the clinical features and outcomes associated with this treatment approach.</P><B>METHODS</B><P>From July 2010 to March 2016, 82 adult craniopharyngioma patients underwent an EEA at the authors’ institution. Of these cases, intraoperative records and immediate postoperative MR images were available for 68 patients. The patients underwent systemized endocrinological evaluation. Eighteen of 68 patients who underwent EEA for recurrence or regrowth of residual lesions after previous surgical management were excluded in the analysis of the anatomical tumor classification. The authors retrospectively analyzed preoperative clinical features and previous anatomical classifications, focusing on the relationship of the pituitary stalk and tumor, to determine predictive factors for the clinical outcome, such as the extent of resection, visual function, endocrinological function, recurrence rate, and complications.</P><B>RESULTS</B><P>The mean tumor size was 2.5 cm (3.1 cm for primary tumors and 1.9 cm for recurrent lesions). Gross-total resection (GTR) was achieved in 62 (91.1%) patients (48 [96.0%] patients with primary tumors and 14 [77.8%] patients with recurrent tumors). The rate of GTR was higher in the primary group than in the group with recurrence (p = 0.038). The overall pre- and postoperative visual impairment scale (VIS) scores were 40.8 and 22.1, respectively (50.9 and 14.3 in the primary group and 30.7 and 29.9 in patients with recurrence, respectively). The improvement rate in VIS score was higher in the primary group than in the recurrent group (p = 0.001). Endocrinological function was improved in 4 patients (5.9%) and deteriorated in 32 of 68 patients (47.1%). Tumor invasion into the center of the pituitary stalk affected the postoperative outcomes most significantly. Cognitive dysfunction was observed in 22 patients before surgery and improved in 20 patients (90.9%) after surgery. Hydrocephalus was found in 7 patients and resolved after surgery in all cases. CSF leakage occurred in 2 (2.9%) of 68 patients and was repaired by revision surgery in both patients. Ten patients without CSF leakage also received antibiotics for the treatment of meningitis. The infection rate was higher in the recurrent group. Postoperative endocrinological evaluation showed no deficits in 12 patients and panhypopituitarism in 55 patients. The remaining patient had growth hormone deficiency. Forty-three patients had new-onset diabetes insipidus, and 1 patient had persistent diabetes insipidus after surgery. There were 2 (2.9%) cases of recurrence during the mean 30.7-month follow-up period; one patient underwent radiosurgery and the other underwent reoperation.</P><B>CONCLUSIONS</B><P>The EEA resulted in excellent surgical outcomes and acceptable morbidity rates, regardless of the anatomical location of the tumor. Invasion of the craniopharyngioma into the center of the pituitary stalk has strong predictive power for postoperative endocrinological outcome.</P>

An Updated Nationwide Epidemiology of Primary Brain Tumors in Republic of Korea, 2013

( Yun-sik Dho ),( Kyu-won Jung ),( Johyun Ha ),( Youngbeom Seo ),( Chul-kee Park ),( Young-joo Won ),( Heon Yoo ) 대한뇌종양학회 대한신경종양학회 2017 Brain Tumor Research and Treatment Vol.5 No.1

Background This report aims to provide accurate nationwide epidemiologic data on primary brain and central nervous system (CNS) tumors in the Republic of Korea. We updated the data by analyzing primary brain and CNS tumors diagnosed in 2013 using the data from the national cancer incidence database. Methods Data on primary brain and CNS tumors diagnosed in 2013 were collected from the Korean Central Cancer Registry. Crude and age-standardized rates were calculated in terms of gender, age, and histological type. Results A total of 11,827 patients were diagnosed with primary brain and CNS tumors in 2013. Brain and CNS tumors occurred in females more often than in males (female:male, 1.70:1). The most common tumor was meningioma (37.3%). Pituitary tumors (18.0%), gliomas (12.7%), and nerve sheath tumors (12.3%) followed in incidence. Glioblastomas accounted for 41.8% of all gliomas. In children (<19 years), sellar region tumors (pituitary and craniopharyngioma), embryonal/primitive/medulloblastoma, and germ cell tumors were the most common tumors. Conclusion This study should provide valuable information regarding the primary brain tumor epidemiology in Republic of Korea

Optimal strategy of gamma knife radiosurgery for craniopharyngiomas

Dho, Yun-Sik,Kim, Yong Hwy,Kim, Jin Wook,Park, Chul-Kee,Chung, Hyun-Tai,Kim, Seung-Ki,Paek, Sun Ha,Wang, Kyu-Chang,Kim, Dong Gyu Springer-Verlag 2018 Journal of neuro-oncology Vol.140 No.1

Catastrophic Intramedullary Abscess Caused by a Missed Congenital Dermal Sinus

Dho, Yun-Sik,Kim, Seung-Ki,Wang, Kyu-Chang,Phi, Ji Hoon The Korean Neurosurgical Society 2015 Journal of Korean neurosurgical society Vol.57 No.3

Congenital dermal sinus (CDS) is a type of occult spinal dysraphism characterized by a midline skin dimple. A 12-month-old girl presented with fever and ascending quadriparesis. She had a midline skin dimple in the upper sacral area that had been discovered in her neonatal period. Imaging studies revealed a holocord intramedullary abscess and CDS. Overlooking CDS or misdiagnosing it as benign sacrococcygeal dimple may lead to catastrophic infection and cause serious neurological deficits. Therefore, further imaging work-up or consultation with a pediatric neurosurgeon is recommended following discovery of any atypical-looking dimples in the midline.

Investigation of the location of atypical teratoid/rhabdoid tumor.

Dho, Yun-Sik,Kim, Seung-Ki,Cheon, Jung-Eun,Park, Sung-Hye,Wang, Kyu-Chang,Lee, Ji Yeoun,Phi, Ji Hoon Springer Verlag 2015 Child's nervous system Vol.31 No.8

<P>The location of a brain tumor is a fundamental characteristic, because various brain tumors develop in relatively specific locations. An atypical teratoid/rhabdoid tumor (AT/RT) is a highly age-specific tumor that occurs in infants and young children. However, AT/RTs develop in a variety of locations in the brain. This study aimed at uncovering the tumor location pattern of AT/RTs to enhance diagnoses.</P>

Recurrence Rate and Prognostic Factors for the Adult Craniopharyngiomas in Long-Term Follow-Up

Park, Hyun Joo,Dho, Yun-Sik,Kim, Jung Hee,Kim, Jin Wook,Park, Chul-Kee,Kim, Yong Hwy Elsevier 2020 World neurosurgery Vol.133 No.-

<P><B>Background</B></P> <P>Craniopharyngiomas show a high recurrence rate despite their pathologically benign nature. Thus, we analyzed the clinical features to elucidate the prognostic factors for the recurrence of craniopharyngiomas in adults with long-term follow-up.</P> <P><B>Methods</B></P> <P>This retrospective study reviewed and analyzed the preoperative features, surgical results, and tumor recurrence of patients who underwent an operation at a single institution from 2004 to 2013.</P> <P><B>Results</B></P> <P>This study analyzed the results of 64 consecutive adult patients, and the median follow-up period was 83.5 months (range 9–163 months). Ten patients had a history of surgery, whereas 4 had a history of adjuvant radiation. Retrochiasmatic tumors (<I>n</I> = 51, 79.7%) were more common than prechiasmatic tumors. Operations were performed via the transcranial approach in 31 (48.4%) patients and transsphenoidal approach in 33. Gross total removal was achieved in 44 (68.8%) patients, and the transsphenoidal approach showed a greater gross total removal rate than the transcranial approach did (97.0% vs. 38.7%, <I>P</I> < 0.001). Adjuvant radiotherapy was performed in 8 patients, and radiosurgery was performed in 2. Recurrence was identified in 25 (39.1%) patients in 45.0 months of the median time to recurrence. The overall actuarial 5- and 7-year progression-free survival rates were 71.8% and 63.6%, respectively. Multivariate analysis revealed that supra- and subdiaphragmatic tumor locations and subtotal removal were risk factors for long-term tumor recurrence.</P> <P><B>Conclusions</B></P> <P>The long-term recurrence rate of craniopharyngiomas was high; therefore, long-term regular follow-up is mandatory. Adjuvant irradiation for remnant tumors showed a long-term tumor control rate comparable to that of completely removed tumors.</P>

Genomic analysis of synchronous intracranial meningiomas with different histological grades

Chowdhury, Tamrin,Yoo, Yongjin,Seo, Youngbeom,Dho, Yun-Sik,Kim, Sojin,Choi, Anna,Choi, Murim,Park, Sung-Hye,Park, Chul-Kee,Lee, Sang Hyung,Lee, Ji Yeoun Springer-Verlag 2018 Journal of neuro-oncology Vol.138 No.1

The Outcomes of Pituitary Apoplexy with Conservative Treatment: Experiences at a Single Institution

Seo, Youngbeom,Kim, Yong Hwy,Dho, Yun-Sik,Kim, Jung Hee,Kim, Jin Wook,Park, Chul-Kee,Kim, Dong Gyu Elsevier 2018 World neurosurgery Vol.115 No.-

<P><B>Objective</B></P> <P>Pituitary apoplexy is an unpredictable complication caused by hemorrhage or infarction in a pituitary adenoma. We retrospectively analyzed the radiologic and clinical outcomes of patients with conservatively managed pituitary apoplexy.</P> <P><B>Methods</B></P> <P>A total of 32 patients who had undergone conservative treatment with high-dose corticosteroid replacement were enrolled in this study. This cohort study consisted of 20 male and 12 female patients. The median patient age was 60 years. Five patients had a previously diagnosed pituitary tumor, and one third of the patients had a history of hypertension.</P> <P><B>Results</B></P> <P>The median follow-up duration was 50 months. The median tumor volumes at the initial and final assessments were 2.75 cm<SUP>3</SUP> (range, 0.32–10.7 cm<SUP>3</SUP>) and 0.64 cm<SUP>3</SUP> (range, 0–8.74 cm<SUP>3</SUP>), respectively. Complete radiographic regression occurred in 9 of the 32 patients, partial regression occurred in 14 patients, and no change in size or progression occurred in 9 patients. Eighteen of the 32 patients had visual disturbances at the initial presentation; in this subgroup, 17 patients showed improvement over the course of the study. One patient had newly developed diplopia related to tumor progression. Nineteen of the 32 patients had ≥1 hormonal deficiency at the initial assessment, 8 of whom recovered to normal endocrine status. Three patients developed a new hormonal deficiency during the follow-up, and 3 patients experienced tumor recurrence.</P> <P><B>Conclusions</B></P> <P>This study showed the regression of tumors related to pituitary apoplexy, with favorable ophthalmologic and endocrinologic recovery. Conservative management should be considered in patients without severe or progressive neuro-ophthalmic deficits.</P> <P><B>Highlights</B></P> <P> <UL> <LI> We investigated the radiologic and clinical outcome of 32 patients with consertavtively treated pituitary apoplexy. </LI> <LI> Conservative management resulted in acceptable neuro-ophthalmic and endocrinologic outcomes. </LI> <LI> Tumor volume pattern within 1–3 three months after apoplexy might be an important prognostic factor of tumor regression. </LI> <LI> Conservative management should be considered if the visual disturbance has not deteriorated. </LI> </UL> </P>

Multi-Layer Onlay Graft Using Hydroxyapatite Cement Placement without Cerebrospinal Fluid Diversion for Endoscopic Skull Base Reconstruction

Kim, Young-Hoon,Kang, Ho,Dho, Yun-Sik,Hwang, Kihwan,Joo, Jin-Deok,Kim, Yong Hwy The Korean Neurosurgical Society 2021 Journal of Korean neurosurgical society Vol.64 No.4

Objective : The skull base reconstruction step, which prevents cerebrospinal fluid (CSF) leakage, is one of the most challenging steps in endoscopic skull base surgery (ESS). The purpose of this study was to assess the outcomes and complications of a reconstruction technique for immediate CSF leakage repair using multiple onlay grafts following ESS. Methods : A total of 230 consecutive patients who underwent skull base reconstruction using multiple onlay grafts with fibrin sealant patch (FSP), hydroxyapatite cement (HAC), and pedicled nasoseptal flap (PNF) for high-flow CSF leakage following ESS at three institutions were enrolled. We retrospectively reviewed the medical and radiological records to analyze the preoperative features and postoperative results. Results : The diagnoses included craniopharyngioma (46.8%), meningioma (34.0%), pituitary adenoma (5.3%), chordoma (1.6%), Rathke's cleft cyst (1.1%) and others (n=21, 11.2%). The trans-planum/tuberculum approach (94.3%) was the most commonly adapted surgical method, followed by the trans-sellar and transclival approaches. The third ventricle was opened in 78 patients (41.5%). Lumbar CSF drainage was not performed postoperatively in any of the patients. Postoperative CSF leakage occurred in four patients (1.7%) due to technical mistakes and were repaired with the same technique. However, postoperative meningitis occurred in 13.5% (n=31) of the patients, but no microorganisms were identified. The median latency to the diagnosis of meningitis was 8 days (range, 2-38). CSF leakage was the unique risk factor for postoperative meningitis (p<0.001). Conclusion : The use of multiple onlay grafts with FSP, HAC, and PNF is a reliable reconstruction technique that provides immediate and complete CSF leakage repair and mucosal grafting on the skull base without the need to harvest autologous tissue or perform postoperative CSF diversion. However, postoperative meningitis should be monitored carefully.

Is Low-Lying Optic Chiasm an Obstacle to an Endoscopic Endonasal Approach for Retrochiasmatic Craniopharyngiomas? (Korean Society of Endoscopic Neurosurgery -003)

Kim, Kyung Hwan,Kim, Yong Hwy,Dho, Yun-Sik,Kim, Jung Hee,Hong, Sang Duk,Choi, Jung Won,Seol, Ho Jun,Nam, Do-Hyun,Lee, Jung-Il,Park, Chul-Kee,Kong, Doo-Sik Elsevier 2018 World neurosurgery Vol.114 No.-

<P><B>Objective</B></P> <P>Despite advances in endoscopic techniques, retrochiasmatic craniopharyngiomas (CPs) are difficult to remove completely, because the low-lying optic chiasm often provides an obstacle to an endoscopic endonasal approach. This study aimed to identify the endoscopic surgical outcomes of the retrochiasmatic CP and resolve the issues related to low-lying optic chiasm.</P> <P><B>Methods</B></P> <P>We reviewed 154 consecutive patients with CP who underwent endonasal endoscopic resection from February 2009 to April 2017 at 2 independent institutions. The topographic relationship of the tumor with the third ventricle, stalk, and optic chiasm and clinical outcomes were investigated.</P> <P><B>Results</B></P> <P>Retrochiasmatic CPs were found in 142 of 154 patients (92.2%). The median follow-up time was 25 months. Gross total resection and near-total resection were achieved in 113 patients (79.6%) and 21 patients (13.8%), respectively. Postoperative cerebrospinal fluid leaks were found in 16 patients (11.3%). Low-lying and high-lying chiasms were found in 44 patients (31.0%) and 98 patients (69.0%), respectively. Low-lying chiasm did not affect clinical outcomes including the extent of resection. Patients with low-lying chiasm showed a marginal trend for postoperative visual deterioration. The ventricular growth pattern representing the origin of the tumor and previous surgery were significantly associated with the position of the optic chiasm (<I>P</I> = 0.007 and 0.001, respectively).</P> <P><B>Conclusions</B></P> <P>An endoscopic endonasal approach is an effective surgical approach for retrochiasmatic CP, even in tumors with low-lying chiasm. However, a thorough and careful dissection is necessary to prevent visual deterioration.</P> <P><B>Highlights</B></P> <P> <UL> <LI> Low-lying chiasm can interfere with endoscopic approach for craniopharyngioma. </LI> <LI> The position of optic chiasm is affected by tumor origin previous surgery. </LI> <LI> Low-lying chiasm does not alter clinical outcomes including extent of resection. </LI> <LI> Endoscopic endonasal approach is feasible even in the presence of low-lying chiasm. </LI> </UL> </P>