Is gross total resection reasonable in adults with craniopharyngiomas with hypothalamic involvement

Objective 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 E.J. Endocrine, ophtalmological and hypothalamic data were retrospectively collected, including BMI, cognitive and social status, with a systematic follow-up interview. MRI were graded according to Puget: 0 – no hypothalamic involvement, 1 – hypothalamic displacement, 2 – hypothalamic involvement. Grade 2 tumors were separated into gross total resection (GTR) or STR. Results We included 22 patients, aged 18 to 79. Presenting symptoms were visual (14, 64%), endocrine dysfunction (10, 45%), BMI>30 (8, 36%), cognitive/psychiatric impairment (9, 41%). Forteen (64%) were grade 2 craniopharyngiomas. GTR was performed in 14 (64%). 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 one; 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.