Craniopharyngioma- A Multimodal Approach in the Management Dilemma

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Background

Although craniopharyngiomas are known to be benign tumors, their management is still problematic because of the propensity of recurrence, as well as, significant morbidity and mortality associated with their management. Moreover, they have different morphological types (solid, cystic and mixed), with each type requiring a different management strategy. Craniopharyngiomas also have a different prognosis in adults and children, being worse in children. They tend to recur after years and it is usually cystic in nature. It is argued that surgery aiming at complete removal is the main therapeutic option for these tumors. However, this goal presents a great challenge without significant intra- and post-operative risks. This is due to the close anatomical relationship between tumor and surrounding cerebrovascular and endocrine structures, presence of islets of neoplastic cells within the brain parenchyma and presence of digitiform extensions of tumor inside the hypothalamus. Tumor recurrence and the need for reoperation may arise despite an initial gross total resection in 10-50%. The treatment of this tumor must be balanced between providing a long-term control while keeping the morbidity and mortality to a minimum. No single treatment has been able to accomplish this delicate balance. Some have proposed a multimodal approach involving a combination of surgery, Ommaya catheter placement, intracavitary chemotherapy, stereotactic intracavitary irradiation and stereotactic radiosurgery. The idea is why use a single technique to attack this disease when we have a whole armamentarium at our disposal. In this issue we hope to accumulate different experiences with this approach and investigate their applicability across the board.

In spite of the benign nature of these tumors, craniopharyngioma management remains problematic. They commonly occur in the pediatric population which makes their management even more difficult. Tumor recurrence is common. A single technique approach does not seem to be sufficient in controlling craniopharyngiomas, so sometimes adjuvant treatments maybe required. In other instances, a management plan including multimodal treatment can be adopted. The role of stereotactic radiosurgery in the management paradigm has been investigated. Recently, less invasive endoscopic techniques have been used. The use of advanced targeted therapy and immunotherapy have been under trial. The diversity of the approaches and techniques used with this tumor indicate the dilemma its treatment poses and the need to address the different treatment strategies that can better serve patients cursed by this disease.

Although craniopharyngiomas are known to be benign tumors, their management is still problematic because of the propensity of recurrence, as well as, significant morbidity and mortality associated with their management. A single technique approach does not seem to be sufficient in controlling craniopharyngiomas, so sometimes adjuvant treatments maybe required. In this issue we are interested in multimodal treatments. Recently, less invasive endoscopic techniques have been used. The use of advanced targeted therapy and immunotherapy have been under trial. The role of stereotactic radiosurgery in the management paradigm can been investigated. Experiences with a combination of techniques are encouraged.

Keywords: Craniopharyngioma, multimodal, microsurgery, pediatric, radiosurgery

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