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S036: COMPARATIVE HYPOTHALAMIC AND ENDOCRINOLOGICAL OUTCOMES OF CRANIOPHARYNGIOMAS BASED ON INFUNDIBULUM SACRIFICE VS. PRESERVATION: A RETROSPECTIVE, MULTI-CENTER RAPID CONSORTIUM STUDY
Brandon Laing¹; Francesca Ghidoni¹; Noa Tal¹; Daniel F Kelly¹; Won Kim²; Marvin Bergsneider²; Kyle Wu³; Daniel Prevedello³; James Evans⁴; Michael Chicoine⁵; Albert Kim⁶; Julie Silverstein⁵; Michael Karsy⁷; Jamie van Gompel⁸; Donato Pacione⁹; Carter Suryadevara⁹; Paul Gardner⁹; Stephanie Cheock¹⁰; Nathan Zwaggerman¹⁰; Varun Kshettry¹¹; Robert Rennert¹²; William Cauldwell¹²; Juan C Fernandez-Miranda¹³; Gabriel Zada¹⁴; Carolina Benjamin¹⁵; Michael Catalino¹⁶; Adam Mamelak¹⁷; Georgios Zenonos¹⁸; Ramin Morshed¹⁹; Spiros Blackburn²⁰; Debraj Mukherjee²¹; Andre Beer-Furlan²²; Andrew Little²³; Kevin Yuen²³; Garni Barkhoudarian¹; ¹Pacific Neuroscience Institute; ²UCLA; ³OSU; ⁴Jefferson University; ⁵University of Missouri; ⁶Washington University; ⁷University of Michigan; ⁸Mayo Clinic; ⁹NYU; ¹⁰University of Wisconsin; ¹¹Cleveland Clinic; ¹²University of Utah; ¹³Stanford University; ¹⁴USC; ¹⁵University of Miami; ¹⁶UVA; ¹⁷Cedars Sinai; ¹⁸UPMC; ¹⁹UCSF; ²⁰UT Houston; ²¹Johns Hopkins University; ²²Moffitt; ²³Barrow Neurological Institute

Background and Objectives: Craniopharyngioma surgery is a balance between gross total resection and neurovascular complication avoidance, including hypothalamic dysfunction.  One surgical nuance is the preservation or sacrifice of the pituitary infundibulum to aid in tumor resection. In this multicenter, retrospective study, we evaluate preservation of the infundibulum during endoscopic endonasal surgery and its effects on postoperative hypothalamic-pituitary function and craniopharyngioma tumor recurrence.

Methods: Retrospective analysis of patients enrolled in a multicenter consortium (Registry of Adenomas of the Pituitary and Related Disorders, RAPID) who underwent surgical treatment for craniopharyngioma was performed. Patient demographics and tumor characteristics were obtained including pathology and imaging features (tumor morphology, and proximity to the chiasm and infundibulum). Patients were grouped based on infundibulum preservation versus resection during surgery. Primary outcomes included hypothalamic dysfunction (temperature regulation, weight gain, circadian rhythm), endocrine deficiencies (arginine vasopressin deficiency, adrenal insufficiency, hypothyroidism, growth hormone deficiency), pre-operative and postoperative body mass index (BMI), length of stay (LOS) and tumor recurrence. Chi-square analysis was used to evaluate differences between categorical variables. Nonparametric tests were used to evaluate differences between continuous variables.  

Results: 576 patients were enrolled in the database, but 200 were excluded from analysis due to lack of infundibulum preservation data. Median follow-up was 12 months (3s-60 months). Of the 376 patients evaluated, 271 (72.1%) patients had adamantinomatous craniopharyngioma while 87 (23.1%) had papillary craniopharyngioma. The infundibulum was preserved in 237 (63%) patients. Post-operative radiation was performed in 26.6% patients. Gross total resection was lower in the infundibulum preservation group (65.5% v 47.6%; p<0.001) Tumor recurrence was higher in the infundibulum preservation group (24.3% v 14.5%; p=0.05) and infundibulum resection led to lower rates of post-operative radiation (15.8%, n=22) compared to stalk-preservation (32.9%, n=78) (p=<0.001). Repeat resection rate was similar between groups, 13.9% in the infundibulum preservation group compared to 10.1% in the resection group (p=0.333). Tumors with transinfundibular morphology had higher rates of infundibulum sacrifice (44.4%) compared to the retro- and pre-infundibular morphology (p=0.002).  There was no significant difference in rate of infundibulum sacrifice between papillary and adamantinomatous subtypes (p=0.379). Infundibular resection was associated with higher rates of AVP deficiency (p=0.001), adrenal insufficiency (p=0.001), and hypothyroidism (p=0.001). BMI was significantly greater in the stalk resection group at 1-year (36.2±16.7 vs. 29.6±6.7; p=0.003) and at latest follow-up (33.6±11.5 vs. 29.5±7.1; p=0.001), with no significant difference in pre-op BMI (p=0.160). Additionally, patients who had infundibulum resection had a greater change in pre-operative and post-operative BMI (2.14 +/- 4.2) compared to the infundibulum preservation group (0.6+/-3.68, p=<0.001). No significant differences were found in cognitive function, sleep wake cycle regulation, or thermoregulation between the two groups.

Conclusions: Infundibulum resection was associated with worse endocrine function, greater long-term postoperative BMI increase and higher LOS. However, Infundibulum sacrifice is associated with a higher rate of GTR and lower rates of tumor recurrence and postoperative radiation. These findings support the careful consideration of infundibulum preservation, highlighting the importance of multidisciplinary management and endocrinological follow-up.  Long term tumor control rates will need to be compared between the two strategies.

 

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