A multimodality approach to the treatment of craniopharyngiomas avoiding hypothalamic morbidity: a UK perspective

The management of craniopharyngiomas is complex and controversial. The perception that they are benign tumours cured by radical surgical resection is not borne out by their often difficult excision, propensity to recur and invade, and high late morbidity and mortality from direct brain injury. Their central location makes visual or pituitary dysfunction and/or hydrocephalus common presenting features. The most important consequence of craniopharyngiomas is hypothalamic injury which may result in severe, crippling and life-threatening sequelae, such as adipsia, morbid obesity, sleep, and behavioural and cognitive disorders. Evidence suggests that unless the tumour is smaller than 2-4 cm in the mid-line and completely resectable without additional hypothalamic or visual compromise, the surgical approach should be conservative even if this leaves residual tumour. Adjuvant focal radiotherapy to residual or recurrent disease has proven efficacy in long-term tumour control. Thus concerns regarding the potential late toxicity of radiotherapy to the developing brain need to be balanced against the recognised morbidity and mortality of recurrent tumour and repeated neurosurgical interventions. Hypothalamic damage is in many cases surgically induced. Given the devastating consequences of such an injury this should be avoided at all costs. Thus the aims of primary treatment should be to relieve tumour-associated compression symptoms, preserve (or improve) vision and hypothalamo-pituitary function, and minimise tumour recurrence with its attendant high morbidity and mortality. National registration and management by multidisciplinary teams in specialised centres according to nationally agreed risk adapted treatment strategies are likely to improve outcomes, as has been demonstrated for example in adult pituitary tumours. Because of the rarity of craniopharyngiomas, international collaborative trials are necessary to properly inform future therapies.