Surgical management of giant craniopharyngiomas: expanded endoscopic endonasal or transcranial approach?

OBJECTIVE: Giant craniopharyngiomas (GCPs) (diameter > 4 cm) are rare tumors that present significant surgical challenges due to their tendency to invade multiple compartments. To date, no studies have directly compared the expanded endoscopic endonasal approach (EEA) with the traditional transcranial approach (TCA) for the resection of GCPs. This study aimed to compare the safety and efficacy of these two surgical approaches within a single institution. METHODS: A retrospective cohort study was conducted on the medical records of patients with GCP who underwent surgery at the authors' institution between February 2011 and October 2023. Patients were divided into two groups based on the surgical approach received: EEA and TCA. The groups were compared on various parameters, including patient and tumor characteristics, surgical outcomes, perioperative complications, and long-term results. RESULTS: Seventy-three patients were included in the analysis, of whom 42 underwent expanded EEA and 31 underwent TCA. Patient and tumor characteristics were comparable between the two groups. The extent of resection and the rate of pituitary stalk preservation were similar in both groups (p = 0.55 and p = 0.16, respectively). Postoperative CSF leaks occurred exclusively in the EEA group, but the difference was not statistically significant (14.3% vs 0.0% in the TCA group, p = 0.08). EEA was associated with superior visual improvement (52.4% vs 22.6% in the TCA group, p = 0.01) and better hypothalamic function (p = 0.04). Postoperative panhypopituitarism (67.7% vs 42.9%, p = 0.04), progression from partial hypopituitarism to panhypopituitarism (48.4% vs 21.4%, p = 0.02), and permanent diabetes insipidus (51.7% vs 26.8%, p = 0.03) occurred more frequently in the TCA group compared with the EEA group. There were no significant differences in tumor recurrence (9.8% for the EEA group and 13.8% for the TCA group, p = 0.89), median BMI gain (1.0 kg/m2 and 1.6 kg/m2, respectively; p = 0.33), long-term hormone replacement (46.3% and 69.0%, respectively; p = 0.06), return to school/work (90.2% and 82.8%, respectively; p = 0.58), or progression-free survival (p = 0.273) between the groups at the last follow-up. CONCLUSIONS: Expanded EEA is associated with a similar gross-total resection rate, greater visual improvement, and better hypothalamic and endocrinological function compared with traditional TCA. Although not statistically significant, EEA was associated with a higher risk for postoperative CSF leaks. These data favor the view that EEA is a safe and effective surgical modality, providing a viable alternative to TCA for GCPs.