# Comparative Outcomes of Gross Total Resection vs. Subtotal Resection Plus Radiotherapy for Preventing Craniopharyngioma Recurrence: A Meta-Analysis of the Endoscopic Endonasal Approach

## TL;DR

A meta-analysis finds that complete tumor removal (GTR) is more effective than partial removal plus radiotherapy in reducing craniopharyngioma recurrence.

## Contribution

This is the largest meta-analysis comparing GTR and STR+XRT outcomes for craniopharyngiomas treated with the endoscopic endonasal approach.

## Key findings

- GTR had a 10% recurrence rate compared to 30% with STR plus XRT (OR = 0.299, p < 0.001).
- Recurrence-free survival was significantly better with GTR (p = 0.008).
- Results remained consistent even when limiting to studies with at least five patients per subgroup.

## Abstract

Craniopharyngioma recurrence rates after surgery remain debated, especially when comparing gross total resection (GTR) with subtotal resection (STR) followed by radiotherapy (XRT). This meta-analysis focused on patients treated with the modern endoscopic endonasal approach (EEA). Data from 11 studies were analyzed, including recurrence rates, surgical method, and follow-up. Results showed a significantly lower recurrence rate after GTR (10%) compared to STR with XRT (30%; OR = 0.299, p < 0.001). This is the largest meta-analysis to date on EEA-treated craniopharyngiomas, supporting GTR as the more effective option in reducing recurrence risk.

Objective: Craniopharyngioma recurrence risk studies comparing gross total resection (GTR) vs. subtotal resection (STR) with radiotherapy (XRT) provide inconclusive or contradictory results. This may be an effect of the small group sizes and diversity in the approaches used. Currently, the endoscopic endonasal approach (EEA) is preferred in craniopharyngioma management. Here, we aimed to perform a meta-analysis comparing recurrence risk after GTR vs. STR plus XRT in patients treated with the EEA regimen. Methods: We performed a systematic literature search of original English language papers on craniopharyngioma management published in the PubMed, Web of Science, and Scopus databases up to 18 October 2023. Eleven articles included data on recurrence rate after EEA: GTR vs. STR with XRT. We extracted the year of publication, number of patients, surgical approach, extent of resection, and follow-up duration. We used meta-analysis for the odds ratio (OR) in fixed and random effects models and Egger’s and Begg’s tests to assess heterogeneity and publication bias. Follow-up duration and time to recurrence were additionally included in Kaplan–Meier curves with log-rank test analysis. Results: We observed a lower recurrence rate in patients after GTR (10%) as compared to STR with XRT (30%), OR = 0.299, p < 0.001. To increase data reliability, we limited our analysis to studies with at least five patients in each subgroup and also observed lower recurrence in patients after GTR (12%) as compared to STR with XRT (27%), OR = 0.376, p = 0.011. Survival analysis confirmed significant differences in recurrence-free survival percentages between these groups (p = 0.008). Conclusions: To date, this is the largest meta-analysis evaluating the recurrence risk in patients undergoing EEA for craniopharyngioma resection, comparing outcomes between those treated with GTR and those treated with STR plus XRT. The results suggest that GTR significantly reduces recurrence risk.