Absence of Hypothalamic Tumor Recurrence Following Endoscopic Endonasal Approaches in Pediatric Large and Giant Craniopharyngioma

Objective: We present a single institutional series of large and giant pediatric craniopharyngioma in patients who underwent endoscopic endonasal approaches (EEA) over a six-year period to evaluate clinical outcomes, rates of recurrence and location of recurrence. We sought to evaluate the locations of recurrence given the nature of our EEA. Methods: Of 22 consecutive patients who were treated with EEA resection between 2016 – 2022 at our institution, 9 had a total of 18 recurrences following EEA. Data was collected via retrospective chart review. Results: Nine patients presenting with Large or Giant adamaninomatous craniopharyngioma met inclusion criteria (3 males, age 9.9 years, range 5.1-13.5 years). Tumor size (mean 4.7 /− 1 cm) was classified as large (≥3 cm, n=5) or giant (≥5 cm, n=4). In the entire series, 20 patients had GTR (91%). There was a total of 18 recurrences with 9 undergoing 1, 8 undergoing 2, and 1 undergoing 3 surgeries respectively. Four received subsequent proton beam therapy (44%) with 2 additionally receiving Avastin at 27 + 13.4 months. Eight (89%) had panhypopituitarism following surgery. One patient with normal pre-operative BMI had a BMI > 98% following surgery. Seven patients who presented with normal BMI remain unchanged following surgery. One with BMI > 98% remained unchanged. In 2 patients presenting with bitemporal hemianopsia, 1 improved and 1 remained unchanged. 2 patients presenting with normal exams remained unchanged. In 3 patients presenting with unilateral visual loss 2, remained unchanged and 1 had worse vision. 2 patients presenting with abnormal visual field exams improved. Two patients had lumbar drains placed prophylactically, one of which required surgery for a CSF leak. All patients had tumor extension through the hypothalamus. Of 5 intrasellar recurrences, 2 involved the Lateral walls, 2 involved the floor and Lateral walls, and 1 involved the floor, lateral wall, and inferior chiasm. Of 4 suprasellar recurrences, 3 involved the optic nerves and 1 involved the cavernous sinus. Conclusion: Despite direct hypothalamic involvement in all patients, hypothalamic morbidity was minimal. Our approach is based upon the consideration that tumor perforating the Lamina Terminalis/ hypothalamus is exophytic in nature. Residual calcification and abnormal appearing tissue is not addressed. Despite visualization that suggests local tumor invasion, our experience has failed to document hypothalamic tumor recurrence to date following aggressive initial resection via EEA. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany