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This correspondence discusses a recent study on developing a clinical rule to predict BRAF mutation status in craniopharyngiomas before surgery based on MRI findings. While the study achieved good classification, concerns are raised about applying the results to other centers without establishing inter-rater reliability of the MRI variables. The letter also discusses the potential for neoadjuvant chemotherapy to improve outcomes by reducing tumor size before surgery, as has been shown to be beneficial for other tumor types, but such approaches have not yet been proven for craniopharyngiomas. Overall, the letter supports further improving quality of life outcomes for craniopharyngioma patients beyond just tumor control.

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31 views1 page

PDF 13

This correspondence discusses a recent study on developing a clinical rule to predict BRAF mutation status in craniopharyngiomas before surgery based on MRI findings. While the study achieved good classification, concerns are raised about applying the results to other centers without establishing inter-rater reliability of the MRI variables. The letter also discusses the potential for neoadjuvant chemotherapy to improve outcomes by reducing tumor size before surgery, as has been shown to be beneficial for other tumor types, but such approaches have not yet been proven for craniopharyngiomas. Overall, the letter supports further improving quality of life outcomes for craniopharyngioma patients beyond just tumor control.

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Amina Gohary
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CORRESPONDENCE

In Reply: A Clinical Rule for Preoperative However, now is the time for investigators to develop noninvasive
Prediction of BRAF Mutation Status or minimally invasive methods of reliable diagnosis of papillary
in Craniopharyngiomas craniopharyngiomas that are portable across the spectrum of
clinical practice against the day this valuable treatment is ready
To the Editor: for use.
We thank the authors for their comment1 on our article, “A
Clinical Rule for Preoperative Prediction of BRAF Mutation Disclosures
Status in Craniopharyngiomas.”2 We appreciate their detailed Dr Cahill has received consultant fees from Lilly and travel fees from Merck.
Dr Brastianos has received consultant fees from Tesaro, Angiochem, Genentech-
investigation highlighting correlations among pathological,
Roche, and Lilly, Speaker’s Honoraria from Merck and Genentech-Roche, and
surgical, and radiological findings from the preoperative magnetic research support (to MGH) from Merck and BMS. The authors have no personal,
resonance imaging. financial, or institutional interest in any of the drugs, materials, or devices
The authors describe a logistic regression model using such described in this article.
variables as “distortion of the anatomical structures constituting
the hypothalamic-pituitary axis,” “mamillary body angle,” and Shingo Fujio, MD, PhD∗ ‡
“tumor topography, shape, and consistency” to predict cranio- Tareq A. Juratli, MD∗ ‡
pharyngioma histology. While the model achieves a gratifying Daniel P. Cahill, MD, PhD‡
degree of correct classification, the applicability of their results Fred G. Barker II, MD‡
to other centers – in the end, the true test of whether a classi- Priscilla K. Brastianos, MD∗
fication scheme is useful – also rests on inter-rater reliability, ∗
Divisions of Neuro-Oncology and Hematology/Oncology
which is not shown here. Indeed, as pointed out by the authors, Departments of Medicine and Neurology
we declined to use a “tumor consistency” variable because this Massachusetts General Hospital Cancer Center
descriptor failed to show adequate inter-rater reliability in our Harvard Medical School
hands. Boston, Massachusetts
A significant advance in surgical oncology elsewhere in the ‡
Department of Neurosurgery
body has been the introduction of neoadjuvant chemotherapy. Massachusetts General Hospital
Particularly in locations where important functions depend on Harvard Medical School
structural integrity of normal tissues, reducing the volume of Boston, Massachusetts
tumor that must be excised can make all the difference in post-
treatment quality of life. This is why neoadjuvant chemotherapy
is now the standard of care for many chemosensitive tumors in
REFERENCES
locations such as the oral cavity, larynx, esophagus, and rectum, 1. Prieto R, Pascual JM, Barrios L. Letter: a clinical rule for preoperative prediction
of BRAF mutation status in craniopharyngiomas. Neurosurgery. 2019;85(5):E962-
as well as for some sarcomas, allowing preservation of key joints E965.
and even limb salvage. 2. Fujio S, Juratli TA, Arita K, et al. A clinical rule for preoperative prediction
Studies have shown that many, perhaps most, patients with of BRAF mutation status in craniopharyngiomas. Neurosurgery. 2019;85(2):
craniopharyngioma may achieve good tumor control, but fail 204-210.
3. Pereira AM, Schmid EM, Schutte PJ, et al. High prevalence of long-term cardio-
to return to work or school. Pereira et al reported that 57% vascular, neurological and psychosocial morbidity after treatment for craniopharyn-
were unable to return to work or school despite 82% achieving gioma. Clin Endocrinol. 2005;62(2):197-204.
a “cure.”3 In addition, a recent study has shown that cranio- 4. Giese H, Haenig B, Haenig A, Unterberg A, Zweckberger K. Neurological and
pharyngioma resection is frequently associated with postoperative neuropsychological outcome after resection of craniopharyngiomas. J Neurosurg.
2019;19:1-10. (doi: 10.3171/2018.10.JNS181557).
neuropsychological deterioration and impaired quality of life.4 All 5. Juratli TA, Jones PS, Wang N, et al. Targeted treatment of papillary craniopharyn-
can agree that these results need further improvement. giomas harboring BRAF V600E mutations. Cancer. published online: 2019. (doi:
While the safety and efficacy of adjuvant chemotherapy for 10.1002/cncr.32197).
papillary craniopharyngiomas is being actively tested,5 it is not
yet clear that this modality will enter routine clinical practice, 10.1093/neuros/nyz327
or where in the sequence of treatments it will be best employed.

E966 | VOLUME 85 | NUMBER 5 | NOVEMBER 2019 www.neurosurgery-online.com

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