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We have read with great interest the article by Bao et al.1 (Bao Y, Pan J, Qi ST, et al: Origin of craniopharyngiomas: implications for growth pattern, clinical characteristics, and outcomes of tumor recurrence. J Neurosurg 125:24–32, July 2016). The authors retrospectively analyzed surgical outcomes in a series of 52 patients, consisting of 20 children and 32 adults, with recurrent craniopharyngiomas (CPs). Overall, radical removal was achieved in 85% of the cases, with a perioperative death rate of 3.85% and a satisfactory outcome in 48% of patients. Tumor recurrence represents one of the most challenging, unsettling issues regarding CPs owing to their unpredictability and the hazardous, demanding surgical treatment required.24 For this reason, we first congratulate Bao et al. for their excellent results—a high percentage of radical removal concurrent with remarkable low morbidity and mortality rates. Apart from their results, we wish to highlight the importance of their analysis, as they found that, among the potential factors that influence patient outcome following repeated surgery for CPs, tumor topography is a major variable that predicts both the postoperative status and the hypothalamic functional outcome.1 Comparison of recurrent CPs growing below (15 tumors) or above (37 tumors) the diaphragma sellae revealed that an acceptable outcome occurred in 87% of the infradiaphragmatic cases, whereas a good outcome was achieved in only 32% of the supradiaphragmatic tumors. In addition, the rates of postoperative obesity and cognitive impairment were higher in the supradiaphragmatic group, particularly in children. In this article we would like to emphasize the importance of a precise CP topography definition to accurately predict the individual surgical risks associated with the treatment of recurrent lesions. Table 1 summarizes outcomes for the largest CP surgical series in which the results were compared between primary and recurrent cases.3,5,7,8,10–13,15,27,29,32 Although comparative evaluation among the cases in these series is complicated by their variable epidemiological composition and lack of validated parameters defining total removal, good outcome, and perioperative mortality, a uniform tendency toward a different outcome for primary and recurrent CPs can be recognized. The rate of radical excision falls dramatically for recurrent CPs, and operative mortality substantially increases for recurrent tumors. Even the most experienced and skilled neurosurgeons practicing aggressive removal in recurrent cases achieved gross-total resection in about only half of the lesions, with an associated mortality rate approximately 4 times higher than the observed incidence among first surgeries.32 The factors involved with such reduced surgical success in recurrent CPs have not been analyzed in detail. In most series, it is simply and vaguely stated that the worse outcome for recurrent CPs is largely attributed to the difficulties in tumor dissection posed by scarring from previous surgeries.12,15,29 Accordingly, the process of scarring induced by surgical maneuvers or dissection is believed to represent the explanation for the firm adherence usually found between recurrent CPs and contiguous neurovascular structures.27,28 Undoubtedly, adhesion strength and extent of tumor play fundamental roles in the possibility of achieving safe surgical removal of recurrent CPs, yet the underlying factors for the heterogeneous types of attachment among CPs have not been properly tackled. Regrettably, a comprehensive, irrefutable analysis of the pathological

Craniopharyngioma recurrence: the impact of tumor topography