Surgical management of giant craniopharyngiomas.

INTRODUCTION: Multimodal treatment in the management of giant craniopharyngiomas (>4 cm in diameter) is necessary to obtain optimal results, and includes conservative or palliative treatment and "aggressive" removal. The significance of a new treatment algorithm including direct surgical resection with the intent to avoid radiation therapy and regrowth will be discussed here. MATERIALS AND METHODS: Between January 1996 and January 2005 16 patients were diagnosed with giant craniopharyngiomas. Two of them underwent only cyst aspiration because of their advanced age and/or lack of improvement of neuropsychological deficits. One patient underwent transsphenoidal operation and in the remaining 13 transcranial surgery was performed. Four additional patients underwent surgery for recurrence. The prospective protocol included pre- and post-operative dynamic endocrine tests, high field 1.5 T MRI and ophthalmological as well as neuropsychological examinations. RESULTS: In resectable tumours, the rate of total removal was ten out of 12 with two recurrences. In the remaining two patients with recurrences this intention was abandoned because of a firm tumour or a deteriorating neuropsychological status prior to the scheduled additional operation. There was no mortality and the morbidity rate was 6.3%. Visual function improved in 11, was unchanged in one and deteriorated in two patients. Secretion of different adenohypophyseal hormones deteriorated after tumour resection in one to three patients, and new diabetes insipidus occurred in six patients. There was no permanent deterioration of neuropsychological function. CONCLUSION: Special reference is given to direct resection of tumours at an optimal timing within this management. If hypothalamic disturbances are absent or improving due to pre-treatment (medical therapy, symptomatic surgery), giant craniopharyngiomas can be surgically removed in more than two of three patients with low morbidity and only moderate deterioration of endocrine function. The latter has to be accepted when curative surgery is intended, but even then, recurrences cannot be prevented. Contraindication for curative surgery is persisting hypothalamic damage necessitating conservative treatment modalities.

The concept of disease: ethical challenges and relevance to dentistry and dental education.

Modern medicine and dentistry face fundamental ethical challenges. To treat or not to treat, that is the question! Can these challenges be met with a rigorous and consistent concept of disease? This is the key question of this article and the ensuing debate is of fundamental importance in the teaching of ethics to medical and dental students. The investigation of traditional concepts of disease reveals that they are flawed and do not withstand ethical challenges. An alternative concept of human ailment is elaborated on, based on the triad disease, illness and sickness. This model is applied to representative cases in medicine in general and dentistry in particular. It is argued that the concepts of disease, illness and sickness represent a framework for analysing and coping with inherent ethical challenges. This reveals that medicine and dentistry are concerned both with biological explanations and with questions of the virtuous life, i.e., both with science and with ethics. These considerations pose challenges for the health professions as a whole, but particularly for those concerned with educating the practitioners of the future.