Endoscopic Endonasal Approach in Clival Chordoma Surgery: Case Series

Abstract

Chordomas are rare and slow-growing locally destructive bone tumors that can develop in the craniospinal axis. It is commonly found in the sacrococcygeal region whereas only 25-35% are found in the clival region. Headache with neurological deficits are the most common clinical presentations. Complete surgical resection either via open or endoscopic endonasal approaches are the main mode of treatment. Here, we report a series of 5 cases of clival chordomas which was managed via endoscopic endonasal approaches in our center. A retrospective analysis of patients who had undergone endoscopic endonasal resection of clival chordoma in Sarawak General Hospital from 2014 to 2018. A total of 5 cases were operated on endoscopically via a combine effort of both the otorhinolaryngology team and the neurosurgical team during the study period from year 2013 to 2018. From our patient, 2 were female and 3 were male patients. The main clinical presentation was headache, squinting of eye and nasopharyngeal fullness. All our patient had endoscopic endonasal debulking of clival tumor done, with average of hospital stay from 9 -23 days. Pos-operatively, patients were discharged back well. Endoscopic endonasal resection of clival chordomas gives good surgical resection results with low morbidity rates and therefore can be considered as a surgical option in centers where the surgical specialties are available.

Intraoperative Magnetic Resonance Imaging Assisted Endoscopic Endonasal Resection of Clival Chordomas

“…Total tumor resection has been shown to be the most important factor in progression-free survival and overall survival in skull base chordomas (4)(5)(6)(7)(8)16). Controversy over aggressive tumor resection in skull base chordomas arises from the tumor's relationship to critical neurovascular structures and that total resection often results in significant morbidity (2,7,8).…”

“…The aim of surgery in tumors that are not suitable for total resection is to decompress critical neurovascular structures, reduce the tumor burden, and establish a pathological diagnosis ( 4 , 6 , 11 , 16 ). Thus, adjuvant radiotherapy can be made safer by creating a suitable space between the tumor and radiosensitive structures such as the brain stem and optic nerve ( 7 , 8 , 18 ).…”

“…Fixed anatomic landmarks play an important role for skull base chordoma surgery because surgeons ensure anatomic orientation and estimation of the degree of resection and the adequacy of neural decompression based on these landmarks ( 3 , 16 ). However, chordomas tend to destroy surgical landmarks, especially by infiltrating bone structures due to their nature ( 8 , 19 ).…”