Endoscopic endonasal approach in the management of skull base chordomas—clinical experience on a large series, technique, outcome, and pitfalls

Abstract

Skull base chordomas represent very interesting neoplasms, due to their rarity, biological behavior, and resistance to treatment. Their management is very challenging. Recently, the use of a natural corridor, through the nose and the sphenoid sinus, improved morbidity and mortality allowing also for excellent removal rates. Prospective analysis of 54 patients harboring a skull base chordoma that were managed by extended endonasal endoscopic approach (EEA). Among the 54 patients treated (during a 72 months period), 21 were women and 33 men, undergoing 58 procedures. Twenty-two cases (40%) were recurrent and 32 (60%) newly diagnosed chordomas. Among the 32 newly diagnosed chordomas, a gross total resection was achieved in 28 cases (88%), a near total (>95% of tumor) in 2 cases (6%), a partial (>50% of tumor) in 2 cases (6%). Among the 22 recurrent chordomas, resection was complete in 7 cases (30%), near total in 7 (30%), and partial in 8 (40%). The global gross total resection rate was 65% (35/54 cases). Four patients (11%) recurred and 4 (11%) progressed within a mean follow-up of 34 months (range 12-84 months). Four patients (11%) were re-operated; one patient (1.8%) died due to disease progression, one patient (1.8%) died 2 weeks after surgery due to a massive bleeding from an ICA pseudo aneurysm. CSF leakage occurred in four patients (8%), and meningitis in eight cases (14%). No new permanent neurological deficit occurred. The EEA management of skull base chordomas requires a long and gradual learning curve that once acquired offers the possibility of either similar or better resection rates as compared to traditional approaches while morbidity is improved.

Skull base chordomas: clinical outcome in a consecutive series of 45 patients with long-term follow-up and evaluation of clinical and biological prognostic factors

“…7,11,56 In the present series, gross-total resection was achieved in 42% of cases; this finding is close to the mean value reported in the literature (mean 42.6%, range 0-72%). 7,11,17 Extensive tumor resection seemed to be easier to achieve in patients who had not undergone previous resection, as mentioned in other reports, 52 although in our series this observation did not reach statistical significance. On multivariate analysis our data confirmed a statistically significant correlation between the degree of tumor resection and survival (p = 0.041), as was shown in the meta-analysis published by Di Maio in 2011.…”

“…4 Lateral and anterolateral approaches were preferentially used in the first years of our experience, but they have been progressively replaced by the extensive application of anterior approaches and endoscopic procedures. According to the main published series, the choice of surgical route is extremely variable, depending mostly on the surgeon's confidence with particular approaches: use of the anterior approach varies from 15% in the Tzortzidis series to 85% in the Crockard series and up to 100% in the purely endoscopic series published by Chibbaro et al 7,11,56 In contrast, the use of lateral approaches ranged from 0 to 78%. 7,11,56 In the present series, gross-total resection was achieved in 42% of cases; this finding is close to the mean value reported in the literature (mean 42.6%, range 0-72%).…”

“…According to the main published series, the choice of surgical route is extremely variable, depending mostly on the surgeon's confidence with particular approaches: use of the anterior approach varies from 15% in the Tzortzidis series to 85% in the Crockard series and up to 100% in the purely endoscopic series published by Chibbaro et al 7,11,56 In contrast, the use of lateral approaches ranged from 0 to 78%. 7,11,56 In the present series, gross-total resection was achieved in 42% of cases; this finding is close to the mean value reported in the literature (mean 42.6%, range 0-72%). 7,11,17 Extensive tumor resection seemed to be easier to achieve in patients who had not undergone previous resection, as mentioned in other reports, 52 although in our series this observation did not reach statistical significance.…”

Tumour seeding in the surgical pathway after resection of skull base chordoma

“…28 The endoscopic endonasal approach offers the advantage of a direct and shorter surgical corridor, magnified visualization but limited exposure of adjacent site to the tumour. However, on the other hand, piecemeal resection, which is usually performed by this technique, could increase the chance of tumour seeding.…”

“…Thus far, no cases of surgical seeding are reported after endoscopy; however, more data and longer follow-up are needed to assess the incidence of tumour implantation in surgical pathway after this technique. 19,28 From the available data of the largest series and the case reports, 9-21 the postoperative radiation volume did not include, in principle, the surgical path and the site of surgical seeding was found outside the radiation fields or in the low dose volumes. Some authors suggested the inclusion of biopsy and surgical pathways in the radiotherapy field in order to reduce the risk of recurrence 12,14 but the inclusion of the entire surgical access path in radiation therapy field still remains a controversial issue as suggested by the recent consensus meeting because of the risk of toxicity related to treating a large target volume to high radiation dose 8 considering the low occurrence rate of surgical seeding that ranges from 1.3% to 7.3% in the reported series.…”