Endoscopic Endonasal Surgery for Clival Chordoma and Chondrosarcoma

Abstract

Background: Conventional microsurgical approaches are limited to exposing the lateral and bilateral regions because of surgical trauma. Total removal of clival chordoma and chondrosarcoma is very difficult. This study was undertaken to determine the potential role of an endoscopic endonasal approach in improved management of clival chordoma and chondrosarcoma. Methods: Seven patients with chordoma and 2 patients with chondrosarcoma treated by endoscopic endonasal surgery between November 2002 and February 2006 were studied prospectively. The mean age was 35 years. The follow-up periods ranged from 3 to 39 months. Results: Total removal was achieved in 6 cases of chordoma and 1 case of chondrosarcoma, with subtotal removal in 1 case of chordoma and of chondrosarcoma. At the last follow-up, 7 patients had no evidence of disease and 1 was alive with disease. The chordomas had recurred in 1 patient after 5 months with subtotal removal. Conclusion: The use of nasoendoscopy to perform clival chordoma and chondrosarcoma surgery is not limited to merely the minimally invasive aspects. It provides better visualization of the deeper anatomical structures in the skull base and affords a means to ‘look around corners’. This approach promises a simple and rapid access to the clivus. It is both a safe and efficient procedure.

Endoscopic Skull Base Surgery

“…Access to the suprasellar lesions by taking down the planum sphenoidale using a microscope was decribed by Laws et al in 1980 (19) and this same approach was adapted for endoscopy. Descriptions of endoscopic access to the cavernous sinus, clivus, odontoid process, pterygopalatine fossa, petrous apex, and midline anterior cranial fossa have now all be published (20-41). These more advanced skull base operations require the use of two surgeons operating with four hands (Fig.…”

“…Despite this weakness, the transphenoidal approach is the most commonly used approach for resection of these tumors. Several reports of endoscopic resection of these lesions have been published (20, 24, 57, 65-67). The largest series represents 11 patients with a mean followup of 27 months (65).…”

The Endoscopic Endonasal Approach for Removal of Petroclival Chondrosarcomas

“…Due to their ventral trajectory, potential advantages of endoscopic endonasal approaches (EEAs) include the possibility of accessing multiple skull base compartments, even bilaterally, in a single procedure while avoiding retraction or manipulation of neurovascular structures; this is exceptionally displayed during endonasal resection of chondrosarcomas. 2,[4][5][6] Hence, herein the authors describe their indications, contraindications, surgical technique and anatomy, complication management, and perioperative care for the endoscopic endonasal resection of skull base chondrosarcomas. Nevertheless, one must be aware that this is a heterogeneous group that may present in a wide variety of scenarios; thus, we will focus on describing the rationale behind surgically addressing those lesions located mainly in the petroclival region with involvement of neighboring compartments.…”

“…Abbreviations: CPA, cerebellopontine angle; CSF, cerebrospinal fluid; GTR, gross total resection; NTR, near total resection; STR, subtotal resection.Data from Refs 2,[4][5][6][27][28][29][30][31][32]. consults are dictated by the patient's response to surgery in terms of nasal healing and crusting.…”

Surgical results of an endoscopic endonasal approach for clival chordomas

“…More recently, some authors have reported the endoscopic endonasal transclival approach for clival chordomas [2,15,18,21,23,26,27,34,41,43,46]. This approach was developed mainly for intrasellar tumors and has been demonstrated to be less invasive with good resection rates for sellar lesions.…”